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BACKGROUND:
Urology resident training has changed significantly in recent years with the introduction of the 80 hour work week, enhanced supervision requirements and the rise of robotic assisted surgery. In response to the challenges posed by robotic surgical training, we have incorporated a milestone based robotic surgery curriculum into our urology resident training program. Components of this program include online modules, achievement of simulation based milestones, and robotic instruction in the laboratory. To evaluate the impact of this curriculum on simulation performance, we measured performance on previously validated daVinci Surgical Simulator (dVSS) exercises.
METHODS:
A previous study from our institution demonstrated superior construct validity of 11 dVSS exercises in differentiating novice from intermediate surgeons. These exercises were performed at baseline by 9 urology residents who then underwent the milestone based training curriculum which included approximately 20 hours of simulation training with 1:1 supervision by an attending robotic surgeon over the course of 12 months. The residents were then re-tested on the 11 exercises. The overall score for each exercise was calculated by the dVSS as a percentage score. The mean score change was calculated for the simulations collectively and for each resident. Statistical significance was determined using the paired T test.
RESULTS:
The resident cohort achieved a mean increase compared to baseline of 9.75 percentage points (p<0.01). The mean score increase for each resident on all exercises ranged from 3.9 to 24.7 percentage points. For 8 of the 9 residents, improvement met statistically significant criteria defined as p<0.05 (see table 1). For the resident cohort, the mean improvement
per exercise ranged from 3.67 to 19.44 percentage points and reached
statistical significance (p<0.05) in 8 of 11 exercises.
Table 1

Resident	#1	#2	#3	#4	#5	#6	#7	#8	#9
Mean Improvement	5.82	8.18	10.73	4	24.72	4.91	3.91	8.45	17
P Value	0.02	0.05	0.02	0.04	<0.01	0.01	0.15	0.03	<0.01

CONCLUSIONS:
A statistically significant increase was seen in resident scores on the robotic simulator following implementation of a milestone based robotic
surgery curriculum. Further study is required to determine whether the curriculum will translate into improved skills and confidence in the operating room and improved patient outcomes.