Effect of Simulation-based Training on Surgical Proficiency and Patient Outcomes: A Randomised Controlled Clinical and Educational Trial

A Systematic Review of Simulation-Based Training Tools in Plastic Surgery

OBJECTIVES

The recent shift from traditional surgical teaching to the incorporation of simulation training in plastic surgery has resulted in the development of a variety of simulation models and tools. We aimed to assess the validity and establish the effectiveness of all currently available simulators and tools for plastic surgery.

DESIGN

Systematic review.

METHODS

The PRISMA 2020 checklist was followed. The review protocol was prospectively registered in PROSPERO (CRD42021231546). Published and unpublished literature databases were searched to the 29th of October 2023. Each model was appraised in accordance with the Messick validity framework, and a rating was given for each section. To determine the effectiveness of each model, the McGaghie model of translational outcomes was used.

RESULTS

On screening 1794 articles, 116 were identified to discuss validity and effectiveness of simulation models in plastic surgery. These were hand surgery (6 studies), breast surgery (12 studies), facial surgery (25 studies), cleft lip and palate surgery (29 studies), rhinoplasty (4 studies), hair transplant surgery (1 study), surgery for burns (10 studies), and general skills in plastic surgery (29 studies). Only 1 model achieved an effectiveness level > 3, and no model had a rating > 2 in all aspects of the Messick validity framework.

CONCLUSION

There are limited models enabling the transfer of skills to clinical practice. No models achieved reductions in surgical complications or costs. There must be more validity studies conducted using updated validity frameworks, with an increased emphasis on the applicability of these simulators to improve patient outcomes and surgical technique. More training tools evaluating both technical and non-technical surgical skills are recommended.

Biotissue Curriculum Translates to Performance in the Operating Room for Gastrojejunostomy and Hepaticojejunostomy in Robotic Pancreaticoduodenectomy

OBJECTIVE

Robotic simulation training curricula aim to aid surgeons in attaining robotic operating room proficiency, but the crossover success remains to be examined.

DESIGN

A retrospective cohort study grading robotic biotissue training models and intraoperative anastomotic videos. The curriculum included deliberate practice of inanimate drills of a hepaticojejunostomy (HJ) and gastrojejunostomy (GJ). Videos were blindly reviewed, and performance was evaluated by time, errors, and Objective Structured Assessment of Technical Skills (OSATS). Spearman's correlation coefficients (ρ) were calculated for prior experience, biotissue performance, and intraoperative performance.

SETTING

University of Pittsburgh Medical Center from 2014 to 2018.

PARTICIPANTS

Thirty-one surgical oncology fellows participated in the 5-step proficiency-based robotic training curriculum for robotic pancreaticoduodenectomy.

RESULTS

Fellows completed an average of 5.1 ± 3.7 HJ and 4.3 ± 3.3 GJ on biotissue. More practice on biotissue correlated with greater improvement on both times to complete an anastomosis (ρ = -0.51) and errors (ρ = -0.45). Average errors on biotissue GJ and longer time on the last attempt correlated with lower average intraoperative GJ OSATS (ρ = -0.64; ρ = -0.66). More errors on the last biotissue GJ correlated with longer average intraoperative GJ time (ρ = 0.58). Errors on the first and average biotissue HJ errors correlated with lower OSATS for the intraoperative HJ (ρ = -0.74; ρ = -0.80).

CONCLUSIONS

Performance on biotissue correlated with intraoperative performance. Results suggest the importance deliberate practice to achieve surgical proficiency.

[Sex-specific differences in surgical confidence: results of the Endo Workshop of the German Society of Residents in Urology 2022]

BACKGROUND

Simulation-based training is gaining importance in urologic residents training.

OBJECTIVES

This prospective study evaluated the influence of the Endo Workshop of the German Society of Residents in Urology e. V. (GeSRU) on surgical confidence.

MATERIALS AND METHODS

GeSRU Endo Workshop 2022 included 1 h simulation-based training sessions on stone removal using ureteroscopy (URS) and transurethral resection of the bladder (TURB). Using an online questionnaire, surgical confidence was assessed before and after the workshop. Surgical assessment relied on the global rating scale (GRS).

RESULTS

Overall, 40 residents participated: 25 (62.5%) men and 15 (37.5%) women. In URS assessment, men vs. women achieved an average of 26.6 vs. 26.1/35 points on the GRS (p = 0.7) and completed the task in 8.1 ± 1.9 vs. 9.9 ± 0.4 min (p < 0.001). In TURB assessment, men vs. women achieved an average of 26.0 vs. 27.3/35 points on the GRS (p = 0.3) and required 7.6 ± 1.9 vs. 7.7 ± 2.2 min (p = 0.9), respectively. Among participants who answered the baseline survey and the evaluation (n = 33), 16 (80%) men vs. 3 (23%) women had surgical confidence to perform URS before (p = 0.01), and 19 (95%) men vs. 7 (54%) women after the workshop (p = 0.03). Regarding the performance of TURB, 10 (50%) men vs. 7 (54%) women reported surgical confidence before (p = 0.1), and 15 (75%) men vs. 10 (77%) women after the workshop (p = 1.0). An increase in surgical confidence to perform URS and TURB was reported by 9 (45%) and 10 (50%) men and 9 (69%) and 8 (62%) women, respectively.

CONCLUSIONS

Endourologic simulation-based training increases surgical confidence of both female and male residents. Despite comparable surgical outcomes, women approach URS with lower surgical confidence compared to their male counterparts.

Comparison of distance versus in-person laparoscopy training using a low-cost laparoscopy simulator-a randomized controlled multi-center trial

INTRODUCTION

Simulation training programs are essential for novice surgeons to acquire basic experience to master laparoscopic skills. However, current state-of-the-art laparoscopy simulators are still expensive, limiting the accessibility to practical training lessons. Furthermore, training is time intensive and requires extensive spatial capacity, limiting its availability to surgeons. New laparoscopic simulators offer a cost-effective alternative, which can be used to train in a digital environment, allowing flexible, digital and personalized laparoscopic training. This study investigates if training on low-cost simulators in a digital environment is comparable to in-person training formats.

MATERIALS AND METHODS

From June 2023 to December 2023, 40 laparoscopic novices participated in this multi-center, prospective randomized controlled trial. All participants were randomized to either the ‟distance" (intervention) or the "in-person" (control) group. They were trained in a standardized laparoscopic training curriculum to reach a predefined level of proficiency. After completing the curriculum, participants performed four different laparoscopic tasks on the ForceSense system. Primary endpoints were overall task errors, the overall time for completion of the tasks, and force parameters.

RESULTS

In total, 40 laparoscopic novices completed digital or in-person training. Digital training showed no significant differences in developing basic laparoscopic skills compared to in-person training. There were no significant differences in median overall errors between both training groups for all exercises combined (intervention 3 vs. control 4; p value = 0.74). In contrast, the overall task completion time was significantly lower for the group trained digitally (intervention 827.92 s vs. control 993.42; p value = 0.015). The applied forces during the final assessment showed no significant differences between both groups for all exercises. Overall, over 90% of the participants rated the training as good or very good.

CONCLUSION

Our study shows that students that underwent digital laparoscopic training completed tasks with a similar number of errors but in a shorter time than students that underwent in-person training. Nevertheless, the best strategies to implement such digital training options need to be evaluated further to support surgeons' personal preferences and expectations.

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

OBJECTIVES

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation.

DESIGN

An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers.

SETTING

Academic medical training centers or conferences in the United States, Rwanda and Kenya.

PARTICIPANTS

10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident.

RESULTS

The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox.

CONCLUSION

The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

Improving surgical technical skills for emergency fixation of unstable pelvic ring fractures: an experimental study using a pelvic ring fracture simulator

BACKGROUND

The management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants' knowledge retention and procedural confidence enhancement.

METHODS

A standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures.

RESULTS

Fifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13).

CONCLUSIONS

Our unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training.

Benefits of simulation on multidisciplinary management of severe pre-eclampsia/severe eclampsia in 15 health districts in eastern Democratic Republic of Congo: A randomized educational trial

OBJECTIVE

The purpose of the present study was to assess the benefits of simulation for advancing knowledge and assisting healthcare staff in optimization of procedures when managing severe pre-eclampsia/eclampsia (sPE/E).

METHODS

A randomized educational trial was conducted with two groups: Group I received theoretical training, while group II received the same training along with simulation scenarios based on the management of sPE/E. The study involved 199 healthcare providers, including physicians, midwives, skilled birth attendants, and nurses. The study analyzed the percentage of correct answers on both the multiple-choice questions (MCQ) and the objective structured clinical examinations (OSCE) to evaluate theoretical knowledge and clinical skills objectively.

RESULTS

Statistically significant differences were found immediately after training between groups I and II, whose mean percentages were 65.0% (±11.2) versus 71.0% (±9.8) (P < 0.001). A statistically significant reduction in the percentage of correct answers was found in both groups and demonstrated a discrepancy between immediate post-training test and post-training test at 3 months scores of 11.6% (±1.3) in group I versus 7.2% (±0.6) in group II. OSCE1 and OSCE2 scores were significantly higher in group II than in group I (P < 0.001).

CONCLUSION

Simulation combined with theoretical training would appear to be an interesting method of training for advancing knowledge and improving skills of healthcare providers in their management of sPE/E. Our goal is for this method to be used to reduce real-life maternal mortality in the South Kivu region of the Democratic Republic of Congo.

Gender differences in ergonomics during simulated ureteroscopy

BACKGROUND

Female urologists report higher rates of work-related physical discomfort compared to male urologists. We compared ergonomics during simulated ureteroscopy, the most common surgery for kidney stones, between male and female urologists.

METHODS

Surface electromyography was used to measure muscle activation during common ureteroscopic tasks in urology trainees and staff with different surgeon positions and ureteroscopes. Subjective workload was assessed using the NASA Task Load Index (NASA-TLX). Paired t-tests, Wilcoxon rank-sum tests, and multivariate regressions were used to compare muscle activation by gender for each trial condition.

RESULTS

There was no difference in age or distribution of training level between genders, though men had larger glove sizes. Across all conditions, women required greater muscle activation in multiple muscle groups and had greater NASA-TLX scores compared to men.

CONCLUSIONS

There may be gender differences in ergonomics during ureteroscopy based on muscle activation and subjective workload, suggesting potential for personalizing surgical ecosystems.

Teaching medical students ultrasound-guided needle aspiration of synthetic cysts: effect of a formalin-embalmed cadaver simulation model

BACKGROUND

Standard training for ultrasound-guided cyst needle aspiration is currently performed on live patients during residency. This practice presents risk of iatrogenic injury to patients and provides a high-stress learning environment for medical trainees. Simulation training using synthetic cysts in a formalin-embalmed cadaver model may allow for realistic, practical, and effective training free from patient risk.

METHODS

Thirty first-year medical students viewed an orientation video, then attended a skills workshop to perform cyst needle aspiration in formalin-embalmed cadaver tissue under ultrasound guidance. Participants were randomly assigned to one of three ultrasound-trained instructor-types which included a medical student, clinical anatomist, or an ultrasound fellowship trained emergency medicine physician. After training, participants underwent a 5-min skills test to assess their ability to drain a synthetic cyst independently. Pre- and post-training self-confidence surveys were administered.

RESULTS

Ultrasound images of synthetic cysts in formalin-embalmed tissue were clear and realistic in appearance, and sonographic needle visualization was excellent. Participants took an average of 161.5 s and 1.9 attempts to complete the procedure. Two of the 30 participants could not complete the procedure within the time limit. Participants' self-reported confidence with respect to all aspects of the procedure significantly increased post-training. Mean confidence scores rose from 1.2 (95% CI 0.96 to 1.39) to 4.4 (95% CI 4.09 to 4.53) (P < 0.0001) Procedure time, number of attempts, performance scores, and self-confidence outcomes were not significantly affected by instructor type.

CONCLUSIONS

The use of synthetic cysts in formalin-embalmed cadaveric tissue is feasible, realistic, and efficacious for the teaching of ultrasound-guided needle aspiration to novice medical trainees. This simulation training method can be delivered effectively by multiple instructor types and may allow medical trainees to increase their tactical skill and self-confidence prior to performing ultrasound-guided cyst needle aspiration on live patients.

[Learn playfully, operate seriously : The new era of surgical training]

BACKGROUND

Traditional surgical training and further education has historically involved long working hours and hands-on experience within the framework of a teacher-apprentice relationship; however, changes in regulatory policy in the USA and subsequently in Switzerland and the European Union from 2003, led to restrictions in the working hours of medical residents. As a result the traditional method of surgical training "see one, do one, teach one" has come under scrutiny, prompting a search for alternative training methods beyond the confines of the operating theater.

OBJECTIVE

This publication highlights the possibilities and limitations associated with the use of virtual reality (VR) and gamification in surgical training and further education. It examines the ability of these technological resources to enhance the effectiveness and engagement of medical residents and the feasibility of incorporating them into the surgical training curriculum.

MATERIAL AND METHODS

The study was based on a literature search for current developments in surgical training, VR and gamification. Furthermore, various studies and projects that investigated the use of VR and gamification in medical training and further education were analyzed.

RESULTS AND DISCUSSION

In this investigation it could be shown that the use of VR reduces the perioperative risks and improves the training environment and learning. The use of gamification also increases the motivation and engagement of the medical residents. As a result the quality of medical education can be improved by the fusion of VR and gamification.

Current Standards for Training in Robot-assisted Surgery and Endourology: A Systematic Review

BACKGROUND AND OBJECTIVE

Different training programs have been developed to improve trainee outcomes in urology. However, evidence on the optimal training methodology is sparse. Our aim was to provide a comprehensive description of the training programs available for urological robotic surgery and endourology, assess their validity, and highlight the fundamental elements of future training pathways.

METHODS

We systematically reviewed the literature using PubMed/Medline, Embase, and Web of Science databases. The validity of each training model was assessed. The methodological quality of studies on metrics and curricula was graded using the MERSQI scale. The level of evidence (LoE) and level of recommendation for surgical curricula were awarded using the educational Oxford Centre for Evidence-Based Medicine classification.

KEY FINDINGS AND LIMITATIONS

A total of 75 studies were identified. Many simulators have been developed to aid trainees in mastering skills required for both robotic and endourology procedures, but only four demonstrated predictive validity. For assessment of trainee proficiency, we identified 18 in robotics training and six in endourology training; however, the majority are Likert-type scales. Although proficiency-based progression (PBP) curricula demonstrated superior outcomes to traditional training in preclinical settings, only four of six (67%) in robotics and three of nine (33%) in endourology are PBP-based. Among these, the Fundamentals of Robotic Surgery and the SIMULATE curricula have the highest LoE (level 1b). The lack of a quantitative synthesis is the main limitation of our study.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Training curricula that integrate simulators and PBP methodology have been introduced to standardize trainee outcomes in robotics and endourology. However, evidence regarding their educational impact remains restricted to preclinical studies. Efforts should be made to expand these training programs to different surgical procedures and assess their clinical impact.

An update on simulation training in rhinology: a systematic review of evidence

BACKGROUND

Rhinological procedures demand a high degree of technical expertise and anatomical knowledge. Because of limited surgical opportunities, ethical considerations and the complexity of these procedures, simulation-based training has become increasingly important. This review aimed to evaluate the effectiveness of simulation models used in rhinology training.

METHODS

Searches were conducted on PubMed, Embase, Cochrane and Google Scholar for studies conducted between July 2012 and July 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis ('PRISMA') protocol defined a final list of articles. Each validated study was assigned a level of evidence and a level of recommendation based on the Oxford Centre of Evidence-Based Medicine classification.

RESULTS

Following exclusions, 42 articles were identified which encompassed six types of simulation models and 26 studies evaluated validity. The rhinological skills assessed included endoscopic sinus surgery (n = 28), skull base/cerebrospinal fluid leak repair (n = 14), management of epistaxis and/or sphenopalatine artery ligation (n = 8), and septoplasty and septorhinoplasty (n = 6). All studies reported the beneficial impact of their simulation models on trainee development.

CONCLUSION

Simulation training in rhinology is a valuable adjunct to traditional surgical education. Although evidence is of moderate quality, the findings highlight the importance of simulation-based training in rhinology training.

Surgical Training Simulators for Rhinoplasty: A Systematic Review

Rhinoplasty training currently follows an apprenticeship model that is largely observational. Trainees have limited experience in performing maneuvers of this complex surgery. Rhinoplasty simulators can address this issue by providing trainees with the opportunity to gain surgical simulator experience that could improve technical competences in the operating room. This review amalgamates the collective understanding of rhinoplasty simulators described to date. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, OVID Embase, OVID Medline, and Web of Science databases were all searched for original research on surgical simulators for rhinoplasty education and reviewed by independent reviewers. Articles underwent title and abstract screening, and then relevant articles underwent full-text review to extract simulator data. Seventeen studies, published between 1984 and 2021, were included for final analysis. Study participant numbers ranged from 4 to 24, and included staff surgeons, fellows, residents (postgraduate year 1-6), and medical students. Cadaveric surgical simulators comprised eight studies, of which three were with human cadavers, one study was a live animal simulator, two were virtual simulators, and six were three-dimensional (3D) models. Both animal and human-based simulators increased the confidence of trainees significantly. Significant improvement in various aspects of rhinoplasty knowledge occurred with implementation of a 3D-printed model in rhinoplasty education. Rhinoplasty simulators are limited by a lack of an automated method of evaluation and a large reliance on feedback from experienced rhinoplasty surgeons. Rhinoplasty simulators have the potential to provide trainees with the opportunity for hands-on training to improve skill and develop competencies without putting patients in harm's way. Current literature on rhinoplasty simulators largely focuses on simulator development, with few simulators being validated and assessed for utility. For wider implementation and acceptance, further refinement of simulators, validation, and assessment of outcomes is required.

Simulation training in urology

PURPOSE OF REVIEW

This review outlines recent innovations in simulation technology as it applies to urology. It is essential for the next generation of urologists to attain a solid foundation of technical and nontechnical skills, and simulation technology provides a variety of safe, controlled environments to acquire this baseline knowledge.

RECENT FINDINGS

With a focus on urology, this review first outlines the evidence to support surgical simulation, then discusses the strides being made in the development of 3D-printed models for surgical skill training and preoperative planning, virtual reality models for different urologic procedures, surgical skill assessment for simulation, and integration of simulation into urology residency curricula.

SUMMARY

Simulation continues to be an integral part of the journey towards the mastery of skills necessary for becoming an expert urologist. Clinicians and researchers should consider how to further incorporate simulation technology into residency training and help future generations of urologists throughout their career.

The use of a porcine model to teach advanced abdominal wall dissection techniques

BACKGROUND

In the era of minimally invasive surgery, it is clear that a robust simulation model is required for the training of surgeons in advanced abdominal wall reconstruction. The purpose of this experimentation was to evaluate whether a porcine model could be used to teach advanced minimally invasive abdominal wall dissection techniques to novice surgeons. Secondary objectives included: time to completion, identification of various anatomical landmarks, to note the difference in porcine and human models and finally, the ability to dock a Da Vinci Xi robotic platform on the porcine model.

METHODOLOGY

Two post-fellowship surgeons were given the task of performing an extended total extraperitoneal dissection (ETEP) on one female Landrace pig under the supervision of a surgeon experienced in robotic-assisted ventral hernia repair. This included insertion of ports, developing a retro-rectus plane, crossover from left to right rectus, bilateral transverse abdominus release, and sub-diaphragmatic dissection. A 5-mm vessel sealer was used to facilitate the dissection. The steps of the surgery were given to the trainees, and an experienced hernia surgeon guided the steps of dissection. The emphasis of the tasks was to develop the planes of extraperitoneal dissection to demonstrate that the porcine model could be considered for a viable and realistic model for training.

RESULTS

The candidates were able to successfully complete the task and dock a Da Vinci Xi with the porcine model providing a realistic platform for training.

CONCLUSION

The porcine model can be a considerable tool in the education of surgeons embarking on learning the art of minimally invasive abdominal wall reconstruction techniques. The advantage of live tissue dissection, similarity in anatomy and the relatively inexpensive availability of porcine models, makes it an unparalleled form of simulation-based training. We believe that this will have transitional capabilities to robotic ETEP education for complex hernia repair.

Assessment of laparoscopic intracorporeal intestinal anastomosis training using simulation-based 3D printed models: exploring surgical performance and learning curves

BACKGROUND AND AIMS

Intestinal anastomosis is a clinical procedure widely used to reconstruct the digestive tract, but authentic laparoscopic intracorporeal intestinal anastomosis (LIIA) models are lacking. However, three-dimensional (3D) printing can enable authentic and reusable models. In this paper, a novel cost-effective 3D-printing training model of LIIA is designed and the authenticity and validity of the model are tested.

METHODS

A fused deposition modeling 3D printing and an assembled lab model were built to test LIIA. Fifteen surgeons were required to perform LIIA, and their operation score and time were recorded and analyzed. Five experts were invited to assess the face and content validity of the models. A study was also performed to further evaluate and validate the learning curve of surgeons.

RESULTS

The difference in modified anastomosis objective structured assessment of technical skills (MAOSATS) scores between the expert, intermediate, and novice groups were significant (64.1±1.8: 48.5±1.7: 29.5±3.1, P <0.001). In addition, the operation time of the procedure was statistically different for all three groups (21.5±1.9: 30.6±2.8:70.7±4.0, P<0.001 ). The five experts rated the face and content validity of the model very highly, with the median being four out of five. Surgeons who underwent repeated training programs showed improved surgical performance. After eight training sessions, the novices' performance was similar to that of the average level of untrained intermediates, while the operation scores of the intermediates were close to that of the average level of experts.

CONCLUSIONS

In this study, it is found that the LIIA model exhibits excellent face, content, and construct validity. Repeated simulation training of the LIIA training program improved the surgeon's operative performance, so the model is considered one of the most effective methods for LIIA training and assessment of surgical quality in the future and for reducing healthcare costs.

The First Entirely 3D-Printed Training Model for Robot-assisted Kidney Transplantation: The RAKT Box

Background

Robot-assisted kidney transplantation (RAKT) is increasingly performed at selected referral institutions worldwide. However, simulation and proficiency-based progression training frameworks for RAKT are still lacking, making acquisition of the RAKT-specific skill set a critical unmet need for future RAKT surgeons.

Objective

To develop and test the RAKT Box, the first entirely 3D-printed, perfused, hyperaccuracy simulator for vascular anastomoses during RAKT.

Design setting and participants

The project was developed in a stepwise fashion by a multidisciplinary team including urologists and bioengineers via an iterative process over a 3-yr period (November 2019-November 2022) using an established methodology. The essential and time-sensitive steps of RAKT were selected by a team of RAKT experts and simulated using the RAKT Box according to the principles of the Vattituki-Medanta technique. The RAKT Box was tested in the operating theatre by an expert RAKT surgeon and independently by four trainees with heterogeneous expertise in robotic surgery and kidney transplantation.

Surgical procedure

Simulation of RAKT.

Measurements

Video recordings of the trainees' performance of vascular anastomoses using the RAKT Box were evaluated blind by a senior surgeon according to the Global Evaluative Assessment of Robotic Skills (GEARS) and Assessment of Robotic Console Skills (ARCS) tools.

Results and limitations

All participants successfully completed the training session, confirming the technical reliability of the RAKT Box simulator. Tangible differences were observed among the trainees in both anastomosis time and performance metrics. Key limitations of the RAKT Box include lack of simulation of the ureterovesical anastomosis and the need for a robotic platform, specific training instruments, and disposable 3D-printed vessels.

Conclusions

The RAKT Box is a reliable educational tool to train novice surgeons in the key steps of RAKT and may represent the first step toward the definition of a structured surgical curriculum in RAKT.

Patient summary

We describe the first entirely 3D-printed simulator that allows surgeons to test the key steps of robot-assisted kidney transplantation (RAKT) in a training environment before performing the procedure in patients. The simulator, called the RAKT Box, has been successfully tested by an expert surgeon and four trainees. The results confirm its reliability and potential as an educational tool for training of future RAKT surgeons.

Prior Robotic Console Expertise May Improve Basic Skills at the New Hugo RAS Simulator: Results from a Cohort Trial and Implications for Skill Transference Across Platforms

Background

Robot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator.

Objective

This study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator.

Design setting and participants

We present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons.

Intervention

All participants underwent a hands-on "pick and place" exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded.

Outcome measurements and statistical analysis

Metrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console).

Results and limitations

All participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower (p < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34-45) compared with both naïve participants (61 s, IQR 53-71) and laparoscopists (93 s, IQR 53-162). The overall score of the exercise decreased with age (p = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups (p = 0.006). Neither gender (p = 0.7) nor videogame use (p = 0.9) correlated significantly with the metrics.

Conclusions

This is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue.

Patient summary

In the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform.

The design and validation of a low-cost trans perineal (TP) prostate biopsy simulator for training: improving trainees' confidence and cognitive targeting skills

PURPOSE

The aim of this research was to create a novel and low-cost TP prostate biopsy simulator that has face, content and construct validity with high educational value.

METHODS

This research developed a trans perineal prostate (TP) biopsy simulator using 3D-printed moulds and tissue-mimicking materials. Important regions (anterior, mid, and posterior zones) were coded with different colours. Ultrasound visible abnormal lesions were embedded in the prostate phantom. Expert and novice participants in TP biopsies were recruited. Essential skills were identified through the consensus of six experts. These skills were assessed through tasks performed by participants. This included the accuracy and timing of systematic and target biopsies. Immediate feedback was determined by the colour of the biopsy cores taken. A survey was distributed to evaluate its realism and educational value.

RESULTS

The material cost of one simulator was £7.50. This simulator was proven to have face, content, and construct validity. There was a significant difference (p = 0.02) in the accuracy of systematic biopsies between both experts and novices. Significant difference was also observed (p = 0.01), in accurately identifying target lesion on ultrasound between both groups. Participants rated the overall realism of the simulator 4.57/5 (range 3-5). 100% of the experts agreed that introducing this simulator to training will be beneficial. 85.7% of the participants strongly agree that the simulator improved their confidence in TP biopsies.

CONCLUSION

There is value in integrating this proof-of-concept TP prostate biopsy simulator into training. It has highly rated educational value and has face, content, and construct validity.

A systematic review of the application of 3D-printed models to colorectal surgical training

BACKGROUND

The aim of this review was to explore the role of three-dimensional (3D) printing in colorectal surgical education and procedural simulation, and to assess the effectiveness of 3D-printed models in anatomic and operative education in colorectal surgery.

METHODS

A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify relevant publications relating to the use of 3D-printed models in colorectal surgery in an educational context. The search encompassed OVID Medline, Web of Science and EMBASE including papers in English published from 1 January 1995 to 1 January 2023. A total of 1018 publications were screened, and 5 met the criteria for inclusion in this review.

RESULTS

Four distinct 3D models were described across five studies. Two models demonstrated objective benefits in the use of 3D-printed models in anatomical education in academic outcomes at all levels of learner medical experience and were well accepted by learners. One model utilised for preoperative visualisation demonstrated improved operative outcomes in complete mesocolic excision compared with preoperative imaging review, with a 22.1% reduction in operative time (p < 0.001), 9.2% reduction in surgical duration (p = 0.035) and 37.3% reduction in intraoperative bleeding volume amongst novice surgeons (p < 0.01). Technical simulation has been demonstrated in a feasibility context in one model but remains limited in scope and application on account of the characteristics of available printing materials.

CONCLUSIONS

3D printing is well accepted and effective for anatomic education and preoperative procedural planning amongst colorectal surgeons, trainees and medical students but remains a technology in the early stages of its possible application. Technological advancements are required to improve the tissue realism of 3D-printed organ models to achieve greater fidelity and provide realistic colorectal surgical simulations.

Skill-qualified surgeons positively affect short-term outcomes after laparoscopic gastrectomy for gastric cancer: a survey of the National Clinical Database of Japan

BACKGROUND

Proficiency of the operating surgeon is one of the most critical factors potentially associated with reductions in complications and surgery-related mortality. With video-rating systems having shown potential for assessing laparoscopic surgeons' proficiency, the Endoscopic Surgical Skill Qualification System (ESSQS) was developed by the Japan Society for Endoscopic Surgery to subjectively assess the proficiency of laparoscopic surgeons by rating applicants' non-edited case videos. We conducted a study to evaluate how ESSQS skill-qualified (SQ) surgeon involvement influences short-term outcomes of laparoscopic gastrectomy performed for gastric cancer.

METHODS

Data from the National Clinical Database regarding laparoscopic distal and total gastrectomy performed for gastric cancer between January 2016 and December 2018 were analyzed. Operative mortality, defined as 30-day mortality or 90-day in-hospital mortality, and anastomotic leakage rates were compared per involvement vs. non-involvement of an SQ surgeon. Outcomes were also compared per involvement of a gastrectomy-, colectomy-, or cholecystectomy-qualified surgeon. The association between the area of qualification and operative mortality/anastomotic leakage was also analyzed with a generalized estimating equation logistic regression model used to account for patient-level risk factors and institutional differences.

RESULTS

Of 104,093 laparoscopic distal gastrectomies, 52,143 were suitable for inclusion in the study; 30,366 (58.2%) were performed by an SQ surgeon. Of 43,978 laparoscopic total gastrectomies, 10,326 were suitable for inclusion; 6501 (63.0%) were performed by an SQ surgeon. Gastrectomy-qualified surgeons outperformed non-SQ surgeons in terms of both operative mortality and anastomotic leakage. They also outperformed cholecystectomy- and colectomy-qualified surgeons in terms of operative mortality or anastomotic leakage in distal and total gastrectomy, respectively.

CONCLUSION

The ESSQS appears to discriminate laparoscopic surgeons who can be expected to achieve significantly improved gastrectomy outcomes.

Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality

OBJECTIVE

The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients.

DESIGN

Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database.

SETTING

Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included.

PARTICIPANTS

All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases.

RESULTS

There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP.

CONCLUSIONS

Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.

Education and training evolution in urolithiasis: A perspective from European School of Urology

Objective

With the worldwide increase in urolithiasis prevalence, the present study aimed to delineate and summarise recent evolutions in training for the management of urolithiasis.

Methods

A PubMed search using the key words "simulation", "training", "ureteroscopy", "RIRS", "URS", "percutaneous nephrolithotomy", "PCNL", "virtual reality", "augmented reality", "artificial intelligence", "healthcare", "curriculum", and "assessment" was used to examine how education and training in urolithiasis have adapted over recent years. Focus was placed on the role of high- and low-fidelity simulation models, virtual reality and artificial intelligence, and standardised assessment and curriculum.

Results

This review supports the necessity to incorporate technology, simulation, and other skill enhancement training modalities into surgical training. However, these cannot solely replace mentored training with an experienced professional supervisor. Whilst technological and simulation advancements are likely to prove increasingly important in urolithiasis training, it is just as important for stratification of robust curricula with validated assessment. We also propose a pathway for future training.

Conclusion

Endourology subspeciality training programmes have successfully incorporated simulation model-based training for skill acquisition, refinement, and improving operative outcomes. Success is achieved by maintaining a delicate balance between machine and in person mentor-based training. A trainee-centred model that follows the proposed curriculum could aid this balance for the future generation of trainees.

Objective structured clinical examination in basic thoracic ultrasound: a European study of validity evidence

BACKGROUND

Basic thoracic ultrasound is being used more frequently by clinicians in several settings due to its high diagnostic accuracy for many common causes of respiratory failure and dyspnoea. However, ultrasound examinations are operator-dependent, and sufficient competences are needed to obtain high sensitivity and specificity of examinations. Additionally, it is crucial for ultrasound operators to perceive the competence to interpret the images and integrate them into the patient history and other examinations. This study aims to explore and gather validity evidence for an objective structured clinical examination test of basic thoracic ultrasound competences and establish a pass/fail score.

METHODS

An expert panel created the test which included two theoretical and five practical stations representing cases with different diagnoses that cause respiratory symptoms and which are possible to establish by basic thoracic ultrasound. Twenty-five participants with different levels of experience in basic thoracic ultrasound completed the test. Data of the test scores were used for item analysis, and exploring validity evidence was done according to Messick's framework which is recommended. The contrasting groups' standard setting method was used to establish a pass/fail score.

RESULTS

The summarised internal consistency reliability was high with a Cronbach's alpha of 0.87. The novice group (n = 4) had a mean test score of 42 ± 10.1 points, the intermediate group (n = 8) scored 79.1 ± 8.1 points, and the experienced group (n = 13) 89.0 ± 6.2 points (one-way ANOVA, p < 0.001). A pass/fail score of 71 points was thus derived (maximum test score = 105 points).

CONCLUSION

We developed a test for the assessment of clinical competences in basic thoracic ultrasound with solid validity evidence, and a pass/fail standard with no false positives or false negatives.

A study of simulation training in laparoscopic bilioenteric anastomosis on a 3D-printed dry lab model

BACKGROUND

There are few studies on simulation training in laparoscopic bilioenteric anastomosis. There is also a lack of mature and reliable training models for bilioenteric anastomosis. In this study, we aimed to assess a feasible training model for bilioenteric anastomosis. Surgeons can improve their surgical ability by performing laparoscopic bilioenteric anastomosis on this model through repeated training.

METHOD

The original articles related to simulation training in surgical anastomosis were identified from January 2000 to November 2021 in the Clarivate Analytics Web of Science Core Collection database. We conducted a bibliometric analysis based on the country of these publications and the type of anastomosis. A 3D-printed bilioenteric anastomosis model was applied in this study. Baseline data of 15 surgeons (5 surgeons of Attendings, 5 surgeons of Fellows, and 5 surgeons of Residents) were collected. The bilioenteric anastomosis data, including the operation time and operation score, were recorded and analyzed. A study of the learning curve was also performed for further assessment.

RESULT

Surgeons at different levels of experience exhibited different levels of performance in conducting laparoscopic bilioenteric anastomosis on this model. Experienced surgeons completed their first training session in a shorter time and obtained a higher surgical score. In turn, repeated training significantly shortened the time of laparoscopic bilioenteric anastomosis for each trainer and improved the surgical score. Surgeons with different levels of experience needed different numbers of cases to reach the stable period of the learning curve. Experienced surgeons were able to reach a proficient level through fewer training cases.

CONCLUSION

A suitable biliary-enteric anastomosis model can help surgeons conduct simulation training and provide experience and skill accumulation for future real operations. Our training model performed well in this study and can effectively accomplish this goal.

Transferability of robotic console skills by early robotic surgeons: a multi-platform crossover trial of simulation training

Robotic surgical training is undergoing a period of transition now that new robotic operating platforms are entering clinical practice. As this occurs, training will need to be adapted to include strategies to train across various consoles. These new consoles differ in multiple ways, with some new vendors using flat screen open source 3D enhanced vision with glasses and differences in design will require surgeons to learn new skills. This process has parallels with aviation credentialling across different aircraft described as type rating. This study was designed to test the hypothesis that technical robotic console operating skills are transferrable across different robotic operating platforms. Ten participants sequentially completed four Mimic®(Surgical Science) simulation exercises on two different robotic operating platforms (DaVinci®, Intuitive Surgical and HUGO™ RAS, Medtronic). Ethical approval and informed consent were obtained for this study. Groups were balanced for key demographics including previous robotic simulator experience. Data for simulation metrics and time to proficiency were collected for each attempt at the simulated exercise and analysed. Qualitative feedback on multi-platform learning was sought via unstructured interviews and a questionnaire. Participants were divided into two groups of 5. Group 1 completed the simulation exercises on console A first then repeated these exercises on console B. Group 2 completed the simulated exercises on console B first then repeated these exercises on console A. Group 1 candidates adapted quicker to the second console and Group 2 candidates reached proficiency faster on the first console. Participants were slower on the second attempt of the final exercise regardless of their allocated group. Quality and efficiency metrics and risk and safety metrics were equivalent across consoles. The data from this investigation suggests that console operating skills are transferrable across different platforms. Overall risk and safety metrics are within acceptable limits regardless of the order of progression of console indicating that training can safely occur across multiple consoles contemporaneously. This data has implications for the design of training and certification as new platforms progress to market and supports a proficiency-based approach.

Simulation training of laparoscopic pancreaticojejunostomy and stepwise training program on a 3D-printed model

AIM

Laparoscopic pancreaticojejunostomy is among the most difficult and high-risk operations. Surgeons with low or moderate seniority rarely are allowed to perform this surgery in clinics. Therefore, there is an urgent need to develop a reliable simulation training model focused on laparoscopic pancreaticojejunostomy and an effective stepwise training program.

METHODS

Surgeons with different working experiences or exposure to different training programs at Sir Run Run Shaw Hospital were divided into four groups. Each was required to perform laparoscopic pancreaticojejunostomy using a designed three-dimensional dry lab model. All surgeons' baseline characteristics and surgical performance, including operation time and score, were recorded and analysed. The authenticity of the model was evaluated by four senior surgeons.

RESULTS

The surgeon group with higher seniority had an older average age, longer working time, and had completed more laparoscopic cholecystectomy and laparoscopic common bile duct exploration procedures. Meanwhile, the surgeon group with higher seniority presented better operation performance, including shorter operation time and higher operation score in their initial simulation training. Resident surgeons who underwent stepwise training with the laparoscopic biliary-enteric anastomosis training program showed better initial performance than resident surgeons who underwent stepwise training with the laparoscopic basic suture training program. After repeated training, the surgeons showed improved surgical performance.

CONCLUSION

Our pancreaticojejunostomy model showed a good degree of discernibility, as surgeons with more experience performed better with the model for their initial simulation training in laparoscopic pancreaticojejunostomy. Stepwise training of the laparoscopic biliary-enteric anastomosis training program helped surgeons obtain a better initial performance, and repeated simulation training on this model improved the surgeon's operative performance.

What are clinically relevant performance metrics in robotic surgery? A systematic review of the literature

A crucial element of any surgical training program is the ability to provide procedure-specific, objective, and reliable measures of performance. During robotic surgery, objective clinically relevant performance metrics (CRPMs) can provide tailored contextual feedback and correlate with clinical outcomes. This review aims to define CRPMs, assess their validity in robotic surgical training and compare CRPMs to existing measures of robotic performance. A systematic search of Medline and Embase databases was conducted in May 2022 following the PRISMA guidelines. The search terms included Clinically Relevant Performance Metrics (CRPMs) OR Clinically Relevant Outcome Measures (CROMs) AND robotic surgery. The study settings, speciality, operative context, study design, metric details, and validation status were extracted and analysed. The initial search yielded 116 citations, of which 6 were included. Citation searching identified 3 additional studies, resulting in 9 studies included in this review. Metrics were defined as CRPMs, CROMs, proficiency-based performance metrics and reference-procedure metrics which were developed using a modified Delphi methodology. All metrics underwent both contents and construct validation. Two studies found a strong correlation with GEARS but none correlated their metrics with patient outcome data. CRPMs are a validated and objective approach for assessing trainee proficiency. Evaluating CRPMs with other robotic-assessment tools will facilitate a multimodal metric evaluation approach to robotic surgery training. Further studies should assess the correlation with clinical outcomes. This review highlights there is significant scope for the development and validation of CRPMs to establish proficiency-based progression curricula that can be translated from a simulation setting into clinical practice.

A Systematic Review of Simulation-Based Training in Vascular Surgery

Introduction

Recent advancements in surgical technology, reduced working hours, and training opportunities exacerbated by the COVID-19 pandemic have led to an increase in simulation-based training. Furthermore, a rise in endovascular procedures has led to a requirement for high-fidelity simulators that offer comprehensive feedback. This review aims to identify vascular surgery simulation models and assess their validity and levels of effectiveness (LoE) for each model in order to successfully implement them into current training curricula.

Methods

PubMed and EMBASE were searched on January 1, 2021, for full-text English studies on vascular surgery simulators. Eligible articles were given validity ratings based on Messick’s modern concept of validity alongside an LoE score according to McGaghie’s translational outcomes.

Results

Overall 76 eligible articles validated 34 vascular surgery simulators and training courses for open and endovascular procedures. High validity ratings were achieved across studies for: content (35), response processes (12), the internal structure (5), relations to other variables (57), and consequences (2). Only seven studies achieved an LoE greater than 3/5. Overall, ANGIO Mentor was the most highly validated and effective simulator and was the only simulator to achieve an LoE of 5/5.

Conclusions

Simulation-based training in vascular surgery is a continuously developing field with exciting future prospects, demonstrated by the vast number of models and training courses. To effectively integrate simulation models into current vascular surgery curricula and assessments, there is a need for studies to look at trainee skill retention over a longer period of time. A more detailed discussion on cost-effectiveness is also needed.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany

Purpose

Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011.

Methods

This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008–2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables.

Results

Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data.

Conclusion

URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03903-2.