The European School of Urology Boot Camp for First-Year Residents: The First Step to Standardization in Surgical Education

Surgical training is a complex process that requires academic and scientific learning as well as technical and nontechnical skills training. While academic and scientific learning is similar in all medical areas, technical skills training is the centerpiece of surgical education and has therefore been the focus of most surgical training curricula. The traditional surgical training model, originally developed by Halsted and Churchill, has been the basis of most residency programs in Urology for more than a century.[1,2] Over the last decades, the traditional surgical training model faced several ethical and regulatory issues that considerably impacted surgical education.[3] In fact, not only was there a subjective decline in residents’ performance (perceived both by program directors and residents themselves) but also there was also an objective decline in proficiency and autonomy levels at the end of residency programs.[4–6] On the other hand, the fact that traditional surgical training programs were based on learning from experience with patients posed severe ethical and insurance-related dilemmas regarding patient safety.[3,7] Altogether, these issues created a considerable challenge to surgical residency programs, ultimately leading to a major paradigm shift in surgical training worldwide. Urology residency training is quite heterogeneous throughout the world, not only in terms of the total duration of training but also in terms of the length of core surgical training, the length of the specific urological training, research requirements, working hours, surgical exposure, and evaluation methods.[8,9] A study by Carrion et al. evaluated the current status of urological training among final-year residents in Europe.[10] Altogether, surgical exposure of residents for procedures seems low, with only 50% of residents performing more than 20 procedures such as TURP, TURBT, or circumcision and <5%–10% performing more than 10 procedures such as percutaneous nephrolithotomy, radical nephrectomies, partial nephrectomies, radical prostatectomies, or radical cystectomies during their training.[10] Overall, only 30% of residents were satisfied with their surgical training and 14% believed that they performed enough surgeries during their training.[10] A systematic review of laparoscopic training in Urology residency programs, encompassing evidence from almost 1000 residents, identified wide variations in terms of exposure to laparoscopy between training programs. Most residents scored their received training as inadequate, which resulted in low degrees of confidence to independently perform solo laparoscopic procedures at the end of their residency.[11] Altogether, these studies showed that current Urology residency programs have limitations that may seriously compromise the quality of urological training and subsequent patient care over the next years. In light of these limitations of traditional surgical training, simulation-based training has been extensively explored over the past decades and used as an adjunct to traditional surgical training. This has led to the development of technical skills through individual hands-on practice.[7] Simulation-based training has been shown to improve operative skills in trainees, with evidence suggesting that the skills acquired through simulation-based training are transferable to an operative setting and that repetitive practice is associated with improved learner outcomes, with more practice yielding better benefits.[12–14] The benefits of simulation in the acquisition of technical skills in Urology are well established.[15,16] Several simulation courses have been developed over the past decades, most of them being procedure specific and usually have a duration of some hours to 2 days. However, considering the complexity of urological training and the multitude of surgical procedures in which urologists must gain proficiency, there was the need to develop a more advanced and structured approach to simulation training. One approach consisted of developing integrated simulation-based training curricula, comprising a series of validated training and assessment levels of progressive complexity. These training curricula supplement the conventional surgical training in a given area. In recent years, the European Association of Urology (EAU), the European School of Urology (ESU), the EAU Section of Uro-technology (ESUT), the EAU Robotic Urology Section (ERUS), and the EAU Urolithiasis Section (EULIS) have developed a series of standardized and validated training programs, such as the European Basic Laparoscopic Urological Skills, the Endoscopic Stone Treatment Step 1 (EST-S1), and the Certified Curriculum of ERUS (CC-ERUS). This has led to the implementation of several structured and integrated training curricula in laparoscopy, endoscopy, and robotics.[17–21] Riding high on the clear success of these activities, ESU, ESUT, ERUS, and EULIS have created the Standardization in Surgical Education (SISE) program, a collaborative venture that aims to implement a comprehensive approach to all training activities within the ESU, encompassing a series of structured, standardized, and validated training curricula targeted at all trainee levels. To allow stepwise training from basic to advanced skills, laparoscopic skills will be provided as in the laparoscopic urology training curriculum, endoscopic skills will be covered by the EST curriculum, robotic skills will be given through the CC-ERUS and transurethral skills by the transurethral training curriculum.[22] The first step in the SISE program is the ESU Urology Boot Camp. The ESU Urology Boot Camp is a standardized course for 1st-year residents, comprising a full day of intensive hands-on training and organized into separate training modules. The aim is to provide high-quality hands-on training, within the framework of a standardized and integrated ESU training program, to give every European Urology resident the possibility to acquire the essential technical skills to perform the most frequent urological procedures before they start working with patients. The Urology Boot Camp model is well established in the training scheme within the United Kingdom, where the Urology Simulation Boot Camp for 3rd/4th-year residents was introduced in 2015 and became mandatory for all Urology residents in 2018.[23,24] One of the most important hallmarks of the ESU Urology Boot Camp is the 1:1:1 training model, where each trainee has a dedicated training station and an experienced trainer for the entire duration of each module, therefore maximizing the learning experience. To this end, a series of different high fidelity models are used, as well as a considerable amount of state-of-the-art urological equipment. Trainees are provided with standardized hands-on training on laparoscopy, flexible, and semi-rigid ureterorenoscopy, transurethral resection of prostate and bladder tumors, flexible and rigid cystoscopy, bladder catheterization, suprapubic catheter placement, and scrotal examination. Following a very successful pilot course in Portugal, in 2018, four additional courses have been made, in Portugal, Belgium, and Serbia. The aim of the ESU Boot Camp Board is to implement ESU Urology Boot Camps in every European country, to be held on an annual basis, to provide high-quality standardized hands-on training to every Urology resident at the beginning of their training.