Training in robotic urology (1): The EAU Skills Centre at ORSI

With rapid developments in the area of robotic surgery and major changes to the landscape in recent years, the training of surgeons on robotic platforms is receiving more attention from the EAU and several other parties. The EAU has the mission to offer best possible care for urology patients, and offering the best possible training for surgeons is a part of that.

• This is the first in a series of articles that explores the developments in robotic surgical training, with further contributions, experiences and visions being published in the coming weeks.

The EAU is a partner in the ORSI Academy in Ghent (Belgium), offering training in urological surgery under the banner of the EAU Skills Centre at ORSI. Mr. Jeroen Van Heesewijk (Gstaad, CH) sits on the ORSI Board of Directors and has had over two decades of experience in robotic urology and setting up training centres around the world on behalf of industry. We spoke to him about the scientific and educational approach at ORSI and how it benefits the EAU, urologists and ultimately the patient.

“The landscape of robotic surgery is rapidly changing, from a phase of near-monopoly by Intuitive to other big players like Medtronic and Medicaroid entering the market in recent years,” says Mr. Van Heesewijk. “When you look at all surgical interventions, worldwide, only 5-6% are currently robotically-assisted so it is a market with a lot of potential for companies to enter.”

In the past, manufacturers took the lead in training surgeons and staff, partly to aid in their own market penetration and adoption of robots in the operating theatre. Nowadays however, a brand-agnostic approach is needed, as robotic systems diversify and surgeons and hospitals are less tied to a single provider. 

“In that sense, ORSI is unique,” says Mr. Van Heesewijk. “We are one of the first centres to use this approach. The shift in approach is similar to how you would get a driving license: you don’t buy a car and get trained by the manufacturer. You take lessons, pass your exam and receive your license, and then you are allowed on the road on your own.”

“We want surgeons to operate safely and competently, irrespective of which surgical system they end up using in their centres. Clinical competencies have to be generic and suitable for every robot. Hospital chains have a stake in surgeons being trained agnostically as well, it’s no longer economically viable to give a training for just one system.”

In order to achieve this, training at the EAU Skills Centre at ORSI is divided into technical skills and clinical skills. “The first is ‘buttonology’, that’s knowing how the machine works, and that part is of course company-specific. But the clinical skills that surgeons are taught, like suturing, approaches and procedures are generic skills, and not brand-specific,” Van Heesewijk explains.

“We’re lucky that the EAU is a shareholder. We want an active dialogue with the leading scientific and medical organisations, and make sure that they condone and support the approach we use.” 

Another unique aspect to the robotic training at ORSI is the methodology, developed in-house, that measures the performance of the trainees and makes sure they are proficient in their skills. “Our proficiency-based progression methodology, developed by the Orsi Academy team of educational specialists, allows us to understand and benchmark all surgical procedures in detail.”

“With more traditional approaches to robotic training, trainees might learn on cadavers or porcine models, ‘graduate’ and it would take another 15-20 cases (patients!) before a proficiency was achieved. We don’t think that’s an acceptable risk. That’s the big advantage of our methodology: surgeons leave the door not just with a certificate of participation, but with empirical proof of what they have accomplished. This methodology has since been tested and proven to be successful.”

Several hundred surgeons have been trained with this philosophy since its implementation in 2019.

With so many (new) interested parties who also have commercial ambitions with their products, it is extremely important that ORSI does not compromise its scientific and clinical integrity.

“We are uncompromisingly committed to clinical outcome,” says Van Heesewijk, “that should never suffer due to commercial goals. One example of how commercial ambitions have historically endangered clinical performance is the wide proliferation of training centres. If there is not enough volume of trainees at these centres, mistakes are made and patients die. If you only train a single person every three weeks you simply don’t have the skills to train a surgeon to the appropriate levels.” 

“What you also see is constant updates to the existing fleet of systems: new innovations or instruments for the robots. First you have to explain all of the training centres how these are to be used safely, how it helps the surgeon, what the clinical implications are for the patient. If that doesn’t happen in a homogenous or controlled environment, everyone is inventing the wheel or making the translation themselves. This can be dangerous.” 

“So for patient safety, we are very careful not to overextend ourselves. We keep our approach and methods concentrated, and manage our competencies carefully.” 

At the same time, there is potential and indeed a need for more training as robots are introduced to more operating theatres around Europe. A shortage of seats at high-level training centres like ORSI could potentially become a bottleneck for the wider introduction of robots in urology.

“ORSI will be growing to accommodate more trainees,” says Mr. Van Heesewijk. “Also we harbour ambitions for more centres under our umbrella, using the same methods and standards of quality. Robotic companies are also interested in this because they don’t have to address their patchwork network every time there’s a new technical innovation. In this example there is one institution that’s responsible and that would be us.” 

“There is no one-size fits all approach though. There are different needs around the world. For instance in East Asia some of the highest-trained surgeons don’t speak English and wouldn’t be able to train at ORSI. There are cultural barriers like the use of porcine models, or prohibitive visa requirements.”

“Ultimately, not every country needs its own training centre but we do involve the companies: where are they planning to introduce their products next? Where does it make sense and would there be sufficient volume? And of course every centre would follow the same proficiency-based progression approach.” 

• Thanks to this collaboration, EAU members receive a 25% discount on courses offered at ORSI using the discount code EAUMEMBER2024.