Simulation of RIRS in soft cadavers: a novel training model by the Cadaveric Research On Endourology Training (CRET) Study Group

Simulators in urology resident's training in retrograde intrarenal surgery

PURPOSE

To evaluate the impact of simulators on the training of urology residents in retrograde intrarenal surgery (RIRS).

METHODS

The study involved training eight urology residents, using two artificial simulators; one developed by the Universidade Estadual do Pará, using three-dimensional printing technology, and the other one patented by the medical equipment manufacturer Boston Scientific The qualification of residents took place through a training course, consisting of an adaptation phase (S0), followed by three training sessions, with weekly breaks between them (S1, S2 and S3). Study members should carry out a RIRS in a standardized way, with step-by-step supervision by the evaluator using a checklist. The participants' individual performance was verified through a theoretical assessment, before and after training (pre- and post-training), as well as by the score achieved in each session on a scale called global psychomotor skill score. In S3, residents performed an analysis of the performance and quality of the simulation, by completing the scale of student satisfaction and self confidence in learning (SSSCL).

RESULTS

At the end of the course, everyone was able to perform the procedure in accordance with the standard. The training provided a learning gain and a considerable improvement in skills and competencies in RIRS, with p < 0.05. SSSCL demonstrated positive feedback, with an overall approval rating of 96%.

CONCLUSIONS

Artificial simulators proved to be excellent auxiliary tools in the training of urology residents in RIRS.

Development and validation of a novel home-made bench-top training model for retrograde intrarenal surgery

PURPOSE

To develop and validate a low-cost homemade bench-top training model to facilitate retrograde intrarenal surgery (RIRS) training.

METHODS

The RIRS training model (G-Model) was developed using a surgical glove and a recycled ureter access sheath. Fifteen participants including 10 residents and 5 urologists were enrolled. Designed training curriculum for residents was carried out. Face validity, content validity, construct validity and criterion validity evaluation of the G-Model were carried out.

RESULTS

The global score of face and content validity was 4.15 ± 0.53 and 4.65 ± 0.29, respectively. For construct validity, the overall modified global rating scale (mGRS) score was significantly improved [12.5 (5.25) vs. 24.0 (5.25), p = 0.004], and the total task time was significantly shortened (39.5 ± 4.48 min vs. 24.1 ± 3.81 min, p < 0.001) within residents after G-Model training. The baseline mGRS score and total task time of residents were poorer than those of urologists [12.5 (5.25) vs. 32.0 (1.00), p < 0.001; 39.5 ± 4.48 min vs. 16.0 ± 1.58 min, p < 0.001]. Spearman correlation analysis revealed strong correlations between residents' G-Model and real patient performance.

CONCLUSION

The current study presented a valid low-cost easily accessible RIRS bench-top training model which could facilitate skill acquisition and translate to real-life scenario.

External Validation of the "Tor Vergata" 3D Printed Models of the Upper Urinary Tract and Stones for High Fidelity Simulation of Retrograde Intrarenal Surgery

INTRODUCTION

Novel training modalities are being investigated to overcome the challenges associated with learning Retrograde IntraRenal Surgery (RIRS). Consequently, a series of 3D printed models of the upper urinary tract and stones designed for ex-vivo surgical simulation was introduced in 2021. This study aims to provide external validation of the training model and assess its role in the development of surgical skills.

MATERIALS AND METHODS

A mixed cohort of 20 urologists at different levels of expertise participated in a whole-day live simulation event to examine the model and perform a timed simulation of intrarenal navigation, stone relocation and laser fragmentation. Operative times were recorded and two independent expert endourologists scored the simulations according to a modified Objective Structured Assessment of Technical Skills" (OSATS) scale. Five novice urologists from the cohort performed three further simulations in a subsequent event to assess improvement in surgical skills.

RESULTS

Face validity was demonstrated with a median score of ≥ 4/5 in in each of the 11 items investigated. Content validity was also successfully reached, with 100% positive impressions with regard to the usefulness for the acquisition of surgical skills. Significant differences were observed among operative times stratified per surgeon experience (all p < 0.0050), thus providing construct validity. Median total OSATS score for novices was 14 (range 8,25) and was found to be significantly different from expected expert performance (p = 0.0010). Repeated simulations by novices led to a progressive reduction of operative times (p=0.0313) and increase in median total OSATS (p =0.0625).

CONCLUSION

The 3D printed models of upper urinary tract and synthetic training stones for the high-fidelity simulation of each phase of RIRS were validate by this study. The results encourage the usage of the models in simulation courses and the evaluation of their potential role in standardised training curricula.

[Impact of simulation-based training in endourology: A systematic review of the literature]

INTRODUCTION

The impact of simulation on the acquisition of surgical skills as well as their transfer to the operating room is still debated. The objective was to assess these two specific points, focusing on the field of endourology.

METHODS

A systematic review of the literature, following the PRIMA statement, was performed using Medline database through September 2021 without time limit. Studies focusing on the impact of simulators on the acquisition of surgical technical skills as well as their transfer to the operating room in the field of endourology were included. The endourological procedures were: cystoscopy, ureteroscopy, percutaneous nephrolithotomy, endoscopic treatment of benign prostatic hyperplasia, endoscopic bladder resection.

RESULTS

Among the 11,442 publications identified, fifty-two studies were included in the analysis. The majority reported an improvement in procedure time of the requested tasks and dexterity of participants, regardless of the type of simulator and procedure. The level of evidence of included studies was often low. Few studies evaluated the transfer of acquired skills from the simulator to the operating room.

CONCLUSION

This review showed the positive impact of simulation on the acquisition of technical skills in endourology. However, in order to include proficiency-based progression in the curriculum of trainees, some parameters such as the choice of reference simulators, choice of tasks, and method of validation of acquired skills must be validated in a consensual manner to offer a quality training.

Introducing 3D printed models of the upper urinary tract for high-fidelity simulation of retrograde intrarenal surgery

PURPOSE

Training in retrograde intrarenal surgery for the treatment of renal stone disease is a challenging task due to the unique complexity of the procedure. This study introduces a series of 3D printed models of upper urinary tract and stones designed to improve the training process.

METHODS

Six different models of upper urinary tract were algorithmically isolated, digitally optimized and 3D printed from real-life cases. Soft and hard stones in different sizes were produced from 3D printed moulds. The models were fitted onto a commercially available part-task trainer and tested for retrograde intrarenal surgery.

RESULTS

Each step of the procedure was simulated with extraordinary resemblance to real-life cases. The unique anatomical intricacy of each model and type of stones allowed us to reproduce surgeries of increasing difficulty. As the case-load required to achieve proficiency in retrograde intrarenal surgery is high, benchtop simulation could be integrated in training programs to reach good outcomes and low complication rates faster. Our models match incredible anatomical resemblance with low production cost and high reusability. Validation studies and objective skills assessment during simulations would allow comparison with other available benchtop trainers and the design of stepwise training programs.

CONCLUSIONS

3D printing is gaining a significant importance in surgical training. Our 3D printed models of the upper urinary tract might represent a risk-free training option to hasten the achievement of proficiency in endourology.

Simulation-Based Training Models for Urolithiasis: A Systematic Review

Objectives: Urolithiasis is one of the most common presentations in urological practice and it is becoming increasingly important to provide structured, simulation-based training using validated training models. This systematic review aims to identify current simulation-based training models and to evaluate their validity and effectiveness. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive search was performed on the Medline and EMBASE databases for English language articles published between 2000 and 2018 describing and/or assessing validity of simulation models for urolithiasis procedures. Studies were qualitatively assessed for validity using the Messick validity framework and models were assigned levels of recommendation using the McGaghie model of translational outcomes. Results: A total of 98 studies were included in this study assessing 51 models, with 28 studies concerning models for urethrocystoscopy, 46 studies for ureterorenoscopy, and 39 studies for percutaneous access and/or nephrolithotomy. Only four models demonstrated a level of recommendation of 4. The most validated models were the URO/PERC-Mentor (Simbionix, Lod, Israel) with multiple studies for each across various procedural skills. Conclusion: There is a wide spectrum of simulation-based models currently available for urolithiasis procedures, mostly with limited validity evidence from small studies. Further research is required with higher levels of evidence including randomized controlled trials. In addition, long-term transfer of skills to the operating room should be assessed to establish whether there is genuine skill development and retention using simulation models and whether this helps to reduce surgical complications.

Current status of wet lab and cadaveric simulation in urological training: A systematic review

INTRODUCTION

We undertook a systematic review of the use of wet lab (animal and cadaveric) simulation models in urological training, with an aim to establishing a level of evidence (LoE) for studies and level of recommendation (LoR) for models, as well as evaluating types of validation.

METHODS

Medline, EMBASE, and Cochrane databases were searched for English-language studies using search terms including a combination of "surgery," "surgical training," and "medical education." These results were combined with "wet lab," "animal model," "cadaveric," and "in-vivo." Studies were then assigned a LoE and LoR if appropriate as per the education-modified Oxford Centre for Evidence-Based Medicine classification.

RESULTS

A total of 43 articles met the inclusion criteria. There was a mean of 23.1 (±19.2) participants per study with a median of 20. Overall, the studies were largely of low quality, with 90.7% of studies being lower than LoE 2a (n=26 for LoE 2b and n=13 for LoE 3). The majority (72.1%, n=31) of studies were in animal models and 27.9% (n=12) were in cadaveric models.

CONCLUSIONS

Simulation in urological education is becoming more prevalent in the literature, however, there is a focus on animal rather than cadaveric simulation, possibly due to cost and ethical considerations. Studies are also predominately of a low LoE; higher LoEs, especially randomized controlled studies, are needed.

Current Educational Interventions for Improving Technical Skills of Urology Trainees in Endourological Procedures: A Systematic Review

Objective: Endourology continues to grow with the introduction of new technologies into clinical practice. Simulators and training models have been developed to improve comfort and proficiency in endoscopic procedures. The purpose of this systematic review was to examine the current educational interventions utilized to improve the performance of endourology trainees and to critically appraise the strengths and limitations of each. Methods: A search of the Ovid MEDLINE, EMBASE, PsycINFO, and the Cochrane Library databases was performed to identify literature focused on current educational interventions for improving technical skills of trainees in endourologic procedures. The Medical Education Research Study Quality Instrument (MERSQI) was used to evaluate the methodological quality of the abstracted articles. Results: Of the 2236 articles identified, 22 met the inclusion criteria. The types of educational interventions included: bench/wet lab models, virtual reality simulators, and instructional courses. Metrics used to quantify the impact of these interventions include global rating scales, Objective Structured Assessment of Technical Skills (OSATS) scores, and task-specific checklists. The setting of these evaluations comprises both virtual reality simulators and live surgery. Conclusions: In the surgical education literature, simulation-based training and assessment continues to play a prominent role in urologic training. The educational interventions highlighted in this review address various aspects of endourology, from stone management to transurethral resection. Additional work is needed to correlate technical performance in clinical and nonclinical settings with patient outcomes and develop a focused approach to nontechnical skill training.

Current Status of Simulation Training in Urology: A Non-Systematic Review

Simulation has emerged as an effective solution to increasing modern constraints in surgical training. It is recognized that a larger proportion of surgical complications occur during the surgeon's initial learning curve. The simulation takes the learning curve out of the operating theatre and facilitates training in a safe and pressure-free environment whilst focusing on patient safety. The cost of simulation is not insignificant and requires commitment in funding, human resources and logistics. It is therefore important for trainers to have evidence when selecting various simulators or devices. Our non-systematic review aims to provide a comprehensive up-to-date picture on urology simulators and the evidence for their validity. It also discusses emerging technologies and future directions. Urologists should embed evidence-based simulation in training programs to shorten learning curves while maintaining patient safety and work should be directed toward a validated and agreed curriculum.

The Impact of Endourological Experience on Flexible Ureteroscopy Outcomes and Performance at Different Levels of Expertise: Retrospective Multifactorial Analysis

INTRODUCTION

The aim of this study was to analyze the influence of residents' participation in flexible ureteroscopy (fURS) on intra- and postoperative outcomes.

MATERIALS AND METHODS

Intra- and postoperative parameters were compared in a retrospective monocentric setting between 3 groups: "resident group" (47 cases) for surgeries performed by experienced residents alone, "consultant group" (245 cases) for surgeries performed by consultants alone, "resident plus consultant group" (124 cases) for training surgeries between September 2013 and June 2017.

RESULTS

Patients operated by residents alone had a significantly smaller median kidney stone diameter (5.0 vs. 7.0 mm for "consultant group" and 6.0 mm for "resident plus consultant group," p = 0.011), shorter operating time (median 47.0 vs. 63.0 and 77.0 min, p < 0.001) and fluoroscopy time (median 39.0 vs. 69.5 and 89.0 s, p < 0.001), as well as shorter postoperative hospital stay (p = 0.013). The laser application rate was the smallest in the "resident group" (10.64 vs. 31.43 and 29.84%, p = 0.009). Univariate analysis revealed no relevant differences regarding flexible ureteroscope defect rate, postoperative stone-free rate, or ≥2 Clavien-Dindo classification complications between the groups (p > 0.05).

CONCLUSION

A proper case selection of less complicated cases, especially without laser application, could balance the experience deficit of the residents. fURS can be incorporated as a part of residents' training without an impact on fURS device defect rate or clinical outcomes.

Ureteroscopic skills with and without Roboflex Avicenna in the K-box® simulator

Introduction

The aim of this study was to evaluate the acquisition of basic ureteroscopic skills with and without Roboflex Avicenna by subjects with no prior surgical training.

Material and methods

Ten medical students were divided in two groups: Group 1 was trained with Roboflex Avicenna and Group 2 with flexible ureteroscope alone, using the K-box^® simulator model. Participants were scored on their ability to perform or not two exercises, recording the time. In addition, the participants were evaluated on the quality of their performance for the following parameters: respect of the surrounding environment, flow of the operation, orientation, vision centering and stability.

Results

The first exercise was completed only by three and four out of five of students in Group 1 and Group 2, respectively. Stability with the scope was significantly more accurate in the first group compared with the second (P = 0.02). There were no differences in timing, flow or orientation between groups. Although not significant, a tendency of respecting the surrounding tissue and maintaining centered vision was perceived more in the first group. As for the second exercise, there were no differences between groups in regard of orientation, flow, respecting the surrounding tissue, stability or the ability of maintaining centered vision. Although not significant, the second group had a tendency of performing the exercise faster.

Conclusions

According to these preliminary results, the acquisition of basic ureteroscopic skills with and without robotic fURS in the K-box^® simulator, by subjects with no prior surgical training, is similar.