Original reportsSimulation-Based Ureteroscopy Training: A Systematic Review
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.
References (44)
- et al.
Virtual reality: surgical application—challenge for the new millennium
J Am Coll Surg
(2001) - et al.
Surgical simulation: a urological perspective
J Urol
(2008) - et al.
Methodologies for establishing validity in surgical simulation studies
Surgery
(2010) - et al.
A novel approach to endourological training: training at the Surgical Skills Center
J Urol
(2001) - et al.
Training on bench models improves dexterity in ureteroscopy
Eur Urol
(2005) - et al.
Validation of a high fidelity adult ureteroscopy and renoscopy simulator
J Urol
(2010) - et al.
The effect of bench model fidelity on endourological skills: a randomized controlled study
J Urol
(2002) - et al.
Randomized prospective blinded study validating acquistion of ureteroscopy skills using computer based virtual reality endourological simulator
J Urol
(2002) - et al.
Assessment of basic endoscopic performance using a virtual reality simulator
J Am Coll Surg
(2002) - et al.
Use of a virtual reality simulator for ureteroscopy training
J Urol
(2004)
Virtual ureteroscopy predicts ureteroscopic proficiency of medical students on a cadaver
J Urol
Effectiveness of procedural simulation in urology: a systematic review
J Urol
Analysis of surgical errors in closed malpractice claims at 4 liability insurers
Surgery
An update and review of simulation in urological training
Int J Surg
Teaching surgical skills—changes in the wind
N Engl J Med
Validation of surgical simulators
J Endourol
No time to train the surgeons
Br Med J
Simulation in surgery: opportunity or threat?
Ir J Med Sci
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
PLoS Med
The assessment of professional competence: developments, research and practical implications
Adv Health Sci Educ Theory Pract
Comparison of results of virtual-reality simulator and training model for basic ureteroscopy training
J Endourol
Comparative performance of high-fidelity training models for flexible ureteroscopy: are all models effective?
Indian J Urol
Cited by (52)
Education and training evolution in urolithiasis: A perspective from European School of Urology
2023, Asian Journal of UrologyThe development and validation of a new simulator for endourology
2023, Actas Urologicas EspanolasValidation of laparoscopy and flexible ureteroscopy tasks in inanimate simulation training models at a large-scale conference setting
2021, Asian Journal of UrologyCitation Excerpt :Flexible ureteroscopes are also expensive to upkeep especially if mishandled by novices. Therefore, a variety of low and high fidelity ureteroscopy training models have been developed and they have been validated to different extents [8] but limited by small numbers. In this context, we aimed to evaluate the feasibility of validating simulation-training tasks in both laparoscopy and flexible ureteroscopy rapidly at a conference setting for residents.
Development of a synchronous motion-tracking and video capture tool for flexible ureteroscopy
2024, Canadian Urological Association JournalEvaluation of XR Applications: A Tertiary Review
2023, ACM Computing Surveys