American Urological Association outlines framework for robotic surgery credentialing

Linthicum, MD-A new AUA standard operating practice document aims to help with robotic surgery credentialing for practicing urologists and those in training.

"Presently, hospital credentialing requirements for urologic robotic surgery are dependent on industry-driven requirements. However, this situation could compromise patient safety because of competing interests among the hospital, physicians, and industry," said Chandru P. Sundaram, MD, chair of the Laparoscopic, Robotic, and New Surgical Technology Committee.

The AUA Core Curriculum for urology residencies now includes a section on laparoscopic and robotic surgery that must be followed in the residency program, whereas training of fellows will be governed by the respective society.

Dr. Sundaram pointed out that a minimum number of procedures for establishing a resident's competency in robotic surgery was not established by the AUA Residency Review Committee. The AUA standard operating practice document recommends that at least 20 cases be performed for a resident to become credentialed in robotic surgery, apart from approval by the residency program director.

In the document, it is recommended that urologists who did not receive robotic surgery training during residency or a fellowship should successfully complete the manufacturer's 90-minute online training module ( http://www.daVinciSurgeryCommunity.com/) and undergo hands-on training and proctoring by experienced surgeons.

Other learning resources include the AUA Handbook of Laparoscopic and Robotic Fundamentals, which is being updated with a test and curriculum, and an online course in robotic surgery that, at press time, was being finalized before release. Dr. Sundaram is the director of the course, which consists of nine sections covering fundamentals for commonly performed procedures. Mani Menon, MD, and Elspeth McDougall, MD, have also been actively involved with the development of the course.

Recognizing that acquisition of surgical skills requires more than cognitive training, it is also recommended that surgeons be observed by a urologist experienced in robotic surgery and gain hands-on experience with system set-up and docking in a laboratory setting, practicing both upper and lower tract approaches. Further skills training may be acquired using inanimate simulation models, animals when available, and virtual reality simulation.

"The AUA realizes there is no validated robotic skills curriculum similar to the fundamentals in laparoscopic surgery for general surgeons. Basic virtual reality skill simulation training has undergone initial validation and may be used widely in the future," Dr. Sundaram said.

Initial cases should be performed in the presence of an experienced proctor who will judge when the newly trained surgeon can perform the specific operation independently. Proctors must have performed more than 50 robotic cases, of which at least 20 are similar to the one that is being proctored.

"The informed consent for the proctored procedures should include information about the proctor and his or her role and responsibilities during surgery. The proctor should have temporary privileges to take over in case of a complication, but legal liability of the proctor should be minimized," Dr. Sundaram said.

Granting, denying privileges

Initially, a surgeon may be granted provisional privileges to operate independently, but early cases should still include the presence of another urologist and appropriate biomedical support. The appropriate hospital committee may determine the period of time and number of cases needed before granting unrestricted privileges.

Once unrestricted privileges are granted, the surgeon's clinical performance, volume, and complications may be monitored by a hospital peer review committee to assure optimal patient care. However, after gaining unrestricted privileges for robotic surgery, urologists may perform procedures different from the type for which privileges were initially granted if the surgeon has privileges to perform the same type of surgery via an open or laparoscopic approach.

If an institution denies or restricts privileges to a physician, there should be an unbiased mechanism for appeal involving a three-person expert panel comprised of one expert selected by the urologist, one by the institution, and the third chosen jointly by the other two experts.