Elsevier

Journal of Surgical Education

Volume 72, Issue 1, January–February 2015, Pages 135-143
Journal of Surgical Education

Original reports
Simulation-Based Ureteroscopy Training: A Systematic Review

https://doi.org/10.1016/j.jsurg.2014.07.003Get rights and content

Objective

Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training.

Design

The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases.

Results

In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study.

Conclusions

Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice.

Introduction

“See one, do one, teach one,” this age-old saying has served surgical training well for many generations; however, this Halstedian model of apprenticeship has recently encountered several problems. Critics claim that this model is unstructured1 and will produce variable educational outcomes owing to the variable flow of patient cases and educational opportunities.2 On top of this, a staggering increase of technology has become available in surgery. Minimally invasive procedures such as ureteroscopy possess a steep learning curve and are not easily mastered3 because of the loss of the usual tactile feedback and depth perception from traditional 3-dimensional procedures.4

Training hours has become an additional concern with the implementation of regulations limiting the number of hours a trainee can work such as the European Working Time Directive. In the past a trainee could expect to have completed approximately 30,000 hours of training before getting a consultant post; this number now lies at 8000 hours.5 Moreover, changing patient attitudes toward being “practiced on,” means that legal and ethical considerations have become a major topic of concern.6 The fact that ureteroscopy is essentially a 1-man procedure also leads to practical difficulties within training. With these current challenges present, it is essential to train for these procedures before operating on patients, and this could be facilitated through surgical simulation. However, several simulators are available, each with their potential advantages and disadvantages (Table 1). These are often costly and therefore must undergo rigorous evaluation through validation studies3 before being used as an educational tool.

With these factors in mind this systematic review aims to the following: (1) to identify the available simulators for diagnostic and therapeutic ureteroscopy, (2) to explore the evidence for their effectiveness using the characteristic criterion, and (3) to recommend a curriculum based on the available literature.

Section snippets

Methods

This study was performed using the guidelines set out by the preferred reporting items for systematic reviews and meta-analysis statement.7

Study Selection

In total, 527 potentially relevant articles were identified. After abstract review, 498 articles were excluded and of the remaining 29 studies, a further 9 were excluded following full-text review. Thus, 20 original articles were included in the systematic review (Fig. 1).

Study Characteristics and Result Synthesis

Selected articles consisted of empirical studies that focused on training and assessment of ureteroscopy simulators. Results were classified according to training modality and then further subdivided into models available for

Uro-Scopic Trainer

The Uro-Scopic Trainer (Limbs & Things Ltd., Bristol, UK) is a high-fidelity physical model of the urinary tract incorporating the pelvis with an attached urethra, bladder, ureter, and collecting system that can be used with standard rigid and flexible ureteroscopy equipment (Fig. 2). Three studies analyzing the Uro-Scopic Trainer were identified. Matsumoto et al.10 used 17 urology residents and found pretest global scores were higher for senior residents than junior residents (27.8 vs 18.6, p

URO Mentor

The URO Mentor (Simbionix, Cleveland, OH) is a high-fidelity, Windows-based virtual-reality simulator that incorporates a mannequin and a computer interface. A variety of endoscopes can be used with a library of virtual patient cases and a range of objective parameters recorded. In total, 10 studies looking at the URO Mentor were identified. It was first described by Michel et al.17 Overall, 7 training courses used the simulator with a high degree of realism and usefulness for education

Animal Models

Overall, 3 studies describing porcine models for ureteroscopy were identified.27, 28, 29 All 3 studies simply described how to create these porcine models with any data regarding educational value still lacking. Despite this, 1 study described the successful use of these models in teaching courses with more than 150 urologists successfully trained using the model.29

Human Cadavers

Currently no validation studies have been performed for the use of human cadavers specifically to ureteroscopy training. However, freshly frozen cadavers have an established educational impact within cystoscopy via a randomized control study of 29 residents conducted by Bowling et al.30 (task specific checklist 92.9% vs 52.5%, p < 0.001 and global rating score 87.8% vs 57.6%, p < 0.001). Furthermore, although not directly assessing cadavers, they were used as the assessment tool to predict

Discussion

This article highlights the current state of validation (Table 3) that has been carried out on current modalities of training in ureteroscopy. Various bench models are currently available with the Uro-Scopic Trainer currently demonstrating face, construct, and concurrent validity and educational impact. Similarly, the Scope Trainer has been validated for content, construct, and predictive validity with educational impact also shown. Finally, the adult ureteroscopy trainer has been investigated

Conclusions

The current simulators available for ureteroscopy have been validated, but to differing levels. Therefore, further validation studies are required, particularly within the bench models. Additionally, further research is required for incorporating the models into a comprehensive curriculum. This should also integrate the nontechnical skills through full-immersive simulation to train and develop the skills that are required in modern surgical practice.

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