Urology Residents' Experience and Attitude Toward Surgical Simulation: Presenting our 4-Year Experience With a Multi-institutional, Multi-modality Simulation Model

Surgical education in urogynecology from low fidelity to virtual reality: Systematic review

IMPORTANCE

Increase dissemination of educational tools in urogynecology.

OBJECTIVE

Describe the effectiveness and public availability of published educational tools for urogynecologic surgery.

STUDY DESIGN

A systematic review was conducted by searching MEDLINE, EMBASE, Cochrane Library, and Web of Science from 1946 to 2023 for articles describing educational tools in urogynecology. There were no restrictions on study design or language. Data were extracted in duplicate using a standardized piloted extraction form, and outcomes were combined descriptively.

RESULTS

2997 titles, 457 abstracts, and 97 full-text articles were analyzed. Of the 97 interventions included, 43 were manuscripts and 54 were conference abstracts. The median study quality was low, with a moderate risk of bias. Six intervention categories were identified: didactics, animal models, cadavers, static models, extended reality (XR), and multimodal workshops. Didactics were subjectively useful for teaching pelvic anatomy and diseases and improving surgical techniques. If good quality, animal models and cadavers provided visual and tactile learning and assessed performance in real-time. Animal models were also anatomically realistic and useful at half the cost of cadavers. Static models and XR improved confidence, knowledge, skills, and error rates despite lack of realism and accurate tissue texture in some models and steep learning curve with XR. Only four models were commercially accessible. Most studies did not assess long-term (>6 months) retention.

CONCLUSION

All educational modalities for urogynecologic surgery are largely realistic and increase participant satisfaction, preparedness, knowledge, skills, and likelihood of use. But only 40% advanced to manuscripts, and even fewer (<5%) were widely available.

Residency Surgical BPH Training Paradigms from MIST to HOLEP

PURPOSE OF REVIEW

Benign prostatic hyperplasia (BPH) is a common medical condition of older men that often requires medical or surgical therapy. Surgical options for BPH have grown exponentially over the last two decades. The numerous options and/or lack of access to them can make it challenging for new trainees to gain proficiency. We examine the literature for available BPH surgical simulators, learning curves, and training pathways.

RECENT FINDINGS

Each BPH surgical therapy has a learning curve which must be overcome. There is an abundance of TURP simulators which have shown face, content, and construct validity in the literature. Similarly, laser therapies have validated simulators. Newer technologies do have available simulators, but they have not been validated. There are strategies to improve learning and outcomes, such as having a structured training program. Simulators are available for BPH surgical procedures and some have been implemented in urology residencies. It is likely that such simulation may make urologists more facile on their learning curves for newer technologies. Further studies are needed. Future directions may include integration of simulator technology into training pathways that include surgical observation and proctorship.

Ex Vivo Porcine Model for Robot-Assisted Partial Nephrectomy Simulation at a High-Volume Tertiary Center: Resident Perception and Validation Assessment Using the Global Evaluative Assessment of Robotic Skills Tool

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and effectiveness of an ex vivo porcine training model as a useful tool to improve surgical skill and confidence with robot-assisted partial nephrectomy (RAPN) among urology residents. Methods: A 2.5 cm circular area of ex vivo porcine kidneys was marked as the area of the tumor. Tumor excision and renorrhaphy was performed by trainees using a da Vinci Si robot. All residents ranging from postgraduate year (PGY) 2 to 5 participated in four training sessions during the 2017 to 2018 academic year. Each session was videorecorded and scored using the global evaluative assessment of robotic skills (GEARS) by faculty members. Results: Twelve residents completed the program. Initial mean GEARS score was 16.7 and improved by +1.4 with each subsequent session (p = 0.008). Initial mean excision, renorrhaphy, and total times were 8.2, 13.9, and 22.1 minutes, which improved by 1.6, 2.0, and 3.6 minutes, respectively (all p < 0.001). Residents' confidence at performing RAPN and robotic surgery increased after completing the courses (p = 0.012 and p < 0.001, respectively). Overall, residents rated that this program has greatly contributed to their skill (4/5) and confidence (4.1/5) in robotic surgery. Conclusions: An ex vivo porcine simulation model for RAPN and robotic surgery provides measurable improvement in GEARS score and reduction in procedural time, although significant differences for all PGY levels need to be confirmed with larger study participation. Adoption of this simulation in a urology residency curriculum may improve residents' skill and confidence in robotic surgery.

Urology Residents' Experience With Simulation: Initial Evaluation of MRI/US Fusion Biopsy Workshop

OBJECTIVE

To evaluate our initial experience with a multi-institutional workshop model of MRI/US fusion biopsy simulation for resident education.

METHODS

Residents from 6 Chicago area urology programs participated in a MRI/US fusion biopsy workshop, which incorporated a 30 minute didactic session followed by hands-on simulation. The workshop was facilitated by fellowship-trained university faculty members and company representatives of MRI/US fusion technologies who provided teaching assistance and verbal feedback. Participants completed pre- and post-test nonvalidated 4-item questionnaires graded on a Likert scale. Information on resident prior experience with TRUS and MRI/US fusion biopsies was also collected. Pre-and postquestionnaires were compared with paired t tests for each survey domain (P <.05 were considered significant).

RESULTS

Thirty-three residents (PGY 1-6, median PGY 3) participated in the workshop. 13 (40.6%) residents reported performing between 51 and 100 TRUS biopsies previously. Twenty-one (65.6%) reported being familiar with PIRADS v2 interpretation of prostate MR imaging, however 17 (53.1%) had never previously performed a MRI/US fusion biopsy. Analysis of pre- and post-test questionnaires showed significant increases in all 4 survey domains (P <.05). Residents demonstrated increased familiarity with indications for fusion biopsy (mean difference = +0.59), preparation for fusion biopsy (mean difference = +1.16), methods of MRI to TRUS image registration (mean difference = +1.38), and the advantages/disadvantages of perineal vs TRUS fusion biopsy (mean difference = +1.25).

CONCLUSION

This workshop model which combines didactics followed by hands-on simulation training is an effective method for increasing the knowledge and familiarity with MRI/US fusion biopsy of trainees.

GreenLight Laser for benign prostatic hyperplasia

PURPOSE OF REVIEW

GreenLight photoselective vaporization (GL-PV) is now established in the treatment of benign prostatic enlargement. The present review outlines the available technical armamentarium and summarizes the current best evidence on functional and safety outcomes. Moreover, future technical developments and refinements are presented.

RECENT FINDINGS

GL-PV has evolved to be the most commonly performed procedure, second to conventional transurethral resection of the prostate (TURP) for surgical management of benign prostatic obstruction (BPO). On the basis of the data published in the randomized controlled Goliath study, GL-PV with 180-W technology is noninferior in terms of functional outcomes compared with TURP considering short and intermediate follow-up with a complication-free rate of around 80% after 24 months.The ongoing push towards high-power lasers can be explained by their more effective tissue ablative effect, leading to shorter operating times. Comparative analysis between high-power and low-power laser systems demonstrated similar retreatment rates and most institutions are, therefore, now performing 180-W GL-PV.Performed as an outpatient procedure, GL-PV is cost-effective with a low hospital re-admission rate. Plasma kinetic vaporization of the prostate (PKVP) has recently emerged as a potential contender in the field; also GreenLight enucleation of the prostate (GreenLEP) might be even more effective than GL-PV.

SUMMARY

GL-PV appears to be a well tolerated surgical alternative for patients suffering from BPO. Long-term follow-up data from 120-W and 180-W laser systems are still pending. Potential competitors have recently been brought to the market and further trials and long-term data will show, whether GL-PV will stand the test of time. Regardless of technical specifications, surgeon's experience remains essential to achieve good functional and safety outcomes.