BJU Int 2023; 131: 177–182 doi:10.1111/bju.15928, 15930 Research Letter European training in urology (ENTRY): quality-assured training for European urology residents Dear Editor, environment, outside of the operating room, in which The general surgical exposure of European urology residents residents can acquire surgical skills, accelerating their learning in the performance of invasive procedures, their confidence in curve without compromising patient safety. the execution, and the overall satisfaction with their training To outline the programme, four co-design sessions have been is low [1]. The EuropeaN Training in uRologY (ENTRY) planned. The first two have already taken place. These project is a cooperative partnership between Humanitas meetings included urologists, urology residents and training University, ORSI Academy and Fundacio Puigvert, aiming to experts and aimed to integrate the different perspectives and improve the training of urology residents in minimally needs of each stakeholder. Afterwards, a workshop with invasive procedures. The ENTRY project is developing an higher education providers from European Union countries educational programme that has three key steps: an eLearning and representatives of national and international urological component; a hands-on simulation phase; and a quality- organizations will take place in the near future, with the aim assured methodology for training in the operating room. The being to validate the final ENTRY programme outline. final ambition of the project is to provide European urology trainers with high-quality teaching tools and compendia, The first aim of the programme has already been identified laying the foundation for a standardized European training (Table 1). This will be to establish a structured training programme for residents based on a scientific training curriculum for a common procedure, i.e., transurethral approach. The project is supported by the European resection of the bladder (TURB). This will provide a high- Commission with an ERASMUS grant (KA220-HED quality approach for real-practice teaching in the operating Cooperation partnerships in higher education). room, according to the PBP methodology. The Delphi A well-established and evidence-based methodology, namely, meeting for assessing the content validity of TURB metrics proficiency-based progression (PBP) training methodology, will take place in Barcelona in October 2022. Subsequently, will be implemented to ensure that training is effective [2–4]. the process to establish construct validity (i.e., the metrics This methodology encompasses straightforward but rigorously distinguish between the objectively assessed performance of defined steps: (i) Detailed characterization of a procedure of experienced and novice urologists when performing the interest through performance metrics. The metrics explicitly procedure) will include several European centres. These identify observable performance units before, during and after centres will also be involved in the proficiency benchmarks the surgical procedure; (ii) validation of the metrics; (iii) that must be accomplished by trainees before training quantitative definition of a benchmark (i.e., proficiency level) progression/completion and subsequent implementation of based on the mean performance of experienced surgeons who their skills in the clinical setting. The construct validity are genuinely skilled at performing the procedure; (iv) evidence will also establish in which phases of the procedure deliberate practice: continuous training with metric-based the performances of expert and novice surgeons differ the feedback until trainees demonstrate the defined proficiency most. This information will inform and guide the benchmark. During this practice, trainees receive ongoing, development of the simulation model. unambiguous, formative feedback using the objective, binary The metrics will then be applied for PBP training on a scored metrics. Previous studies have shown that PBP simulator for TURB. Finally, the eLearning module, training reduces objectively assessed intra-operative procedure composed of online lessons, tutorials and illustrative videos performance errors by ~60% in comparison to traditional and including thorough explanation of the methodology itself training programmes, including not only the Halstedian and its application to both the hands-on training and the model but also newer approaches, such as simulation-based clinical practice on real patients, will be developed. The first training, mastery learning and proficiency-based learning [5]. outcome from our project will be to construct a PBP training Even more importantly, PBP requires trainees to meet curriculum for the TURB procedure, including eLearning, quantitatively defined performance benchmarks before PBP-based simulation training and a process for integration advancing in their training, with the goal of achieving of this learning in real practice in the operating room. proficiency before starting their practice in the operating room, on real patients [4]. The eLearning and the hands-on After a train-the-trainers course, a pilot testing of the simulation components provide a safe and controlled curriculum, aiming to reach out to 20 tutors and 150 urology Ó 2022 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International. www.bjui.org wileyonlinelibrary.com This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. Research Letter Table 1 Summary of the ENTRY project phases and predicted results. circumstances exist that present a potential disclosure of interests. Project phases Project results o Buffi1,2, Marco Paciotti1,2 , Nicol 1. Co-design sessions Outline of the programme 2. Validation workshop Validation of the programme Anthony G. Gallagher3,4,5, Pietro Diana1,2 , 3. Results production Structured curriculum course for TURB Ruben De Groote3,6 , Giovanni Lughezzani1,2 , 1. Development of the metrics for TURB Andrea Gallioli7 , Paolo Casale1, Joan Palou7,8, 2. Delphi meeting Alexandre Mottrie3,6 and Alberto Breda7,8 3. Validation of the metrics for TURB 1 4. Proficiency assessment and definition IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy, 5. Development of a PBP training 2 Department of Biomedical Sciences, Humanitas University, curriculum course 1. eLearning modules Pieve Emanuele, Milan, Italy, 3ORSI Academy, Ghent, 2. PBP-based simulation training Belgium, 4Faculty of Medicine, KU Leuven, Leuven, Belgium, 3. Methodology for real practice in the 5 School of Medicine, Faculty of Life and Health Sciences, operating room Pilot testing Ulster University, Coleraine, UK, 6Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium, PBP, proficiency-based progression; TURB, transurethral resection of the 7 bladder. Department of Urology, Fundacio Puigvert, Barcelona, Spain and 8Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain residents, will evaluate the curriculum and assess its impact on the trainees’ performance (and, eventually, their peri- References operative and clinical outcomes). Once validated, we hope 1 Carrion DM, Rodriguez-Socarras ME, Mantica G et al. Current status of that the curriculum will be very appealing to all the European urology surgical training in Europe: an ESRU–ESU–ESUT collaborative centres for training their residents. study. World J Urol 2020; 38: 239–46 2 Gallagher AG, De Groote R, Paciotti M, Mottrie A. Proficiency-based Consequently, we aim to expand the offer of structured, progression training: a scientific approach to learning surgical skills. Eur PBP-based training curricula for a number of Urol 2022; 81: 394–5 endourological and minimally invasive procedures. Indeed, 3 Mottrie A, Mazzone E, Wiklund P et al. Objective assessment of the TURB training curriculum can represent the starting intraoperative skills for robot-assisted radical prostatectomy (RARP): point for developing metrics and training models for several results from the ERUS scientific and educational working groups metrics endoscopic procedures of the lower and upper urinary tract, initiative. BJU Int 2021; 128: 103–11 4 Vanlander AE, Mazzone E, Collins JW et al. Orsi consensus meeting on firstly, transurethral resection of the prostate and ureteric European robotic training (OCERT): results from the first multispecialty stenting. The development of further metrics will be consensus meeting on training in robot-assisted surgery. Eur Urol 2020; 78: successive to the construct validity of the TURB metrics. 713–6 For this purpose, the ENTRY project will be open to other 5 Mazzone E, Puliatti S, Amato M et al. A systematic review and meta- centres and urological societies willing to develop synergies analysis on the impact of proficiency-based progression simulation training aimed at innovating surgical training of European urology on performance outcomes. Ann Surg 2021; 274: 281–9 6 Somani B, Brouwers T, Veneziano D et al. Standardization in surgical residents [6,7]. Clinical evidence strongly suggests that the education (SISE): Development and implementation of an innovative skill of the operating surgeon is related to clinical outcomes training program for urologic surgery residents and trainers by the [8]. Since better training almost certainly means better European School of Urology in collaboration with the ESUT and EULIS outcomes, these projects could have a huge positive impact sections of the EAU. Eur Urol 2021; 79: 433–4 on patients, surgeons and healthcare systems. Moreover, it 7 Aydin A, Ahmed K, Van Hemelrijck M et al. Simulation in urological will boost the attractiveness of urology residency schools training and education (SIMULATE): protocol and curriculum development of the first multicentre international randomized controlled across Europe. trial assessing the transferability of simulation-based surgical training. BJU Int 2020; 126: 202–11 Disclosure of Interests 8 Curtis NJ, Foster JD, Miskovic D et al. Association of surgical skill assessment with clinical outcomes in cancer surgery. JAMA Surg 2020; 155: 590–8 Nicolo Buffi, Marco Paciotti, Anthony G. Gallagher, Pietro Diana, Ruben De Groote, Giovanni Lughezzani, Andrea Correspondence: Marco Paciotti, ORSI Academy, Gallioli, Paolo Casale, Joan Palou, Alexandre Mottrie and Proefhoevestraat 12, 9090 Melle, Ghent, Belgium. Alberto Breda report grants from ERASMUS + during the conduct of the study. No other relationships/conditions/ e-mail: paciottimarco@gmail.com Ó 2022 The Authors. 178 BJU International published by John Wiley & Sons Ltd on behalf of BJU International.