The Role of Simulation in Surgical Training: An Analysis of Controversies

Abstract

The technologies applied to surgery cause urologists to use modified anatomic approaches, different surgical steps, and new instruments. In parallel, patients themselves require novel techniques and expect improved outcomes. It has been suggested that the introduction of new surgical techniques, even in high-volume centers with experienced surgeons, leads to impaired outcomes, at least initially, compared with the standard [1]. In contrast, the traditional volume-based apprenticeship is associated with higher rates of complications until the initial part of the learning curve is reached [2]. Performing surgery on animal models and on human fresh cadavers has historically been the only available option. Animals provide a system with living tissues and reactions to tissue damage (eg, active bleeding), but they have different anatomy, even if somehow close, and do not represent a realistic pathologic model. Alternatively, cadavers offer the best anatomic experience, but the tissues are passive and generally healthy. Finally, both are limited by ethics and costs. For all of these reasons, surgical simulators are now considered possible learning tools for trainees to better perform surgery. Beyond these reasonable considerations, some questions should be raised. First, we must definitively distinguish basic tasks (eg, suturing, knot tying, cutting, tissue handling and manipulation, or dissection) from surgery, that is, a much more complex process that combines understanding of the disease and a permanent technical adaptation to local conditions. The ideal patient, if one exists, is certainly not representative of the daily, yearly, or even career experience of the surgeon.