Betty Blocks



Supplementary Table 1 – Components of the intensive week of simulation-based training

|Training type |Training model |Exercises |Time |

|Basic theoretical and practical |da Vinci Si, robotic pelvic trainer (skills |Robotic draping |2 h |

|training |drill device) |Robotic docking | |

| | |Console setting and basic management | |

| |Video clips of robotic procedures performed |Learning of the surgical steps of the main robotic |2 h |

| |by experts |urologic procedures | |

| |Case observation in the operating room |Learning of the surgical steps of the main robotic |8 h |

| | |urologic procedures | |

|Virtual reality simulation |da Vinci surgical simulator system |Camera and clutching |6 h |

| | |Endowrist manipulation | |

| | |Energy and dissection | |

| | |Needle control | |

| | |Needle driving | |

| | |Suturing | |

|Dry laboratory |Robotic pelvic trainer (skills drill device) |Camera and clutching |2 h |

| | |Endowrist manipulation | |

| | |Energy and dissection | |

| | |Needle control | |

| | |Needle driving | |

| | |Suturing | |

|Wet laboratory |Chicken gizzard model (dead material) |Simulation of urethrovesical anastomosis |4 h |

| |Pig kidney model (dead material) |Simulation of partial nephrectomy | |

| |Live pig model |Partial nephrectomy |12 h |

| | |Pyeloplasty | |

| | |Cystotomy and bladder suturing | |

| | |Ureterovesical reimplantation | |

| | |Cystoprostatectomy | |

| | |Urethrovesical anastomosis | |

|Cadaver training |Balsamed cadaver |Robot-assisted radical prostatectomy |4 h |

Supplementary Table 2 – Difficulty levels of the surgical steps for modular training of robot-assisted radical prostatectomy (modified Stolzenburg criteria, difficulty level I–V)

|Surgical step |Difficulty level |

|Trocar placement |I |

|Robot set-up |I |

|Bladder detachment |I |

|Pelvic lymph node dissection |III |

|Endopelvic fascia incision |I |

|Bladder neck incision |III |

|Section of the vasa and preparation of seminal vesicles |II |

|Dissection of the posterior plane |III |

|Dissection of the prostatic pedicles |IV |

|Dissection of the neurovascular bundles |V |

|Ligation of the Santorini plexus |II |

|Apical dissection |IV |

|Urethrovesical anastomosis |III |

Supplementary Table 3 – GEARS scale used to assess the technical performance of fellows

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Supplementary Table 4 – Procedure-specific scale used to assess the technical performance of fellows in robot-assisted radical prostatectomy

| |1 |2 |3 |4 |5 |

| |Very poor |Poor |Fair |Good |Excellent |

|Bladder detachment | | | | | |

|Endopelvic fascia incision | | | | | |

|Ligation of the dorsal vein complex | | | | | |

|Bladder neck incision | | | | | |

|Dissection of the vasa and seminal vesicles | | | | | |

|Preparation and section of the prostatic pedicles | | | | | |

|Dissection of the neurovascular bundles | | | | | |

|Apical dissection and section of the urethra | | | | | |

|Urethrovesical anastomosis | | | | | |

Supplementary Table 5 – Generic dedicated scoring criteria used to assess the quality of video-recorded surgical steps performed by the participants at the end of the training

|Parameter |Score |Meaning |Descriptive examples |

|Instrument use |1 |Dangerous |Entering instruments blindly |

| |2 |Incompetent |Several attempts |

| |3 |Safe |Identifying anatomy |

| |4 |Masterful |No bleeding, instruments in sight |

|Tissue handling |1 |Traumatic |Uncontrolled movements |

| |2 |Laborious |Repeated attempts |

| |3 |Safe |Effective handling with some damage |

| |4 |Masterful |Avoiding damage |

|Errors |1 |Bleeding |Tissue avulsion, damage to organs |

| |2 |Minor bleeding |Occasional bleeding, no damage |

| |3 |Minimal bleeding |Minimal damage |

| |4 |No bleeding | |

|End result |1 |Damage to organs |Bladder, prostate, bowel |

| |2 |Inadequately performed |Urologist took over |

| |3 |Sufficient |Ready for the next step |

| |4 |Masterful | |

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