Platinum Priority – EducationEditorial by Jens-Uwe Stolzenburg, Hasan A.R. Qazi and Bhavan Prasad Rai on pp. 300–301 of this issue

Pilot Validation Study of the European Association of Urology

Robotic Training Curriculum

Alessandro Volpe a,b, Kamran Ahmed c, Prokar Dasgupta c, Vincenzo Ficarra a,d,Giacomo Novara a,e, Henk van der Poel f, Alexandre Mottrie a,g,*

a OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium; b Division of Urology, University of Eastern Piedmont, Novara, Italy; c MRC Centre for

Transplantation, Kings College London, Guy’s Hospital, London, UK; d Department of Experimental and Clinical Medical Sciences, Division of Urology,

University of Udine, Udine, Italy; e Department of Surgical, Oncological and Gastrointestinal Sciences, Division of Urology, University of Padua, Padua, Italy;f Division of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; g Division of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:

Accepted October 14, 2014

Keywords:

Curriculum

Radical prostatectomy

Robotics

Simulation

Training

Abstract

Background: The development of structured and validated training curricula is one of the current

priorities in robot-assisted urological surgery.Objective: To establish the feasibility, acceptability, face validity, and educational impact of a

structured training curriculum for robot-assisted radical prostatectomy (RARP), and to assess

improvements in performance and ability to perform RARP after completion of the curriculum.Design, setting, and participants: A 12-wk training curriculum was developed based on an expert

panel discussion and used to train ten fellows from major European teaching institutions. The

curriculum included: (1) e-learning, (2) 1 wk of structured simulation-based training (virtual reality

synthetic, animal, and cadaveric platforms), and (3) supervised modular training for RARP.Outcome measurements and statistical analysis: The feasibility, acceptability, face validity, and

educational impact were assessed using quantitative surveys. Improvement in the technical skills of

participants over the training period was evaluated using the inbuilt validated assessment metrics on

the da Vinci surgical simulator (dVSS). A final RARP performed by fellows on completion of their

training was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) score and

generic and procedure-specific scoring criteria.Results and limitations: The median baseline experience of participants as console surgeon was 4 mo

(interquartile range [IQR] 0–6.5 mo). All participants completed the curriculum and were involved in a

median of 18 RARPs (IQR 14–36) during modular training. The overall score for dVSS tasks significantly

increased over the training period ( p < 0.001-0.005). At the end of the curriculum, eight fellows (80%)

were deemed able by their mentors to perform a RARP independently, safely, and effectively. At

assessment of the final RARP, the participants achieved an average score�4 (scale 1–5) for all domains

using the GEARS scale and an average score >10 (scale 4–16) for all procedural steps using a generic

dedicated scoring tool. In performance comparison using this scoring tool, the experts significantly

outperformed the fellows (mean score for all steps 13.6 vs 11).Conclusions: The European robot-assisted urologic training curriculum is acceptable, valid, and

effective for training in RARP.Patient summary: This study shows that a 12-wk structured training program including simulation-

based training and mentored training in the operating room allows surgeons with limited robotic

experience to increase their robotic skills and their ability to perform the surgical steps of robot-

assisted radical prostatectomy.

# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. OLV Vattikuti Robotic Surgery Institute, Department of Urology,Onze-Lieve-Vrouw Hospital, Moorselbaan 164, 9300 Aalst, Belgium. Tel. +32 53 724378;Fax: +32 53 724411.E-mail address: a.mottrie@telenet.be (A. Mottrie).

http://dx.doi.org/10.1016/j.eururo.2014.10.0250302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction

The concept of surgical training has been evolving in the last

decade from the traditional concept of ‘‘see one, do one, teach

one’’ towards better defined and standardized methodolo-

gies for surgical education based on the development of skill-

based curricula [1–5]. Furthermore, the development and

diffusion of surgical robotic platforms are increasingly

supporting the development, use, and validation of simula-

tion-based training methods ranging from bench-top syn-

thetic models, animal, and cadavers to high-fidelity virtual

training platforms [6–8]. Simulation-based training should

be an essential part of surgical training programs to

significantly improve the technical and nontechnical skills

of trainees, shorten their learning curves for different

procedures, and improve surgical safety [9,10].

Nevertheless, training for robotic techniques remains

mainly unstructured. There has been a recent call by various

training bodies for the development of well-organized

educational curricula to increase preclinical exposure and of

validated assessment tools that allow constructive feedback

for performance improvement. These curricula, as well as

proficiency-based credential processes, are important for

improving patient safety and surgical outcomes in urologi-

cal surgery [5,11].

On the basis of these considerations, the European

Association of Urology (EAU) Robotic Urologic Section

(ERUS) has designed and developed a structured training

program and curriculum in urology that focuses on robot-

assisted radical prostatectomy (RARP). The aim of the

present study was to assess the feasibility, acceptability,

face validity, and educational impact of this curriculum, and

to assess improvements in performance and ability to

perform RARP after completion of the curriculum.

2. Materials and methods

2.1. Study design and participants

This was a longitudinal prospective study using quantitative observa-

tional measures. The participants were ten international fellows training

in robotic surgery provided by major teaching European institutions

under the recommendation of an expert mentor.

2.2. Curriculum

The curriculum was developed based on an expert panel discussion [12]

and was used for training of fellows. The key components of the curriculum

include: (1) e-learning, (2) an intensive week of structured, simulation-

based training (virtual reality synthetic, animal, and cadaveric platforms),

and (3) supervised modular training in RARP (Fig. 1).

2.3. Process

The overall study duration was 12 wk. After evaluation of baseline

experience, the fellows underwent e-learning using the e-module

developed by the ERUS expert panel [13] and observed and assisted in

live surgery for 3 wk. The participants then underwent an intensive week

of structured, simulation-based laboratory training including virtual

reality simulation (da Vinci surgical simulator, dVSS) and dry and wet

laboratory simulation platforms (synthetic, animal, and cadavers)

(Supplementary Table 1). Following this, the fellows participated into

a modular training program under supervision, which involved

progressive, proficiency-based training through surgical steps with

increasing levels of complexity (Supplementary Table 2) [14]. The

fellows continued the training until they carried out a full RARP

procedure, which was assessed by their mentors and video-recorded for

review and evaluation of performance by blind assessors.

2.4. Study outcomes

The outcomes of interest were (1) the feasibility, acceptability, face

validity, and educational impact of the curriculum [15] and (2)

improvements in performance and ability to perform RARP following

completion of the curriculum. Face validity is the extent to which the

learning and assessment environment resembles the situation in the real

world [15].

2.5. Evaluation of outcome parameters

Feasibility, acceptability, face validity, and educational impact were

assessed using quantitative surveys that were developed and validated

according to the expert opinions of robotic surgeons.

The technical skills of the participants were assessed via inbuilt

validated assessment metrics on the dVSS. The specific skills included[(Fig._1)TD$FIG]

BASELINE EVALUATION

F

E

D

C

B

A

E-learning module Operating room observation(bedside-console)

SIMULATION-BASED TRAINING(1-wk intensive course)

Virtual realitysimulation

Dry lab Wet lab

MODULAR CONSOLE TRAINING

TRANSITION TO FULL PROCEDURAL TRAINING(Video recording of a full case of RARP)

FINAL EVALUATION

Fig. 1 – Structure of the European Association of Urology Robotic Training Curriculum.

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9 293

moving the camera and clutching, manipulating the endowrist, use of

energy and dissection, and needle driving. The score at baseline and on

final assessment were compared to determine the improvement in basic

robotic skills.

Following successful completion of the modular training, the

mentors evaluated the procedural skills of the fellows in performing

RARP using the validated Global Evaluative Assessment of Robotic Skills

(GEARS) score (Supplementary Table 3) [16]. The mentors also assessed

the quality of the surgical skills for each surgical step using a RARP

procedure-specific scoring scale (Supplementary Table 4) ranging from

1 to 5, for which �3 was considered safe.

Videos of the final RARP procedures performed by each fellow were

further assessed by blinded, expert robotic surgeons using a generic

dedicated scoring criterion for each procedural step (Supplementary

Table 5). This score ranged from 4 to 16, and�10 was considered safe. The

videos of each surgical step were assessed by the same two independent

reviewers for all participants. The scores obtained by the fellows were

compared with those assigned by the same blinded reviewers to the

performance of two expert robotic surgeons to establish the construct

validity of the assessment. Construct validity is the extent to which a test is

able to discriminate between various levels of expertise [15].

2.6. Statistical analysis

Descriptive statistics were performed for the available variables.

Categorical variables are reported as frequency and percentage, and

continuous variables as median and interquartile range (IQR) or mean and

standard deviation, as appropriate. Mean values among groups were

compared using the Student t test and analysis of variance, as appropriate.

Statistical significance was set at p � 0.05. The statistical analysis was

carried out using SPSS version 20 (IBM Corp., Armonk, NY, USA).

3. Results

The characteristics and previous robotic experience of the

participants are reported in Table 1. Most participants had

minimal or no previous experience of simulation-based

training. The median times of involvement as a table

assistant and a console surgeon at baseline were 9.5 mo

(IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning

module and passed the final test for assessment of

theoretical knowledge. All fellows observed and assisted

in the recommended number of procedures (>12 cases)

during the first 3 wk of the curriculum, participated

successfully in all activities during the intensive week of

laboratory training, and completed the 8 wk of supervised

modular training. The median number of RARPs they were

involved in as console surgeons during modular training

was 18 (IQR 14–36).

The overall scores obtained by participants for perfor-

mance of four different dVSS tasks at baseline, during

the training program (weeks 4 and 5), and at the end of the

curriculum are reported in Figure 2. For all exercises the[(Fig._2)TD$FIG]

0 4 5 12

0

20

40

60

80

100

Camera and Clutching - Ring walk 3

100

90

80

70

60

0 4 5 12Training week

Training week

Training week

Ove

rall

scor

e (%

)

Ove

rall

scor

e (%

)

Ove

rall

scor

e (%

)

Ove

rall

scor

e (%

)

Training week

100

90

80

70

60

100

90

80

70

60

0 4 5 12 0 4 5 12

Needle driving - Suture sponge 2Energy and dissection - Energy switch 2

Endowrist manipulation - Match board 2

Fig. 2 – Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and aftercompletion of the curriculum. * Significant difference compared to overall score before the curriculum ( p < 0.05).8 Significant difference compared tooverall score in week 4 ( p < 0.05).

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9294

overall score significantly increased over the training period

( p < 0.001–0.005).

The GEARS scale was used by mentors to evaluate the final

RARP performance of fellows (Fig. 3A). Good to excellent

scores were obtained by 80–100% of trainees for their

depth perception (median 5, IQR 4–5), bimanual dexterity

(median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5),

force sensitivity (median 4, IQR 4–5), autonomy (median 4,

IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills.

A procedure-specific scale was used to score the performance

of fellows for each RARP surgical step (Fig. 3B).

Eight trainees (80%) were considered by their mentors

able to perform a RARP independently, safely, and efficiently

on completion of the curriculum. Three (30%) were consid-

ered able to perform a complex RARP independently, safely,

and effectively.

The blinded video-based assessment results for RARP

steps performed by each fellow and two robotic experts

are shown in Table 2. The fellows achieved an average score

that was considered safe (�10) for all surgical steps. The

highest average scores were obtained for bladder detach-

ment and urethrovesical anastomosis. When the scores for

all procedural steps were assessed, eight fellows (80%)

reached an average score�10. The two participants who did

not reach an average sufficient score were residents. The

robotic experts significantly outperformed the fellows

overall (mean score 13.6 vs 11) and for all RARP steps

except bladder detachment and endopelvic fascia incision,

confirming the construct validity of the assessment (Fig. 4).

Table 2 – Results for blinded video-based assessment of individual procedural steps in robot-assisted radical prostatectomy performed byfellows and robotic experts according to a generic dedicated scoring scale ranging from 4 to 16, with I10 considered safe

Bladderdetachment

Endopelvicfascia incision

Ligation ofdorsal vein

complex

Bladder neckincision

Dissectionof vasa and

seminalvesicles

Preparationand sectionof prostatic

pedicles

Dissection ofneurovascular

bundles

Apicaldissection

Urethrovesicalanastomosis

Mean

Fellow A 11.5 11 10.5 10.5 9.5 8.5 9.5 7 9.5 9.7

Fellow B 11 11 12 12 9.5 12 10.5 12 10 11.1

Fellow C 12 12.5 NP 12 10 12 11 11 13.5 11.8

Fellow D 12 12.5 8.5 11 8 8 NP 10.5 14.5 10.6

Fellow E 12 10 11 10 11 12 12 10 12.5 11.2

Fellow F 12 12 10 10 13.5 12 12.5 10 14 11.8

Fellow G NP 10 NP 9.5 6 8 6.5 6 14.5 8.6

Fellow H 11.5 12 12 10.5 10.5 10 9.5 9 12 10.8

Fellow I 12.5 12.5 10.5 12 13.5 12.5 13 14 11 12.3

Fellow L 12 12.5 NP 12 12.5 10 14 10.5 12 11.9

Expert A 13.5 12.5 NP 13 12 13.5 13.5 13 14.5 13.2

Expert B NP 12 15 14 14 13.5 13.5 14 15.5 13.9

NP = not performed.

Table 1 – Baseline characteristics and robotic experience ofparticipants

Median age, yr (IQR) 35 (31–36)

Training stage, n (%)

Resident 3 (30)

Fellow 5 (50)

Staff 2 (20)

Involvement in robotic surgery as table assistant

Median time, mo (IQR) 9.5 (5.75–16)

Median cases, n (IQR) 50 (29.5–175)

Involvement in robotic surgery as console surgeon

Median time, mo (IQR) 4 (0–6.5)

Median cases, n (IQR) 12 (0–24)

Median experience of virtual reality simulation, h (IQR) 0.5 (0–6.5)

Median experience of dry laboratory, h (IQR) 0 (0–8)

Median experience of wet laboratory, h (IQR) 0 –

IQR = interquartile range.

[(Fig._3)TD$FIG]

Fig. 3 – Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculumusing (A) the GEARS scale and (B) a procedure-specific scale.

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9 295

6.0

Fellows Fellows

Fellows Fellows

FellowsFellowsFellows

6.0

8.0

9.0

10.0

11.0

12.0

13.0

14.0

Bladder neck incision Dissection of vasa / seminal vesicles

10.0

12.0

14.0

Sco

re

Sco

reS

core

Sco

re

Sco

re

10.0

10.5

11.0

11.5

12.0

12.5

8.0

9.0

10.0

11.0

12.0

13.0

14.0

Overall procedure Ligation of dorsal vein complex

Sco

re

Sco

re

Sco

re

Sco

reFellows

6.0

8.0

10.0

12.0

14.0

Apical dissection

10.0

12.0

14.0

16.0

Urethrovesical anastomosis

8.0

9.0

10.0

11.0

12.0

13.0

14.0

Preparation and section of prostatic pedicles

Fellows

Experts Experts Experts

ExpertsExpertsExperts

ExpertsExpertsExperts

Dissection of neurovascular bundles

8.0

10.0

12.0

14.0

Endopelvic fascia incision

8.0

10.0

12.0

14.0

Fig. 4 – Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

EU

RO

PE

AN

UR

OL

OG

Y6

8(

20

15

)2

92

–2

99

29

6

The results for quantitative surveys completed at the end

of curriculum are reported in Figure 5. All fellows gave an

excellent overall evaluation of the training program and felt

that the curriculum was very effective in improving their

console exposure, their basic robotic skills, and their ability

to perform RARP.

4. Discussion

This is the first study that incorporates and validates

different components of a training curriculum for robot-

assisted surgery at a multi-institutional level. The study

demonstrates that a 12-wk structured training program

including theoretical e-learning, laboratory training, and

modular training in the operating room is feasible, accept-

able, and effective in improving the technical robotic skills

and ability of young surgeons with limited previous robotic

experience to perform the surgical steps of RARP. The study

also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in

the field of surgical education, especially in minimally

invasive laparoscopic and robotic surgery [3,4,9,10]. How-

ever, curricula for training in robotic urologic procedures

have not yet been standardized and the optimal integration

of simulation-based training in surgical training programs

is not clearly defined or evidence-based. The definition of

curricula for each surgical procedure and their validation

and progressive implementation are important for accredi-

tation of surgeons and teams for each specific intervention,

with the ultimate aim of improving surgical safety and

patient outcomes [5,11].

To date, three basic curricula for training and assessment

of robotic surgeons have been developed and reported in

the literature [3,4,17]. It has been shown that they are valid,

feasible, and effective in significantly improving basic

robotic surgery skills. However, these curricula do not

include modular training in the operating room and they

have not been validated for specific procedures.

On the basis of these considerations, the ERUS board

members designed and proposed a curriculum for RARP

including simulation-based and modular console training

with an expert mentor. The curriculum content was finalized

in accordance with the expert opinion of robotic surgeons

across various regions to ensure content validation [12].

The program is a step forward from existing approaches

because it includes all the simulation training modalities

available (virtual reality simulation, bench-top models, live

animal surgery, and cadaveric procedures) combined with

clinical training in the form of a mini-fellowship. Fellowships

are actually considered a key component of training for

complex urologic procedures such as RARP [18].

An ideal training program should be feasible, acceptable,

valid, and economically sustainable, with an effective

educational impact [15]. Our results show that the EAU

robotic training curriculum is feasible and acceptable, as all

participants were very satisfied with the program and would

highly recommend it to other colleagues. All modules of the

curriculum were found to be useful, although the fellows

subjectively found the virtual reality simulation training, the

dry and wet laboratories, and the cadaver training particu-

larly valuable. These data suggest that all these elements

should ideally be integrated in training programs, although

there are cost, ethical, and regulatory issues to take into

account. The centralization of simulation training in an

intensive week at a single, fully equipped training centre was

well perceived and proved to be effective, as previously

demonstrated in other studies [19].

An effective simulation-based training program repre-

sents the ideal background for clinical training in the

operating room. The concept of modular training proposed

by Stolzenburg et al [14] for laparoscopic radical prostatec-

tomy was adopted in the curriculum for progressive,

proficiency-based training of a fellow through steps of

increasing levels of difficulty in a surgical procedure. This

strategy has the potential to overcome the problems of

teaching complex surgical procedures, allowing safe train-

ing of surgeons with limited expertise and potentially

accelerating their learning curve. The importance of proper

mentoring for effective modular training has recently been

highlighted [18].

This pilot study showed that the EAU robotic training

curriculum can effectively improve the basic robotic skills

[(Fig._5)TD$FIG]

Fig. 5 – Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic TrainingCurriculum via quantitative surveys.

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9 297

of participants, as demonstrated by the significant improve-

ment in overall scores achieved by fellows at the end of the

curriculum for all dVSS tasks. The first weeks of simulation

training were found to be particularly effective in this

respect, potentially allowing participants to optimize the

results of subsequent training in the operating room.

Importantly, at the end of the curriculum the majority of

fellows were able to perform RARP with good or acceptable

technical quality, as reflected by scores from mentors and

blinded reviews of video-recorded surgeries. The two

participants who were not deemed able to perform RARP

safely and efficiently by the end of the training program

were residents. This may indicate that the curriculum is

more likely to be effective for urologists who have already

completed their basic training in residency programs.

The curriculum also provided constructive feedback on

the performance of fellows for individual procedural steps.

Overall, the fellows were able to reach similar performance

levels compared to expert surgeons for the easiest RARP

steps, such as bladder detachment and endopelvic fascia

incision. However, the experts achieved significantly better

scores for challenging parts of the procedure, confirming

the construct validity of the assessment. Fellows who did

not reach sufficient scores for specific surgical steps will

need further training before being deemed able to safely

perform RARP independently.

Finally, the results indicate that the curriculum has a

good educational impact, as well as face validity, defined as

the extent to which the program is subjectively viewed as

delivering the desired goal. In fact, the majority of the

participants felt that the curriculum significantly improved

their robotic skills and their ability to perform different

RARP steps. However, further comparative studies and,

ideally, randomized controlled trials will be needed to

assess whether this curriculum is superior to traditional

nonstructured training for RARP.

This study has some limitations. First, the number of

participants was limited. Second, although the participants

had limited previous robotic experience, they were not all

completely novice to console surgery, so the results for the

training program may be overestimated. The experience

level of mentors was not factored in the analysis, but they

were all high-volume robotic surgeons at teaching institu-

tions. Third, modular training was not standardized and the

console exposure of the participants was variable. Fourth,

assessment of the technical skills of the fellows using GEARS

and the procedure-specific scoring scale at the end of the

training program was performed by their mentors. Howev-

er, to standardize the assessment process and minimize bias

due to nonblinded assessment, the mentors were informed

about and educated in the use of the scoring systems. Fifth,

the performance of fellows in RARP video clips was assessed

using a new scoring tool. The contents of this scoring

criterion were developed and validated on the basis of

expert opinion. Sixth, a 3-mo training program may be too

short for some fellows to achieve sufficient skills to

adequately perform complex parts of the procedure. Finally,

there was no specific training or proper pre- and post-

training assessment of nontechnical skills.

This study represents the first step towards the

definition of an ideal training program for RARP and of

criteria for accreditation of surgeons for this procedure.

Further studies need to be carried out to address the issues

associated with certification and recertification using

training curricula.

5. Conclusions

This study establishes the effectiveness of the first

structured training curriculum for robot-assisted surgery

that integrates simulation-based training in dry and wet

laboratories, and modular training in the operating room

with expert mentorship. The study shows that the 12-wk

curriculum is valid, feasible, and acceptable, and has a good

educational impact, allowing participants to improve their

basic robotic skills and their ability to perform the surgical

steps of RARP. Further studies are needed to better define

the ideal length and structure of these training programs.

Author contributions: Alexandre Mottrie had full access to all the data in

the study and takes responsibility for the integrity of the data and the

accuracy of the data analysis.

Study concept and design: Mottrie, Dasgupta, van der Poel, Ficarra, Volpe.

Acquisition of data: Volpe.

Analysis and interpretation of data: Volpe, Ahmed.

Drafting of the manuscript: Volpe, Ahmed.

Critical revision of the manuscript for important intellectual content:

Mottrie, Dasgupta, van der Poel, Novara, Ficarra.

Statistical analysis: Volpe.

Obtaining funding: None.

Administrative, technical, or material support: None.

Supervision: Mottrie.

Other (specify): None.

Financial disclosures: Alexandre Mottrie certifies that all conflicts of

interest, including specific financial interests and relationships and

affiliations relevant to the subject matter or materials discussed in the

manuscript (eg, employment/affiliation, grants or funding, consultan-

cies, honoraria, stock ownership or options, expert testimony, royalties,

or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: None.

Acknowledgments: We would like to thank the ten participants

(F. Audenet, A. Briganti, M. Brown, V. De Marco, M. Gan, M. Janssen,

M. Oderda, R. Navarro, R. Sanchez Salas, and E. Wit) and their respective

mentors and teaching institutions (R. Sanchez Salas, Institut Montsouris,

Paris, France; F. Montorsi, San Raffaele Hospital, Vita Salute University,

Milan, Italy; P. Dasgupta, Guy’s Hospital, Kings College, London, UK;

W. Artibani, University of Verona, Verona, Italy; G. De Naeyer, OLV

Hospital, Aalst, Belgium; M. Stockle, University of Saarland, Homburg/

Saar, Germany; T. Piechaud, Clinique Saint Augustin, Bordeaux, France;

A. Ruffion, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon,

France; P. Wiklund, Karolinska University Hospital, Stockholm, Sweden;

and H. van der Poel, The Netherlands Cancer Institute, Amsterdam, The

Netherlands) for their contribution, enthusiasm, and dedication to this

project. We would like also to acknowledge the contributions of the

ERUS board members (http://www.uroweb.org/sections/robotic-

urology-erus/?no_cache=1) and the reviewers of the surgical videos

(C. Assenmacher, N. Buffi, G. D’Elia, P. Dekuiper, N. Doumerc, V. Ficarra,

S. Klaver, D. Murphy, K. Palmer, C.H. Rochat, C. Vaessen, B. van

Cleynenbruegel, C. Wagner, J. Walz, C. Wijburg, and J. Witt).

E U R O P E A N U R O L O G Y 6 8 ( 2 0 1 5 ) 2 9 2 – 2 9 9298

Appendix A. Supplementary data

Supplementary data associated with this article can be

found, in the online version, at http://dx.doi.org/10.1016/j.

eururo.2014.10.025.

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