The learning curve for robotic-assisted pyeloplasty in urologists with no prior robotic experience using an ex-vivo model: A prospective, controlled study

Introduction: Despite the increasing trend of utilizing robotic techniques in pyeloplasty, little is known about the learning curve for robot-assisted pyeloplasty (RAP) amongst urologists with no prior robotic experience. Therefore, the present study aimed to evaluate the learning curve of residents in the last year or new urologists performing RAP using an ex-vivo model.
Methods: A prospective ex-vivo model study was conducted including participants who were either residents in the last year or new urologists. All participants had obtained the E-BLUS certification or they were able to complete its 4 tasks successfully in a dry lab, without prior robotic experience. Each participant performed four consecutive RAPs using the Avatera system on an ex-vivo porcine model. The primary endpoint of the present study was the change in the average time to complete the anastomosis from the first to fourth attempts.
Results: Nine urologists and 8 residents were enrolled in this study. All participants successfully completed the four RAP attempts. Each surgeon demonstrated a reduction in the time to complete anastomosis from the 1^st to 4^th attempt with an average of value of 4.41±1.06 minutes (p=0.003). The decrease in time was statistically significant in both urologists and residents subgroups (4.5±1.41 minutes p=0.049 and 4.33±0.71 minutes p=0.035, respectively). 
Conclusions: The training on the ex-vivo model could lead, in only a few attempts, to a significant improvement in skills and in the required time of experienced-naïve surgeons to complete a RAP.