Proctoring in Robot-Assisted Urologic Surgery: Safety and Implementation Patterns from a Multicentre Registry

Proctoring in Robot-Assisted Urologic Surgery: Safety and Implementation Patterns from a Multicentre Registry | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Proctoring in Robot-Assisted Urologic Surgery: Safety and Implementation Patterns from a Multicentre Registry Gianluigi Califano This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9306332/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study aimed to characterise perioperative safety and real-world implementation patterns of proctoring in robot-assisted laparoscopic urologic surgery performed with the da Vinci Surgical System across heterogeneous centres and surgeons. A personal registry of 150 consecutive manufacturer-registered proctoring procedures performed between July 2022 and February 2026 was analysed. The primary outcome was 30-day major complications (Clavien-Dindo ≥ III); secondary outcomes included intraoperative blood transfusion, conversion to open surgery, reoperation and endovascular embolisation. Overall, 150 proctored cases were delivered across 18 centres and 25 surgeons. The most frequent procedures were robot-assisted radical prostatectomy (RARP, n = 76), robot-assisted partial nephrectomy (RAPN, n = 44) and robot-assisted radical nephrectomy (RARN, n = 12). Thirty-day Clavien-Dindo ≥ III complications occurred in two cases (1.3%), with one patient requiring reoperation and one undergoing arterial embolisation; no 30-day mortality occurred, and no conversion to open surgery was recorded. Implementation patterns differed by baseline experience: among surgeons with low overall robotic exposure, the first proctored procedure was most commonly RARP, whereas surgeons with higher baseline experience more often initiated proctoring with non-RARP procedures. In conclusion, formal proctoring in robot-assisted laparoscopic urologic surgery across multiple centres was associated with a low rate of major complications and no conversions to open surgery. Reporting temporal trends, centre-procedure distribution and baseline surgeon experience alongside safety outcomes may provide a pragmatic framework for evaluating structured proctoring programs in routine practice. robot-assisted laparoscopic surgery proctoring surgical training implementation patient safety urology Figures Figure 1 Figure 2 Figure 3 Introduction Robot-assisted laparoscopic surgery (RALS) is now widely implemented in urologic practice, extending beyond high-volume referral centres into heterogeneous real-world settings 1 , 2 . As robotic platforms and surgical indications expand 3 , safe program initiation and procedural diversification have become increasingly relevant, particularly in centres with different organizational structures, team experience, and baseline surgical volumes 3 , 4 . Proctoring is commonly used to support the safe introduction of robotic surgery and new procedures in several surgical fields 4 – 6 . In routine practice, proctoring provides intraoperative supervision, structured feedback, and procedural standardisation during early implementation. This role is particularly relevant in urology 7 , where centres may adopt different procedures at different stages of robotic program development. Published evidence on proctoring in RALS remain limited. To address this knowledge gap, the study relied on a personal registry of consecutive official proctoring sessions in urologic RALS across multiple centres in Italy. The aim was to describe perioperative safety and real-world implementation patterns, and to propose a pragmatic reporting framework for proctoring-supported adoption and optimisation of procedures in routine practice. Materials and Methods A multi-centre observational study was conducted using a prospectively maintained personal registry of consecutive formal manufacturer-registered proctoring sessions in RALS performed between July 2022 and February 2026. The registry captures only proctoring sessions conducted within the manufacturer pathway and does not include informal mentoring visits performed outside this documented process. For analysis and reporting, centres and surgeons were anonymised. Data Collection For each proctored case, the registry recorded the date of the session, procedure type, centre and platform characteristics, surgeon characteristics, baseline, and perioperative outcomes. Centre-level variables included centre type (academic, public hospital, teaching hospital, private clinic), robotic platform model (da Vinci Xi or X), and dual-console availability. Teaching hospital was defined as a public hospital embedded within a residency training network, with trainees routinely present. Surgeon characteristics included age at the first proctored case, professional position (chief or consultant), and baseline robotic experience. Baseline robotic experience was recorded in two ways: overall robot-assisted laparoscopic experience and procedure-specific RALS experience for the index procedure, each categorised as 0, 1–15, 16–29, or > 30 prior cases. Baseline non-robotic experience was also captured for the index procedure, including prior laparoscopic and open experience, each categorised as 0, 100 prior cases. For experience-focused analyses, data were summarised at the surgeon-procedure level using the first proctoring episode for each surgeon and procedure combination. The number of participating centres and proctored surgeons was captured, along with the distribution of cases across centres and surgeons (cases per centre and per surgeon, and the number of distinct procedure types per centre and per surgeon). Proctoring activity was quantified both as sequential case accrual over time and as bimonthly case volume, including bimesters with no proctoring activity. Procedures were classified as: robot-assisted radical prostatectomy (RARP), robot-assisted partial nephrectomy (RAPN), robot-assisted radical nephrectomy (RARN), robot-assisted nephroureterectomy (RANU), robot-assisted radical cystectomy (RARC), robot-assisted simple prostatectomy (RASP), robot-assisted pyeloplasty (RAPP), robot-assisted hysterectomy (RAHYS), robot-assisted ureteroneocystostomy (RAUNC), and robot-assisted ureterectomy (RAURET). Outcomes Perioperative outcomes were recorded at case level. The primary outcome was 30-day major complications, defined as Clavien-Dindo grade III or higher. Secondary outcomes included intraoperative blood transfusion, conversion to open surgery, reoperation, and endovascular embolization. Complications were assessed within 30 days and graded according to the Clavien-Dindo classification; 30-day event ascertainment relied on routine post-proctoring follow-up communication with surgeons and centres as part of standard debriefing and outcome review. To describe implementation patterns over program maturation, the initiation phase was defined a priori as the first five consecutive proctored cases performed in each centre; all subsequent cases were classified as post-initiation. Statistical analysis Analyses were descriptive, presented as medians and inter-quartile ranges (IQR) for continuous variables and counts and percentages for categorical variables. Outcomes were summarised overall and stratified by procedure type and by initiation versus post-initiation phase. Ethics The study was conducted in accordance with the Declaration of Helsinki. The registry included de-identified observational data collected as part of routine clinical practice; ethics oversight was handled according to applicable local regulations. Results A total of 150 formal proctored cases were recorded between July 2022 and February 2026, delivered over 112 proctoring days (74 days with one case and 38 days with two cases) across 18 centres and 25 proctored surgeons (Table 1). Five centres involved two or more proctored surgeons. Median case volume per centre was 6 (1–30), and per surgeon 6 (1–14). The median number of distinct procedure types was 2 (1–6) per centre and 2 (1–5) per surgeon (Table 1). The predominant platform was da Vinci Xi (121/150, 80.7%), with the X platform used in 29/150 (19.3%) cases; a dual console was available in 45/150 (30.0%) cases (Table 1). The temporal trajectory of activity and procedural mix is shown in Fig. 1 A, with corresponding bimonthly case volume (including bimesters without activity) in Fig. 1 B. Proctored procedures included RARP (n = 76), RAPN (n = 44), RARN (n = 12), RAPP (n = 7), RANU (n = 4), RARC (n = 2), RAUNC (n = 2), and three single procedures (RASP, RAHYS, and RAURET; n = 1 each) (Fig. 1 A). Using the predefined centre-level definition of initiation (first five proctored cases per centre), 80/150 (53.3%) cases occurred during the initiation phase and 70/150 (46.7%) during post-initiation (Table 1). Surgeons had a median age of 52.2 years (34.5–69.3) at their first proctored case; 15/25 (60.0%) were classified as chiefs and 10/25 (40.0%) as consultants (Table 1). Baseline overall robotic experience at the first proctored case was heterogeneous: 0 prior cases in 9/25 (36.0%), 1–15 in 11/25 (44.0%), 16–29 in 1/25 (4.0%), and > 30 in 4/25 (16.0%). The distribution of proctored procedures across centres is illustrated in Fig. 2 . At the surgeon-procedure level (first proctoring for each surgeon-procedure pair), baseline overall and procedure-specific robotic experience are summarised in Fig. 3 A. Proctoring most commonly commenced with RARP and was frequently delivered to surgeons with lower baseline overall robotic exposure, whereas proctoring for other index procedures generally occurred in surgeons with higher baseline experience. Procedure-specific robotic exposure at first proctoring was predominantly zero across most procedures. Baseline non-robotic background (laparoscopic/open) by procedure is shown in Fig. 3 B. Perioperative safety outcomes are reported in Table 2. No conversions to open surgery occurred. Intraoperative transfusion was recorded in 2/150 (1.3%) cases. Thirty-day major complications (Clavien-Dindo ≥ III) occurred in 2/150 (1.3%), with no events graded > III. Reoperation occurred in 1/150 (0.7%) and endovascular embolization in 1/150 (0.7%) (Table 2). Major complications occurred exclusively during the post-initiation phase (0/80 during initiation vs 2/70, 2.9%, post-initiation). By procedure, major complications occurred in RAPN (1/44, 2.3%) and RANU (1/4, 25%), with none observed after RARP or in the remaining procedures (Table 2). Case-level details of the two major complications are provided in Table 3. Discussion This multi-centre series describes real-world implementation patterns and perioperative safety during formal proctoring in RALS. Across 150 consecutive proctored cases delivered in 18 centres and 25 surgeons, major 30-day complications (Clavien-Dindo ≥ III) were uncommon and no conversions to open surgery or deaths occurred. In addition, the study provides an implementation map of how robotic programs diversify beyond radical prostatectomy, often the most common entry procedure during early adoption, and how baseline surgeon experience varies according to the index procedure at first proctoring. At present, evidence on how surgeons acquire robotic surgical expertise 8 and how proctoring should be optimally delivered remains limited, and standardised training pathways are not uniformly implemented 9 . In a multicentre survey of Italian urologists who underwent proctoring, conducted across both early program initiation and subsequent procedural expansion, proctoring was consistently perceived as essential for safe implementation and for supporting standardisation of training and practice 4 . These findings align with the present real-world series, in which surgeons with heterogeneous backgrounds accessed formal proctoring and baseline experience varied systematically by index procedure. Within this formal pathway, proctoring comprised a structured perioperative process rather than intraoperative oversight alone. Sessions typically included preoperative case sharing and planning (clinical history, diagnostic work-up, radiological imaging, and intended surgical strategy), standardisation of key preoperative set-up steps (patient positioning, operating-room ergonomics, trocar placement, and robotic arm configuration), and real-time intraoperative supervision aimed at reinforcing standardised operative steps, with targeted technical support when required for safety or teaching (including, where available, the use of a dual console). A structured post-case debrief was undertaken to review strengths and critical points, discuss technical and non-technical performance, agree priorities for improvement, and align postoperative management and the plan for subsequent cases. Deviations from the expected postoperative course, including complications, were shared and reviewed to ensure appropriate management and feedback into ongoing optimisation. A key observation was the procedural sequencing and its relationship with baseline robotic experience. Proctoring most commonly commenced with RARP, frequently in surgeons with lower baseline robotic exposure, consistent with the role of prostatectomy as the entry procedure for many centres initiating RALS urological programs. In contrast, proctoring for other index procedures, particularly RAPN and upper-tract surgery, was generally undertaken in surgeons with greater baseline experience. This pattern is clinically intuitive and suggests that formal proctoring is deployed in different contexts: early program initiation for prostate surgery and later procedural expansion for more complex or diverse indications. Importantly, procedure-specific robotic experience at the time of first proctoring was predominantly zero across most procedures, highlighting the practical need for structured supervision when centres broaden their robotic portfolio even after initial program establishment. The centre-procedure network further illustrates the breadth of surgical activity delivered under formal proctoring and the heterogeneity of case distribution across institutions. Although a subset of centres accounted for higher volumes and broader procedural diversity, the overall program reflects a wide spectrum of adoption patterns. The temporal analysis also demonstrated sustained delivery of proctoring sessions, with periods of increased case volume that may reflect both growing demand and progressive program maturation across participating centres. With respect to safety, the low rate of major complications and the absence of surgical conversions suggest that formal proctoring conducted within an official pathway can be delivered safely across multiple centres and procedures in routine practice. The two major events observed in this series occurred during the post-initiation phase and involved non-prostate procedures. Both events were managed with prompt reintervention (surgical revision following RANU and endovascular embolization after RAPN). However, the limited number of events precludes any meaningful inference regarding predictors of complications, differences between procedures, or comparisons between initiation and post-initiation phases. These findings also have practical implications for the reporting and benchmarking of proctoring programs. First, implementation metrics such as procedure mix, centre-procedure networks, and temporal activity provide important context for interpreting safety outcomes and understanding how proctoring is deployed in real-world settings. Second, baseline surgeon experience should be explicitly considered, as it differs systematically according to the index procedure and may influence both the objectives and intensity of proctoring. Finally, the adoption of a standardised minimum reporting set (including denominators at case, surgeon, and centre level, procedure-specific distribution, and clear definitions of major complications and key intraoperative events) may improve comparability across programs and support quality assurance within formal proctoring pathways. Several limitations should be acknowledged. Patient case mix and operative complexity were not incorporated into the present analysis, and risk-adjusted comparisons were therefore not performed. Thirty-day event capture relied on routine follow-up communication with surgeons and centres and may have resulted in underreporting of minor complications. Additionally, the small number of major complications limits statistical inference. Finally, the registry includes only official sessions conducted by a single proctor and does not account for potential additional mentorship or training activities that centres or surgeons may have received outside the documented manufacturer pathway before, during, or after the proctoring sessions included in this study. In conclusion, analysis of a personal registry of consecutive formal proctoring sessions across multiple centres demonstrates low rates of major perioperative complications and provides a pragmatic representation of real-world implementation patterns. Reporting procedural sequencing, centre-procedure distribution, and baseline surgeon experience alongside safety outcomes may offer a useful framework for the evaluation and benchmarking of proctoring programs in routine robotic urological practice. References New Technology and Health Care Costs — The Case of Robot-Assisted Surgery | New England Journal of Medicine. Accessed March 4, 2026. https://www.nejm.org/doi/abs/10.1056/NEJMp1006602 Würnschimmel C, Wenzel M, Moschovas MC, et al. Current training landscape for novice robotic surgeons: an international investigative survey by the Junior-ERUS/Young academic urologists (YAU) robotics in urology working group. World J Urol . 2025;43(1):467. doi:10.1007/s00345-025-05845-5 Brassetti A, Ragusa A, Tedesco F, et al. Robotic Surgery in Urology: History from PROBOT® to HUGOTM. Sensors . 2023;23(16):7104. doi:10.3390/s23167104 Califano G, Di Bello F, Collà Ruvolo C, et al. Proctoring in robot-assisted urologic surgery: insights from a multicenter survey. J Robot Surg . 2025;19(1):352. doi:10.1007/s11701-025-02541-9 Infante Altamirano M, Lujan HJ. Is proctoring in robotic surgery truly helpful? Evaluating general surgeons’ perspectives. J Robot Surg . 2025;20(1):86. doi:10.1007/s11701-025-03043-4 Mitzman B, Smith BK, Varghese TK. Resident Training in Robotic Thoracic Surgery. Thorac Surg Clin . 2023;33(1):25-32. doi:10.1016/j.thorsurg.2022.07.009 Lovegrove CE, Elhage O, Khan MS, et al. Training Modalities in Robot-assisted Urologic Surgery: A Systematic Review. Eur Urol Focus . 2017;3(1):102-116. doi:10.1016/j.euf.2016.01.006 Green CA, Lin J, Higgins R, O’Sullivan PS, Huang E. Expertise in perception during robotic surgery (ExPeRtS): What we see and what we say. Am J Surg . 2022;224(3):908-913. doi:10.1016/j.amjsurg.2022.05.006 Brinkman WM, Schout BMA, Rietbergen JB, et al. Training robotic surgery in urology: experience and opinions of robot urologists. Int J Med Robot Comput Assist Surg MRCAS . 2015;11(3):308-318. doi:10.1002/rcs.1631 Tables Tables 1 to 3 are available in the supplementary files section Additional Declarations No competing interests reported. Supplementary Files Table1.pptx Table2.pptx Table3.pptx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9306332","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621668257,"identity":"c47fb205-40c3-477c-85e8-2a2a1e3f255c","order_by":0,"name":"Gianluigi 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implemented in urologic practice, extending beyond high-volume referral centres into heterogeneous real-world settings\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. As robotic platforms and surgical indications expand\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, safe program initiation and procedural diversification have become increasingly relevant, particularly in centres with different organizational structures, team experience, and baseline surgical volumes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eProctoring is commonly used to support the safe introduction of robotic surgery and new procedures in several surgical fields\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In routine practice, proctoring provides intraoperative supervision, structured feedback, and procedural standardisation during early implementation. This role is particularly relevant in urology\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, where centres may adopt different procedures at different stages of robotic program development.\u003c/p\u003e \u003cp\u003ePublished evidence on proctoring in RALS remain limited. To address this knowledge gap, the study relied on a personal registry of consecutive official proctoring sessions in urologic RALS across multiple centres in Italy. The aim was to describe perioperative safety and real-world implementation patterns, and to propose a pragmatic reporting framework for proctoring-supported adoption and optimisation of procedures in routine practice.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA multi-centre observational study was conducted using a prospectively maintained personal registry of consecutive formal manufacturer-registered proctoring sessions in RALS performed between July 2022 and February 2026. The registry captures only proctoring sessions conducted within the manufacturer pathway and does not include informal mentoring visits performed outside this documented process. For analysis and reporting, centres and surgeons were anonymised.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eFor each proctored case, the registry recorded the date of the session, procedure type, centre and platform characteristics, surgeon characteristics, baseline, and perioperative outcomes. Centre-level variables included centre type (academic, public hospital, teaching hospital, private clinic), robotic platform model (da Vinci Xi or X), and dual-console availability. Teaching hospital was defined as a public hospital embedded within a residency training network, with trainees routinely present. Surgeon characteristics included age at the first proctored case, professional position (chief or consultant), and baseline robotic experience. Baseline robotic experience was recorded in two ways: overall robot-assisted laparoscopic experience and procedure-specific RALS experience for the index procedure, each categorised as 0, 1\u0026ndash;15, 16\u0026ndash;29, or \u0026gt;\u0026thinsp;30 prior cases. Baseline non-robotic experience was also captured for the index procedure, including prior laparoscopic and open experience, each categorised as 0, \u0026lt;\u0026thinsp;20, 20\u0026ndash;50, 51\u0026ndash;99 or \u0026gt;\u0026thinsp;100 prior cases. For experience-focused analyses, data were summarised at the surgeon-procedure level using the first proctoring episode for each surgeon and procedure combination.\u003c/p\u003e \u003cp\u003eThe number of participating centres and proctored surgeons was captured, along with the distribution of cases across centres and surgeons (cases per centre and per surgeon, and the number of distinct procedure types per centre and per surgeon). Proctoring activity was quantified both as sequential case accrual over time and as bimonthly case volume, including bimesters with no proctoring activity. Procedures were classified as: robot-assisted radical prostatectomy (RARP), robot-assisted partial nephrectomy (RAPN), robot-assisted radical nephrectomy (RARN), robot-assisted nephroureterectomy (RANU), robot-assisted radical cystectomy (RARC), robot-assisted simple prostatectomy (RASP), robot-assisted pyeloplasty (RAPP), robot-assisted hysterectomy (RAHYS), robot-assisted ureteroneocystostomy (RAUNC), and robot-assisted ureterectomy (RAURET).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003ePerioperative outcomes were recorded at case level. The primary outcome was 30-day major complications, defined as Clavien-Dindo grade III or higher. Secondary outcomes included intraoperative blood transfusion, conversion to open surgery, reoperation, and endovascular embolization. Complications were assessed within 30 days and graded according to the Clavien-Dindo classification; 30-day event ascertainment relied on routine post-proctoring follow-up communication with surgeons and centres as part of standard debriefing and outcome review. To describe implementation patterns over program maturation, the initiation phase was defined a priori as the first five consecutive proctored cases performed in each centre; all subsequent cases were classified as post-initiation.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were descriptive, presented as medians and inter-quartile ranges (IQR) for continuous variables and counts and percentages for categorical variables. Outcomes were summarised overall and stratified by procedure type and by initiation versus post-initiation phase.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki. The registry included de-identified observational data collected as part of routine clinical practice; ethics oversight was handled according to applicable local regulations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 150 formal proctored cases were recorded between July 2022 and February 2026, delivered over 112 proctoring days (74 days with one case and 38 days with two cases) across 18 centres and 25 proctored surgeons (Table\u0026nbsp;1). Five centres involved two or more proctored surgeons.\u003c/p\u003e \u003cp\u003eMedian case volume per centre was 6 (1\u0026ndash;30), and per surgeon 6 (1\u0026ndash;14). The median number of distinct procedure types was 2 (1\u0026ndash;6) per centre and 2 (1\u0026ndash;5) per surgeon (Table\u0026nbsp;1). The predominant platform was da Vinci Xi (121/150, 80.7%), with the X platform used in 29/150 (19.3%) cases; a dual console was available in 45/150 (30.0%) cases (Table\u0026nbsp;1). The temporal trajectory of activity and procedural mix is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, with corresponding bimonthly case volume (including bimesters without activity) in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eProctored procedures included RARP (n\u0026thinsp;=\u0026thinsp;76), RAPN (n\u0026thinsp;=\u0026thinsp;44), RARN (n\u0026thinsp;=\u0026thinsp;12), RAPP (n\u0026thinsp;=\u0026thinsp;7), RANU (n\u0026thinsp;=\u0026thinsp;4), RARC (n\u0026thinsp;=\u0026thinsp;2), RAUNC (n\u0026thinsp;=\u0026thinsp;2), and three single procedures (RASP, RAHYS, and RAURET; n\u0026thinsp;=\u0026thinsp;1 each) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Using the predefined centre-level definition of initiation (first five proctored cases per centre), 80/150 (53.3%) cases occurred during the initiation phase and 70/150 (46.7%) during post-initiation (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eSurgeons had a median age of 52.2 years (34.5\u0026ndash;69.3) at their first proctored case; 15/25 (60.0%) were classified as chiefs and 10/25 (40.0%) as consultants (Table\u0026nbsp;1). Baseline overall robotic experience at the first proctored case was heterogeneous: 0 prior cases in 9/25 (36.0%), 1\u0026ndash;15 in 11/25 (44.0%), 16\u0026ndash;29 in 1/25 (4.0%), and \u0026gt;\u0026thinsp;30 in 4/25 (16.0%).\u003c/p\u003e \u003cp\u003eThe distribution of proctored procedures across centres is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. At the surgeon-procedure level (first proctoring for each surgeon-procedure pair), baseline overall and procedure-specific robotic experience are summarised in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA. Proctoring most commonly commenced with RARP and was frequently delivered to surgeons with lower baseline overall robotic exposure, whereas proctoring for other index procedures generally occurred in surgeons with higher baseline experience. Procedure-specific robotic exposure at first proctoring was predominantly zero across most procedures. Baseline non-robotic background (laparoscopic/open) by procedure is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePerioperative safety outcomes are reported in Table\u0026nbsp;2. No conversions to open surgery occurred. Intraoperative transfusion was recorded in 2/150 (1.3%) cases. Thirty-day major complications (Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III) occurred in 2/150 (1.3%), with no events graded\u0026thinsp;\u0026gt;\u0026thinsp;III. Reoperation occurred in 1/150 (0.7%) and endovascular embolization in 1/150 (0.7%) (Table\u0026nbsp;2). Major complications occurred exclusively during the post-initiation phase (0/80 during initiation vs 2/70, 2.9%, post-initiation). By procedure, major complications occurred in RAPN (1/44, 2.3%) and RANU (1/4, 25%), with none observed after RARP or in the remaining procedures (Table\u0026nbsp;2). Case-level details of the two major complications are provided in Table\u0026nbsp;3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multi-centre series describes real-world implementation patterns and perioperative safety during formal proctoring in RALS. Across 150 consecutive proctored cases delivered in 18 centres and 25 surgeons, major 30-day complications (Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III) were uncommon and no conversions to open surgery or deaths occurred. In addition, the study provides an implementation map of how robotic programs diversify beyond radical prostatectomy, often the most common entry procedure during early adoption, and how baseline surgeon experience varies according to the index procedure at first proctoring.\u003c/p\u003e \u003cp\u003eAt present, evidence on how surgeons acquire robotic surgical expertise\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and how proctoring should be optimally delivered remains limited, and standardised training pathways are not uniformly implemented\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. In a multicentre survey of Italian urologists who underwent proctoring, conducted across both early program initiation and subsequent procedural expansion, proctoring was consistently perceived as essential for safe implementation and for supporting standardisation of training and practice\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These findings align with the present real-world series, in which surgeons with heterogeneous backgrounds accessed formal proctoring and baseline experience varied systematically by index procedure.\u003c/p\u003e \u003cp\u003eWithin this formal pathway, proctoring comprised a structured perioperative process rather than intraoperative oversight alone. Sessions typically included preoperative case sharing and planning (clinical history, diagnostic work-up, radiological imaging, and intended surgical strategy), standardisation of key preoperative set-up steps (patient positioning, operating-room ergonomics, trocar placement, and robotic arm configuration), and real-time intraoperative supervision aimed at reinforcing standardised operative steps, with targeted technical support when required for safety or teaching (including, where available, the use of a dual console). A structured post-case debrief was undertaken to review strengths and critical points, discuss technical and non-technical performance, agree priorities for improvement, and align postoperative management and the plan for subsequent cases. Deviations from the expected postoperative course, including complications, were shared and reviewed to ensure appropriate management and feedback into ongoing optimisation.\u003c/p\u003e \u003cp\u003eA key observation was the procedural sequencing and its relationship with baseline robotic experience. Proctoring most commonly commenced with RARP, frequently in surgeons with lower baseline robotic exposure, consistent with the role of prostatectomy as the entry procedure for many centres initiating RALS urological programs. In contrast, proctoring for other index procedures, particularly RAPN and upper-tract surgery, was generally undertaken in surgeons with greater baseline experience. This pattern is clinically intuitive and suggests that formal proctoring is deployed in different contexts: early program initiation for prostate surgery and later procedural expansion for more complex or diverse indications. Importantly, procedure-specific robotic experience at the time of first proctoring was predominantly zero across most procedures, highlighting the practical need for structured supervision when centres broaden their robotic portfolio even after initial program establishment.\u003c/p\u003e \u003cp\u003eThe centre-procedure network further illustrates the breadth of surgical activity delivered under formal proctoring and the heterogeneity of case distribution across institutions. Although a subset of centres accounted for higher volumes and broader procedural diversity, the overall program reflects a wide spectrum of adoption patterns. The temporal analysis also demonstrated sustained delivery of proctoring sessions, with periods of increased case volume that may reflect both growing demand and progressive program maturation across participating centres.\u003c/p\u003e \u003cp\u003eWith respect to safety, the low rate of major complications and the absence of surgical conversions suggest that formal proctoring conducted within an official pathway can be delivered safely across multiple centres and procedures in routine practice. The two major events observed in this series occurred during the post-initiation phase and involved non-prostate procedures. Both events were managed with prompt reintervention (surgical revision following RANU and endovascular embolization after RAPN). However, the limited number of events precludes any meaningful inference regarding predictors of complications, differences between procedures, or comparisons between initiation and post-initiation phases.\u003c/p\u003e \u003cp\u003eThese findings also have practical implications for the reporting and benchmarking of proctoring programs. First, implementation metrics such as procedure mix, centre-procedure networks, and temporal activity provide important context for interpreting safety outcomes and understanding how proctoring is deployed in real-world settings. Second, baseline surgeon experience should be explicitly considered, as it differs systematically according to the index procedure and may influence both the objectives and intensity of proctoring. Finally, the adoption of a standardised minimum reporting set (including denominators at case, surgeon, and centre level, procedure-specific distribution, and clear definitions of major complications and key intraoperative events) may improve comparability across programs and support quality assurance within formal proctoring pathways.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. Patient case mix and operative complexity were not incorporated into the present analysis, and risk-adjusted comparisons were therefore not performed. Thirty-day event capture relied on routine follow-up communication with surgeons and centres and may have resulted in underreporting of minor complications. Additionally, the small number of major complications limits statistical inference. Finally, the registry includes only official sessions conducted by a single proctor and does not account for potential additional mentorship or training activities that centres or surgeons may have received outside the documented manufacturer pathway before, during, or after the proctoring sessions included in this study.\u003c/p\u003e \u003cp\u003eIn conclusion, analysis of a personal registry of consecutive formal proctoring sessions across multiple centres demonstrates low rates of major perioperative complications and provides a pragmatic representation of real-world implementation patterns. Reporting procedural sequencing, centre-procedure distribution, and baseline surgeon experience alongside safety outcomes may offer a useful framework for the evaluation and benchmarking of proctoring programs in routine robotic urological practice.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNew Technology and Health Care Costs \u0026mdash; The Case of Robot-Assisted Surgery | New England Journal of Medicine. Accessed March 4, 2026. https://www.nejm.org/doi/abs/10.1056/NEJMp1006602\u003c/li\u003e\n \u003cli\u003eW\u0026uuml;rnschimmel C, Wenzel M, Moschovas MC, et al. Current training landscape for novice robotic surgeons: an international investigative survey by the Junior-ERUS/Young academic urologists (YAU) robotics in urology working group. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2025;43(1):467. doi:10.1007/s00345-025-05845-5\u003c/li\u003e\n \u003cli\u003eBrassetti A, Ragusa A, Tedesco F, et al. Robotic Surgery in Urology: History from PROBOT\u0026reg; to HUGOTM. \u003cem\u003eSensors\u003c/em\u003e. 2023;23(16):7104. doi:10.3390/s23167104\u003c/li\u003e\n \u003cli\u003eCalifano G, Di Bello F, Coll\u0026agrave; Ruvolo C, et al. Proctoring in robot-assisted urologic surgery: insights from a multicenter survey. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2025;19(1):352. doi:10.1007/s11701-025-02541-9\u003c/li\u003e\n \u003cli\u003eInfante Altamirano M, Lujan HJ. Is proctoring in robotic surgery truly helpful? Evaluating general surgeons\u0026rsquo; perspectives. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2025;20(1):86. doi:10.1007/s11701-025-03043-4\u003c/li\u003e\n \u003cli\u003eMitzman B, Smith BK, Varghese TK. Resident Training in Robotic Thoracic Surgery. \u003cem\u003eThorac Surg Clin\u003c/em\u003e. 2023;33(1):25-32. doi:10.1016/j.thorsurg.2022.07.009\u003c/li\u003e\n \u003cli\u003eLovegrove CE, Elhage O, Khan MS, et al. Training Modalities in Robot-assisted Urologic Surgery: A Systematic Review. \u003cem\u003eEur Urol Focus\u003c/em\u003e. 2017;3(1):102-116. doi:10.1016/j.euf.2016.01.006\u003c/li\u003e\n \u003cli\u003eGreen CA, Lin J, Higgins R, O\u0026rsquo;Sullivan PS, Huang E. Expertise in perception during robotic surgery (ExPeRtS): What we see and what we say. \u003cem\u003eAm J Surg\u003c/em\u003e. 2022;224(3):908-913. doi:10.1016/j.amjsurg.2022.05.006\u003c/li\u003e\n \u003cli\u003eBrinkman WM, Schout BMA, Rietbergen JB, et al. Training robotic surgery in urology: experience and opinions of robot urologists. \u003cem\u003eInt J Med Robot Comput Assist Surg MRCAS\u003c/em\u003e. 2015;11(3):308-318. doi:10.1002/rcs.1631\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"robot-assisted laparoscopic surgery, proctoring, surgical training, implementation, patient safety, urology","lastPublishedDoi":"10.21203/rs.3.rs-9306332/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9306332/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to characterise perioperative safety and real-world implementation patterns of proctoring in robot-assisted laparoscopic urologic surgery performed with the da Vinci Surgical System across heterogeneous centres and surgeons. A personal registry of 150 consecutive manufacturer-registered proctoring procedures performed between July 2022 and February 2026 was analysed. The primary outcome was 30-day major complications (Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III); secondary outcomes included intraoperative blood transfusion, conversion to open surgery, reoperation and endovascular embolisation. Overall, 150 proctored cases were delivered across 18 centres and 25 surgeons. The most frequent procedures were robot-assisted radical prostatectomy (RARP, n\u0026thinsp;=\u0026thinsp;76), robot-assisted partial nephrectomy (RAPN, n\u0026thinsp;=\u0026thinsp;44) and robot-assisted radical nephrectomy (RARN, n\u0026thinsp;=\u0026thinsp;12). Thirty-day Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III complications occurred in two cases (1.3%), with one patient requiring reoperation and one undergoing arterial embolisation; no 30-day mortality occurred, and no conversion to open surgery was recorded. Implementation patterns differed by baseline experience: among surgeons with low overall robotic exposure, the first proctored procedure was most commonly RARP, whereas surgeons with higher baseline experience more often initiated proctoring with non-RARP procedures. In conclusion, formal proctoring in robot-assisted laparoscopic urologic surgery across multiple centres was associated with a low rate of major complications and no conversions to open surgery. Reporting temporal trends, centre-procedure distribution and baseline surgeon experience alongside safety outcomes may provide a pragmatic framework for evaluating structured proctoring programs in routine practice.\u003c/p\u003e","manuscriptTitle":"Proctoring in Robot-Assisted Urologic Surgery: Safety and Implementation Patterns from a Multicentre Registry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 02:03:58","doi":"10.21203/rs.3.rs-9306332/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c443f8b3-e249-4a93-bb55-aff60d5f7608","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T04:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 02:03:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9306332","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9306332","identity":"rs-9306332","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}