The gold standard treatment option for men under 70 with early-stage, organ-confined cancer is surgical removal of the prostate using nerve-sparing radical prostatectomy. Since its introduction, surgical robotics has achieved widespread acceptance for performing radical prostatectomies in both the United States and Europe, and is increasing in adoption worldwide. In the U.S., robotic-assisted radical prostatectomy (RARP) is now the most common treatment for localized prostate cancer. Faster operating times, less blood loss, fewer complications, and shorter hospital stays are just a few of the reasons for its popularity among both patients and surgeons. In the coming years, it is anticipated that relative case volumes for the surgical robots will grow significantly as newer robotic systems are added or replaced in hospitals worldwide.
There is a debate going on currently about the importance of simulated procedural training and the best way to approach it. One approach is to have a complete virtual reality environment where students can “play “at learning the procedure and carry out any task they wish. A second way of learning, which Mimic believes works best is to learn from industry leading surgeons/proctors who can guide students through their own approaches and challenge the learner’s knowledge acquisition. This learning process is then augmented by specific virtual reality tasks that are key parts of the procedure to develop critical psychomotor skills.
There are currently no studies that have been carried out that have been able to validate either approach to procedural training. This is partly due to the recognition that the technology is still not fully advanced enough to simulate the complexity of human tissue and surgical interaction and include all the myriad of potential outcomes as surgeons learn through trial and error.
Clinical societies such as EAU have published guidelines for a structured training program and curriculum for teaching surgeons how to perform a RARP (see European Urology, August 2015, Volume 68, Issue 2, Pages 292–299). Although there is wide acceptance for key steps and strategies for the procedure, differences between cases (e.g. patient considerations, cancer location, desire for neurovascular bundle preservation, need for sentinel lymph node dissection, etc.), differences between robotic platforms (e.g. Xi vs Si), and surgeon preference or experience may warrant some variations in the surgical strategy. For this reason, Mimic has decided to simultaneously release two versions of their Maestro ARTM RARP training curricula. One has been developed based on the da Vinci® Si platform with Dr. Henk Van der Poel (filmed at the Netherlands Cancer Institute, Amsterdam, The Netherlands); the other is based on the da Vinci® Xi platform with Dr. Vip Patel (filmed at Florida Hospital, Orlando, FL, USA).
Both procedures offer a complete training solution for RARP, from initial patient and robot setup, to the final urethrovesical anastomosis. Each Maestro ARTM training curriculum integrates high definition 3D video footage from an actual RARP (narrated by the surgeon who performed the case) with augmented reality interactive tasks such as recognition of key anatomical structures, identification of surgical planes and landmarks, energy application, tissue retraction, and multiple choice questions. Additionally, each Maestro curriculum includes a set of virtual reality exercises selected by the surgeon and designed to teach specific robotic skills that are important at the various stages of the procedure.
The table below highlights the variation between the two curricula:
Although the major steps of the procedures are the same, the Si and Xi versions of the Mimic Maestro ARTM RARP curricula are differentiated at several key moments. These include: the location and technique for the initial peritoneal dissection and entry into the Space of Retzius, the timing and suturing technique used to ligate the Dorsal Venous Complex, the approach for the dissection of the posterior bladder neck and seminal vesicles, the strategy used during the preservation of the neurovascular bundle, and the type of suture and technique for the posterior reconstruction (Rocco stitch) and urethrovesical anastomosis.
Additionally, the Xi module highlights a new feature giving the surgeon the ability to rotate a 30 degree endoscope from a 30-down view to a 30-up view with the push of a button in order to gain greater visualization beneath the prostate during posterior dissection. Ultimately, the different styles, teaching preferences, and words of wisdom from our two surgeon collaborators offer a complete and well-rounded training pathway for any surgeon wanting to learn best practices for RARP on either robotic platform.