Evaluation of a Virtual Reality Percutaneous Nephrolithotomy (PCNL) Surgical Simulator

A Systematic Review of Immersive Virtual Reality for Nontechnical Skills Training in Surgery

OBJECTIVE

Immersive virtual reality (IVR) can be utilized to provide low cost and easily accessible simulation on all aspects of surgical education. In addition to technical skills training in surgery, IVR simulation has been utilized for nontechnical skills training in domains such as clinical decision-making and pre-operative planning. This systematic review examines the current literature on the effectiveness of IVR for nontechnical skill acquisition in surgical education.

DESIGN

A literature search was performed using MEDLINE, EMBASE, and Web of Science for primary studies published between January 1, 1995 and February 9, 2022. Four reviewers screened titles, abstracts, full texts, extracted data, and analyzed included studies to answer 5 key questions: How is IVR being utilized in nontechnical skills surgical education? What is the methodological quality of studies? What technologies are being utilized? What metrics are reported? What are the findings of these studies?

RESULTS

The literature search yielded 2340 citations, with 12 articles included for qualitative synthesis. Of included articles, 33% focused on clinical decision-making and 67% on anatomy/pre-operative planning. Motion sickness was a recorded metric in 25% of studies, with an aggregate incidence of 13% (11/87). An application score was reported in 33% and time to completion in 16.7%. A commercially developed application was utilized in 25%, while 75% employed a noncommercial application. The Oculus Rift was used in 41.7% of studies, HTC Vive in 25%, Samsung Gear in 16.7% of studies, Google Daydream in 8%, and 1 study did not report. The mean Medical Education Research Quality Instrument (MERSQI) score was 10.3 ± 2.3 (out of 18). In all studies researching clinical decision-making, participants preferred IVR to conventional teaching methods and in a nonrandomized control study it was found to be more effective. Averaged across all studies, mean scores were 4.33 for enjoyment, 4.16 for utility, 4.11 for usability, and 3.73 for immersion on a 5-point Likert scale.

CONCLUSIONS

The IVR nontechnical skills applications for surgical education are designed for clinical decision-making or anatomy/pre-operative planning. These applications are primarily noncommercially produced and rely upon a diverse array of HMDs for content delivery, suggesting that development is primarily coming from within academia and still without clarity on optimal utilization of the technology. Excitingly, users find these applications to be immersive, enjoyable, usable, and of utility in learning. Although a few studies suggest that IVR is additive or superior to conventional teaching or imaging methods, the data is mixed and derived from studies with weak design. Motion sickness with IVR remains a complication of IVR use needing further study to determine the cause and means of mitigation.

Recent Advances in Surgical Simulation For Resident Education

PURPOSE OF REVIEW

Surgical simulation has become a cornerstone for the training of surgical residents, especially for urology residents. Urology as a specialty bolsters a diverse range of procedures requiring a variety of technical skills ranging from open and robotic surgery to endoscopic procedures. While hands-on supervised training on patients still remains the foundation of residency training and education, it may not be sufficient to achieve proficiency for graduation even if case minimums are achieved. It has been well-established that simulation-based education (SBE) can supplement residency training and achieve the required proficiency benchmarks.

RECENT FINDINGS

Low-fidelity modules, such as benchtop suture kits or laparoscopic boxes, can establish a strong basic skills foundation. Eventually, residents progress to high-fidelity models to refine application of technical skills and improve operative performance. Human cadavers and animal models remain the gold standard for procedural SBE. Recently, given the well-recognized financial and ethical costs associated with cadaveric and animal models, residency programs have shifted their investments toward virtual and more immersive simulations. Urology as a field has pushed the boundaries of SBE and has reached a level where unexplored modalities, e.g., 3D printing, augmented reality, and polymer casting, are widely utilized for surgical training as well as preparation for challenging cases at both the residents, attending and team training level.

Preoperative Virtual Reality Surgical Rehearsal of Renal Access during Percutaneous Nephrolithotomy: A Pilot Study

Percutaneous Nephrolithotomy (PCNL) is a procedure used to treat kidney stones. In PCNL, a needle punctures the kidney through an incision in a patient’s back and thin tools are threaded through the incision to gain access to kidney stones for removal. Despite being one of the main endoscopic procedures for managing kidney stones, PCNL remains a difficult procedure to learn with a long and steep learning curve. Virtual reality simulation with haptic feedback is emerging as a new method for PCNL training. It offers benefits for both novices and experienced surgeons. In the first case, novices can practice and gain kidney access in a variety of simulation scenarios without offering any risk to patients. In the second case, surgeons can use the simulator for preoperative surgical rehearsal. This paper proposes the first preliminary study of PCNL surgical rehearsal using the Marion Surgical PCNL simulator. Preoperative CT scans of a patient scheduled to undergo PCNL are used in the simulator to create a 3D model of the renal system. An experienced surgeon then planned and practiced the procedure in the simulator before performing the surgery in the operating room. This is the first study involving survival rehearsal using a combination of VR and haptic feedback in PCNL before surgery. Preliminary results confirm that surgical rehearsal using a combination of virtual reality and haptic feedback strongly affects decision making during the procedure.

Trends and Innovations of Simulation for Twenty First Century Medical Education

In the last two decades there has been an enormous growth in the use of clinical simulation. This teaching-learning methodology is currently the main tool used in the training of healthcare professionals. Clinical simulation is in tune with new paradigms in education and is consistent with educational theories that support the use of experiential learning. It promotes the development of psychomotor skills and strengthens executive functions. This pedagogical approach can be applied in many healthcare topics and is particularly relevant in the context of restricted access to clinical settings. This is particularly relevant considering the current crisis caused by the COVID-19 pandemic, or when trying to reduce the frequency of accidents attributed to errors in clinical practice. This mini-review provides an overview of the current literature on healthcare simulation methods, as well as prospects for education and public health benefits. A literature search was conducted in order to find the most current trends and state of the art in medical education simulation. Presently, there are many areas of application for this methodology and new areas are constantly being explored. It is concluded that medical education simulation has a solid theoretical basis and wide application in the training of health professionals at present. In addition, it is consolidated as an unavoidable methodology both in undergraduate curricula and in continuing medical education. A promising scenario for medical education simulation is envisaged in the future, hand in hand with the development of technological advances.

Percutaneous nephrolithotomy - the puncture

OBJECTIVE

To determine what importance is given to the puncture and assistive technologies in percutaneous nephrolithotomy (PNL) in the current urological literature.

METHODS

PubMed was searched for English publications and reviews for the keywords: 'percutaneous nephrolithotomy', 'percutaneous nephrostomy', 'puncture'. The search was limited to the last 5 years, January 2016 until February 2021. Based on 183 abstracts, 121 publications were selected, read, and reviewed. References, older or seminal papers were read and cited if they contributed to a better understanding. A total of 198 references form the basis of this narrative review.

RESULTS

The puncture is frequently referred to as the most crucial part of PNL. In contrast, the influence of the puncture on the failure rate of PNL and the specific puncture-related complications seems to be low in the single-digit percentage range. However, there are no universally accepted definitions and standards measuring the quality of puncture. Consequently, the impact of the puncture on general PNL complications, on stone scores predicting success rates and on learning curves evaluating surgeons' performance have not been systematically studied. Assistive technologies rely on fluoroscopy and ultrasonography, the latter of which is becoming the preferred imaging modality for monitoring the entire procedure. Needle bending, a problem relevant to all puncture techniques, is not addressed in the urological literature.

CONCLUSIONS

The importance attached to puncture in PNL in the current urological literature is subjectively high but objectively low. Some basics of puncture are not well understood in urology. Disciplines other than urology are more actively involved in the development of puncture techniques.

Data analytics interrogates robotic surgical performance using a microsurgery-specific haptic device

OBJECTIVES

With the increase in robot-assisted cases, recording the quantifiable dexterity of surgeons is essential for proficiency evaluations. The present study employs sensor-based kinematics and recorded surgeon experience for evaluating a new haptic device.

METHODS

Thirty surgeons performed a task simulating micromanipulation with neuroArmPLUS^HD and two commercially available hand-controllers. The surgical performance was evaluated based on subjective measures obtained from survey and objective features derived from the sensors. Statistical analyses were performed to assess the hand-controllers and regression analysis was used to identify the key features and develop a machine learning model for surgical skill assessment.

FINDINGS

MANCOVA tests on objective features demonstrated significance (α = 0.05) for time (p = 0.02), errors (p = 0.01), distance (p = 0.03), clutch incidents (p = 0.03), and forces (p = 0.00). The majority of metrics were in favor of neuroArmPLUS^HD. The surgeons found it smoother, more comfortable, less tiring, and easier to maneuver with more realistic force feedback. The ensemble machine learning model trained with 5-fold cross-validation showed an accuracy (SD) of 0.78 (0.15) in surgeon skill classification.

CONCLUSIONS

This study validates the importance of incorporating a superior haptic device in telerobotic surgery for standardization of surgical education and patient care.