Given the particular technical challenges of complex laparoscopic urological surgery some centres have moved instead to robotic-assisted surgery. Robotic surgery does not demand the same level of laparoscopic skill, it provides a 3D image, removes counter-intuitive hand movements and filters tremor. As a result it is even more precise than laparoscopic surgery and the expectation is that functional outcomes should improve. Unfortunately the costs are prohibitive and it is only economically viable to high volume centres.

Performing complex minimal access surgery requires a new skills set, not just for the main operator, but for the whole surgical team. Theatre staff must familiarize themselves with the equipment used and should know the steps of the procedure to better anticipate the surgeon’s needs. One or two trained surgical assistants are also required. A trained surgical practitioner can provide consistency in this role and become a linchpin for the team. As trained assistants they are familiar with the steps of the procedure, all the specialist equipment and liaise with suppliers. We have found it useful when training and indeed setting up a laparoscopic service for the whole team to visit an established centre, usually that of the mentor, prior to starting a new procedure. This gives an opportunity for the team to learn by legitimate peripheral participation and by observing the established team, asking questions and identifying potential pitfalls prior to encountering them in their own unit.

The role of minimal access surgery in the field of urological surgery is ever expanding. Advances in equipment and extensive skills development have led to more and more procedures being carried out laparoscopically. This brings advantages for patients, but also particular challenges in technical skills training. We would recommend that learning the technical skills required for laparoscopic urological surgery take place within a defined curriculum. Training requires observation, sustained deliberate practice, including a combination of high and low fidelity simulation, and a modular approach to real life surgery that is appropriately mentored. For established consultants and post CCT trainees we would recommend a whole team approach to learning with a mentorship programme to ensure patient safety and quality control. Once surgeons have been signed off they must maintain their skills by performing a minimum number of cases per annum and participating in ongoing appraisal by auditing their own results and submitting to the national audit.