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Page 2 of 14 Farinha et al. Mini-invasive Surg 2023;7:38 https://dx.doi.org/10.20517/2574-1225.2023.50

previous findings stand for the low level of evidence supporting the efficacy of the described TMs in the acquisition
of skills required to safely perform PN.

Keywords: Surgical training, robot-assisted partial nephrectomy, construct validation, training model

INTRODUCTION
The difficult learning curve of laparoscopy and the advent of robotic surgery reinforced this transition
[1-3]
and led to an exponential increase in the number of robot-assisted partial nephrectomy (RAPN) procedures
performed. This is a complex and index procedure that urologists need to learn how to perform safely and
has a difficult learning curve that requires a step-by-step training process. RAPN has several critical steps
and requires the need to obtain negative surgical margins and control bleeding to avoid a potentially life-
[4,5]
threatening hemorrhage .

The introduction of surgical innovations and the need to ensure patient safety motivated international
[6,7]
experts to develop structured training programs with validated curricula that include acquiring
procedural skills in laboratory training models (TMs) and not simply relying on caseload. Rather, the goal
necessitates demonstration of a proficiency benchmark in the skills laboratory before performing the
procedure on a patient .
[6]
Having access to a training center with animal-based ex- or in-vivo TMs might be the best option .
[7]
Unfortunately, most trainees do not have access to this type of training facility, and since many hospitals
cannot afford to purchase a robotic platform specifically for training purposes, 3D printed models and
virtual reality (VR) simulators are considered cost-effective solutions for the acquisition of partial
nephrectomy (PN) procedural skills.

Skills acquired using TMs can be transferred to the skill level required for safe surgical practice , especially
[8]
if surgeons are enrolled in a proficiency-based progression (PBP) training program for PN . However, this
[9]
approach is contingent on high-level validation evidence supporting the use of a TM .
[10]
This review sought to evaluate the type and level of validation in the literature on the efficacy of existing PN
TMs and demonstrate the skill acquisition and performance levels required for safe surgical practice.

MATERIALS AND METHODS
Search strategy
A systematic review of the literature was conducted using the PubMed, Cochrane Library Central,
EMBASE, MEDLINE, and Scopus databases. We searched from the inception of the databases until April
2023. All references in the included papers on TMs were also screened. The keywords used for this research
were “Partial nephrectomy AND Training models”. The scope of this research was limited to the English
language. This systematic review was reported in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines [11,12] .

Data extraction and analysis
After identifying all eligible studies, two independent reviewers (Farinha RJ and Mazzone E) screened all
titles and abstracts or full texts for further clarification and inclusion. Literature reviews, editorial
commentaries, and non-PN TM studies were excluded from the initial screening. Randomized controlled
trials (RCTs) and nonrandomized observational studies (cohort studies) on validity and skill transfer from