Training, Credentialing, Proctoring And Medicolegal Risks Of Robotic Urological Surgery: Recommendations Of The Society Of Urologic Robotic Surgeons

Robotic prostatectomy is the #1 choice for the treatment of early-stage prostate cancer in the United States. This minimally invasive procedure is performed with the assistance of the da Vinci® Surgical System which provides unsurpassed benefits to both surgeon and patient. The robotic prostatectomy has benefits that both surgeon and patient can appreciate. The da Vinci® robot provides surgeons an alternative to both traditional open prostatectomy and conventional laparoscopic prostatectomy thus allowing the surgeon to perform major surgery through six small incisions which dramatically enhances visualization of the surgical field. This increased visualization allows the surgeon the capability of sparing more nerves compared to that of a traditional prostatectomy. Nerve sparing could potentially lead to an earlier return of sexual function and urinary incontinence.

The rapid application of laparoscopic and robotic surgery to radical prostatectomy for prostate cancer has really mirrored that of the laparoscopic cholecystectomy in the early 1990s. It is estimated that in 2009 85% of all radical prostatectomies will be performed robotically. This approach has become the standard of care in many urologic communities around the country but as in the initial years of the laparoscopic choleceptectomy, the robot lacks guidelines for the training and safe application of this new technology to clinical practice.

In this report undertaken by the Society of Urologic Robotic Surgeons (SURS), a literature review was performed on the safety and medical/legal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robotic assisted radical prostatectomy. The differences between proctoring and preceptoring are outlined by the authors and the medical/legal implications of each are defined.

The authors’ hope that this article will serve as a catalyst for the development of guidelines for robotic training and credentialing of surgeons in their medical centers has already occurred. In this regard, the American Urologic Association Laparoscopy and Robotic Surgery Committee is presently in the process of finalizing guidelines for residency training and surgeon activity with regards to basic robotic skills. These guidelines will be very similar to those developed by the SAGES and American College of Surgeons as the Fundamentals of Laparoscopic Surgery (FLS). As this article points out the majority of malpractice claims resulting from robotic surgical errors are due to systems malfunctions. Of 444 closed malpractice claims 75% arose during intraoperative care with systems factors contributing to 82% of the cases, and most of these were due to inexperience or lack of technical competence (41%).

Therefore, it would seem imperative for us to adequately train surgeons on the technical aspects of the equipment that they will be using in their clinical practice. As such, the AUA Basic Robotic Skills Guidelines will address the basic technical knowledge as well as skills required to perform effective and safe robot assisted surgical procedures, and are anticipated to be available on the AUA website in 2010.

Zorn KC, Gautam G, Shalhav AL, Clayman RV, Ahlering TE, Albala DM, Lee DI, Sundaram CP, Matin SF, Castle EP, Winfield HN, Gettman MT, Lee BR, Thomas R, Patel VR, Leveillee RJ, Wong C, Badlani GH, Rha KH, Eggener SE, Wiklund P, Mottrie A, Atug F, Kural AR, Joseph JV; Members of the Society of Urologic Robotic Surgeons.

J Urol. 2009 Sep;182(3):1126-32
10.1016/j.juro.2009.05.042

Written by UroToday.com Contributing Editor Elspeth M. McDougall, MD, FRCSC, MHPE

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