REVIEWS Simulation-based training and assessment in urological surgery Abdullatif Aydin1, Nicholas Raison1, Muhammad Shamim Khan1,2, Prokar Dasgupta1,2 and Kamran Ahmed1,2
Abstract | Simulation has become widely accepted as a supplementary method of training. Within urology, the greatest number of procedure-specific models and subsequent validation studies have been carried out in the field of endourology. Many generic-skills simulators have been created for laparoscopic and robot-assisted surgery, but only a limited number of procedurespecific models are available. By contrast, open urological simulation has only seen a handful of validated models. Of the available modalities, virtual reality (VR) simulators are most commonly used for endourology and robotic surgery training, the former also employing many high-fidelity bench models. Smaller dry-lab and ex vivo animal models have been used for laparoscopic and robotic training, whereas live animals and human cadavers are widely used for full procedural training. Newer concepts such as augmented-reality (AR) models and patient-specific simulators have also been introduced. Several curricula, including one recommended within, have been produced, incorporating various different training modalities and nontechnical skills training techniques. Such curricula and validated models should be used in a structured fashion to supplement operating room training. Full immersion simulation An inflatable low-fidelity and highly immersive operating room environment utilised for technical and nontechnical skills training.
High-fidelity operating room simulation Simulation-based technical and nontechnical skills training in a dedicated high-fidelity operating room.
MRC Centre for Transplantation, King’s College London, 5th Floor Southwark Wing, Guy’s Hospital, London SE1 9RT, UK. 2 The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, 1st Floor Southwark Wing, Guy’s Hospital, London SE1 9RT, UK. 1
Correspondence to P.D.
[email protected] doi:10.1038/nrurol.2016.147 Published online 23 Aug 2016; corrected online 31 Aug 2016
In the past two decades, surgical education has been greatly influenced by industries such as aviation and the military, which heavily rely on simulation training before real-life exposure1,2. Through the use of simulation, a large part of the procedural learning curve can be acquired using training models; thus, training in the simulation laboratory has been widely adopted to enhance performance in the operating room3. As a result, surgical simulation has advanced at a rapid pace, becoming an established and valid method of training4–6. Technical skills can be acquired using a number of different simulation modalities including virtual reality (VR) simulators, bench-top models, animal tissue or live animals, and human cadavers, each with their own advantages and disadvantages (TABLE 1). Nontechnical skills (NTS) simulation training has not received as much attention, but is becoming increasingly more popular both in the clinical wards and operating-room setting. NTS training in the operating room can be conducted via full immersion simulation or high-fidelity operating room simulation. Despite an increase in the popularity of surgical training models7, these must be rigorously evaluated in order to demonstrate the validity, acceptability, reliability, and educational effect of each tool before it is
used in training and assessment. A number of parameters against which assessment of simulators must take place have been defined (BOX 1)8,9. This Review will provide an overview of the different types of simulation-based training tools available in endoscopic, laparoscopic, robotic, and open urological surgery, and evaluate the evidence for these tools in line with the widely used validation criteria. Furthermore, we will identify advances in urological simulation over the past 10 years, and recommend a training pathway for the use of simulation-based systems.
Endourology The closed-cavity nature of endourological surgery means that it is particularly well-suited to simulation training and, as a result, many training simulators have been produced in the past 20 years10 (TABLE 2). Virtual reality simulation Urolithiasis. The URO Mentor (Simbionix, USA) is a VR simulator that incorporates a mannequin and computer interface. The simulator includes a cystoscope, semirigid ureteroscope and a flexible scope, as well as guidewires and baskets. The URO Mentor simulates patient anatomy, instrument navigation, and contains a variety of preprogrammed basic tasks and a library of
NATURE REVIEWS | UROLOGY
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REVIEWS Key points • The largest number of urological training simulators have been produced for training in endourology; these models are also the most robustly evaluated, with the URO Mentor (Symbionix, USA) holding the highest level of evidence • Despite great numbers of generic skills simulators, laparoscopic and robotic procedural models are few in number • Development of models for open urological surgery has been limited, with currently available models supported by only low levels of evidence • A number of curricula have been produced, incorporating various different training modalities and nontechnical skills, with the aim of optimizing simulation training • Patient-specific simulation — in the form of virtual reality (VR) simulators and 3D-printed models — is on the increase, which could prove to be useful in anticipation of complex cases • A curriculum for training in urological techniques is recommended
virtual stones and stricture cases for practicing semirigid and flexible ureteroscopy (URS). For each task, a range of objective parameters are recorded. Following development, this system has become the most thoroughly evaluated simulator in urology, with many studies demonstrating its validity (TABLE 2). It has demonstrated face11–14, content13,14, and construct11,12,15–20 validity for cystoscopy training, whereby significant improvements have been observed in the surgical skill levels of novices in direct correlation with simulator time (P
