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Volume 14 Supplement 1 September 2026 emjreviews.com

Review of

SERUS 2026 Robotic Surgery in Urology

Interviews: Erdem Canda and Ahmed Ghazi explore robotics, surgery, and AI innovation Article: Standardising Curricula and 3D-Printed Models for Simulation-Based Surgical Education

Urology Supplement

Contents 04

Welcome

Congress Review

Review of the South East Robotic Urology Surgeons (SERUS) Meeting 2026, 19th July

Congress Interviews 13 17 20 23

Ahmed Ghazi Olivier Alenda Erdem Canda Derya Tilki

Articles 25

Emerging Role of Standardised Curricula and 3D-Printed Models for Simulation-Based Surgical Education: European Youth School of Robotic Technology (EYOUSORT) Review Sarikaya AF et al.

Workload Differences Between Bedside Assistants and Console Surgeons Using the Senhance® Surgical System for Robotic Radical Prostatectomy Kuliš T et al.

"This combination of expert-led presentations and practical training provided delegates with opportunities to explore both the clinical and technical aspects of robotic surgery"

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Aims and Scope EMJ Urology is an open access, peer-reviewed eJournal committed to helping elevate the quality of healthcare in urology by publishing content on all aspects of urological function and disease. The journal is six weeks after the South East Robotic Urology Surgeons (SERUS) Meeting 2026, and features highlights from this congress, alongside interviews with experts in the field and an in-depth feature on a congress session. EMJ Urology also publishes peer-reviewed research papers, review articles, and case reports in the field. In addition, the journal welcomes the submission of features and opinion pieces intended to create a discussion around key topics in the field and broaden readers’ professional interests. The journal is managed by a dedicated editorial team that adheres to a rigorous double-blind peer-review process, maintains high standards of copy editing, and ensures timely publication. EMJ Urology endeavours to increase knowledge, stimulate discussion, and contribute to a better understanding of practices in the field. Our focus is on research that is relevant to healthcare professionals in this field. We do not publish veterinary science papers or laboratory studies not linked to patient outcomes. We have a particular interest in topical studies that advance research and inform of coming trends affecting clinical practice in urology. Further details on coverage can be found here: www.emjreviews.com Editorial Expertise EMJ is supported by various levels of expertise: • • • •

Guidance from an Editorial Board consisting of leading authorities from a wide variety of disciplines. Invited contributors who are recognised authorities in their respective fields. Peer review, which is conducted by expert reviewers who are invited by the Editorial team and appointed based on their knowledge of a specific topic. An experienced team of editors and technical editors.

Peer Review On submission, all articles are assessed by the editorial team to determine their suitability for the journal and appropriateness for peer review. Editorial staff, following consultation with a member of the Editorial Board if necessary, identify three appropriate reviewers, who are selected based on their specialist knowledge in the relevant area. All peer review is double blind. Following review, papers are either accepted without modification, returned to the author(s) to incorporate required changes, or rejected. Editorial staff have final discretion over any proposed amendments.

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Submissions We welcome contributions from professionals, consultants, academics, and industry leaders on relevant and topical subjects. We seek papers with the most current, interesting, and relevant information in each therapeutic area and accept original research, review articles, case reports, and features. We are always keen to hear from healthcare professionals wishing to discuss potential submissions, please email: editorial.assistant@emjreviews.com To submit a paper, use our online submission site: https://emj.kriyadocs.com/welcome Submission details can be found through our website: www.emjreviews.com/contributors/authors Reprints All articles included in EMJ are available as reprints (minimum order 1,000). Please contact hello@emjreviews.com if you would like to order reprints. Distribution and Readership EMJ is distributed through controlled circulation to healthcare professionals in the relevant fields across Europe. Indexing and Availability EMJ is indexed on DOAJ, the Royal Society of Medicine, and Google Scholar®. EMJ is available through the websites of our leading partners and collaborating societies. EMJ journals are all available via our website: www.emjreviews.com Open Access This is an open-access journal in accordance with the Creative Commons Attribution-Non Commercial 4.0 (CC BY-NC 4.0) license. Congress Notice Staff members attend medical congresses as reporters when required. This Publication Publication Date: September 2026 Online ISSN: 2053-4213 All information obtained by EMJ and each of the contributions from various sources is as current and accurate as possible. However, due to human or mechanical errors, EMJ and the contributors cannot guarantee the accuracy, adequacy, or completeness of any information, and cannot be held responsible for any errors or omissions. EMJ is completely independent of the review event (SERUS 2026) and the use of the organisations does not constitute endorsement or media partnership in any form whatsoever. The cover photo is of Istanbul, Türkiye, the location of SERUS 2026. Front cover and contents photograph: Istanbul, Türkiye © muratart / stock.adobe.com.

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Welcome Dear Readers,

Editorial Director Andrea Charles

It is our pleasure to welcome you to the ‘Robotic Surgery in Urology' special edition of EMJ Urology, featuring expert insights and coverage from the 2026 South East Robotic Urology Surgeons (SERUS) Meeting, held at the Rahmi M. Koç Academy of Interventional Medicine, Education, and Simulation (RMK AIMES) Surgical Training Facility in Istanbul, Türkiye.

Editor Sean Boyle Managing Editor Darcy Richards Associate Editor Helena Bradbury Senior Copy Editor Noémie Fouarge

The Meeting brought together leading experts from across Southeast Europe and around the world to share cuttingedge insights into the latest advances in robotic urology. With multiple robotic platforms showcased and collaboration spanning surgical centres internationally, the Meeting provided an exciting forum for sharing innovation, experience, and expertise in this rapidly evolving field.

Copy Editors Meghan Garcka, Lizzie Green, Sarah Jahncke Editorial Leads Katrina Thornber, Aleksandra Zurowska Senior Editorial Co-ordinator Bertie Pearcey

In our congress review, we spotlight a selection of key presentations from the event, alongside the latest research and perspectives featured in our peer-reviewed content.

Editorial Co-ordinators Jess Nicholson, Alena Sofieva

We would like to take this opportunity to thank the SERUS Committee, Editorial Board, peer reviewers, authors, and interviewees for their valuable contributions in bringing this innovative issue to life.

Editorial Assistants Niamh Holmes, Josh Lister, Nonyelum Okonkwo Creative Director Tim Uden Design Manager Stacey White

We hope you enjoy reading and find this special edition both informative and inspiring.

Senior Designers Tamara Kondolomo, Owen Silcox

Niamh Holmes Editorial Assistant

Designers Shanjok Gurung, Fabio Van Paris Junior Designers Molly Edwards, Fraser Hoey, Cameron Levett, Helena Spicer, Caleb Wylie Marketing Director Stephanie Corbett Business Unit Lead Kelly Byrne

Chief Executive Officer Justin Levett

Editorial enquiries: editor@emjreviews.com Sales opportunities: salesadmin@emjreviews.com Permissions and copyright: accountsreceivable@emjreviews.com Reprints: info@emjreviews.com Media enquiries: marketing@emjreviews.com

Chief Commercial Officer Dan Healy Founder and Chairman Spencer Gore

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Urology Congress Feature:

The Future of Robotic Surgery A 2026 trial found remote robotic surgery non-inferior to local surgery at up to 2,800 km. From the EAU Congress 2026.

Read the full article here

Feature:

Bracing for the Flood: How Should We Manage Prostate Cancer Care by 2050? Prostate cancer cases will nearly double by 2050. Jonas J.L. Meenderink and Monique J. Roobol argue that the answer is safely doing less, not more.

Read the full article here

Podcast:

Revolutionising Prostate Cancer Diagnosis Veeru Kasivisvanathan on the shift from random biopsy to precision pathways, and the overdiagnosis problem it created.

Listen to the full podcast here

EMJ - Elevating the Quality of Healthcare Globally

Congress Introduction

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SERUS 2026

Congress Review Review of the South East Robotic Urology Surgeons (SERUS) Meeting 2026 Location:

Istanbul, Türkiye

Date:

19th July 2026

Citation:

EMJ Urol. 2026;14[Suppl 1]:6-12. https://doi.org/10.33590/emjurol/GWA4W68I

THE SOUTH East Robotic Urology Surgeons (SERUS) Meeting, hosted by Erdem Canda at the Rahmi M. Koç Academy of Interventional Medicine, Education, and Simulation (RMK AIMES) Surgical Training Facility in Istanbul, Türkiye, brought together specialists from Southeast Europe and beyond to share perspectives on developments in robotic urology. Held in Istanbul, a city connecting Europe and Asia, the meeting provided a fitting setting for discussions centred on collaboration and innovation. The scientific programme on 19th July 2026 spanned a broad range of topics in robotic urology, with specialists presenting their experiences, techniques, and perspectives on the evolving role of robotic surgery. The following day featured a hands-on robotic surgery workshop, giving delegates the opportunity to practise new techniques and apply the concepts discussed during the scientific sessions. This combination of expert-led presentations and practical training provided delegates with opportunities to explore both the clinical and technical aspects of robotic surgery. This congress review highlights two presentations from the meeting. Kaloyan Davidoff, University Multiprofile Hospital for Active Treatment (UMHAT) Sofiamed, Sofia, Bulgaria, presented on 3D perfusion mapping in robotic partial nephrectomy, exploring how patient-specific vascular mapping could support more precise surgical planning and renal preservation.

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Mudhar N. Hasan, Mediclinic City Hospital, Dubai, United Arab Emirates, discussed the application of robotic surgery in paediatric urology, focusing on how robotic techniques can be adapted to the anatomical and reconstructive challenges of paediatric surgery.

This combination of expert-led presentations and practical training provided delegates with opportunities to explore both the clinical and technical aspects of robotic surgery

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Integration of 3D Perfusion Mapping with Robotic Partial Nephrectomy Shows Potential Authors:

Kaloyan Davidoff,1 Nikola Tzvetkov,1 Kristiyan Krastev,1 Koray Ibrahimov,1 Nikola Stoyanov,1 Ivan Gospodinov1 1.

Urology Clinic, University Hospital “Sofiamed”, Sofia, Bulgaria

KALOYAN Davidoff, UMHAT Sofiamed, Sofia, Bulgaria, delivered an innovative presentation on the ‘Integration of 3D Perfusion Mapping in Robot-Assisted Partial Nephrectomy’ to a room of delegates, following on from previous presentations highlighting novel technological development in robotic nephrectomy surgery. He explored how patient-specific 3D vascular mapping could potentially support more tailored surgical planning and help surgeons balance effective tumour excision with maximal preservation of healthy renal parenchyma.1

Although main artery clamping provides a reliable and bloodless field for tumour excision, it exposes the entire kidney to ischaemia. Postoperative renal function following partial nephrectomy is influenced by baseline renal function, the amount of preserved functional parenchyma, and ischaemic injury.2,3 Selective arterial clamping aims to minimise unnecessary ischaemia by restricting vascular occlusion to the tumour-bearing territory while maintaining perfusion to the remaining kidney.4-8

Whilst conventional CT angiography and 3D reconstruction demonstrate renal arterial anatomy, they do not directly identify the parenchymal territory supplied by each arterial branch.2,3 This distinction is clinically important because renal arterial anatomy can be highly variable between patients, and simply identifying the location of an arterial branch does not necessarily indicate precisely which portion of the renal parenchyma it supplies. Davidoff described how Navigation of Vascularity (NaVa) uses a mathematical allocation algorithm and AssistoAR to convert patient-specific arterial anatomy into color-coded renal perfusion territories to support preoperative selective-

Whilst conventional CT angiography and 3D reconstruction demonstrate renal arterial anatomy, they do not directly identify the parenchymal territory supplied by each arterial branch

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The remaining renal parenchyma maintained visible fluorescence, supporting preservation of perfusion outside the targeted territory

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clamping planning. The technology therefore provides an additional layer of anatomical information by linking the renal arterial tree to its predicted functional perfusion territories. This allows the surgeon to visualise the individual arterial branches providing blood to the tumour region and the healthy parenchyma tissue.

Davidoff discussed how, at this stage, NaVa should be regarded as a patient-specific tool that supports decision-making to avoid unnecessary loss or devascularisation of healthy renal tissue. However, further prospective validation is required to determine whether this approach provides a consistent long-term renal functional benefit.

In the case presented by Davidoff, NaVa mapping dentified the perfusion territory containing the tumour and the corresponding arterial branch selected for clamping.

Overall, Davidoff’s presentation highlighted the potential of integrating computational 3D perfusion mapping with robotic surgery. The approach illustrates how patient-specific vascular and perfusion information could contribute to more personalised partial nephrectomy, and could be incorporated into surgical planning rather than relying solely on conventional anatomical imaging. While further clinical validation is required, the presented case demonstrated how this technology may help surgeons achieve precise tumour excision while minimising unnecessary ischaemia to healthy renal parenchyma.

Following selective arterial clamping, intraoperative indocyanine-green imaging demonstrated spatial correspondence between the predicted perfusion territory and the observed ischaemic field. The remaining renal parenchyma maintained visible fluorescence, supporting preservation of perfusion outside the targeted territory. Importantly, the procedure and reported short-term postoperative course were uncomplicated. Negative surgical margins were observed and renal function was preserved. CC BY-NC 4.0 Licence

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Robotic Surgery Shows Promise in Paediatric Urology, but Complexity Remains Author:

Mudhar N. Hasan1 1.

Department of Urology, Mediclinic City Hospital, Dubai, United Arab Emirates

ROBOTIC surgery could offer particular advantages in paediatric urology, where surgeons must perform complex reconstructive procedures within small and anatomically confined spaces, according to Mudhar N. Hasan, who presented the experience of the paediatric and adult robotic urology programme at Mediclinic City Hospital, Dubai, United Arab Emirates.9

Pyeloplasty was presented as one of the most favourable applications of robotic surgery in children However, paediatric robotic surgery is not simply a smaller version of adult surgery. Hasan highlighted the need to adapt port placement to the limited abdominal space of infants and children. The presentation also described the use of trans-abdominal hitch sutures to provide tissue retraction without requiring an additional robotic arm. Speaking from the perspective of an adult robotic surgeon, Hasan described how the Mediclinic team has adapted robotic expertise to paediatric procedures, while emphasising the anatomical and technical differences involved in operating on children. Unlike adult urology, where robotic surgery is often used for extirpative procedures, paediatric urology is predominantly reconstructive, Hasan noted. 3D visualisation, tremor filtration, and wristed instruments may be particularly valuable for delicate intracorporeal suturing in confined spaces. 10

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The Mediclinic programme’s experience spans upper- and lower-tract procedures, including pyeloplasty, partial and radical nephrectomy, and robotic-assisted laparoscopic ureteral reimplantation. Pyeloplasty was presented as one of the most favourable applications of robotic surgery in children. Hasan reported 22 robotic pyeloplasties within the programme’s experience. More complex reconstruction remains challenging. Augmentation cystoplasty, which involves incorporating bowel into the urinary tract, was described as particularly

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Unlike adult urology, where robotic surgery is often used for extirpative procedures, paediatric urology is predominantly reconstructive, Hasan noted

demanding, with an average operative time of 441 minutes and estimated blood loss of 71 mL. The presentation reported a 32% rate of high-grade complications for bladder reconstruction, highlighting the importance of preoperative videourodynamics, surgical experience, and long-term follow-up.

urology, but that successful implementationdepends on appropriate patient selection, specialist expertise, and close collaboration between adult robotic and paediatric surgeons.

Hasan argued that these complications reflect the biological and procedural complexity of reconstruction rather than the robotic platform itself. While robotic technology can enhance surgical precision and dexterity, it does not remove the learning curve associated with complex paediatric procedures. A key feature of the Mediclinic approach is its collaborative model, bringing together adult robotic expertise and paediatric anatomical expertise. The programme was launched in March 2021, with Hasan describing the model as a way of combining experience with robotic instrumentation and 3D visualisation with specialist knowledge of paediatric anatomy. The centre’s reported outcomes were favourable. Among 25 patients, Hasan reported a high surgical success rate, no major complications or returns to theatre, and hospital stays of 1–2 days. These figures were presented as favourable compared with global benchmarks, although they represent the centre’s own reported experience. The presentation concluded that age alone should not be considered a barrier to robotic pyeloplasty. Hasan reported comparable outcomes across age groups, alongside lower postoperative pain and substantially lower narcotic requirements in children than adults. Overall, the presentation suggested that robotic technology can expand minimally invasive options in paediatric CC BY-NC 4.0 Licence

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References

De Backer P et al. A novel threedimensional planning tool for selective clamping during partial nephrectomy: validation of a perfusion zone algorithm. Eur Urol. 2023;83(5):413-21.

Secin FP et al. Importance and limits of ischemia in renal partial surgery: experimental and clinical research. Adv Urol. 2008;2008:102461.

Marconi L et al. Renal preservation and partial nephrectomy: patient and surgical factors. Eur Urol Focus. 2016;2(6):589-600.

Kwon O et al. Backleak, tight junctions, and cell- cell adhesion in postischemic injury to the renal allograft. J Clin Invest. 1998;101(10):2054-64.

Amparore D et al. Robotic-assisted partial nephrectomy with minimal surgical impact after 3D virtual planning for the treatment of small renal masses. Eur Urol Open Sci. 2023;55(Suppl 2):S220.

Davidoff K et al. Integration of 3D perfusion mapping in robot-assisted partial nephrectomy. Presentation. SERUS Meeting, 19 July, 2026.

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Mir MC et al. Parenchymal volume preservation and ischemia during partial nephrectomy: functional and volumetric analysis. Urology. 2013;82(2):263-9.

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Vangeneugden J et al. Threedimensional perfusion-zone models allow more selective clamping during robot-assisted partial nephrectomy: brief report on a retrospective analysis. Eur Urol Open Sci. 2025;82:128-30.

Hasan MN. Bridging worlds: insight into pediatric robotic urology from an adult robotic surgeon’s perspective. Presentation. SERUS Meeting, 19 July, 2026.

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Congress Interview

Congress Interviews EMJ is delighted to present exclusive interviews with four leading figures in robotic urology: Ahmed Ghazi, who explores AI-driven surgical guidance, digital twins, simulation, and the future of robotic innovation; Olivier Alenda, who discusses surgical excellence, patientcentred outcomes, and the importance of maintaining core open and laparoscopic skills; Erdem Canda, who examines the growth of robotic urology across Southeastern Europe, regional training, collaboration, and equitable access; and Derya Tilki, who highlights advances in robotic prostate cancer surgery, personalised patient selection, evidence-based innovation, and the potential of AI and imaging to improve outcomes. Featuring: Ahmed Ghazi, Olivier Alenda, Erdem Canda, and Derya Tilki

Citation:

EMJ Urol. 2026;14[Suppl 1]:13-16. https://doi.org/10.33590/emjurol/84F63MC5

Robotic surgery has transformed urology over the past 2 decades. Looking ahead, what do you think will define the next major leap in robotic innovation?

Ahmed Ghazi Director and Associate Professor of Urology, Surgical Learning and Innovation Center of Excellence (SLICE), Lutherville; Director of Minimally Invasive & Robotic Surgery, The Johns Hopkins Hospital Brady Urological Institute, Baltimore, Maryland, USA

Looking at how we could democratise availability of experts within robotic surgery is essential

I think robotic innovation is going to revolve around more of a software application rather than a hardware application. Robotic surgery has really pushed the limits of how we perform surgery and how we find postoperative recovery, but we have not advanced at a similar pace in the field intraoperative guidance. For example, we remove the entire prostate for one or two cancerous lesions. The reason is not that we can't cut it out, we just don't know where the cancer is. So, I think the idea of intraoperative navigation and intraoperative cancer localisation would be very interesting from a robotic standpoint. Having those tools

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will not transform how we do surgery, but it will transform the outcomes of our surgery. However, I don't think we can send patients home any sooner; I think we've hit the limit there. I do believe that the next thing to do now is improve intraoperative surgical guidance.

Many new technologies promise to make surgery more precise or efficient. Which innovations do you believe have had the greatest real-world impact on patient care, and which are still waiting to prove their value? Within robotic surgery, I do believe it is the miniaturisation of our platforms, regardless of what type they are. Even in the regular multiport systems, the arms are getting slimmer: we went from 10 mm to 8 mm, then 5 mm. Now we have a single-port system, and reducing the amount of tissue damage to get to the target organ is where

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I think robotics is really showing a huge benefit. I think we're in that phase now, which is further miniaturisation of what we can do. On the other hand, I think looking at how we could democratise availability of experts within robotic surgery is essential. There is a huge push towards telesurgery, but there is a significant amount of ethics, rules, and regulations involved, making it very difficult for us to standardise it worldwide. However, the fact that there are existing platforms now coming along as a standard is pushing the other platforms to become standard. A very good example is in cars. The rear-view mirror or rear-view camera became standard in some cars, and now,

because it's safer, it has become standard in every car. So, I think the idea that we are starting to add things to our armamentarium that have now become almost standard is really starting to guide the industry towards improving access to surgery.

AI is increasingly being discussed in surgical practice. Where do you see AI making the greatest contribution to robotic urology over the next decade?

AI is really improving the way that we actually do robotic surgery. There's patient selection, and there's the ability to predict nomograms on the outcomes: AI is doing all of that, but let's talk about the actual operative

procedure itself. AI is something that we have to be very careful with in terms of how we frame it. It essentially takes a big bunch of data, organises it in a certain way, and gives us an explainable outcome at the end. However, sometimes it's not explainable. There was a landmark paper that looked at the differences between surgeons who have better outcomes when performing part of a robotic procedure when undertaking an anastomosis, and found out that moving the fourth arm more frequently caused fewer complications. It doesn't translate to something clinical to us, but it does imply that moving more efficiently leads to fewer complications. We have to be very careful about how we interpret AI. I think AI's biggest push is going

Training is a long process, but, unfortunately, it is being framed as a very short process, which is not possible. You don't learn to drive a car in two sessions

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to be about collecting all the data that we accumulate as experts. As an expert, you see subtle things in the field. You start to understand how close you can cut to the cancer and avoid a critical structure nearby without seeing the actual cancer, that is what we call surgical expertise, translated through thousands of cases. I think AI needs to take that from the surgeon's brain and explain it in a way that somebody who doesn't have over 1,000 procedures under their belt can understand, and so I think the biggest use of AI is going to be getting people to think like an expert. However, the amount of work required to do that is tremendous.

give them unbiased data. So, I think it’s essential in preoperative patient selection and decision-making. Then, when the patient comes to you, you're able to take all their data and present predictions for their positive margins, continence, functional outcomes, etc. That would be great because we cannot normally predict that.

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What safeguards should be in place as AI becomes more integrated into surgical decision-making? There should be full transparency. That's the problem with AI: the results are sometimes not understandable. Therefore, we need to understand the process. That's number one.

Do you foresee AI becoming an intraoperative assistant, or will its greatest value lie in preoperative planning and postoperative analysis? We speak to our colleagues in the operating room and have discussions with them; if they're not in the room, we go over things in our own minds. AI is never going to make a decision for you. Instead, it's going to guide your thoughts and organise them in a way that makes it easier for you to interpret what the surgeon is visualising in realtime. In terms of having AI in the operating room, yes, I think that is an incredible application for it. In terms of preoperative planning and postoperative analysis, AI has already proven itself in patient decision-making. When a patient comes to a surgeon or a radiation oncologist about their opinion, its always heavily biased towards their field. We have an inherent bias towards our own specialty when deciding what to do with our patients; however, AI can have a clean, clear understanding of what the patient needs and CC BY-NC 4.0 Licence

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Number two, I think it should be highly regulated by a governing body. There must be guardrails so that it doesn't become an industry-driven process. Finally, it has to be based on patient consent. Patients should be able to opt out of including their data. Nobody will, but they have to have the choice.

Your work has explored surgical simulation and patient-specific rehearsal. How do you see these technologies changing the way surgeons prepare for complex procedures? I've been working on surgical training, developing hydrogels, and developing curriculums for the last 2 decades. So, what is my ultimate goal? If we are able to have people learn a skill like robotic surgery or learn a new robotic platform within the comfort of their home; think about somebody putting on a pair of AI or virtual reality glasses and practicing the surgery. Imagine that I’m going to have a complex case tomorrow. I'm going to upload the scans, and I can rehearse various different scenarios which might occur during the operation and prepare for them. What we are building towards is really a tripartite mission: developing the ultimate and the best training platform, developing very accurate clinical assessments that can be meaningful to the trainee, and incorporating all of that into a translatable curriculum that improves patient outcomes. That is the culmination of all the work I've been doing: the simulation platform or our physical model. We developed something that's very unique, very specific, and very realistic. In terms of assessments, we're looking at not only accurate assessments, but automated 16

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ones. What is left is not building the curriculum, it's the adoption of the curriculum. Training is a long process, but, unfortunately, it is being framed as a very short process, which is not possible. You don't learn to drive a car in two sessions. You learn to drive a car over a longer period of time. Pilots do the same thing with planes. Robotic surgery shouldn't be different, we just don't have a credentialing body that forces us to do certain things in a certain way. Our goal is to make it easier for somebody to train, but there has to be a governing body.

How close are we to creating a true digital twin of a patient that could be used to rehearse surgery before entering the operating theatre? We are there. We are able to create the anatomy and pathology very accurately, and AI is doing this a lot faster. So, manual segmentation has become automated now. The only problem is we have two barriers. First, we only have the organ; we don’t have all the organs that surround it. We need to simulate the entire procedure, not only the critical component. Second, we do not have the incentive to encourage people to do this, because everyone's very busy and everybody thinks they're an expert. And even the best expert still sees a case that is new to them here and there. As a result, nobody forces or encourages anybody to do this. There has to be an incentive, and my thought process is as follows: when you buy car insurance and you get a black box that measures your speed, that will reduce your premium. This is the same thing. If a surgeon agrees to take the time to do a rehearsal, they should be

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incentivised with a fee towards the case itself. The leading part shouldn't be the patient or the physician; it should be the insurance, because, by doing this, they reduce the liability on the patient, which is to their benefit and to the patient's benefit. Offering this would be an incentive to utilise the digital twins. So, we do have half of the digital play. We just need the other half. However, even if we had this other half, and I've been doing this long enough to say this, the problem is having people enforce it.

How can surgeons remain active drivers of innovation rather than just adopting technologies developed by others? That is a very interesting question, and unfortunately it is not something you can change in a person. I see myself as somebody that gets a little bit mundane if I'm doing the same thing over and over again. So, I'm always looking for the best thing for my patient, whether that’s an approach, a technique, or a new robot, and that is where I feel satisfied that I have served my patients well. I think the way to remain an active driver of innovation is to have a registry where patients are aware of surgeons' outcomes. It's like going in and seeing the surgeon's track record, transparent to the patient. That will hold both accountable. So, I think the only way you can get people to innovate is to show that there are innovators and there are non-innovators. As a result of that, everybody will force you to become an innovator on some level.

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Citation:

Robotic surgery has become an established part of urological practice. Looking back over your career, what do you think has been the most significant change in the way robotic surgery is performed?

Department of Urology, Polyclinique Les Fleurs, Elsan Group, Ollioules; Faculty Member, IRCAD, Strasbourg, France; Board Member, French Association of Urology (AFU); Treasurer, French National Council of Urology Professionals (CNP Urology); President, UroPACA Uro-Oncology Meeting (UROPACA)

The ergonomics of the modern console combined with increasingly advanced and precise instruments drastically reduce both physical and cognitive fatigue for the surgeon

Congress Interview

EMJ Urol. 2026;14[Suppl 1]:17-19. https://doi.org/10.33590/emjurol/T5870N9H

Q1 Olivier Alenda

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If I had to pinpoint the single most critical factor, it is the sheer magnificence of 3D visualisation. This unprecedented clarity allowed us to go far beyond mere precise dissection; it granted us a near-microscopic understanding of anatomy. For radical prostatectomies, this was a complete game changer. It is these fine anatomical details, now clearly visible, that have allowed me to achieve exceptional functional outcomes both in terms of early continence and, crucially, the preservation of sexual function. Beyond visualisation, entire operational efficiency has shifted. The ergonomics of the modern console combined with increasingly advanced and precise instruments drastically reduce both physical and cognitive fatigue for the surgeon. This allows us to perform a high volume of complex cases back-to-back in a single day with maximum consistency and safety. Today, this technological trajectory shows no signs of slowing down; the arrival of singleport platforms and the progressive integration of AI are simply continuing this journey towards ultimate precision and efficiency.

What distinguishes a truly exceptional robotic surgeon from one who is simply technically proficient?

console, but an exceptional robotic surgeon understands that expertise is defined by the ability to lead a team and by operational efficiency. Being an expert means knowing how to surround oneself with a closeknit team to ensure the patient’s absolute safety and the smooth running of operations. It is about putting the ‘cockpit philosophy’ into practice: perfecting the docking process, streamlining the rotation of operating theatres, and ensuring that all those involved function as a synchronised unit. An exceptional surgeon does not merely perform the procedure to perfection; they also manage a highly efficient, safe, and productive operating theatre.

How do you balance achieving the best oncological outcome with preserving function and quality of life for your patients? The unrivalled visualisation and dissection capabilities offered by modern robotics undoubtedly help us achieve better anatomical outcomes. However, the key to striking this balance lies in discipline: we must always remain strictly focused on oncological outcomes. We must not allow our enthusiasm for this technology to cloud our clinical judgement. Striking the right balance requires the utmost caution and rigour in selecting our patients and determining the appropriate indications. Technology is an aid, but oncological safety remains the absolute priority.

Technical proficiency involves knowing how to use the CC BY-NC 4.0 Licence

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An exceptional surgeon does not merely perform the procedure to perfection; they also manage a highly efficient, safe, and productive operating theatre

Yes, this has made discussions about recovery much more precise, but it means I have to manage expectations very carefully. Although I can promise a more precise dissection and better preservation of function, I always emphasise that the robot is a tool, not a guarantee. The discussion focuses mainly on choosing the technology best suited to their specific condition, whilst ensuring they understand that safety and oncological recovery always take precedence over aesthetic considerations or the appeal of the technology itself.

My patients have taught me that true surgical success encompasses their entire journey, far beyond what the data reflects. They seek predictability, safety, and a stress-free perioperative experience. A well-organised team, which ensures a smooth and complication-free journey from the waiting room to discharge, provides a level of psychological reassurance that no manual can fully capture. Safety and efficiency at the hospital level translate directly into patient confidence.

As well as intellectual acuity, I am looking for trainees who have a solid grounding in conventional laparoscopy or open surgery. The best urologists specialising in robotic surgery are often those who have already palpated tissue with their own hands. As robotic surgery does not provide haptic feedback (force feedback), a trainee must be able to visually anticipate tissue resistance. Someone who already understands tissue sensitivity through their experience in laparoscopy will adapt to the robotic console much more confidently and intuitively.

Has robotic surgery changed the conversations you have with patients when discussing treatment options or expectations?

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What have your patients taught you about successful surgery that isn't reflected in the literature or training manuals?

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As someone involved in surgical education, what qualities do you look for in trainees who want to specialise in robotic urology?

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Training is now highly structured, but we are facing a major shortcoming. Today, robotics is a key pillar of residency training, but the younger generation is losing the ability to switch to open or laparoscopic surgery when a robotic procedure encounters serious complications or equipment failure. We urgently need to improve our training programme whilst preserving the fundamentals of training in open and laparoscopic surgery. An excellent robotic surgeon must know exactly what to do when they have to step away from the console and perform the procedure manually.

I hope that they will seamlessly integrate rapidly evolving technologies, particularly AI, and that they will facilitate the transition from multi-port to single-port platforms, whilst maintaining a sense of surgical humility. Although fifth-generation robots are striving to improve force feedback, the next generation will need to be able to handle these state-of-the-art instruments whilst strictly adhering to the appropriate clinical guidelines. I hope they will achieve a future where technology is pushed to its absolute limits, whilst always remaining grounded in the timeless fundamental principles of surgical safety and respect for anatomy.

How has the way we train robotic surgeons changed over the past decade, and where do you think further improvements are needed?

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Looking ahead, what would you most like to see the next generation of robotic urologists achieve?

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We urgently need to improve our training programme whilst preserving the fundamentals of training in open and laparoscopic surgery

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Citation:

Erdem Canda Director, RMK AIMES Training & Conference Center; Department of Urology, Koç University Hospital, Istanbul, Türkiye

Southeastern Europe has seen remarkable growth in robotic urology over the past decade. How have you seen the field develop across the region, and what has driven that progress? What unique strengths does Southeastern Europe bring to the international robotic urology community? Robotic surgery has many advantages for the patients, including less bleeding, less complications, faster recovery, and early discharge from the hospital. In addition, it has many advantages for the surgeon, as one can operate in a comfortable sitting position, having 3D magnified vision with dexterity of the hands and being able to use four robotic arms. Both the patients and hospitals are aware of these advantages, so patients are demanding robotic surgery and hospitals invest in this technology. Robotic surgery is therefore expanding all over the world and also in Southeast Europe. In addition, we now have a younger generation trained in robotic surgery. As the number of robotic platforms increases and competition grows, costs seem to be decreasing, with different financial solutions offered by companies enabling many 20

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hospitals to reach one of these robotic systems. Southeast Europe has a young generation who are now well trained with strong academic background and who are now able to reach the robotic systems that I think have the potential to lead their region.

Although access to robotic surgery has expanded, differences remain between countries. What do you see as the biggest barriers to achieving more equitable access across the region? Cost might be the primary barrier. Robotic surgery seems to be more costly in the short term; however, considering the advantages of less bleeding, less complications, faster recovery, and early discharge from the hospital, its cost decreases significantly. I can now see that the cost of adopting robotic surgery is decreasing as more affordable robotic systems become available and manufacturers offer a range of financing options, enabling more hospitals to access this technology. I also see that, although some USA-based robotic surgery companies do not operate in every market, Chinese manufacturers are entering these markets with lower-cost systems and flexible financing models, allowing many more countries to adopt robotic surgical technology.

How can centres with more established robotic programmes support hospitals and surgeons who are just beginning their robotic journey? As an example, at our training centre RMK AIMES, Istanbul, Türkiye, which is located in the

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same campus with Koç University Hospital, Istanbul, Türkiye, where I work as a faculty member in the department of urology, we organise many hands-on training courses using different training models in robotic urology, robotic gynaecology, robotic general surgery, and robotic thorax surgery in all levels, including beginner level, intermediate level, and advanced level, with different robotic systems that are available at our facilities. In addition, we offer robotic case observation in our operating rooms. In this way, trainees learn and observe lots of tips and tricks from our robotic surgical teams. We have structured robotic surgical training programmes that enable them to start and successfully proceed during their robotic surgery training journey.

What role do you see professional societies such as the South East Robotic Urology Surgeons (SERUS) playing in establishing regional standards for education, accreditation, and best practice in robotic urology? Societies like SERUS gather colleagues from the region and give them the opportunity to share their experience and knowledge in the field of robotic surgery and speed up the whole process. In this way, more colleagues have access to training, exposure to experienced centres, and upto-date knowledge. In addition, it opens the doors of academic collaboration and friendship. Stepwise education is accredited with high standards and offered to many colleagues. Fellowships are organised with many training

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opportunities. For colleagues in the region, it might be easier and less costly to join regional robotic training and academic activities such as those offered by SERUS. Many may not be able to join the European or North American meetings, events, congresses, and courses easily for many reasons.

SERUS has become an important platform for surgeons from Southeastern Europe. What was the original vision for the society, and how has that vision evolved? SERUS is a collective organisation of robotic surgeons that was founded in 2024. Its primary objectives include exchanging expertise and information, fostering cooperation, and camaraderie among its members as well as with other societies, conducting collaborative research, and organising joint conferences and activities focused on the advancements in robotic urology.

Looking ahead, where would you like SERUS to be in 5 or 10 years? We have established a SERUS editorial and advisory board composed of colleagues not only from Southeast Europe but also from all over the world, creating a strong academic and experienced team. Our first SERUS robotic multicentre and international collaborative study was presented by Ahmet Furkan Sarıkaya, Viransehir State Hospital, Sanliurfa, Türkiye, one of our active members, at the British Association of Urological Surgeons (BAUS) Congress

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in London this year. With this strong academic foundation and dedicated background, I think that SERUS will be organising many events, symposiums, courses, even congresses, and publishing papers within 5 years. Beyond that, I believe SERUS has the potential to become a leading robotic urology organisation in the region, working closely with the European Association of Urology Robotic Urology Section (ERUS), the North American Robotic Urology Symposium (NARUS), the Society of Robotic Surgery (SRS), the Society of Urologic Robotic Surgeons (SURS), and the Endourological Society.

Q7 The future of robotic urology is bright and promising, and SERUS forms a global alliance for surgical precision

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What opportunities do you see for multicentre research and collaborative clinical studies within the region? As I mentioned, our first SERUS robotic multicentre and international collaborative study was presented by Sarıkaya, one of our active members, during the BAUS Congress in

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London this year. Hopefully, the paper will be accepted and published in one of the peerreviewed journals this year. We have already started to carry out multicentre research and collaborative clinical studies within the region. In SERUS, we have a very motivated and young group of colleagues who are willing to collaborate, and the potential is great and promising.

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If you could leave delegates attending SERUS this year with one message about the future of robotic urology in Southeastern Europe, what would it be? The future of robotic urology is bright and promising, and SERUS forms a global alliance for surgical precision. South East Europe has a great and young

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group of colleagues who are interested in technology and they will quickly get involved and progress in robotic surgery. Lastly, with the availability of less costly new robotic platforms on the market, access to robotic surgery will be easier both for patients and hospitals.

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Citation:

Looking at the field today, what do you see as the greatest advances in robotic prostate cancer surgery over the past decade?

Martini-Klinik Prostate Cancer Center, University Medical Centre Hamburg-Eppendorf (UKE), Germany

Higher-resolution 3D visualisation, refined nerve-sparing techniques, and single-port/multi-arm platform advances have improved precision, reduced blood loss, and shortened recovery compared to open and early laparoscopic approaches.

Q2 Real-time imaging fusion, AI-assisted intraoperative guidance for margin assessment, and haptic feedback likely offer the biggest near-term gains

As robotic technology continues to evolve, how do we ensure that innovation translates into meaningful improvements in oncological, functional, and quality-of-life outcomes for patients? By anchoring adoption in prospective, outcome-driven trials and registries that track cancer control, continence, and potency rather than just perioperative metrics, so technology serves patients rather than being a novelty for its own sake.

New robotic technologies and surgical techniques are introduced very rapidly. What level of evidence do you believe is needed before these innovations should become part of routine clinical practice? Ideally, prospective comparative data and registries demonstrating non-inferiority or benefit in oncological and functional outcomes before a technology replaces standard practice, though reasonable surgeons disagree on how strict that bar should be for incremental refinements.

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EMJ Urol. 2026;14[Suppl 1]:23-24. https://doi.org/10.33590/emjurol/W6Y110U3

Q1 Derya Tilki

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With advances in imaging, genomics, and risk stratification, how has patient selection for robotic surgery changed, and where do you see it evolving in the future? Multiparametric MRI, targeted biopsy, and genomic risk classifiers have allowed more precise identification of who truly needs surgery versus active surveillance; the trend is towards increasingly individualised, biology-driven selection rather than prostate-specific antigen test/Gleason score alone.

As robotic surgery becomes the norm for many trainees, how can we make sure they develop not only technical proficiency, but also good oncological judgement and decision-making? Structured simulation curricula, proctored case volumes, and deliberate case-based discussion of margins, staging, and decisionmaking (not just console time) are needed so judgement develops.

Looking ahead, which developments, whether in robotic platforms, imaging integration, AI, or surgical planning, do you believe have the greatest potential to improve robotic prostate cancer surgery? Real-time imaging fusion, AIassisted intraoperative guidance for margin assessment, and haptic feedback likely offer the biggest near-term gains in precision and outcomes.

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Priorities include better real-time margin detection, standardised functional outcome reporting, and long-term comparative data on newer single-port and next-generation platforms versus established systems.

Standardising outcome reporting and quality benchmarks across centres, so patients and surgeons alike can meaningfully compare functional and oncological results.

What unanswered research questions in robotic uro-oncology do you think should be the highest priority over the next 5–10 years?

If you could change one aspect of robotic prostate cancer surgery over the next decade to improve patient care, what would it be?

Multiparametric MRI, targeted biopsy, and genomic risk classifiers have allowed more precise identification of who truly needs surgery versus active surveillance

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Article

Emerging Role of Standardised Curricula and 3D-Printed Models for Simulation-Based Surgical Education: European Youth School of Robotic Technology (EYOUSORT) Review Authors:

*Ahmet Furkan Sarikaya,1 Serdar Aydin,2 İlkan Tatar,3 Elisabetta Costantini,4,5 Benoit Peyronnet,6 Krystel Nyangoh Timoh,6 M. Sherif Mourad,7 Serkan Özcan,8 Emre Huri,9 Abdullah Erdem Canda10,11 1. 2.

Department of Urology, Viranşehir State Hospital, Şanlıurfa, Türkiye Department of Obstetrics and Gynecology, Faculty of Medicine, Koç University, İstanbul, Türkiye 3. Department of Anatomy, Hacettepe University Faculty of Medicine, Ankara, Türkiye 4. Department of Medicine and Surgery, University of Perugia, Terni, Italy 5. Andrological and Urogynecological Clinic, Santa Maria Terni Hospital, University of Perugia, Terni, Italy 6. Department of Gynecology, Rennes University Hospital, France 7. Ain Shams University, Cairo, Egypt 8. Department of Urology, İzmir Kâtip Çelebi University, Türkiye 9. Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye 10. Department of Urology, Faculty of Medicine, Koç University, İstanbul, Türkiye 11. Rahmi M. Koc Academy of Interventional Medicine, Education, and Simulation (RMK AIMES), İstanbul, Türkiye *Correspondence to ahmetfs@hotmail.com Disclosure:

The authors have declared no conflicts of interest.

Received:

05.06.26

Accepted:

07.08.26

Keywords:

Innovation, medical education, surgery, technology, urology.

Citation:

EMJ Urol. 2026;14[Suppl 1]:25-32. https://doi.org/10.33590/emjurol/Y23M25L1

Abstract Background: The rapid expansion of robotic and minimally invasive surgery has created an urgent need for structured, simulation-based training beyond the traditional apprenticeship model. Current robotic surgery curricula commonly include didactics, virtual simulation, dry-lab training, bedside assistance, and supervised console experience; however, their content, assessment methods, and certification standards remain highly variable. 3D printing may address key gaps by providing patient-specific, anatomically accurate, and tactile models for surgical planning, rehearsal, and hands-on skills training. Objective: To summarise the educational value of surgical simulation and 3D-printed models in modern surgical training, particularly within robotic surgery.

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Article Methods: This narrative review was based on a literature search of PubMed, Scopus, and Google Scholar. Relevant studies on robotic surgery curricula, virtual reality simulation, proficiency-based training, objective assessment, and 3D-printed surgical models were identified and narratively synthesised. Results: Simulation-based curricula support progressive skill acquisition in a safe environment before patient exposure. The Fundamentals of Robotic Surgery curriculum has demonstrated improved trainee performance in a multicentre randomised trial, supporting proficiencybased progression before clinical application. 3D-printed models provide additional value by improving spatial anatomical understanding, surgical confidence, procedural rehearsal, and patient-specific decision-making. In urology, these models have been most commonly applied to nephron-sparing surgery and prostate surgery, where complex anatomy and robotic loss of haptic feedback make tactile simulation particularly relevant. Recent systematic reviews report promising improvements in trainee anatomical understanding, technical performance, confidence, and familiarity with complex surgical steps, although studies remain heterogeneous and often small-scale. Conclusion: Surgical simulation and 3D-printed models represent complementary tools for competency-based surgical education. Their integration into standardised curricula may improve trainee preparedness, reduce learning curves, and enhance patient safety. Future studies should validate objective performance metrics, cost-effectiveness, and clinical skill transfer within multicentre training programmes.

Key Points 1. Robotic and minimally invasive surgery are rapidly becoming standardised, creating a need for structured, simulation-based training beyond the traditional apprenticeship model. 2. This narrative review summarises the educational value of surgical simulation and 3D-printed models in modern surgical training, particularly within robotic surgery. 3. Although further studies are required to validate objective performance metrics, cost-effectiveness, and clinical skill transfer, surgical simulation and 3D-printed models may serve as valuable complementary tools within competency-based surgical education.

INTRODUCTION Surgical education has changed substantially, particularly over the last 2 decades. Traditional apprenticeship-based models, commonly summarised as ‘see one, do one, teach one’, were developed in an era with different operative volumes and lower technological complexity. Today, surgical training is increasingly shaped by minimally invasive and robotic techniques, requiring structured curricula, simulation-based education, and objective assessment methods.1 Among recent technological advances, robotic surgery has had a particularly profound impact on surgical training. 26

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Robotic systems provide several technical advantages, including 3D visualisation, tremor filtration, improved ergonomics, and enhanced dexterity. At the same time, these technologies require surgeons to develop entirely new psychomotor and technical skills compared to conventional open surgery.2 As robotic procedures rapidly expanded across urology, general surgery, gynaecology, and cardiothoracic surgery, concerns regarding how residents should be trained also became increasingly important. In many institutions, the expansion of robotic surgery occurred faster than the development of standardised educational systems. Several studies demonstrated

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substantial variability between residency programmes regarding simulation access, resident console participation, curriculum structure, and technical assessment.3,4 Some residents gain early robotic exposure and structured simulator training, while others complete residency with relatively limited console experience. This inconsistency has become one of the major driving forces behind the growing interest in structured robotic curricula and simulationbased surgical education. At the same time, simulation gradually shifted from being an optional educational adjunct to becoming an essential component of modern surgical training. Simulation-based education provides trainees with opportunities for repetitive practice outside the operating room without concerns regarding patient safety, operative stress, or time pressure.5 More recently, advances in 3D-printing technologies have further expanded surgical simulation by enabling the creation of anatomically realistic and patientspecific physical models.6 Taken together, these developments are reshaping surgical education towards a more structured, competency-based, and simulationintegrated model. This narrative review summarises current evidence regarding standardised robotic surgery curricula, simulation-based education, objective assessment, and 3D printing in surgical training. Relevant literature was identified through PubMed, Scopus, and Google Scholar using combinations of keywords including “robotic surgery,” “robotic curriculum,” “simulation,” “virtual reality,” “3D printing,” and “surgical education.” Priority was given to peer-reviewed English-language articles, including systematic reviews, RCTs, consensus statements, and landmark educational studies. Studies were selected based on their relevance to the scope of this review. As this is a narrative review, no formal systematic review methodology or quality assessment was performed.

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THE NEED FOR STANDARDISED ROBOTIC CURRICULA One of the major problems in contemporary surgical education is the lack of uniformity between training programmes. Although robotic surgery is now widely integrated into surgical practice, educational pathways remain highly heterogeneous. A collaborative European study evaluating urology residency training showed that many residents believed they lacked sufficient operative exposure during residency, and trainee confidence strongly correlated with surgical volume and access to simulation resources.3 This variability is particularly evident in robotic surgery training. Tom et al.4 reported that although robotic exposure had become increasingly common in general surgery residency programmes in the USA, major differences still existed regarding curriculum structure, technical assessment, certification requirements, and resident console participation.4 These findings highlight an important educational challenge: technological advancement has progressed more rapidly than curriculum standardisation. Several groups have therefore advocated for competency-based robotic curricula integrating simulation, objective assessment, and stepwise progression models.2,7 One of the most influential initiatives was the development of the Fundamentals of Robotic Surgery curriculum. Unlike procedurespecific pathways, the Fundamentals of Robotic Surgery programme was designed as a platform-independent and specialtyindependent curriculum focusing on universal robotic skills, communication, safety, and psychomotor competency.8 Most modern robotic curricula now follow a sequential structure. Training usually begins with online didactic modules and simulation-based psychomotor exercises, followed by bedside assisting, console participation, and eventually supervised operative autonomy.9 However, progression through these stages is often inconsistent. Zhao et al.9 identified limited robotic case volume, inadequate console exposure, operating room hierarchy, and attending surgeons’ trust in trainee skills as major

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barriers affecting the transition from bedside assistant to console surgeon. Because of these limitations, many authors emphasise that robotic surgical education should be competence-based rather than purely time-based. Schreuder et al.5 argued that robotic training should include objective assessment at every stage and rely on validated educational principles rather than informal operative exposure alone. Similarly, Ahmed et al.7 proposed an internationally standardised robotic curriculum incorporating simulation, cognitive training, procedural education, and formal assessment strategies. Although the principles of competencybased robotic training are now widely accepted, considerable variability remains in how these curricula are implemented and evaluated. A recent systematic review by Basile et al.10 identified numerous robotic surgery simulators, assessment tools, and structured curricula, yet only a limited number demonstrated predictive validity or were supported by high-level evidence. Importantly, while Proficiency-Based Progression (PBP) curricula consistently outperformed traditional training methods in preclinical settings, relatively few existing curricula have fully incorporated objective performance metrics and validated proficiency benchmarks. These findings suggest that further efforts are required to establish robust, evidencebased educational pathways capable of ensuring reproducible training outcomes across institutions.10 Recent studies also suggest that structured robotic curricula improve resident preparedness and educational consistency. Madion et al.11 reported that nearly 70% of general surgery residency programmes in the USA now include formal robotic curricula, although significant variability still exists regarding implementation and resident autonomy. Hague et al.12 described the integration of robotics into residency training as an “unchecked technological revolution,” emphasising that technological dissemination has often outpaced educational oversight.12

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Supporting this concept, the multicentre randomised PROVESA trial demonstrated that trainees completing a PBP curriculum for robotic suturing were significantly more likely to achieve predefined proficiency benchmarks than those receiving traditional training. Participants trained using PBP also committed substantially fewer technical errors, highlighting the educational value of objective performance metrics and benchmark-driven progression. These findings provide high-level evidence that standardised, proficiency-based curricula can improve the quality and consistency of robotic surgical training beyond conventional apprenticeship models (Table 1).13

SIMULATION-BASED SURGICAL EDUCATION Simulation-based training has become one of the central pillars of modern surgical education. Current simulation modalities include box trainers, cadaveric models, virtual reality simulators, augmented reality systems, animal laboratories, and patientspecific physical models. One of the greatest strengths of simulation is the opportunity for repetitive practice. Trainees can perform the same technical manoeuvre multiple times without patientrelated risk or intraoperative stress. Simulation also allows the development of psychomotor coordination and procedural familiarity before participation in live surgery. The increasing complexity of minimally invasive surgery further accelerated the adoption of simulation-based education. Zhang et al.14 emphasised that procedures such as laparoscopic hepatobiliary and pancreatic surgery require navigation through intricate anatomical relationships under restricted tactile feedback conditions, making traditional apprenticeship models increasingly insufficient. Among simulation modalities, virtual reality platforms have attracted significant attention in robotic surgery training. Moglia et al.15 concluded that robotic virtual reality simulators demonstrated strong face

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Table 1: Overview of the principal structured robotic surgery curricula, their educational components, assessment strategies, and key educational objectives.

Curriculum

Main components

Assessment method

Key educational message

FRS

Didactic modules, psychomotor skills, communication, safety

Standardised performance assessment

Platform-independent basic robotic skills

PBP

Simulation until predefined proficiency benchmark

Objective proficiency metrics

Fewer technical errors and improved performance

Institution-specific curricula

Variable combination of VR simulation, dry lab, and console exposure

Often non-standardised

Considerable heterogeneity between training programmes

FRS: Fundamentals of Robotic Surgery; PBP: proficiency-based progression; VR: virtual reality.

and construct validity, although evidence regarding skill transfer into the operating room remained relatively limited. More recent evidence has become increasingly supportive. Schmidt et al.16 demonstrated that technical skills acquired through robotic virtual reality simulators could be transferred into the operating room, while simulator performance also correlated with intraoperative performance metrics. Similarly, Kiely et al.17 showed in an RCT that participants completing a proficiencybased virtual reality robotic suturing curriculum demonstrated significantly greater improvement in robotic suturing performance than controls. These findings suggest that simulation-based robotic education can accelerate early technical skill acquisition and shorten the initial learning curve. Importantly, simulation also improves educational reproducibility. Unlike opportunistic operative exposure, simulation ensures that trainees encounter standardised tasks and comparable educational experiences. This consistency is particularly valuable in robotic surgery, where institutional variability remains substantial. Beyond technical skills acquisition, simulation has become an integral component of structured robotic training pathways. Contemporary curricula increasingly combine multiple simulation modalities, including didactic teaching, CC BY-NC 4.0 Licence

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dry-laboratory exercises, virtual reality simulation, bedside assistance, and supervised console training, rather than relying on a single educational platform. Such multimodal approaches allow trainees to progressively acquire cognitive knowledge, psychomotor skills, and procedural competence within a standardised educational framework. Recent systematic reviews suggest that combining complementary simulation modalities provides a more comprehensive learning experience than isolated simulation techniques alone.18 However, no single simulation modality perfectly reproduces live surgery. Virtual reality simulators provide unlimited procedural repetition and objective performance metrics, but often lack realistic haptic feedback. Physical models offer greater tactile realism, but may fail to replicate dynamic physiological responses such as tissue perfusion or bleeding. Consequently, many educational programmes now favour hybrid simulation ecosystems integrating multiple modalities (Table 2).

THE EMERGING ROLE OF 3D-PRINTED MODELS Among recent developments in simulationbased education, 3D printing has emerged as one of the most promising technologies. By converting radiological imaging datasets

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into patient-specific physical models, 3D printing allows realistic anatomical replication for procedural planning and surgical training.6 Unlike purely virtual simulation systems, 3D-printed models provide direct instrument interaction and tactile feedback. This physical realism is particularly valuable in robotic and minimally invasive surgery, where depth perception, instrument handling, and spatial orientation are critical technical components. Applications of 3D printing in surgical education continue to expand rapidly. Langridge et al.6 demonstrated successful implementation of 3D-printing technologies across multiple specialties including neurosurgery, orthopaedics, vascular surgery, otolaryngology, and urology. Reported benefits included improved anatomical understanding, enhanced procedural planning, increased trainee confidence, and accelerated technical skill acquisition. Within urology, 3D printing has been increasingly used for robotic partial nephrectomy, pyeloplasty, renal transplantation, ureteroscopy, and pelvic surgery simulation. Campi et al.19 developed the first entirely 3D-printed robotic kidney transplantation simulator, known as the ‘RAKT Box’, specifically designed for robotic vascular training. Their work illustrated how highly specialised robotic procedures could be translated into realistic simulation environments. Beyond procedure-specific simulation, 3D printing has become an increasingly versatile educational platform throughout surgical training. Recent systematic reviews have demonstrated that 3D-printed models are now integrated across numerous surgical specialties and are used not only for procedural simulation, but also for anatomical teaching, preoperative planning, and resident education. Their high degree of anatomical fidelity and customisation allows trainees to rehearse both common procedures and uncommon anatomical scenarios in a standardised environment. 30

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Similar findings have also been reported in colorectal surgery, where 3D-printed models have been shown to improve anatomical education and preoperative visualisation, although further advances in printing materials are still required to achieve higher-fidelity procedural simulation. Furthermore, trainee satisfaction with 3D-printed simulation has consistently been reported to be high, supporting its growing incorporation into modern surgical curricula.20,21 Another major advantage of 3D printing is personalisation. Patient-specific models can replicate complex anatomical variations and pathological conditions that may rarely be encountered during routine residency training, thereby supporting precision surgical education and individualised procedural rehearsal. Beyond surgeon training, these models have also emerged as valuable tools for patient education by improving patients’ understanding of anatomy, planned surgical procedures, and doctor–patient communication, further broadening the educational impact of 3D printing.22 Repeated training using realistic 3D-printed models has also demonstrated measurable educational benefits. Xia et al.23 showed that trainees practising laparoscopic intracorporeal intestinal anastomosis on 3D-printed models achieved significant improvements in technical performance and learning curves. Similar benefits have been reported in hepatobiliary surgery, where a recent systematic review found that 3D-printed models improved operative performance, enhanced anatomical understanding, and increased trainee confidence across a variety of educational settings. Collectively, these findings suggest that realistic physical simulation can facilitate technical skill acquisition and procedural confidence across different surgical specialties.24 Despite these encouraging findings, several challenges continue to limit the widespread implementation of 3D-printed simulation. Although recent advances in printing technology have reduced manufacturing costs and improved model accessibility,

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Table 2: Advantages and limitations of major simulation modalities.

Modality

Advantages

Limitations

Virtual reality

Unlimited repetition, objective metrics

Limited haptic feedback

Dry laboratory

Low cost, basic skills

Limited anatomical realism

Animal models

Tissue realism

Ethical concerns, high cost

Cadaveric models

Excellent anatomy

Availability, cost

3D-printed models

Patient-specific anatomy, tactile interaction

Printing time, material limitations

the production process still requires image segmentation, technical expertise, and dedicated printing infrastructure. In addition, accurately reproducing tissue biomechanics, vascular perfusion, and bleeding remains challenging, limiting the realism of current models. Consequently, most authors advocate integrating 3D-printed simulators with complementary educational modalities rather than considering them complete replacements for cadaveric, animal, or virtual reality simulation.25,26

INTEGRATION OF 3D PRINTING INTO SURGICAL CURRICULA Despite increasing enthusiasm surrounding 3D-printing technologies, integration into formal surgical curricula remains inconsistent. Most current applications remain institution-specific rather than universally standardised. Nevertheless, evidence increasingly supports incorporating realistic physical simulation models into structured educational pathways. Barron et al.27 emphasised that simulation training using congenital 3D cardiac models improved technical performance and facilitated skill transfer into the operating room. Importantly, they argued that simulation should no longer be viewed as an optional adjunct, but rather as a routine component of modern surgical education. Effective integration of 3D printing into curricula requires alignment between educational objectives and simulation design. Models developed for anatomical teaching CC BY-NC 4.0 Licence

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differ substantially from those intended for procedural rehearsal or competency assessment. Consequently, simulation fidelity should be tailored according to the targeted educational outcome. The future likely lies in hybrid educational systems combining online didactics, virtual simulation, physical 3D-printed models, bedside participation, and supervised operative progression. As competencybased education continues to evolve, simulation and 3D-printing technologies will likely become central components of surgical curricula rather than supplementary educational tools.

CONCLUSION Modern surgical education is transitioning from traditional apprenticeship-based models towards structured, competency-based, simulation-integrated training systems. The rapid expansion of minimally invasive and robotic surgery has accelerated the need for standardised curricula capable of ensuring safe and measurable skill acquisition. Simulation-based education offers reproducible and risk-free environments for deliberate practice and objective assessment. Within this evolving landscape, 3D-printed models represent one of the most promising innovations due to their ability to provide patient-specific anatomical realism and procedural rehearsal opportunities.

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Although important limitations remain, including validation, standardisation, cost, and realism challenges, current evidence strongly supports the growing role of simulation and 3D-printing technologies within modern surgical education. Beyond improving technical proficiency, structured simulation-based training may contribute to patient safety by allowing surgeons to acquire and refine skills before performing procedures on patients. As References Knudsen JE et al. Simulation training in urology. Curr Opin Urol. 2024;34(1):37-42.

Chen R et al. A comprehensive review of robotic surgery curriculum and training for residents, fellows, and postgraduate surgical education. Surg Endosc. 2020;34(1):361-7.

Carrion DM et al. Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study. World J Urol. 2020;38(1):239-46.

Tom CM et al. A survey of robotic surgery training curricula in general surgery residency programs: how close are we to a standardized curriculum? Am J Surg. 2019;217(2):256-60.

Schreuder HW et al. Training and learning robotic surgery, time for a more structured approach: a systematic review. Bjog. 2012;119(2):137-49.

Langridge B et al. Systematic review of the use of 3-dimensional printing in surgical teaching and assessment. J Surg Educ. 2018;75(1):209-21.

Ahmed K et al. Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts. BJU Int. 2015;116(1):93-101.

11. Madion MP et al. Robotic surgery training curricula: prevalence, perceptions, and educational experiences in general surgery residency programs. Surg Endosc. 2022;36(9):6638-46.

Zhao B et al. Making the jump: a qualitative analysis on the transition from bedside assistant to console surgeon in robotic surgery training. J Surg Educ. 2020;77(2):461-71.

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19. Campi R et al. The first entirely 3D-printed training model for robotassisted kidney transplantation: the RAKT Box. Eur Urol Open Sci. 2023;53:98-105. 20. Taritsa IC et al. Three-dimensional printing in surgical education: an updated systematic review of the literature. J Surg Res. 2024;300:425-31.

12. Hague CM, Merrill SB. Integration of robotics in urology residency programs: an unchecked technological revolution. Curr Urol Rep. 2021;22:47.

21. To G et al. A systematic review of the application of 3D-printed models to colorectal surgical training. Tech Coloproctol. 2023;27(4):257-70.

13. De Groote R et al. Proficiency-based progression training for robotic surgery skills training: a randomized clinical trial. BJU Int. 2022;130(4):528-35.

22. Masanet S et al. Using 3D-printing technology for patient education: a review of the literature. 3D Print Med. 2025;11(1):49.

14. Zhang Y, Shen J. Simulationbased training and education in laparoscopic hepatobiliary and pancreatic surgery. Front Surg. 2026;13:1787299. 15. Moglia A et al. A systematic review of virtual reality simulators for robot-assisted surgery. Eur Urol. 2016;69(6):1065-80. 16. Schmidt MW et al. Virtual reality simulation in robot-assisted surgery: meta-analysis of skill transfer and predictability of skill. BJS Open. 2021;5(2):zraa066.

Smith R et al. Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14-society consensus template of outcomes measures and curriculum development. Int J Med Robot. 2014;10(3):379-84.

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Future surgical curricula will likely rely increasingly on integrated simulation ecosystems combining structured progression pathways with realistic physical and virtual simulation platforms.

10. Basile G et al. Current standards for training in robot-assisted surgery and endourology: a systematic review. Eur Urol. 2024;86(2):130-45.

robotic surgery continues to expand, integrating standardised simulation curricula into surgical education has the potential to improve both training quality and patient care.

17. Kiely DJ et al. Virtual reality robotic surgery simulation curriculum to teach robotic suturing: a randomized controlled trial. J Robot Surg. 2015;9:179-86. 18. Walshaw J et al. Essential components and validation of multi-specialty robotic surgical training curricula: a systematic review. Int J Surg. 2025;111(4):2791-809.

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23. Xia J et al. Assessment of laparoscopic intracorporeal intestinal anastomosis training using simulation-based 3D printed models: exploring surgical performance and learning curves. Int J Surg. 2023;109(10):2953-61. 24. Lin J et al. 3D printing technology in hepatobiliary surgery education: a systematic review. Ann Med. 2025;57(1):2601411. 25. Ghazi AE, Teplitz BA. Role of 3D printing in surgical education for robotic urology procedures. Transl Androl Urol. 2020;9(2):931-41. 26. Jiang Y et al. The current application of 3D printing simulator in surgical training. Front Med. 2024;11:1443024. 27. Barron DJ et al. Training on congenital 3D cardiac models - will models improve surgical performance? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2023;26:9-17.

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Article

Workload Differences Between Bedside Assistants and Console Surgeons Using the Senhance® Surgical System for Robotic Radical Prostatectomy Authors:

*Tomislav Kuliš,1,2 Toni Zekulić,1 Tvrtko Hudolin,1,2 Luka Penezić,1 Nikola Knežević,1,2 Jerko Anđelić,1 Tomislav Sambolić,1 Željko Kaštelan1,2 1. Department of Urology, University Hospital Centre Zagreb, Croatia 2. University of Zagreb, School of Medicine, Croatia *Correspondence to tkulis@kbc-zagreb.hr

Disclosure:

Kuliš serves as a proctor for Asensus Surgical, the manufacturer of the Senhance® robotic platform. The remaining authors declare no conflicts of interest. All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. All authors contributed to drafting the article or revising it critically for important intellectual content. All authors had final approval of the version to be published. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Received:

06.06.26

Accepted:

29.07.26

Keywords:

Radical prostatectomy, robotic surgery, Senhance® (Asensus Surgical, Morrisville, North Carolina, USA), Surgery Task Load Index (SURG-TLX), workload.

Citation:

EMJ Urol. 2026;14[Suppl 1]:33-41. https://doi.org/10.33590/emjurol/LWU8CD53

Abstract Background: Robotic radical prostatectomy requires coordinated work between console surgeons and bedside assistants, but workload may be distributed differently between these roles. Aims: This study aimed to compare perceived workload between console surgeons and bedside assistants during Senhance® (Asensus Surgical, Morrisvile, North Carolina, USA) robot-assisted radical prostatectomy. Methods: Perceived workload was assessed using the Surgery Task Load Index (SURG-TLX) after Senhance robot-assisted radical prostatectomy. The questionnaire was completed independently and immediately after each procedure. A total of 47 responses from console surgeons and 51 responses from bedside assistants were analysed. Because individual participants completed repeated questionnaires, role-related differences were analysed using generalised estimating equations, with participant identity specified as the clustering variable and an exchangeable working correlation structure.

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Findings: Bedside assistants reported significantly higher physical demands, temporal demands, and overall workload. Console surgeons reported significantly higher situational stress and distractions. Mental demands and task complexity did not differ significantly between roles. Conclusions: Workload profiles differ between console surgeons and bedside assistants during Senhance robotic radical prostatectomy. These findings may inform future improvements in robotic system design, role-specific team training, and operating room ergonomics.

Key Points 1.

Robotic surgery redistributes workload between console surgeons and bedside assistants, but the physical, cognitive, and temporal demands associated with these distinct roles remain insufficiently characterised.

Using 98 SURG-TLX assessments from robotic radical prostatectomies performed with the Senhance® system, this study compared workload between console surgeons and bedside assistants while accounting for repeated measurements.

Bedside assistants experienced greater physical and temporal demands and higher overall workload, whereas console surgeons reported greater situational stress and distractions, highlighting the need for role-specific workflow and training strategies.

BACKGROUND AND AIMS Numerous scientific papers have examined improved patient outcomes associated with robotic surgery, especially regarding shorter hospital stays, reduced perioperative pain and blood loss, faster recovery, and many other benefits of minimally invasive approaches.1 However, there is significantly less literature addressing physical and mental demand, as well as situational and overall stress among console surgeons and bedside assistants during robotic surgery procedures. Several studies comparing open and laparoscopic approaches reported a higher physical burden with increased rates of discomfort after laparoscopic operations and even work-related injuries.2-4 In the modern era of robotic surgery, certain limitations of laparoscopy are addressed, resulting in lower rates of postoperative discomfort and pain compared to laparoscopy. However, the burden remains significant.5-9 In contrast to laparoscopy, it becomes crucial to emphasise that a substantial difference in tasks exists between console surgeons and bedside assistants in robotic surgery. Thus, demands and stress might vary more than in laparoscopy, and analysis should focus on the different positions 34

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held during surgery. Unfortunately, only minimal research regarding the comparison of physical and mental burden during robotic surgery between console surgeons, bedside assistants, and trainees exists.10 A systematic review further highlighted substantial heterogeneity in workload assessment methods and concluded that firm comparisons of physical and mental demands across open, laparoscopic, and robotic surgery remain difficult.11 The Senhance® (Asensus Surgical, Morrisvile, North Carolina, USA) surgical system has been used in clinical practice since 2017. It is a modular robotic platform with three or four separate robotic arms and an open console. The system uses laparoscopy-based instruments with force-limitation and haptic feedback, an ergonomic chair, and eye-tracking camera control. Clinical experience with the platform has been reported in abdominal surgery, gynaecology, and urology.12-22 Subjective workload in surgery is commonly assessed using the NASA Task Load Index (NASA-TLX) or the Surgery Task Load Index (SURG-TLX).7,23-25 SURG-TLX was developed specifically for the surgical environment and assesses mental demands, physical demands,

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temporal demands, task complexity, situational stress, and distractions.25 This paper aims to analyse differences in workload between console surgeons and bedside assistants during surgery with the Senhance robotic platform using the SURG-TLX questionnaire.

METHODS This observational questionnaire study assessed perceived intraoperative workload during extraperitoneal robot-assisted radical prostatectomy performed using the Senhance robotic platform. Workload was evaluated with the SURG-TLX questionnaire, which comprises six domains: • • • • • •

Mental demands: How mentally fatiguing was the procedure? Physical demands: How physically fatiguing was the procedure? Temporal demands: How hurried or rushed was the pace of the procedure? Task complexity: How complex was the procedure? Situational stress: How anxious did you feel while performing the procedure? Distractions: How distracting was the operating environment?

Perceived workload in each domain was rated on a scale from 0–100. The six domains were also compared pairwise in 15 comparisons to determine their relative contribution to perceived workload. For each domain, the number of times it was selected as the greater contributor to workload, ranging from 0–5, was multiplied by its corresponding rating score. Weighted domain scores therefore ranged from 0–500. The overall workload score was calculated by summing the six weighted domain scores and dividing the total by 15, in accordance with the SURG-TLX weighting procedure.25 The SURG-TLX questionnaire was completed independently by the console surgeon and bedside assistant immediately after each procedure. The study included nine unique members of the robotic surgical team. Three participants completed SURGTLX questionnaires while performing both CC BY-NC 4.0 Licence

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the console surgeon and bedside assistant roles, whereas six participants contributed questionnaires only while performing the bedside assistant role. The bedside assistant group consisted of senior residents and young urologists. Overall, 47 console surgeon assessments and 51 bedside assistant assessments were analysed. Questionnaires were collected during later institutional experience with the platform, between approximately the 300th and 400th procedures, to reduce the influence of the initial platform learning curve. At the authors’ institution, the console surgeon performs skin incisions, insufflation, and trocar placement before moving to the robotic console. The bedside assistant docks the robotic arms and, during the procedure, changes instruments, places clips, uses advanced bipolar instruments, assists with tissue manipulation, and resolves robotic arm collisions. These role-specific tasks formed the clinical context in which workload was assessed. Case-related factors such as BMI, prostate volume, nerve-sparing status, prior abdominal surgery, and detailed pelvic anatomy were not included as covariates in the present workload analysis. The potential influence of case complexity is therefore considered in the interpretation and limitations of the study. Data were analysed using IBM SPSS Statistics version 25 (IBM, Armonk, New York, USA). Because multiple questionnaires were completed by the same participants, observations were treated as clustered rather than independent. Differences between surgical roles were analysed separately for each SURG-TLX domain and for overall workload using generalised estimating equations (GEE) with a Gaussian distribution and identity link. Participant identity was specified as the clustering variable, an exchangeable working correlation structure was used, and robust covariance estimates were applied. Surgical role was entered as a categorical predictor. Effect estimates are presented as estimated mean differences with 95% CI. A two-sided p value <0.05 was considered statistically significant.

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This study did not involve patient randomisation, additional patient intervention, or collection of identifiable patient data. The workload analysis was based on anonymised SURG-TLX questionnaires completed by surgical team members, some of whom are co-authors of this manuscript. The use of the Senhance robotic platform was approved by the institutional Ethics Committee (02/21 AG).

surgeons (estimated mean difference: 159.73; 95% CI: 43.27–276.20; p=0.007) and higher temporal demands (estimated mean difference: 173.94; 95% CI: 120.41– 227.47; p<0.001). Overall workload was also significantly higher among bedside assistants (estimated mean difference: 18.02; 95% CI: 4.00–32.04; p=0.012).

FINDINGS A total of 98 SURG-TLX assessments were analysed: 47 completed for the console surgeon role and 51 for the bedside assistant role. After accounting for repeated assessments within participants using GEE, significant role-related differences were identified in physical demands, temporal demands, situational stress, distractions, and overall workload. Bedside assistants reported significantly higher physical demands than console

Console surgeons reported significantly higher situational stress (estimated mean difference: −25.71; 95% CI: −42.27–−9.15; p=0.002) and higher distraction scores (estimated mean difference: −44.89; 95% CI: −78.81–−10.97; p=0.009). No significant role-related differences were observed for mental demands (bedside versus console estimated mean difference: 6.54; 95% CI: −74.38–87.45; p=0.874) or task complexity (bedside versus console estimated mean difference: 7.33; 95% CI: −30.90–45.56; p=0.707). Notably, three participants contributed workload assessments in both surgical roles. In descriptive within-participant

Table 1: Generalised estimating equation analysis of role-related differences in SURG-TLX workload scores.

SURG-TLX domain

Direction

Estimated mean difference

95% CI

P value

Mental demands

No significant difference

+6.54

−74.38–87.45

0.874

Physical demands

Bedside higher

+159.73

43.27–276.20

0.007

Temporal demands

Bedside higher

+173.94

120.41–227.47

<0.001

Task complexity

No significant difference

+7.33

−30.90–45.56

0.707

Situational stress

Console higher

−25.71

−42.27–−9.15

0.002

Distractions

Console higher

−44.89

−78.81–−10.97

0.009

Overall workload

Bedside higher

+18.02

4.00–32.04

0.012

SURG-TLX: Surgery Task Load Index.

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Figure 1: Box-and-whisker plots of SURG-TLX domain and overall workload scores by surgical role.

SURG-TLX: Surgery Task Load Index.

comparisons, all three reported higher physical demands, temporal demands, and overall workload when performing the bedside assistant role than when operating at the console. This direction of change was consistent with the role effects identified in the GEE analysis. The results are summarised in Table 1 and Figure 1.

DISCUSSION The present study demonstrates that intraoperative workload during Senhance robot-assisted radical prostatectomy differs according to surgical role. After accounting for repeated assessments within individual participants, bedside assistants reported higher physical demands, temporal demands, and overall workload, whereas console surgeons reported higher situational stress and distractions. Mental demands and task complexity did not differ significantly CC BY-NC 4.0 Licence

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between roles. These findings suggest that evaluation of workload in robotic surgery should extend beyond the console surgeon and consider the distinct demands placed on each member of the surgical team. Robotic platforms have changed the traditional operating room environment by separating console-based operating from bedside tasks.10,22 In the Senhance system, separate robotic arms and additional equipment occupy space around the operating table, while the console surgeon is physically separated from the patient. Based on the authors’ institutional workflow, they speculate that this configuration contributes to different workload profiles between roles. Efficient use of the platform requires familiarity with procedural steps and coordinated communication between the console surgeon, bedside assistant, and nursing staff. In the authors’ institution, more than 1,200 Senhance robot-assisted radical

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prostatectomies have been performed by an experienced robotic surgical team. During the procedure, the bedside assistant is responsible for docking, instrument exchange, clip placement, use of advanced bipolar instruments, tissue manipulation, and management of robotic arm collisions. The assistant frequently works between robotic arms in a restricted space. These technical and spatial demands contribute to the greater physical workload observed in the bedside role. Conversely, the console surgeon is physically separated from the operating table and is therefore highly dependent on the bedside assistant and nursing staff. This reduced handson control may contribute to situational stress, particularly during intraoperative complications or technical difficulties. Previous studies using task-load questionnaires have generally reported laparoscopic surgery as more physically demanding than robotic surgery, although findings regarding mental workload are inconsistent.11,26 A meta-analysis of electromyographic studies found lower biceps activation during robotic surgery than during conventional laparoscopy, whereas differences in other muscle groups were less consistent.9 Subjective ergonomic assessments have likewise generally favoured robotic over laparoscopic surgery.27 However, comparisons between surgical modalities do not capture workload distribution within a robotic team. The authors’ findings indicate that the ergonomic advantages experienced by a console surgeon should not be assumed to extend to the bedside assistant. Physical demands were significantly higher among bedside assistants. The modular configuration of the Senhance robotic arms and the limited working space around the male pelvis may require stretching, reaching across the patient, and prolonged nonneutral positioning. These explanations remain interpretative because objective ergonomic measurements were not performed. Nevertheless, the consistency of the role-related difference after accounting for repeated assessments supports greater attention to bedside ergonomics.

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Temporal demands were also significantly higher among bedside assistants in the cluster-adjusted analysis. The authors speculate that the bedside assistant’s need to respond to multiple procedural requests, including instrument exchange, clip placement, camera-related assistance, and management of arm collisions, which may create a greater perception of time pressure. Mental demands and task complexity did not differ significantly between roles after adjustment for repeated assessments. The diversity of bedside tasks could plausibly increase cognitive workload, whereas procedural decision-making at the console may impose a different form of mental demand. The absence of a significant role effect suggests that these domains may be more strongly influenced by individual experience, case characteristics, or specific intraoperative events than by role alone. Situational stress was significantly higher among console surgeons. Previous research has demonstrated that mental stress during minimally invasive surgery may vary according to surgical interface and operator experience.28 The authors speculate that reduced direct access to the patient and dependence on the bedside assistant during bleeding, impaired visualisation, robotic arm collisions, or technical difficulties may contribute to this finding. The console surgeon remains responsible for procedural decision-making while relying on the bedside team to perform several immediate physical actions. This interpretation is consistent with the role structure of the procedure but should not be considered a direct causal mechanism. Distraction scores were also significantly higher among console surgeons after accounting for repeated assessments. Potential sources include operating room communication, movement of personnel, and case-irrelevant conversation. Because the present study did not objectively classify or record distraction events, the mechanisms underlying this difference remain speculative.

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An important observation was that the role-related workload pattern was also evident among experienced console surgeons who performed both functions. When these participants assumed the bedside assistant role, all three reported greater physical demands, temporal demands, and overall workload than during their console assessments. Moreover, their bedside assessments did not suggest a lower physical or overall workload than that reported by participants who performed only the bedside role; numerically, physical, temporal, and overall workload scores were higher among the crossover participants while working bedside. This pattern argues against the observed bedside workload being explained solely by lesser surgical experience or unfamiliarity with robotic surgery. Rather, it supports the interpretation that the physical and temporal demands are inherent, at least in part, to the bedside role itself. The higher overall workload among bedside assistants appears to reflect the combined physical and temporal demands of the bedside role. These findings have practical implications for robotic surgical training and operating room organisation. Bedside assistance should be treated as a defined technical role requiring structured preparation rather than as a passive transitional position before console training. Training programmes may benefit from rolespecific instruction in instrument exchange, collision management, anticipation of procedural steps, and communication during critical events. Ergonomic assessment of bedside positioning and robotic arm configuration should also be incorporated into local quality-improvement processes. The choice of workload instrument should also be considered. The authors used SURG-TLX because it was developed and validated specifically for surgical tasks and includes surgery-relevant domains such as task complexity, situational stress, and distractions.25 However, much of the broader workload literature uses NASATLX.23,24 Unlike NASA-TLX, SURG-TLX does not include separate performance and frustration domains. These dimensions may capture additional aspects of workload, CC BY-NC 4.0 Licence

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particularly in settings where the console surgeon has reduced direct access to the patient. The use of SURG-TLX therefore limits direct comparability with predominantly NASA-TLX-based studies and may not capture all relevant dimensions of perceived workload. This study has several limitations. First, it was conducted at a single high-volume centre with extensive experience in Senhance robot-assisted radical prostatectomy. Questionnaires were collected after the initial institutional learning curve, between approximately the 300th and 400th procedures. Workload during early implementation may differ substantially because team members are simultaneously acquiring platform familiarity, communication routines, and role-specific technical skills. The present findings therefore primarily reflect an experienced robotic programme and should not be directly extrapolated to centres during initial adoption. Second, although 98 procedure-level workload assessments were analysed, they were contributed by a limited number of individual participants and the number of questionnaires per participant was unbalanced. The authors addressed intra-individual correlation using GEE with participant-level clustering; nevertheless, the limited number of participants restricts generalisability and may influence the precision of role-effect estimates. Third, workload was self-reported and may be influenced by individual perception, experience, and fatigue. Fourth, case-level variables that may influence workload, including BMI, prostate volume, nerve-sparing status, prior abdominal surgery, pelvic anatomy, and operative difficulty, were not included in the model. The authors therefore cannot exclude residual confounding by case complexity. Future prospective studies should collect these variables and evaluate their independent association with workload.

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Fifth, participant experience was not uniform. Assessments reflected an experienced institutional robotic programme, but individuals differed in their exposure to console and bedside roles. Three participants contributed assessments in both roles, whereas other participants contributed bedside assessments only. Although participantlevel clustering accounted for repeated measurements, differences in previous surgical and platform experience may still influence perceived workload. Finally, the findings are specific to the Senhance platform and extraperitoneal radical prostatectomy. Robotic systems differ in console design, docking, instrument exchange, robotic arm configuration, and the degree of bedside assistant involvement. Workload data from the Senhance platform therefore cannot be directly extrapolated to systems such as the da Vinci surgical system (Intuitive Surgical, Sunnyvale, California, USA) or to other robotic procedures. Future studies should prospectively evaluate workload across different phases of robotic implementation, incorporate objective ergonomic and intraoperative event measures, and compare rolespecific workload across robotic platforms.

References 1.

Fitch K et al. Cost differences between open and minimally invasive surgery. Manag Care. 2015; 24(9):40-8.

Gofrit ON et al. Surgeons' perceptions and injuries during and after urologic laparoscopic surgery. Urology. 2008;71(3):404-7.

Park A et al. Patients benefit while surgeons suffer: an impending epidemic. J Am Coll Surg. 2010;210(3):306-13.

Sari V et al. The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy. Minim Invasive Ther Allied Technol. 2010;19(2):105-9.

Santos-Carreras L et al. Survey on surgical instrument handle design: ergonomics and acceptance. Surg Innov. 2012;19(1):50-9.

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Multicentre studies with larger numbers of individual surgeons and bedside assistants are required to determine whether the workload patterns observed in this study are platform-specific or represent broader characteristics of robotic team organisation.

CONCLUSION During Senhance robot-assisted radical prostatectomy, bedside assistants experienced greater physical demands, temporal demands, and overall workload, whereas console surgeons reported greater situational stress and distractions. These role-specific differences support structured bedside-assistant training, deliberate team communication strategies, and ergonomic optimisation of the bedside working environment. The observation that experienced console surgeons showed a similar shift toward higher physical, temporal, and overall workload when performing bedside assistance further supports the role-specific nature of these demands. Future research should evaluate whether targeted training and systemlevel ergonomic interventions can reduce workload and improve team performance across different robotic platforms and phases of the learning curve.

Yu D et al. Intraoperative workload in robotic surgery assessed by wearable motion tracking sensors and questionnaires. Surg Endosc. 2017;31(2):877-86.

Hubert N et al. Ergonomic assessment of the surgeon's physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot. 2013;9(2):142-7.

Wee IJY et al. A systematic review of the true benefit of robotic surgery: ergonomics. Int J Med Robot. 2020;16(4):e2113.

Hislop J et al. Muscle activation during traditional laparoscopic surgery compared with robot-assisted laparoscopic surgery: a meta-analysis. Surg Endosc. 2020;34(1):31-8.

10. Athanasiadis DI et al. An analysis of the ergonomic risk of surgical trainees and experienced surgeons during laparoscopic procedures. Surgery. 2021;169(3):496-501.

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11. Park LS et al. Are surgeons working smarter or harder? A systematic review comparing the physical and mental demands of robotic and laparoscopic or open surgery. World J Surg. 2021;45(7):2066-80. 12. Knežević N et al. Senhance robotassisted adrenalectomy: a case series. Croat Med J. 2022;63(2):197-201. 13. Hudolin T et al. Senhance robotic radical prostatectomy: a single-centre, 3-year experience. Int J Med Robot. 2023;19(6):e2549. 14. Kastelan Z et al. Upper urinary tract surgery and radical prostatectomy with Senhance robotic system: single center experience-first 100 cases. Int J Med Robot. 2021;17(4):e2269. 15. Kastelan Z et al. Extraperitoneal radical prostatectomy with the Senhance robotic platform: first 40 cases. Eur Urol. 2020;78(6):932-4.

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16. Kastelan Z et al. Extraperitoneal radical prostatectomy with the Senhance Surgical System robotic platform. Croat Med J. 2019;60(6):556-9. 17. Kulis T et al. Comparison of extraperitoneal laparoscopic and extraperitoneal Senhance radical prostatectomy. Int J Med Robot. 2022;18(1):e2344. 18. Kulis T et al. Senhance robotic radical prostatectomy. Acta Clin Croat. 2022;61(Suppl 3):45-50. 19. Coussons H, Feldstein J. Senhance surgical system in benign hysterectomy: a real-world comparative assessment of case times and instrument costs versus da Vinci robotics and laparoscopic-assisted vaginal hysterectomy procedures. Int J Med Robot. 2021;17(4):e2261.

21. Venckus R et al. Robotic-assisted radical prostatectomy with the Senhance robotic platform: single center experience. World J Urol. 2021;39(12):4305-10.

25. Wilson MR et al. Development and validation of a surgical workload measure: the Surgery Task Load Index (SURG-TLX). World J Surg. 2011;35(9):1961-9.

22. Darwich I et al. The TransEnterix European Patient Registry for RoboticAssisted Laparoscopic Procedures in Urology, Abdominal, Thoracic, and Gynecologic Surgery (“TRUST”). Surg Technol Int. 2021;38:103-7.

26. Menke V et al. The stress for surgeons: exploring stress entities with the robotic Senhance surgical system. J Robot Surg. 2024;18(1):94.

23. Lowndes BR et al. NASA-TLX assessment of surgeon workload variation across specialties. Ann Surg. 2020;271(4):686-92. 24. Law KE et al. NASA-Task Load Index differentiates surgical approach: opportunities for improvement in colon and rectal surgery. Ann Surg. 2020;271(5):906-12.

27. Monfared S et al. A comparison of laparoscopic and robotic ergonomic risk. Surg Endosc. 2022;36(11):8397-402. 28. Klein MI et al. Mental stress experienced by first-year residents and expert surgeons with robotic and laparoscopic surgery interfaces. J Robot Surg. 2014;8(2):149-55.

20. Sasaki M et al. Short-term results of robot-assisted colorectal cancer surgery using Senhance Digital Laparoscopy System. Asian J Endosc Surg. 2022;15(3):613-8.

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