Current Status of Simulation and Training Models in Urological Surgery: A Systematic Review

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.

PATIENT SUMMARY

Simulation-based training and programs in which progression is based on proficiency represent the new standard of quality for achieving surgical proficiency in urology. Studies have demonstrated the educational impact of these approaches. However, there are still no standardized training pathways for several urology procedures.

Three Dimensional Printing Technology Used to Create a High-Fidelity Ureteroscopy Simulator: Development and Validity Assessment (Rein-3D-Print-UroCCR-39)

OBJECTIVE

To create and assess the validity of a high-fidelity, three dimensional (3D) printed, flexible ureteroscopy simulator resulting from a real case.

METHODS

A patient's CT scan was segmented to obtain a 3D model in .stl format, including the urinary bladder, ureter and renal cavities. The file was printed and a kidney stone was introduced into the cavities. The simulated surgery consisted of monobloc stone extraction. Nineteen participants split into 3 groups according to their level (6 medical students, 7 residents and 6 urology fellows) performed the procedure twice at a 1-month interval. They were rated according to a global score and a task-specific score, based on an anonymized, timed video recording.

RESULTS

Participants demonstrated a significant improvement between the 2 assessments, both on the global score (29.4 vs 21.9 points out of 35; P < .001) and the task-specific score (17.7 vs 14.7 points out of 20; P < .001) as well as procedure time (498.5 vs 700 seconds; P = .001). Medical students showed the greatest progress for the global score (+15.5 points (mean), P = .001) and the task-specific score (+6.5 points (mean), P < .001). 69.2% of participants considered the model as visually quite realistic or highly realistic and all of them judged it quite or extremely interesting for intern training purposes.

CONCLUSION

Our 3D printed ureteroscopy simulator was able to enhance the progress of medical students who are new to endoscopy, whilst being valid and reasonably priced. It could become part of a training program in urology, in line with the latest recommendations for surgical education.

Development and Validation of a Laparoscopy Simulation Model of Pyeloplasty for Pediatric Patients

Introduction: Given the extensive training required for laparoscopic pyeloplasty and the difficulties achieving this training, there is a need to recreate the activity in a controlled environment, but high-fidelity models are unavailable or expensive. Our objective was to develop a model of pyeloureteral junction stenosis, resembling the anatomical details and consistency of natural tissue, for a replicable, cheaper, and realistic simulation model of laparoscopic pyeloplasty in children. Materials and Methods: A three-dimensional, printed synthetic model was created from magnetic resonance urography. The model comprises a plastic kidney as the reusable structure and a silicone renal pelvis and ureter as the interchangeable structure. We evaluated realism and performance with surgeons and residents at different levels of training, comparing operative time and complications of the procedure. Results: Twenty-four participants were recruited; 41.7% had previous experience in laparoscopic pyeloplasty, with 5.5 years of experience in laparoscopic surgery (interquartile range [IQR] 2-7.75). There were no cases of stenosis, but leaks accounted for 41.7%. The procedure lasted 72 minutes (IQR 55-90), with significant differences according to the level of training (85 minutes for residents, 68 minutes for pediatric surgeons and urologists, and 40 minutes for laparoscopic surgeons; P: .011) and years of previous experience in laparoscopic surgery (P: .003). Conclusions: A high-fidelity, replicable, and low-cost pyeloureteral stenosis model was developed to simulate laparoscopic pyeloplasty in pediatric patients.

A systematic review of robotic surgery curricula using a contemporary educational framework

BACKGROUND

There has been a rising trend in robotic surgery. Thus, there is demand for a robotic surgery curriculum (RSC) for training surgical trainees and practicing surgeons. There are limited data available about current curricular designs and the extent to which they have incorporated educational frameworks. Our aim was to study the existing robotic surgery curricula using Kern's 6-step approach in curriculum development.

METHODS

A systematic review was conducted using PubMed, PubMed Central, Cochrane, Embase, and Scopus (we searched studies from 2001 to 2021). PRISMA Guidelines was used to guide the search. Curriculum designed for general surgery and its subspecialties were included. Urology and gynecology were excluded. The articles were reviewed by five reviewers.

RESULTS

Our review yielded 71 articles, including 39 curricula at 9 different settings. Using Kern's framework, we demonstrated that the majority of robotic surgery curricula contained all the elements of Kern's curricular design. However, there were significant deficiencies in important aspects of these curricula i.e., implementation, the quality of assessment tools for measurement of performance and evaluation of the educational value of these interventions. Most institutions used commercial virtual reality simulators (VRS) as the main component of their RSC and 23% of curricula only used VRS.

CONCLUSIONS

Although majority of these studies contained all the elements of Kern's framework, there are critical deficiencies in the components of existing curricula. Future curricula should be designed using established educational frameworks to improve the quality of robotic surgery training.

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.

A Radial Basis Function Neural Network Approach to Predict Preschool Teachers' Technology Acceptance Behavior

With the continual development of artificial intelligence and smart computing in recent years, quantitative approaches have become increasingly popular as an efficient modeling tool as they do not necessitate complicated mathematical models. Many nations have taken steps, such as transitioning to online schooling, to decrease the harm caused by coronaviruses. Inspired by the demand for technology in early education, the present research uses a radial basis function (RBF) neural network (NN) modeling technique to predict preschool instructors' technology usage in classes based on recognized determinant characteristics of technology acceptance. In this regard, this study utilized the RBFNN approach to predict preschool teachers' technology acceptance behavior, based on the theory of planned behavior, which states that behavioral achievement, in our case the actual technology use in class, depends on motivation, intention and ability, and behavioral control. Thus, this research design is based on an adapted version of the technology acceptance model (TAM) with eight dimensions: D1. Perceived usefulness, D2. Perceived ease of use, D3. Perceived enjoyment, D4. Intention to use, D5. Actual use, D6. Compatibility, D7. Attitude, and D8. Self-efficacy. According to the TAM, actual usage is significantly predicted by the other seven dimensions used in this research. Instead of using the classical multiple linear regression statistical processing of data, we opted for a NN based on the RBF approach to predict the actual usage behavior. This study included 182 preschool teachers who were randomly chosen from a project-based national preschool teacher training program and who responded to our online questionnaire. After designing the RBF function with the actual usage as an output variable and the other seven dimensions as input variables, in the model summary, we obtained in the training sample a sum of squares error of 37.5 and a percent of incorrect predictions of 43.3%. In the testing sample, we obtained a sum of squares error of 14.88 and a percent of incorrect predictions of 37%. Thus, we can conclude that 63% of the classified data are correctly assigned to the models' dependent variable, i.e., actual technology use, which is a significant rate of correct predictions in the testing sample. This high significant percentage of correct classification represents an important result, mainly because this is the first study to apply RBFNN's prediction on psychological data, opening up a new interdisciplinary field of research.

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

BACKGROUND

It is hypothesised that simulation enhances progression along the initial phase of the surgical learning curve.

OBJECTIVE

To evaluate whether residents undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This international, multicentre, randomised controlled trial recruited 94 urology residents with experience of zero to ten procedures and no prior exposure to simulation in ureterorenoscopy, selected as an index procedure.

INTERVENTION

Participants were randomised to simulation or conventional operating room training, as is the current standard globally, and followed for 25 procedures or over 18 mo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on the Objective Structured Assessment of Technical Skill (OSATS) scale over three consecutive operations, was measured. Surgical complications were evaluated as a key secondary outcome. This trial is registered at www.isrctn.com as ISCRTN 12260261.

RESULTS AND LIMITATIONS

A total of 1140 cases were performed by 65 participants, with proficiency achieved by 21 simulation and 18 conventional participants over a median of eight and nine procedures, respectively (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.72-2.75). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring a lower number of procedures (HR 0.89, 95% CI 0.39-2.02). Significant differences were observed in overall comparison of OSATS scores between the groups (mean difference 1.42, 95% CI 0.91-1.92; p < 0.001), with fewer total complications (15 vs 37; p = 0.003) and ureteric injuries (3 vs 9; p < 0.001) in the simulation group.

CONCLUSIONS

Although the number of procedures required to reach proficiency was similar, simulation-based training led to higher overall proficiency scores than for conventional training. Fewer procedures were required to achieve proficiency in the complex form of the index procedure, with fewer serious complications overall.

PATIENT SUMMARY

This study investigated the effect of simulation training in junior surgeons and found that it may improve performance in real operating settings and reduce surgical complications for complex procedures.

[Transurethral resection of the urinary bladder : Status quo and outlook on new developments]

BACKGROUND

Transurethral resection of the urinary bladder (TURB) is the standard intervention in the diagnostic workup and treatment of non-muscle invasive bladder cancer. In order to minimize cancer recurrence and potential complications, continuous technical development of TURB is of high clinical interest.

OBJECTIVES

Presentation of the current standards and discussion of technological changes.

MATERIALS AND METHODS

Analysis of the current guideline recommendations and literature research.

RESULTS

The limitations of classic monopolar TURB is supplemented by new resection methods (en bloc) and technologies (bipolar and laser resection). Along with improved visualization through partially established technologies of photodynamic and digital image enhancement, there is potential for optimization regarding the likelihood of recurrences and complications as well as the histological quality of the resected material.

CONCLUSION

A positive impact on the oncological value and safety of TURB seems possible through the use of modern technologies. Further establishment up to evidence-based guideline recommendations are necessary.

Development and assessment of an ex-vivo bench model aimed at laparoscopic ureteric reconstructive techniques

INTRODUCTION/BACKGROUND

Reconstructive and ablative urologic techniques require special technical mastery, especially the intracorporeal suturing.

OBJECTIVE

To report the subjective evaluation of a versatile ex-vivo model aimed to practice laparoscopic ureteric reconstructive techniques (LURT) on box-trainer.

STUDY DESIGN

The model is a continuous portion of porcine urinary bladder ("dilated pelvis"), the vesico-ureteral joint ("stenosis") and healthy ureter. All 127 participants (n = 119 urologists and n = 8 paediatric surgeons) performed on the model laparoscopic Anderson-Hynes dismembered pyeloplasty, and then, in the animal model, different LURT procedures (ureteroneocystostomy, ureteric reimplantation and/or dismembered pyeloplasty). The model was subjectively evaluated (face and content validity), through a 12 items questionnaire, based on a Likert scale (1-5 points) and a global question (1-10 points).

RESULTS

The total mean rating for 11/12 items was very high (>4points). Only one was rated under 3 points. The overall total mean rating from 1 to 10 points was very high (9.19 ± 0.82 points). In 10/12 items, expert's feedback (content validity) prevailed over non-experts (face validity).

DISCUSSION/CONCLUSION

The model was highly accepted for the practice of LURT techniques. Additionally, it is cost-effective, easy to assemble, ethically considerate, and realistic.

Recommendations for the use of coronary and valve simulators in cardiac surgical training: a systematic review

OBJECTIVES

The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results.

METHODS

A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed.

RESULTS

Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established.

CONCLUSIONS

Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest.

The SIMULATE ureteroscopy training curriculum: educational value and transfer of skills

Objective

Different simulation modalities may be utilised in a curricular fashion to benefit from the strengths of each training model. The aim of this study is to evaluate a novel multi-modality ureterorenoscopy (URS) simulation curriculum in terms of educational value, content validity, transfer of skills and inter-rater reliability.

Methods

This international prospective study recruited urology residents (n = 46) with ≤ 10 URS experience and no prior simulation training. Participants were guided through each phase of the expert-developed SIMULATE URS curriculum by trainers and followed-up in the operating room (OR). Video recordings were obtained during training. A post-training evaluation survey was distributed to evaluate content validity and educational value, using descriptive statistics. Performance was evaluated using the objective structured assessment of technical skills (OSATS) scale to measure improvement in scores throughout the curriculum. Pearson’s correlation coefficient and Cohen’s kappa tests were utilised to investigate correlation and agreement between raters.

Results

Participants reported gaining OR-transferrable skills (Mean: 4.33 ± 0.67) and demonstrated marked improvement in throughout the curriculum, transferred to the OR for both semi-rigid URS (p = 0.004) and flexible URS (p = 0.007). 70% of participants were successfully followed-up in the OR (n = 32). No differences were identified with the additional use of fresh frozen cadavers (p = 0.85, p = 0.90) and the URO Mentor VR simulator (p = 0.13, p = 0.22). A moderate level of correlation was noted on the video OSATS assessments, between two expert assessors (r = 0.70), but a poor agreement with the live rating.

Conclusion

The SIMULATE URS training curriculum received high educational value from participants, who demonstrated statistically significant improvement with consecutive cases throughout the curriculum and transferability of skills to the OR in both semi-rigid and flexible URS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03604-w.

Validation of a Bench-Top Training Model for Retrograde Intrarenal Surgery

OBJECTIVE

To validate the in-house built Styrofoam box bench-top training model for retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

This study was performed in the setting of a half-day RIRS course. During the course, participants performed RIRS on a locally built bench-top model. We recruited 26 participants, comprising 20 trainees and 6 experts. Trainees and experts were asked to fill a self-administered questionnaire assessing various components of RIRS to assess the face and content validity. For construct validity, experts using Objective Structured Assessment of Technical Skills (OSATS) rated trainees and the mean OSATS score of junior versus senior residents was compared.

RESULTS

As per trainees, the model was 86% (4.3/5) realistic, which was backed by experts who found this model to be 87.6% (4.38/5) realistic. The overall face validity of the model was 86.4% (4.32/5). The overall content validity of this model was 83.4% (4.17/5). Majority of the participants thought that this tool is useful for learning technique (4.38 ± 0.49) and safe-conduct (4.31 ± 0.73) of the procedure. The trainees concurred that the skills acquired are transferable to the operating room (4.23 ± 0.76). However, the construct validity by comparing mean OSATS score of junior versus senior residents was 19.5 ± 3.5 and 23 ± 4.5. A p value of 0.11 could not be established.

CONCLUSION

This study has demonstrated the face, content, and construct validity of the bench-top training model for RIRS. Further evaluation is necessary to compare its effectiveness against other available models to demonstrate concurrent validity.

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.

The effects of COVID-19 on training within urology: Lessons learned in virtual learning, human factors, non-technical skills and reflective practice

The COVID-19 pandemic has changed training and recruitment in urology in unprecedented ways. As efforts are made to ensure trainees can continue to progress, lessons can be learned to improve training and urological practice even after the acute phase of the pandemic is over. Novel methods of education through virtual learning have burgeoned amidst the social distancing the pandemic has brought. The importance of training in human factors and non-technical skills has also been brought to the fore while operating under the constraints of personal protective equipment and working in new teams and unfamiliar environments. This paper critically appraises the available evidence of how urological training has been affected by COVID-19 and the lessons we have learned and continue to learn going forward.

Level of Evidence

Not Applicable.

Development and validation a task-specific checklist for a microsurgical varicocelectomy simulation model

PURPOSE

To develop and validate a new test of specific technical skills required for microsurgical varicocelectomy.

MATERIALS AND METHODS

An electronic questionnaire was sent to 558 members of the Brazilian Society of Urology for the validation of the task-specific checklist (TSC) for assessment of microsurgical varicocelectomy. Participants who had experience in this procedure were selected as judges. For construct validation, 12 participants including attending urologists and urological residents in training were recruited for voluntary participation. We formed a group of three experts and a group of nine novices, who had to perform the steps of microsurgical varicocelectomy on a simulation model using human placenta. Each participant was filmed and two blinded raters would then evaluate their performance using the TSC of microsurgical varicocelectomy.

RESULTS

14 judges were recruited. The assessment tool was reformulated, according to the judges suggestions and had the content validity achieved. The final version of the TSC was comprised of the task-specific score, a series of 4 items scored in a binary fashion designed for microscopic sub-inguinal varicocelectomy. The differences between the performance of participants with different levels of experience reflected the construct validity. The reliability between the raters was high. The mean time required to complete the training of microsurgical varicocelectomy in simulation model was significantly shorter for experts compared to novices (201 vs. 496 seconds, p=0.01).

CONCLUSIONS

This preliminary study suggests that the task-specific checklist of microsurgical varicocelectomy is reliable and valid in assessing microsurgical skills.

Transurethral resection of bladder tumour (TURBT)

The goals of transurethral resection of bladder tumour (TURBT) are to identify and eradicate visualized bladder tumour if technically safe and feasible and to obtain a specimen of satisfactory quality to enable accurate histological diagnosis. In the setting of high grade bladder tumour this generally entails the inclusion of detrusor muscle and assessment for the presence of associated carcinoma in situ (CIS), lymphovascular involvement or any variant form of bladder cancer. This will assist in determining risk stratification and prognostication of the bladder cancer and guides further treatment planning. Conversely, if suboptimal TURBT is performed there will be detrimental consequences on patient outcomes in regards to undergrading or understaging, increased recurrence or progression, and subsequently need for further treatments including more invasive interventions. This review article firstly summarises the key principles and complications of TURBT, as well as significance of re-TURBT. We also discuss a number of modifications and advances in detection technology and resection techniques that have shown to improve perioperative as well as pathological and oncological outcomes of bladder cancer. They include enhanced cystoscopy such as blue light cystoscopy (BLC), narrow band imaging (NBI) and en bloc resection of bladder tumour (ERBT) technique using various types of energy source.

Non-technical skills for urological surgeons (NoTSUS): development and evaluation of curriculum and assessment scale

Objective

In the last decade non-technical skills (NTS) have emerged as a vital area for improvement within surgery. This study aims to develop and evaluate a Non-technical Skills for Urological Surgeons (NoTSUS) training curriculum and assessment scale.

Methods

This international, longitudinal and observational study began with a 3-round Delphi methodology to refine curriculum contents and rating scale. Sessions with up to four participants were delivered where each candidate undertook an independent scenario within the validated full immersion simulation environment. Candidates were assessed using both the NoTSS (Non-technical Skills for Surgeons) and NoTSUS rating scales by NTS-trained and non-trained experts. A post-training evaluation survey was distributed.

Results

62 participants comprising trainees (n = 43) and specialists (n = 19) undertook the NoTSUS course. The NoTSS and NoTSUS scales correlated well, with a mean difference of 3.3 in the overall total (p = 0.10, r = 0.53). However, there was significant differences in scores between the NoTSS-trained and non-trained raters (n = 28, p = 0.03). A one-way ANOVA test revealed significant improvement throughout the four simulation scenarios in each session (p = 0.02). The NoTSUS curriculum received positive feedback from participants and demonstrated educational value and acceptability.

Conclusions

The NoTSUS curriculum has demonstrated high educational value for NTS training aimed at urologists, with marked improvement throughout sessions. Correlation of NoTSUS and NoTSS scales proves its suitability for evaluating NTS in future training. Demonstration of inter-rater reliability indicates that the scale is reliable for use in assessment by expert faculty members. Furthermore, qualitative feedback from participants suggests gain of transferrable skills over the course.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03406-6) contains supplementary material, which is available to authorized users.

Simulation in Urological Training and Education (SIMULATE): Protocol and curriculum development of the first multicentre international randomized controlled trial assessing the transferability of simulation-based surgical training

OBJECTIVES

To report the study protocol for the first international multicentre randomized controlled trial investigating the effectiveness of simulation-based surgical training and the development process for an evidence-based training curriculum, to be delivered as an educational intervention.

PARTICIPANTS AND METHODS

This prospective, international, multicentre randomized controlled clinical and educational trial will recruit urology surgical trainees who must not have performed ≥10 of the selected index procedure, ureterorenoscopy (URS). Participants will be randomized to simulation-based training (SBT) or non-simulation-based training (NSBT), the latter of which is the current sole standard of training globally. The primary outcome is the number of procedures required to achieve proficiency, where proficiency is defined as achieving a learning curve plateau of 28 or more on an Objective Structured Assessment of Technical Skills (OSATS) assessment scale, for three consecutive operations, without any complications. All participants will be followed up either until they complete 25 procedures or for 18 months. Development of the URS SBT curriculum took place through a two-round Delphi process.

RESULTS

A total of 47 respondents, consisting of trainees (n = 24) with URS experience and urolithiasis specialists (n = 23), participated in round 1 of the Delphi process. Specialists (n = 10) finalized the content of the curriculum in round 2. The developed interventional curriculum consists of initial theoretic knowledge through didactic lectures followed by select tasks and cases on the URO-Mentor (Simbionix, Lod, Israel) VR Simulator, Uro-Scopic Trainer (Limbs & Things, Bristol, UK) and Scope Trainer (Mediskills, Manchester, UK) models for both semi-rigid and flexible URS. Respondents also selected relevant non-technical skills scenarios and cadaveric simulation tasks as additional components, with delivery subject to local availability.

CONCLUSIONS

SIMULATE is the first multicentre trial investigating the effect and transferability of supplementary SBT on operating performance and patient outcomes. An evidence-based training curriculum is presented, developed with expert and trainee input. Participants will be followed and the primary outcome, number of procedures required to proficiency, will be reported alongside key clinical secondary outcomes, (ISCRTN 12260261).

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.

Cadaveric Models for Renal Transplant Surgery Education: a Comprehensive Review

PURPOSE OF REVIEW

To evaluate the utility of cadaveric models for kidney transplant (KT) surgery training.

RECENT FINDINGS

Medline® and PubMed® databases were searched for English and Spanish language articles published describing different learning models used in KT formation. We evaluated the use of cadavers preserved by Thiel's embalming method (TEM) as KT simulation models. Students were divided in groups of 4 people: four trainees mentored by an expert in KT surgery. Among the trainees were surgical residents and low-experience surgeons. A total of 39 TEM preserved bodies were used, of which 75 viable renal grafts were obtained. In each cadaver, two complete transplantation processes were performed, each consisting of en bloc nephrectomy with the trunk of aorta and inferior vena cava, bench surgery and perfusion with saline of the organ, and KT surgery. As with any surgical procedure, learning KT surgery is a stepwise process that requires years of dedication. The models available for the surgical simulation of KT surgery allow to practice and achieve dexterity in performing the procedure in a safe and reproducible way. Training on TEM-preserved corpses offers a highly realistic model for the surgical simulation of KT surgery.

The role of dry-lab and cadaveric simulation for cystoscopy and intravesical Botulinum toxin injections

Background

The aim of this study is to assess validity of the ETXY Multifunctional trainer (ProDelphus, Olinda, Pernambuco, Brazil), a bench-top dry-lab model for simulation of cystoscopy and intravesical injections of Botulinum Toxin A (BTX-A) injections, in terms of educational value, feasibility and acceptability as well as evaluating the use of fresh frozen cadavers for intravesical BTX-A injections.

Methods

Prospective study with novice trainees and urologists (n=58) trained by experts (n=14) in a 30-min hands-on training session in intravesical administration of BTX-A over 6 training sessions throughout one year. Outcome measures were demonstrated through distribution and analysis of evaluation surveys on a 5-point Likert scale.

Results

There were 56 participants (96.6%) believed that the model has a role in training for the procedure. Participants also reported the training being an important confidence-booster for performing BTX-A injections (mean: 4.05/5) and useful for teaching procedural steps (mean: 3.89). Experts highly rated the realism of the simulator especially in simulation of needle penetration (mean: 3.98) and delivery (mean 4.03). Fresh frozen cadavers had a mean realism rating of 4.54 and participants affirmed that they should be routinely used for training and assessment (mean: 3.92).

Conclusions

This study demonstrated face and content validity in addition to establishing the feasibility and acceptability of the ETXY Multifunctional model in the training of intravesical BTX-A administration. Additionally, the simulator demonstrated educational value and fresh frozen cadavers were shown to be the preferred simulation modality for this procedure. Further evaluation in randomised controlled studies is needed to demonstrate higher evidence quality.

3D printing technology and its role in urological training

PURPOSE

Surgical simulation and 3D printing have both been gaining traction exclusively over the past decade, and now have started to appear simultaneously in current research. The opinion that surgical simulation should be part of surgery curricula is becoming ever more apparent. In this review, we highlight and briefly examine the 3D printing workflow, and each facet of the current body of literature using this technology in the augmentation of surgical training, in addition to the challenges currently faced.

METHODS

A broad literature search was conducted pertaining to the utilisation of 3D printing in urology, aiming to sample the majority of use-cases of this fairly novel technology. The 3D printing workflow, current use-cases of 3D printing as applied to urological training, and challenges faced have been described.

RESULTS

A respectable number of surgical use-cases utilising 3D printing technology in their development were identified, including but not limited to percutaneous nephrolithotomy, partial nephrectomy, renal transplantation, laparoscopic pyeloplasty, prostate brachytherapy, transurethral resection of bladder tumours, urethrovesical anastomosis simulation devices, in addition to laparoscopic trainers and robotic surgery phantoms.

CONCLUSION

Over the last decade, urology has taken this cutting-edge technology in its stride; flaunting its efficacy in the augmentation of a number of procedural training applications. The number of use cases for this technology is only expected to rise as its virtues are demonstrated, the ease of use and availability of 3D printing units advances, and costs abated.

Evaluation of the Endo-Uro trainer for semi-rigid ureteroscopy training

Background:

The aim of this study was to evaluate the validity of evidence of the Endo-Uro Trainer (SAMED, Dresden, Germany) for semi-rigid ureteroscopy.

Methods:

Novice (n = 29), intermediate-level (n = 25), and expert (n = 24) urological surgeons were recruited to participate in the study. Novices were allocated randomly to Groups A and B, where A performed two set procedures using the already validated Uro-Scopic Trainer (Limbs and Things, Bristol, UK), and Group B used the Endo-Uro trainer. Subsequently they were crossed over to perform the same two procedures using the other model. Intermediate and expert groups performed the same procedure on the Endo-Uro trainer only. Objective Structured Assessment of Technical Skills (OSATS) and the procedural times were collected and analyzed. All participants were invited to complete a final evaluation survey.

Results:

The evaluation survey revealed a realism rating in all aspects, with a mean Likert rating of 4.04/5. Significant differences were observed in performance time between novices and experts (p = 0.0014), and between intermediates and experts (p = 0.0113). OSATS scores differed significantly between all groups (p < 0.0001). Group B novices showed statistically significant improvement in performance time (p = 0.0012) and OSATS scores (p = 0.0439) after the crossover. Significant differences in performance time (p = 0.0025) between groups A and B were also observed post-crossover.

Conclusions:

This study demonstrated content validity for the Endo-Uro Trainer model. In addition, the model was shown to be capable of differentiating levels of experience, which contributes to the acceptance of the validity hypothesis. Improvement in performance using the model demonstrates its effectiveness for training.

Real-Time Needle Force Modeling for VR-Based Renal Biopsy Training with Respiratory Motion Using Direct Clinical Data

Realistic tool-tissue interactive modeling has been recognized as an essential requirement in the training of virtual surgery. A virtual basic surgical training framework integrated with real-time force rendering has been recognized as one of the most immersive implementations in medical education. Yet, compared to the original intraoperative data, there has always been an argument that these data are represented by lower fidelity in virtual surgical training. In this paper, a dynamic biomechanics experimental framework is designed to achieve a highly immersive haptic sensation during the biopsy therapy with human respiratory motion; it is the first time to introduce the idea of periodic extension idea into the dynamic percutaneous force modeling. Clinical evaluation is conducted and performed in the Yunnan First People's Hospital, which not only demonstrated a higher fitting degree (AVG: 99.36%) with the intraoperation data than previous algorithms (AVG: 87.83%, 72.07%, and 66.70%) but also shows a universal fitting range with multilayer tissue. 27 urologists comprising 18 novices and 9 professors were invited to the VR-based training evaluation based on the proposed haptic rendering solution. Subjective and objective results demonstrated higher performance than the existing benchmark training simulator. Combining these in a systematic approach, tuned with specific fidelity requirements, haptically enabled medical simulation systems would be able to provide a more immersive and effective training environment.

Effectiveness of the HoloLens mixed-reality headset in minimally invasive surgery: a simulation-based feasibility study

Background

The advent of Virtual Reality technologies presents new opportunities for enhancing current surgical practice. Studies suggest that current techniques in endoscopic surgery are prone to disturbance of a surgeon’s visual-motor axis, influencing performance, ergonomics and iatrogenic injury rates. The Microsoft^® HoloLens is a novel head-mounted display that has not been explored within surgical innovation research. This study aims to evaluate the HoloLens as a potential alternative to conventional monitors in endoscopic surgery.

Materials and methods

This prospective, observational and comparative study recruited 72 participants consisting of novices (n = 28), intermediate-level (n = 24) and experts (n = 20). Participants performed ureteroscopy, within an inflatable operating environment, using a validated training model and the HoloLens mixed-reality device as a monitor. Novices also completed the assigned task using conventional monitors; whilst the experienced groups did not, due to their extensive familiarity. Outcome measures were procedural completion time and performance evaluation (OSATS) score. A final evaluation survey was distributed amongst all participants.

Results

The HoloLens facilitated improved outcomes for procedural times (absolute difference, − 73 s; 95% CI − 115 to − 30; P = 0.0011) and OSAT scores (absolute difference, 4.1 points; 95% CI 2.9–5.3; P < 0.0001) compared to conventional monitors. Feedback evaluation demonstrated 97% of participants agreed or strongly agreed that the HoloLens will have a role in surgical education (mean rating, 4.6 of 5; 95% CI 4.5–4.8). Furthermore, 95% of participants agreed or strongly agreed that the HoloLens is feasible to introduce clinically and will have a role within surgery (mean rating, 4.4 of 5; 95% CI 4.2–4.5).

Conclusion

This study demonstrates that the device facilitated improved outcomes of performance in novices and was widely accepted as a surgical visual aid by all groups. The HoloLens represents a feasible alternative to the conventional setup, possibly by aligning the surgeon’s visual-motor axis.

[Simulation-based training in urology: A systematic literature review]

CONTEXT

Simulation-based training is taking an increasingly important place in surgical training and is becoming mandatory with the latest reform of the French medical studies.

OBJECTIVES

The objectives of this work were to report the various simulation tools available for the surgical training in urology, along with their validation level, through a systematic literature review.

DOCUMENTARY SOURCES

A search was conducted using Medline^® with the terms "urology" and "simulator". Articles in English and French were selected.

STUDY SELECTION

Two hundred and ninety-one abstracts were read, allowing for the selection of 154 articles read to assess their eligibility. Studies whose main objective was not the validation of a simulator, studies describing animal models or studies whose full text was not available were excluded.

RESULTS

One hundred and six studies were analyzed in this review. The simulators described were classified in 7 categories: laparoscopic surgery, robotic surgery, ureteroscopy, percutaneous nephrolithotomy, endoscopic bladder and prostate surgery, basic skills in urology, and ultrasound-guided prostate interventions simulators. Apparent and content validity were demonstrated for most simulators, but construct and predictive validity were often lacking.

LIMITATIONS

We did not consider the use of simulators as competency evaluation tools. Besides, the latest terminology proposed to define the various validation steps was not taken into account.

CONCLUSION

Many simulators are available in the field of urology and allow the reproduction of a large variety of urological procedures. However, their validation level is inconsistent, and has to be taken into account when choosing a simulator for surgical training, along with its cost, the eagerness of students to use the simulator and its availability.

Novel Use of Household Items in Open and Robotic Surgical Skills Resident Education

Background

The aim of this study was to investigate the effectiveness of surgical simulators created using household items and to determine their potential role in surgical skills training.

Methods

Ten urology residents attended a surgical skills workshop and practiced using surgical simulators and models. These included a wound closure model, an open prostatectomy model, a delicate tissue simulation, a knot-tying station, and a laparoscopic simulator. After the workshop, the residents completed a 5-point Likert questionnaire. Primary outcome was face validity of the models. Secondary outcomes included usefulness as a training tool and ability to replicate the models.

Results

All models were easily created and successfully represented the surgical task being simulated. Residents evaluated the activities as being useful for training purposes overall. They also felt confident that they could recreate the simulators.

Conclusion

Low-fidelity training models can be used to improve surgical skills at a reasonable cost. The models will require further evaluation to determine construct validity and to determine how the improvements translate to OR performance. While high-fidelity simulators may continue to be utilized in formal surgical training, residents should be encouraged to supplement their training with innovative homemade models.

Nontechnical Skills in Surgery: A Systematic Review of Current Training Modalities

BACKGROUND

The complexity of the operating room requires a surgeon to have both technical ability and an array of nontechnical skills. The emphasis on technical skills during surgical training is well established, however it is deficiencies in nontechnical skills that have been identified as the main cause of errors in the operating room.

OBJECTIVE

This systematic review aims to identify current methods used to teach nontechnical skills and how these methods are assessed to determine their validity, evidence, and role in training.

METHODS

MEDLINE and Embase databases were searched for English language articles between 2000 and 2017 for nontechnical surgical skills training. Original research articles were included if they described non-technical surgical skills training modalities and their assessment. Results were assessed for the level of evidence and each modality was awarded a level of recommendation, using a modified educational Oxford Centre for Evidence-Based Medicine classification, as adapted by the European Association of Endoscopic Surgery.

RESULTS

A total of 19 studies were identified pertaining to high fidelity simulation (n = 8), low fidelity simulation (n = 6), didactic teaching (n = 2) and crisis resource management (n = 3). Of the included studies 1 was classified Level 1b, 1 level 2b, 7 level 2b, 2 level 2c, and 8 level 3.

CONCLUSION

With the importance of nontechnical skills being increasingly recognized, it is essential for surgeons to receive adequate training in nontechnical skills. Therefore the most valuable teaching modalities such as high and low fidelity simulation needs to be implemented into surgical training curricula.

3D Printed Surgical Simulation Models as educational tool by maxillofacial surgeons

INTRODUCTION

The aim of this study was to evaluate whether inexpensive 3D models can be suitable to train surgical skills to dental students or oral and maxillofacial surgery residents. Furthermore, we wanted to know which of the most common filament materials, acrylonitrile butadiene styrene (ABS) or polylactic acid (PLA), can better simulate human bone according to surgeons' subjective perceptions.

MATERIALS AND METHODS

Upper and lower jaw models were produced with common 3D desktop printers, ABS and PLA filament and silicon rubber for soft tissue simulation. Those models were given to 10 blinded, experienced maxillofacial surgeons to perform sinus lift and wisdom teeth extraction. Evaluation was made using a questionnaire.

RESULTS

Because of slightly different density and filament prices, each silicon-covered model costs between 1.40-1.60 USD (ABS) and 1.80-2.00 USD (PLA) based on 2017 material costs. Ten experienced raters took part in the study. All raters deemed the models suitable for surgical education. No significant differences between ABS and PLA were found, with both having distinct advantages.

CONCLUSION

The study demonstrated that 3D printing with inexpensive printing filaments is a promising method for training oral and maxillofacial surgery residents or dental students in selected surgical procedures. With a simple and cost-efficient manufacturing process, models of actual patient cases can be produced on a small scale, simulating many kinds of surgical procedures.

Acute Ischemic Priapism Management: An Educational and Simulation Curriculum

Introduction

Ischemic priapism is a urologic emergency managed by both urologic and nonurologic providers in the community. Given ischemic priapism's rare occurrence and the time-sensitive nature of treatment, effective provider education on management of this entity is imperative. We sought to develop a low-cost effective simulation model and curriculum to enhance trainee education.

Methods

A comprehensive didactic curriculum based on national urologic guidelines was developed, along with a low-cost, easily reproducible priapism simulator using hot dogs and Red Vines candy. The simulators cost $1.25 each, and assembly took 10 minutes. All materials were reviewed by three urology faculty members. The curriculum was piloted with two andrology fellowship-trained urology faculty among eight urology residents (PGY2-PGY4/U1-U2) and one medical student. Participants provided feedback regarding the overall course as well as the face and content validity of the simulator.

Results

Cognitive test scores significantly improved on average by 15.0% (p = .002), and confidence improved from baseline somewhat or very much among 88.9% of participants after completion of the curriculum. The task trainer was rated easy to use (average score: 4.78 out of 5), and 77.8% of participants though it was somewhat or very useful for training (average score: 4.00 out of 5). Additionally, 77.8% recommended its incorporation into resident training (average score: 4.00 out of 5).

Discussion

This simulation curriculum is effective, inexpensive, and easily reproducible, making it ideal for groups with limited resources. Expanding access to simulation-based curricula on priapism management may improve education of both urologic and nonurologic trainees.

Establishing objective benchmarks in robotic virtual reality simulation at the level of a competent surgeon using the RobotiX Mentor simulator

Background

To establish objective benchmarks at the level of a competent robotic surgeon across different exercises and metrics for the RobotiX Mentor virtual reality (VR) simulator suitable for use within a robotic surgical training curriculum.

Methods

This retrospective observational study analysed results from multiple data sources, all of which used the RobotiX Mentor VR simulator. 123 participants with varying experience from novice to expert completed the exercises. Competency was established as the 25th centile of the mean advanced intermediate score. Three basic skill exercises and two advanced skill exercises were used.

Setting

King’s College London.

Participants

84 Novice, 26 beginner intermediates, 9 advanced intermediates and 4 experts were used in this retrospective observational study.

Results

Objective benchmarks derived from the 25th centile of the mean scores of the advanced intermediates provided suitably challenging yet also achievable targets for training surgeons. The disparity in scores was greatest for the advanced exercises. Novice surgeons are able to achieve the benchmarks across all exercises in the majority of metrics.

Conclusion

We have successfully created this proof-of-concept study, which requires validation in a larger cohort. Objective benchmarks obtained from the 25th centile of the mean scores of advanced intermediates provide clinically relevant benchmarks at the standard of a competent robotic surgeon that are challenging yet also attainable. That can be used within a VR training curriculum allowing participants to track and monitor their progress in a structured and progressional manner through five exercises. Providing clearly defined targets, ensuring that a universal training standard has been achieved across training surgeons.

Simulation in urological training: Where are we in 2017?

Traditional Halstedian principles are no longer compatible with modern day urological training. Changing patterns of healthcare provision and the advanced nature of minimally invasive urological surgery have resulted in trainees receiving reduced exposure to independent operative experience. The drive towards consultant-delivered care, coupled with the introduction of the European working time directive, necessitate the urology trainee to meet end-of-training competencies with fewer learning opportunities compared with previous generations. Simulation provides an opportunity to compensate for reduced operative experience by augmenting both technical and non-technical skills development. A variety of simulation models can be used from cadaveric, synthetic and animal models to advanced virtual reality to aid surgical training. Whilst simulation is not without limitations, it has the potential to significantly enhance procedural competency and non-technical skills in a risk-free environment. Clear benefits, including equipment familiarity and trainee confidence have been demonstrated. However, direct transferability of these benefits to an operating-theatre is not clearly evident. Whilst not a substitute for clinical practice, simulation is likely to prove itself as a valuable adjunct to urological training. In this narrative review, we examine the current literature on simulation training in relation to urological surgery.

Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review

OBJECTIVE

To conduct a systematic review of orthopedic training and assessment simulators with reference to their level of evidence (LoE) and level of recommendation.

DESIGN

Medline and EMBASE library databases were searched for English language articles published between 1980 and 2016, describing orthopedic simulators or validation studies of these models. All studies were assessed for LoE, and each model was subsequently awarded a level of recommendation using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education.

RESULTS

A total of 76 articles describing orthopedic simulators met the inclusion criteria, 47 of which described at least 1 validation study. The most commonly identified models (n = 34) and validation studies (n = 26) were for knee arthroscopy. Construct validation was the most frequent validation study attempted by authors. In all, 62% (47 of 76) of the simulator studies described arthroscopy simulators, which also contained validation studies with the highest LoE.

CONCLUSIONS

Orthopedic simulators are increasingly being subjected to validation studies, although the LoE of such studies generally remain low. There remains a lack of focus on nontechnical skills and on cost analyses of orthopedic simulators.

Transurethral Resection of Bladder Tumors: Improving Quality Through New Techniques and Technologies

PURPOSE OF REVIEW

Cystoscopy with transurethral resection of bladder tumors (TURBT) is essential in the diagnosis of bladder cancer as well as the management of non-muscle-invasive disease yet remains a comparatively imprecise procedure secondary to variability among patients, tumors, and surgeons alike. We will review evolving technologies and techniques used to enhance safety and efficacy of TURBT performance and education in the management of bladder cancer.

RECENT FINDINGS

Though a generally safe procedure, efficacy of TURBT in terms of complete tumor excision, appropriate pathologic diagnosis, and absence of complications can vary significantly with direct impact on patient outcomes. Application of new techniques including bipolar electrocautery and photodynamic enhancement continues to shape endoscopic management of bladder cancer and improve safety, tumor excision rates, and downstream outcomes. High-quality bladder tumor resection is essential for effective bladder cancer management. Technologies such as bipolar electrocautery and photodynamic visualization improve safety and tumor eradication. Improved education and surgical technique will further standardize high-level outcomes for patients undergoing TURBT.