With any new surgical technology, i.e. robotics, potentially come new and unexpected serious complications that were not seen in the previous standard way of doing things. In Endourology examples include avulsion or perforation of the ureter during ureteroscopy and for laparoscopy damage to blood vessel or bowel by the Veress needle or laparoscopic instruments. Robotic technology also has its own unique issues relating to the patients steep Trendelenburg position in lithotomy stirrups and potentially as a result of the remote placement of the primary surgeon at the robotic console away from the patient. The paper Pridgeon et al.  looking at the incidence of lower limb compartment syndrome in the UK for patients undergoing robot-assisted radical prostatectomy (RARP) reports another very serious and devastating, but thankfully rare, problem.
Pridgeon et al.  have assessed the incidence of leg compartment syndrome in 17 centres with >3000 cases during a 7-year period. What is of huge significance to the reader wishing to avoid this disturbing problem is the individual patient and procedure issues surrounding each of the nine cases. All but one involved a console time of >4 h, which probably equates to a ‘legs in stirrups’ time of >4.5 h. Five patients were obese (BMI of >30 kg/m2) and three were early in the centre's RARP experience (initial 20 cases) and hence well within the early learning curve. The remaining patient had undergone a previous coronary artery bypass graft.
Clearly the most important associated factor for these cases of compartment syndrome was operative duration. For procedural time, many would initially think that this cannot be a true metric for surgical quality, as anyone can rush things but for an operation such as RARP with multiple and complex steps, console times of >4 h are often seen as a trigger for an additional risk of both surgical and anaesthetic complications and these should decrease naturally as surgical experience increases . The procedural time reflects not just the experience of the primary surgeon but also that of the assistant, scrub nurses and anaesthetist in positioning the patient, draping and docking the robot, assisting the case, and introducing and closing the ports.
Early in a centres’ experience of RARP, case selection itself is vital. Procedures will naturally be slower initially, so avoiding operating on patients where procedural time is critical or those with complicating issues that require additional operative steps makes sense. Novice robotic surgeons should think hard about attempting surgery on patients with peripheral vascular disease, high BMI (>35 kg/m2), and previous abdominal surgery. Those with high-risk disease requiring an extended pelvic lymph node dissection, very large glands or those requiring salvage surgeries should also be avoided.
What was not asked was how many of the primary surgeons in these cases had undergone a dedicated robotic fellowship either in the UK or abroad but I would think the answer was zero (confirmed with authors). A dedicated period of focussed training in robotic techniques usually enables involvement in >100 RARP cases, high-level mentoring, simulation training and allows surgeons to start not just competent but really proficient. The Vickers group has clearly shown that fellowship trained surgeons produce superior cancer control after RARP . It is therefore no surprise that the UK centres that have started their robotic programmes with young fellowship trained urologists have universally done well. For those learning de novo at their own institution, then a dedicated mentor should be employed who sets ground rules to limit console times before each case but collaboration with a young fellowship trained colleague is easier.
In 2013 our patients deserve to be operated upon by dedicated, fully trained and proficient surgeons and if RARP cases cannot be completed in <4 h then perhaps further training is required.