Before committing to development of a robotic program, it is imperative to understand the regional environment within which this program will function. Robotic surgery entails very substantial capital and consumable costs that will impact feasibility and put financial pressure on program success. A market analysis focusing on the healthcare competition and available patient population should be completed prior to moving forward with purchasing robotic hardware [1]. If the surrounding competition is fierce and the patient referral base is questionable, then a large expenditure to build a robotics program may be hard to justify. At the very least, these challenges should be clearly outlined and the timeline transparent to all parties with a stake in program success (including hospital administrators who approve millions of dollars in expenditures for robotic hardware ). In some cases, a robotics program may yield benefits to the institution that far outweigh financial concerns including establishing a local reputation for innovation and advancing a training mission [2].

There is significant potential benefit to building a robotics program around one or more experienced robotic surgeons rather than solely around individuals who have just completed training and are still mastering these procedures. A wealth of literature supports improvement in outcomes and efficiency as surgeons ascend the robotics learning curve [3–5], factors that are particularly critical during the early days of a new program. Moreover, operative time (along with case volume) is a major factor determining the cost-effectiveness of robotic surgery [6, 7].

When first starting out, it is advantageous for the institution to identify a Robotic Coordinator who serves as the coordinating liaison between Intuitive Surgical Inc . (Sunnyvale, CA), the manufacturer of the da Vinci^® Surgical System , and the hospital robotics team. Intuitive Surgical offers a 1-week course for liaison staff that comprehensively addresses all aspects of coordinating a robotic surgical program. The robotic coordinator should ideally be recruited from within the operating room (OR) staff and be familiar with daily operations within the OR. In our experience, there is great value in selecting an OR technician or nurse from the Urology Service for the position of coordinator, if the bulk of the early caseload will be urologic cases. These specific individuals already have a detailed understanding of the specific challenges involved in urological procedures and may be able to anticipate potential problems as these cases are transitioned to robotic-assisted laparoscopic approaches.

The primary responsibility of the coordinator is to ensure the operational status of the da Vinci^® robotic hardware and to proactively recognize problems with the unit that may require repair. This includes generalized maintenance planning as well as coordinating any necessary robot service. The Readiness Guide by Intuitive Surgical is a comprehensive user manual that may be valuable during the initial phase of setting up a team. The robotic coordinator also has a primary role in assuring that the necessary consumables (such as drapes and robotic instruments) are available prior to cases and that a functional system is in place to assure appropriate restocking.

The Robotic Coordinator is the go-to person responsible for assuring that all elements of the program interact together productively. It is important to have an easily identifiable individual who is ultimately responsible for the day-to-day activities of the robotic program . This individual takes a lead role in addressing concerns from all team members and eliminating roadblocks that threaten efficiency and patient safety.

No matter the anticipated surgical volume, it is highly advantageous to organize a dedicated OR team to staff all robotic cases. Ideally, these are volunteers who have expressed a specific interest in robotic surgery and wish to establish specialized expertise in this area within the OR . As the caseload increases, the robotic team should expand to allow coverage of robotic cases by team members under all circumstances. Nurses and OR technicians who were early team members can play a critical role in training new personnel to expand the team.

Basic training offered by Intuitive Surgical includes a da Vinci^® system component and room setup overview, system connection orientation, and an introduction to the patient cart and control console. The training also incorporates important practical aspects of arm draping, lens calibration, and sterilization procedures. The goal of this process is to familiarize the participant with all relevant technical details of the da Vinci^® robotic unit.

As a general rule, we have found value in the OR team being acquainted with the subspecialty of surgery and understanding the critical aspects of each type of procedure. In setting up a team for urologic robotic surgery , it is advantageous to pick personnel with previous urologic experience. Robotic procedures in resident training are usually broken down into step-by-step modules. It is critical that the entire team is made familiar with these steps and how the addition of robotics may alter them. In more complex cases, it may be helpful to provide written flow sheets to allow preparation before the procedure.