352 patient7,37–39 it is also cost effective if it reduces the duration of the learning curve. Since the average learning curve of RARP surgeons described in the study by Steinberg et al. is 77 cases costing 217.034 dollars a minimal reduction of the learning curve could cover the cost of the advanced course in RAS.36 Currently the effect of structured training on the learning curve remains unclear since the study presented in chapter 5 is a survey no accurate data on the learning curve of the participants is presented. The results do show more than half of the participants performed between 52 and 130 (partial) RARP cases during their fellowship, one third of the participants even performed more than 130 (partial) RARP cases during the fellowship, this could mean some fellows have passed the learning curve during the fellowship under the tutelage of experienced surgeon in a Host centre.7,37–39 The second part of the thesis focuses on the following research question: How can the performance of robotic surgeon’s best be assessed? The use of surgical video assessment to relate a surgeons skills to the patients post-operative outcomes has been proven in the past.40,41 The analysis of intraoperative videos allows for detailed analysis and assessment of surgical skills. The Robot Assisted Radical Prostatectomy (RARP) is a laparoscopic procedure in which the intra-corporeal images can be recorded. The RARP is one of the most performed procedures in urology. For this reason, we chose the RARP procedure to start with the development of surgical skills assessment using surgical video analysis. A detailed step-by-step description of the surgery is needed to use the surgical videos for the assessment of surgical skills and the detection of adverse outcomes. The study presented in chapter 6 shows the steps of the RARP surgery which expert robot surgeons believe are of interest in finding the origins of adverse postoperative outcome and complications. During a Delphi session, peri-operative events that could influence the postoperative outcome (urinary continence and potency) were defined. A new assessment template, the PROTEST assessment method, was designed based on these findings. The PROTEST assessment method is the only assessment method which combines subjective surgical skills assessment, objective metrics of procedural steps and peri-operative events in one assessment method. Examples of other template-based video assessment methods are the Prostatectomy Assessment and Competency Evaluation (PACE)42 and the Global Evaluative Assessment of Robotic Skill (GEARS)43 method. The PACE method developed by the group of Hussein et.al.42 has its focus on objective and procedure specific assessment of skills. The GEARS method can be used to differentiate levels of robotic sur-
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