Proficiency based curriculum was introduced by a group from the University of Texas Southwestern Medical Center. It is comprised of inanimate tasks, online didactics and a half-day tutorial [11]. The course takes 2 months to complete and the 9 tasks are expected to be performed by trainees until they reach suitable levels of proficiency. It has also been validated among different groups who found this course to be highly relevant for surgical training [17]. One of its advantages is the assurance of proficiency for all surgeon learners.

A formal fellowship is considered as one of the most structured form of proctorship, mentoring and training program. Most of the programs are modular based [19] and has been proven to have a beneficial educational impact. Its objective is to develop a systematic teaching method, which is reproducible. Guided learning has always been part of fellowship wherein trainees perform progressive steps of the operation under careful guidance of an instructor with constant and immediate feedback. It has long been believed that guided learning lead to improved proficiency in operative techniques. It reinforces the flow of operation by direct and immediate guidance from the attending surgeon to the trainee. In turn, this translates into a safer and effective way of surgical education. With the aim of further standardization, very recently Hung et al. [20] reported improvements in training from a structured learning program in robotic surgery using proficiency scores. This has boosted the confidence of trainees' robotic skills. As a result, they have now adopted the use of this quantitative feedback based on proficiency scores.

Another form of mentorship is a mini-fellowship. It has previously proven to have a high take rate [21] and has allowed postgraduate urologist to operate safely and independently with excellent progress across their initial learning curve. Notably, mini-fellowship programs have been more profoundly helpful among partner surgeons who took the course together rather than those who did not [22]. This effect explains its high take rate among attendees. Perhaps, it may have a subjective sense of trust between console surgeon and his bedside assistant as both were trained in the same way. Most urologists prefer this option, since it requires only a short amount of time, while training is intensive. This would allow them to immediately adapt it into their own clinical practice. However, progression of skills after training may still be questionable particularly among low caseload surgeons.

On the other hand, Kwon et al. [25] reported that proctorship program has provided efficiency and rapid progression of learning curve among surgeons. They described it as a rotational form of participation in the operation when one takes the role of console surgeon while the other acts like a proctor. In their program, they reported acceptable 8% complication rates comparable to what is reported in the literature and an average prostatectomy time of 2 hours in their first 100 patients, which were better than expected for an initial series. There have been continuing demands for improvement of acquisition of robotic skills. Moreover, an extended proctorship has been implemented by a group of urologists. They have found this to be beneficial with increased take rate and reduced learning curve with a score of 4.2 in 5-point Likert scale among participants [26]. Provision of proctorship has made trainees achieve earlier performance of independent robotic cases. This has allowed a conduction of safe surgery with the proctor guiding the trainee throughout the procedure during his early learning curve cases. As previously mentioned, formal fellowship training is considered the most structured form of proctorship and mentoring. Amidst longer duration, it provides more number of cases, postoperative management of complex cases and even progression to advanced skills which one may not attain from other forms like mini-fellowship and mentored courses. Common lines are always present between proctorship and mentorship and are often used interchangeably. However, in any form it is always aimed to provide the acquisition of robotic skills that are safe and reproducible. With the aim of achieving better interaction between robotic trainee and proctor, technological advancements such as 3-dimensional (3D) hands and instruments for telestration have been added to proctorship armamentarium [27]. All of which has its own advantages and disadvantages from the perspective of cost, duration and actual acquisition and application of robotic skills (Table 2). Successful training programs have allowed progressive interaction and involvement of surgeon teacher and learners. During early years of robotic training, proctoring environment has been difficult due to 1 surgeon and 1 console. Since the release of the dual-console of da Vinci Si Surgical System, more suitable proctoring environment has been made available for proctors as well as trainees (Fig. 2). This modality of proctorship has provided a safe method of proctoring without prolonging the operative time and compromising patient safety [28]. Likewise, the future looks promising for mentoring and proctorship as technology has emerged to facilitate telementoring thereby facilitating proctorship and mentoring from a remote place [29].

Proctoring has been used to hasten the steep learning curve one may encounter in acquiring robotic skill. Proctors and mentors play an important role in certifying one's competency in robotic skills. Unfortunately, there is no standardized rule in certifying a surgeon to become a proctor. To the very least, a urologist can be proctor to other surgeon if he has successfully performed 20 independent robotic surgery cases [7].

Legal dilemmas have always been a challenge among proctor and mentor surgeons.

There is no clear implication whether a proctor is liable over an impending eventuality of serious complications. Courts have put trainee surgeon the sole responsible party on this case. Nevertheless, proper explanation of surgeon trainee and proctor role should be clearly discussed with the patient prior to surgical consent to avoid any possibility of legal precedents [30]. However, it is not routinely practiced especially in robotic cases. Most guidelines recommend a proctor to intervene if the patient's well-being is in danger. However, doctor-patient relationship only exists between the patient and surgeon trainee. As a result, proctors are not held liable on this scenario. For rare instances that a proctor has intervened over a trainee in an emergency situation, legal implications still remain unclear. In emergency cases, converting robotic surgery to open is the safest and most effective way to alleviate legal burden on the proctor but rather the trainee takes hold of the full responsibility. Aside from the legal implications, time and financial constrains maybe another form of limiting factor for success of program which entails proctorship [31]. Another factor is lack of availability of simple cases in centers where the surgeon trainee would commence his robotic clinical application. These shortcomings need to be better addressed to avoid any medicolegal implications in the future and, ultimately, to provide optimal patient safety and care.