337 General discussion, conclusions, and future perspectives docking and simulation training). A theoretical basis for this training can be found in the basic proficiency requirements for RAS as designed by Porte et.al.4 After this basic training, certification of participants should be pursued. Residents with this certificate should be allowed to start the first steps of RAS in a training hospital under strict supervision of an expert RAS surgeon. This could also mark the start of the procedural training or table side assistance phase of training. In the Certified Curriculum of the European Association of Urology Robotic Urology Section (CC-ERUS) fellowship participants must do a 4-week mandatory live case observation and table side assistance training prior to an advanced robotic skills course.31 In a modified form and duration this could also be implemented in a residency program. Literature suggests novice surgeons should do a minimal of 10 procedures as table side assistant32,33 before starting surgery using the surgical robot. Certification criteria for basic RAS surgical skills should be developed following a similar process as laparoscopic surgery, i.e., the Program for Laparoscopic Urologic Skills (PLUS) or European Basic Laparoscopic Urological Skills (E-BLUS) examination1–3. The basic RAS training should be followed by an advanced training in RAS, in the form of a specialty specific or surgery specific training containing different aspects of VR simulation, dry lab training and wet lab training including animal models. The advanced training ensures participants to learn how to perform the surgery and how to react to complications such as bleeding of major vessels. This training could be completed either by VR simulator assessment or surgical video assessment. The completion of this advanced training module should result in a certificate, marking the start of the operative console phase of training. Since this training program is modular a choice can be made to only allow residents with a specific interest in RAS to participate in the advanced RAS training module. The basic RAS training should be provided for all residents since the skills learned in this module are paramount for a safe use of the surgical robot. Without completing the basic RAS training, residents should not be allowed to be a bedside assistant during RAS surgery, nor take their first steps in RAS under supervision of an expert RAS surgeon. Another possibility would be the development of a training curriculum based on proficiency-based training, in which the learner can only proceed to the next step after acquiring a specific proficiency level during training. In contrast to conventional training, this training method allows for the possible variability in the learning curve of a novice surgeon. Where in conventional training all novices receive the same time to train a specific aspect of the task, in proficiency based training the novice is only allowed to progress to the next training level if the previous task is performed consistently to a
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