Training on Bench Models Improves Dexterity in Ureteroscopy

doi:10.1016/j.eururo.2005.04.031

European Urology

Volume 48, Issue 3, September 2005, Pages 458-463

https://doi.org/10.1016/j.eururo.2005.04.031 Get rights and content

Abstract

Introduction:

There is a need for alternative training in endourology. Computerised simulators have been introduced but have, so far, not been compared to real surgery. Bench models have proved to be comparable to real surgery when performing standard procedures in the upper urinary tract.

Objective:

To validate training on bench models as a tool to improve dexterity in semi-rigid ureteroscopy.

Methods:

Urology residents were tested when performing semi-rigid ureteroscopy on a bench model (Mediskills), before and after training. All standard equipment and instruments, including fluoroscopy, were available. For the test procedure we used a task-specific checklist and a global score (maximum score 10 + 9 = 19). After base line assessment, the participants practised under supervision. After training they were reassessed, using the same procedure as previously.

Results:

The performance was significantly better after the training. Results before/after were: 5.1/9.2, 2.6/7.8 and 7.7/17.2 for task-specific checklist, global score and total score respectively. All residents felt more familiar with the instruments and the procedure after the training.

Conclusion:

Training on bench models for ureteroscopy enhanced the manual dexterity as well as familiarity with the method and is recommendable before operating on patients.

Introduction

There is a need for alternative training in endourology. Traditionally, surgery is learned by an inexperienced surgeon assisting a more senior colleague, and gradually performing the procedure by him- or herself. However, time in the operating room is costly and teaching is time consuming. There is also a safety aspect to consider. If the trainees have the opportunity to get familiar with the instruments as well as the surgical procedure, before operating on a patient, it is likely to be safer for the patient. It may also improve the trainee's self-confidence. Moreover, endourological procedures are often one-man procedures and therefore difficult to teach even though most centres have access to camera equipment.

Surgery on animals has been used for training in open surgery and laparoscopy but it is costly and not always approved of ethically. Less expensive, and maybe even more ethically acceptable, is to use the porcine urinary tract, from already slaughtered pigs, for training [1]. However, there is still the issue of the risk of infections by using the instrument in organs from an animal.

In recent years virtual reality (VR) simulators have been introduced as training tools. For laparoscopic surgery, it has been demonstrated that virtual reality training could improve the performance in the operating room [2]. Also in endourology VR simulators have been introduced. However, they have not yet been proved to be comparable to real surgery in the upper urinary tract. In a British study, the URO-Mentor simulator vas validated for cystoscopy [3]. Ten novice subjects with no endoscopic experience were compared to seven urologists with respect to their ability to find a number of landmarks in the bladder. Before training, the experienced urologists performed significantly better than the unexperienced group. After ten VR cystoscopies the novice subjects found as many landmarks as the urologists but they needed more time. It was concluded that the system has construct validity. In an American study, medical students and urology registrars were evaluated performing ureteroscopy on a VR simulator as well as on a human cadaver [4]. For the medical students, their performance on the VR simulator correlated well with their performance on the cadaver. However, this was not the case for the urology registrars.

Bench models have proved to be comparable to open surgery on animals and human cadavers for surgical training and assessment of surgical skill when objective structured assessment of surgical skills (OSATS) has been used [5].

In a previous study, a scope trainer from Mediskills Ltd, UK, was validated by our group [6]. Sixteen consultant urologists were assessed while performing semi-rigid ureteroscopy twice on patients and once on the Mediskills scope trainer, using the OSATS protocol. As in the present study, the model procedure was carried out in the operating room. The bench model, which is endoscopically very realistic, proved to be comparable to real surgery on patients for standard endoscopic procedures in the upper urinary tract.

The aim of the present study was to evaluate if training on the bench model simulator improved the ureteroscopic skill in urology trainees.

Section snippets

Material and methods

The study was organized as hands-on courses in cystoscopy and semi-rigid ureteroscopy. The first two courses were one-day courses, practising only semi-rigid ureteroscopy. The outcome was so positive that we decided to extend it to two-day courses and add a few tasks, placement of a double pig-tail catheter and endoscopic treatment of ureteric stones with Ho/Yag laser and pneumatic lithotripsy. However, the participants were tested for cystoscopy and semi-rigid ureteroscopy only. The courses

Results

Twenty-six urology residents were included in the study. Of the participants 11 were female and 15 male. Their previous experience in urology practice was 29 months (mean value), range 6–84 months. Their experience of advanced endourology was 3 months (mean value), range 0–18 months. Five of the participants had performed 6–10 ureteroscopies and seven had performed 1–5 procedures before attending the course. The other 14 participants had never performed the procedure themselves but they had all

Discussion

The need for alternative training in surgery has been brought to attention during the last ten years. As mentioned before, both safety and economical aspects urge for this kind of training. However, when it comes to alternative training it is important to know what is really practised and whether the training is transferable to the operating room. In some studies it has been proven that alternative training improves practical skills. Seymour et al. demonstrated that surgery registrars who had

Conclusions

Training on bench models in a realistic setting improved dexterity in endoscopic manoeuvres in the upper urinary tract. Training on models before operating on patients is recommendable.

Acknowledgements

We thank professor Steinar Karlsen and Dr Palle Osther, the theatre staff in Örebro University Hospital, Uppsala University Hospital and Karolinska University Hospital for participation and co-operation. We also thank Olympus Optical AB for providing camera equipment, cystoscopes and ureteroscopes and Boston Scientific Microvasive for providing endourological accessories.

The courses were supported by a grant from The Swedish Urological Association Foundation.

Editorial comment

M.P. Laguna,

References (14)

K. Ogan et al.
Virtual ureteroscopy predicts ureteroscopic proficiency of medical students
J Urol
(2004)
D. Anastakis et al.
Assessment of technical skills transfer from the bench training model to the human model
Am J Surg
(1999)
G. Velmahos et al.
Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory
Am J Surg
(2004)
E. Grober et al.
Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill
J Urol
(2004)
L. Jacomides et al.
Use of a virtual reality simulator for ureteroscopy training
J Urol
(2004)
J. Watterson et al.
A randomized, prospective blinded study validating the acquisition of ureteroscopy skills using a computer based virtual reality endourological simulator
J Urol
(2002)
D. Wilhelm et al.
Assessment of basic endoscopic performance using a virtual reality simulator
J Am Coll Surg
(2002)

There are more references available in the full text version of this article.

Cited by (52)

Education and training evolution in urolithiasis: A perspective from European School of Urology
2023, Asian Journal of Urology
With the worldwide increase in urolithiasis prevalence, the present study aimed to delineate and summarise recent evolutions in training for the management of urolithiasis.
A PubMed search using the key words “simulation”, “training”, “ureteroscopy”, “RIRS”, “URS”, “percutaneous nephrolithotomy”, “PCNL”, “virtual reality”, “augmented reality”, “artificial intelligence”, “healthcare”, “curriculum”, and “assessment” was used to examine how education and training in urolithiasis have adapted over recent years. Focus was placed on the role of high- and low-fidelity simulation models, virtual reality and artificial intelligence, and standardised assessment and curriculum.
This review supports the necessity to incorporate technology, simulation, and other skill enhancement training modalities into surgical training. However, these cannot solely replace mentored training with an experienced professional supervisor. Whilst technological and simulation advancements are likely to prove increasingly important in urolithiasis training, it is just as important for stratification of robust curricula with validated assessment. We also propose a pathway for future training.
Endourology subspeciality training programmes have successfully incorporated simulation model-based training for skill acquisition, refinement, and improving operative outcomes. Success is achieved by maintaining a delicate balance between machine and in person mentor-based training. A trainee-centred model that follows the proposed curriculum could aid this balance for the future generation of trainees.
Three Dimensional Printing Technology Used to Create a High-Fidelity Ureteroscopy Simulator: Development and Validity Assessment (Rein-3D-Print-UroCCR-39)
2023, Urology
To create and assess the validity of a high-fidelity, three dimensional (3D) printed, flexible ureteroscopy simulator resulting from a real case.
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.
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.
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.
Impact of simulation-based training in endourology: A systematic review of the literature
2022, Progres en Urologie
L’apport de la simulation sur l’acquisition des compétences techniques chirurgicales ainsi que leur transfert à l’environnement réel est débattu. L’objectif a été d’apporter des éléments de réponse sur ces deux points, en se focalisant sur le domaine de l’endo-urologie.
Une revue systématique de la littérature, suivant les recommandations PRISMA, a été effectuée à partir de la base de données Medline jusqu’à septembre 2021, sans restriction de temps. Les études s’attachant à analyser l’impact des modèles de simulation sur l’acquisition des compétences techniques chirurgicales ainsi que leur transfert à l’environnement réel dans le domaine de l’endo-urologie ont été incluses. Les interventions d’endo-urologie concernées étaient : la cystoscopie, l’urétéroscopie, la néphrolithotomie percutanée, le traitement endoscopique de l’hypertrophie bénigne de prostate, la résection endoscopique de vessie.
Sur les 11 442 études identifiées, cinquante-deux ont été incluses dans l’analyse. La majorité rapportait une amélioration du temps d’exécution de la tâche demandée et de la dextérité des participants, quel que soit le type de simulateur et d’intervention, bien que le niveau de preuve soit souvent faible. Peu d’études ont évalué le transfert des compétences acquises à l’environnement réel.
Cette revue a montré l’impact positif de la simulation sur l’acquisition des compétences techniques en endo-urologie. Cependant, afin d’intégrer au mieux ces outils dans le cursus des chirurgiens en formation, certains aspects tels que le choix de simulateurs de référence, des tâches et du mode de validation des acquis doivent être validés de manière consensuelle pour offrir une formation de qualité.
The impact of simulation on the acquisition of surgical skills as well as their transfer to the operating room is still debated. The objective was to assess these two specific points, focusing on the field of endourology.
A systematic review of the literature, following the PRIMA statement, was performed using Medline database through September 2021 without time limit. Studies focusing on the impact of simulators on the acquisition of surgical technical skills as well as their transfer to the operating room in the field of endourology were included. The endourological procedures were: cystoscopy, ureteroscopy, percutaneous nephrolithotomy, endoscopic treatment of benign prostatic hyperplasia, endoscopic bladder resection.
Among the 11,442 publications identified, fifty-two studies were included in the analysis. The majority reported an improvement in procedure time of the requested tasks and dexterity of participants, regardless of the type of simulator and procedure. The level of evidence of included studies was often low. Few studies evaluated the transfer of acquired skills from the simulator to the operating room.
This review showed the positive impact of simulation on the acquisition of technical skills in endourology. However, in order to include proficiency-based progression in the curriculum of trainees, some parameters such as the choice of reference simulators, choice of tasks, and method of validation of acquired skills must be validated in a consensual manner to offer a quality training.
Validation of laparoscopy and flexible ureteroscopy tasks in inanimate simulation training models at a large-scale conference setting
2021, Asian Journal of Urology
Simulation based training with training models is being increasingly used as a tool to help trainees mount the learning curve. However, validation studies of surgical simulators are often limited by small numbers. We aim to evaluate the feasibility of validating simulation-training tasks in laparoscopy and flexible ureteroscopy (FURS) rapidly at a large-scale conference setting for residents.
Seventy-six urology residents from various Asian countries were assessed on their laparoscopic and FURS skills during the 14th Urological Association of Asia Congress 2016. Residents performed the peg transfer task from the fundamentals of laparoscopic surgery (FLS) and completed inspection of calyces and stone retrieval using a flexible ureteroscope in an endourological model. Each participant's experience (no experience, 1–30 or >30 procedures) in laparoscopy, rigid ureteroscopy (RURS) and FURS was self-reported.
Median time taken to complete the laparoscopic task decreased with increasing laparoscopic experience (209 s vs. 177 s vs. 145 s, p=0.008) whereas median time taken to complete the FURS tasks reduced with increasing FURS experience (405 s vs. 250 s vs. 163 s, p=0.003) but not with RURS experience (400.5 s vs. 397 s vs. 331 s, p=0.143), demonstrating construct validity. Positive educational impact of both tasks was high, with mean ratings of 4.16/5 and 4.10/5 respectively, demonstrating face validity.
Our study demonstrates construct and face validities of laparoscopy and FURS simulation tasks among residents at a conference setting. Validation studies at a conference setting can be an effective avenue for evaluating simulation models and curriculum in the future.
Validation of the Advanced Scope Trainer for Flexible Ureterorenoscopy Training
2017, Urology
To validate the Advanced Scope Trainer (AST; Mediskills, Northampton, UK). The AST is a currently unvalidated simulator, developed for flexible ureterorenoscopy (fURS) training. This study aims to assess the face, content, construct, and concurrent validity to assess the level of transferability of skills to the operating room.
This prospective, observational, and comparative study recruited novices (n = 19) and trainees (n = 34), with participants performing a diagnostic fURS, followed by removal of a lower pole stone, on the AST. Fifteen participants performed a fURS on fresh frozen cadavers to assess concurrent validity. Trainees were supervised by expert urologists (n = 7) during each procedure. Performance was evaluated using the validated Objective Structured Assessment of Technical Skills (OSATS) assessment. Face and content validity were demonstrated by anonymous surveys from participants and faculty.
Face validity assessment revealed that trainees found the simulator was 76% realistic (3.8/5 on a Likert scale). Laser stone fragmentation (4.11 ± 0.85) and manual stone extraction (4.03 ± 0.85) were thought to be the most realistic components and guidewire insertion (3.14 ± 1.35) the least. Participants also believed the simulator to be useful, giving transferrable skills to take into the operating room, demonstrating content validity. Using an OSATS assessment, concurrent validity was demonstrated in “respect for tissue” (P = .0105) and “time and motion” (P = .0196). Construct validity was also demonstrated when comparing novices to trainees (mean OSATS 10.11 ± 2.28 vs 23.89 ± 5.38).
This study has demonstrated face, content, construct, and concurrent validity of the AST for fURS training. Further evaluation is necessary to demonstrate construct and predictive validity of skills gained using the model.
Effectiveness of a newly-developed training module using 3D printing for the navigation during retrograde intrarenal surgery
2022, Investigative and Clinical Urology

View all citing articles on Scopus

View full text

EndourologyTraining on Bench Models Improves Dexterity in Ureteroscopy

Abstract

Introduction:

Objective:

Methods:

Results:

Conclusion:

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Acknowledgements

J Urol

Am J Surg

Am J Surg

J Urol

J Urol

J Urol

J Am Coll Surg

Endourology
Training on Bench Models Improves Dexterity in Ureteroscopy