Endourology Training Research Articles

Endourological panorama and current state of training in endourology among European teaching hospitals.

Endourological panorama and current state of training in endourology among European teaching hospitals.

Trends of "Artificial Intelligence, Machine Learning, Virtual Reality, and Radiomics in Urolithiasis" over the Last 30 Years (1994-2023) as Published in the Literature (PubMed): A Comprehensive Review.

Purpose: To analyze the bibliometric publication trend on the application of "Artificial Intelligence (AI) and its subsets (Machine Learning-ML, Virtual reality-VR, Radiomics) in Urolithiasis" over 3 decades. We looked at the publication trends associated with AI and stone disease, including both clinical and surgical applications, and training in endourology. Methods: Through a MeshTerms research on PubMed, we performed a comprehensive review from 1994-2023 for all published articles on "AI, ML, VR, and Radiomics." Articles were then divided into three categories as follows: A-Clinical (Nonsurgical), B-Clinical (Surgical), and C-Training articles, and articles were then assigned to following three periods: Period-1 (1994-2003), Period-2 (2004-2013), and Period-3 (2014-2023). Results: A total of 343 articles were noted (Groups A-129, B-163, and C-51), and trends increased from Period-1 to Period-2 at 123% (p = 0.009) and to period-3 at 453% (p = 0.003). This increase from Period-2 to Period-3 for groups A, B, and C was 476% (p = 0.019), 616% (0.001), and 185% (p < 0.001), respectively. Group A articles included rise in articles on "stone characteristics" (+2100%; p = 0.011), "renal function" (p = 0.002), "stone diagnosis" (+192%), "prediction of stone passage" (+400%), and "quality of life" (+1000%). Group B articles included rise in articles on "URS" (+2650%, p = 0.008), "PCNL"(+600%, p = 0.001), and "SWL" (+650%, p = 0.018). Articles on "Targeting" (+453%, p < 0.001), "Outcomes" (+850%, p = 0.013), and "Technological Innovation" (p = 0.0311) had rising trends. Group C articles included rise in articles on "PCNL" (+300%, p = 0.039) and "URS" (+188%, p = 0.003). Conclusion: Publications on AI and its subset areas for urolithiasis have seen an exponential increase over the last decade, with an increase in surgical and nonsurgical clinical areas, as well as in training. Future AI related growth in the field of endourology and urolithiasis is likely to improve training, patient centered decision-making, and clinical outcomes.

Absence of detrusor muscle in TUR-BT specimen – can we predict who is at highest risk?

IntroductionAs a high-quality TUR-BT is important to ensure adequate treatment for bladder cancer patients, the aim of the current study is to investigate the impact of patient-related, surgical and tumor-specific parameters on detrusor muscle (DM) absence (primary objective) and to assess the impact of DM on the prognosis after a TUR-BT (secondary objective).Patients and methodsTransurethral resection of bladder tumors (TUR-BTs) between 2009 and 2021 were retrospectively screened (n = 3237). We included 2058 cases (1472 patients) for the primary and 472 patients for secondary objective. Clinicopathological variables including tumor size, localization, multifocality, configuration, operation time and skill-level of the urologist were assessed. We analyzed predictors for missing DM and prognostic factors for recurrence-free survival (RFS) for the complete cohort and subgroups.ResultsDM was present in 67.6% (n = 1371/2058). Surgery duration (continuous, minutes) was an independent predictor for absence of DM in the complete cohort (OR:0.98, r:0.012, 95%CI:0.98–0.99, p = 0.001). Other significant risk factors for missing DM were papillary tumors (OR:1.99, r:0.251, 95%CI:1.22–3.27, p = 0.006) in the complete cohort and bladder-roof and posterior-bladder-wall localization for re-resections. Absence of DM in high-grade BC correlated with reduced RFS (HR:1.96, 95%CI:1.0–3.79, p = 0.045).ConclusionSufficient time for a TUR-BT is mandatory to assure DM in the TUR-BT specimen. Also, cases with more difficult locations of bladder tumors should be performed with utmost surgical diligence and endourological training should incorporate how to perform such operations. Of note, DM correlates with improved oncological prognosis in high-grade BC.

Role of virtual reality in improving the spatial perception of the kidney during flexible ureteroscopy: A feasibility study using virtual reality simulators and 3D models.

The aims were to describe a software-based reconstruction of the patient-specific kidney cavity intraluminal appearance via a head-mounted device and to estimate its feasibility for training novices. In total, 15 novices were recruited. Each novice was shown a three-dimensional reconstruction of a patient's computed tomography scan, whose kidney was printed. They then joined the surgeon in the operating room and assisted them in detecting the stone during flexible ureteroscopy on the printed model. Then, each participant did a 7-day virtual reality (VR) study followed by virtual navigation of the printed kidney model and came to the operating room to help the surgeon with ureteroscope navigation. The length of the procedure and the number of attempts to find the targeted calyx were compared. With VR training, the length of the procedure (p = 0.0001) and the number of small calyces that were incorrectly identified as containing stones were significantly reduced (p = 0.0001). All the novices become highly motivated to improve their endourological skills further. Participants noticed minimal values for nausea and for disorientation. However, oculomotor-related side effects were defined as significant. Five specialists noticed a good similarity between the VR kidney cavity representation and the real picture, strengthening the potential for the novice's education via VR training. Virtual reality simulation allowed for improved spatial orientation within the kidney cavity by the novices and could be a valuable option for future endourological training and curricula.

MP25-20 TRENDS IN THE GLOBAL ENDOUROLOGY TRAINING PIPELINE: CONTEMPORARY ANALYSIS OF FELLOWSHIP MATCH OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP25-20 TRENDS IN THE GLOBAL ENDOUROLOGY TRAINING PIPELINE: CONTEMPORARY ANALYSIS OF FELLOWSHIP MATCH OUTCOMES Garrett Ungerer, Reza Roshandel, Aaron Potretzke, and Kevin Koo Garrett UngererGarrett Ungerer More articles by this author , Reza RoshandelReza Roshandel More articles by this author , Aaron PotretzkeAaron Potretzke More articles by this author , and Kevin KooKevin Koo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003253.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The proportion of urology residents who choose to pursue fellowship training has steadily increased over the past decade. The Endourological Society fellowship match allocates fellowship positions for advanced endoscopic and minimally invasive surgical training in 83 programs across 5 continents. To understand contemporary trends in the global endourology training pipeline, we aimed to analyze results of the annual endourology fellowship match, conducted by the American Urologic Association. METHODS: We analyzed endourology fellowship match statistics from the AUA for the match years 2014-2023 to characterize trends in application volumes, vacancies, applicants, and successful matches. RESULTS: Over the past 10 years, the number of applicants entering the match increased from 54 to 86. In parallel with this increasing demand in fellowship training, the number if training opportunities has increased from 34 programs offering 36 positions in the 2014 match to 54 programs offering 59 positions in the 2023 match. Despite consistent excess of applicants relative to available positions, an average of 13 positions are unfilled each year (range 8-19) corresponding to 26% of available positions (range 18-43%). Of the potential reasons for this, applicant desirability did not appreciably change: an average of 75% of applicants (range 72%-80%) were ranked by programs each year. Increase in positions and applicants is occurring in parallel. For the prior 10 match cycles, programs received an average of 15 applications (range 14-18) and offered 7 interviews to applicants (range 6-9). Applicants consistently completed an average of 4 interviews (range 3-6). Finally, on average 75% of vacancies were filled by US graduating residents (range 55%-89%), compared to 17% by non-US-trained candidates and 8% by prior US graduates. The number of successful female candidates averaged 5 per year, increasing from 3 women in 2014 to 11 in 2023. CONCLUSIONS: Despite increasing applicant demand and global supply of endourology fellowship positions, only 3 out of 4 applicants are ranked by programs, and a relatively high proportion of vacancies go unfilled each year. Female and non-US-trained candidates remain underrepresented. Strategies to bolster the endourology training pipeline merit increased attention. Source of Funding: none to report © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e350 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Garrett Ungerer More articles by this author Reza Roshandel More articles by this author Aaron Potretzke More articles by this author Kevin Koo More articles by this author Expand All Advertisement PDF downloadLoading ...

On the rocks: can urologists identify stone composition based on endoscopic images alone? A worldwide survey of urologists.

As part of the management of nephrolithiasis, determination of chemical composition of stones is important. Our objective in this study is to assess urologists' accuracy in making visual, intraoperative determinations of stone composition. We conducted a REDCap survey asking urologists to predict stone composition based on intraoperative images of 10 different pure-composition kidney stones of 7 different types: calcium oxalate monohydrate (COM), calcium oxalate dihydrate (COD), calcium phosphate (CP) apatite, CP brushite, uric acid (UA), struvite (ST) and cystine (CY). To evaluate experience, we examined specific endourologic training, years of experience, and number of ureteroscopy (URS) cases/week. A self-assessment of ability to identify stone composition was also required. With a response rate of 26% (366 completed surveys out of 1,370 deliveries), the overall accuracy of our cohort was 44%. COM, ST, and COD obtained the most successful identification rates (65.9%, 55.7%, and 52.0%, respectively). The most frequent misidentified stones were CP apatite (10.7%) and CY (14.2%). Predictors of increased overall accuracy included self-perceived ability to determine composition and number of ureteroscopies per week, while years of experience did not show a positive correlation. Although endoscopic stone recognition can be an important tool for surgeons, it is not reliable enough to be utilized as a single method for stone identification, suggesting that urologists need to refine their ability to successfully recognize specific stone compositions intraoperatively.

Prospective, Randomized Comparative Evaluation of a Novel Hands-On Endourology Training Curriculum

Introduction: The aim of this randomised prospective trial was to evaluate a novel hands-on endourological training programme (HTP) and compare it to the standard endourological colloquium (SC). Methods: A new HTP was created based on a sequence of theoretical, video-based, and practical elements emphasising contemporary teaching methods. An existing SC in which live endourological operations were attended served as a comparison. Medical students were enrolled in a ratio of 1:2 (SC:HTP). Objective knowledge questionnaires (5 questions, open answers) and subjective Likert-type questionnaires (rating 1–3 vs. 4–5) were used for evaluation. Primary endpoint was urological knowledge transfer; secondary endpoints were learning effects, progression, and urological interest. Results: 167 students (SC n = 52, HTP n = 115) were included. The knowledge assessment showed a significant increase in knowledge transfer benefitting the HTP on all 5 surveyed items (mean: n = 4/5/4/3/2 vs. n = 2/3/1/1, p < 0.0001). Interest and duration of the course were rated significantly more positively by HTP students (100.0/95.0% vs. 85.0/70.0%, p < 0.0001). The HTP students were significantly more confident in performing a cystoscopy independently (HTP 43.5% vs. SC 11.5%, p < 0.0001) and significantly claimed more often to have gained interdisciplinary and urological skills during the course (HTP 90.0/96.5% vs. SC 23.1/82.7%, p < 0.0001/p = 0.003). HTP students were also more likely to take the course again (HTP 98.2% vs. SC 59.6%, p < 0.0001). Conclusion: Modifying endourological teaching towards hands-on teaching resulted in stronger course interest, greater confidence regarding endourologic procedures, and significantly increased urologic knowledge transfer.

Impact of simulation-based training in endourology: A systematic review of the literature

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.

Cirugía renal percutánea, experiencia inicial en el Hospital General de Morelia “Dr. Miguel Silva”

Abstract Background: The first reports of percutaneous nephrolithotomy date back to 1941, when Rupel and Brown performed the extraction of a pyelic stone by introducing an endoscope through a mature nephrostomy tract. Over the years, multiple improvements have been made in the equipment used, variations in the positions of the patients for a better approach, a decrease in the diameter of the tract, currently being considered by the European and North American guidelines as the treatment of first choice for kidney stones. Primary Objective: show the experience in this type of surgery after its introduction in the Urology Department in a second level hospital. Secundary Objetives: To evaluate the safety and efficacy of percutaneous renal surgery in a hospital where open surgery is traditionally performed for the treatment of renal lithiasis. Materials and methods: A retrospective study is carried out in patients undergoing Percutaneous Renal Surgery (PCNL) at the General Hospital of Morelia of the Ministry of Health between February 2011 and March 2012. Surgical time, complications, days of hospital stay, percentage of residual lithiasis and fluoroscopy time. Results: Sixty four patients were studied, of which 41 (64%) were male and 23 (36%) female; average age of 34 years; 13 (20.31%) patients with staghorn stones, 20 (31.25%) with stones in several calyces and 31 (48.43%) with single stones, 10 (15.62%) patients with bilateral stones; calculation free rate 87.5%; The complications presented according to the Claiven-Dindo was 14%; average fluroscopy time of 2.2 minutes.Conclusions: Percutaneous nephrolithotomy is a surgical technique that, despite being considered the treatment of choice for kidney stones, is still little performed in provincial medical centers. To carry it out, training in endourology of the surgeon, persistence, and conviction of the rest of the surgical service, anesthesiologists and hospital managers of the benefits granted to the patient in the treatment of lithiasis as well as economic benefits to the institution is required. Percutaneous renal surgery is a safe surgery, with a high success rate, rapid patient recovery and shorter hospital stay.

Percutaneous renal surgery, first experience at the Hospital General de Morelia "Dr. Miguel Silva"

Abstract&#x0D; Background: The first reports of percutaneous nephrolithotomy date back to 1941, when Rupel and Brown performed the extraction of a pyelic stone by introducing an endoscope through a mature nephrostomy tract. Over the years, multiple improvements have been made in the equipment used, variations in the positions of the patients for a better approach, a decrease in the diameter of the tract, currently being considered by the European and North American guidelines as the treatment of first choice for kidney stones.&#x0D; Primary Objective: show the experience in this type of surgery after its introduction in the Urology Department in a second level hospital.&#x0D; Secundary Objetives: To evaluate the safety and efficacy of percutaneous renal surgery in a hospital where open surgery is traditionally performed for the treatment of renal lithiasis.&#x0D; Materials and methods: A retrospective study is carried out in patients undergoing Percutaneous Renal Surgery (PCNL) at the General Hospital of Morelia of the Ministry of Health between February 2011 and March 2012. Surgical time, complications, days of hospital stay, percentage of residual lithiasis and fluoroscopy time.&#x0D; Results: Sixty four patients were studied, of which 41 (64%) were male and 23 (36%) female; average age of 34 years; 13 (20.31%) patients with staghorn stones, 20 (31.25%) with stones in several calyces and 31 (48.43%) with single stones, 10 (15.62%) patients with bilateral stones; calculation free rate 87.5%; The complications presented according to the Claiven-Dindo was 14%; average fluroscopy time of 2.2 minutes.Conclusions: Percutaneous nephrolithotomy is a surgical technique that, despite being considered the treatment of choice for kidney stones, is still little performed in provincial medical centers. To carry it out, training in endourology of the surgeon, persistence, and conviction of the rest of the surgical service, anesthesiologists and hospital managers of the benefits granted to the patient in the treatment of lithiasis as well as economic benefits to the institution is required. Percutaneous renal surgery is a safe surgery, with a high success rate, rapid patient recovery and shorter hospital stay.

P0962 - The role of simulation in endourology training: development and validation of a 3D-printed model

P0962 - The role of simulation in endourology training: development and validation of a 3D-printed model

Development Methodology of the Novel Endoscopic Stone Treatment Step 2/A Training/Assessment Curriculum and a Roadmap on Developing Hands-on Training Curriculums in Future: An International Collaborative Work by European Association of Urology Sections.

Background: Basic simulation training in endourology was established with the endoscopic stone treatment step 1 (EST-s1), which is now recognized worldwide for training and examination. Following on from EST-s1, the endoscopic stone treatment step 2 (EST-s2) was started by the European Association of Urology (EAU) sections. Objective: We describe the methodology used in the development of EST-s2 assessment curriculum. Materials and Methods: The "full-life cycle curriculum development" template was followed for curriculum development, focusing on intermediate training of EST protocol with complex endourologic tasks. A cognitive task analysis (CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EAU Urolithiasis Section experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in European Urology Residents Education Programme 2019 and in phase five the protocol was finalized with full tutor instruction sheet. Results: The EST-s2/A curriculum development took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees, respectively. Although the experts agreed that EST-s2/A protocol was well structured (96%), covered the complex endourologic maneuvers (92%), and was useful to optimize and improve hands-on-training (HoT) sessions (92%), the overall evaluation was scored 4.25/5 by trainees. Conclusion: We describe the development methodology for intermediate EST curriculum, which also provides a roadmap on developing other HoT protocols in future. Patients Summary: In this report we described the development of the novel intermediate training curriculum for EST, called EST-s2, which took 3 years of collaborative work inside the EAU. This article is aimed to strengthen the standards in curriculum development and clearly describe the background of this new EAU official endourology protocol.

Soft Urinary Bladder Phantom for Endoscopic Training

Bladder cancer (BC) is the main disease in the urinary tract with a high recurrence rate and it is diagnosed by cystoscopy (CY). To train the CY procedures, a realistic bladder phantom with correct anatomy and physiological properties is highly required. Here, we report a soft bladder phantom (FlexBlad) that mimics many important features of a human bladder. Under filling, it shows a large volume expansion of more than 300% with a tunable compliance in the range of 12.2 ± 2.8 – 32.7 ± 5.4 mL cmH2O−1 by engineering the thickness of the bladder wall. By 3D printing and multi-step molding, detailed anatomical structures are represented on the inner bladder wall, including sub-millimeter blood vessels and reconfigurable bladder tumors. Endoscopic inspection and tumor biopsy were successfully performed. A multi-center study was carried out, where two groups of urologists with different experience levels executed consecutive CYs in the phantom and filled in questionnaires. The learning curves reveal that the FlexBlad has a positive effect in the endourological training across different skill levels. The statistical results validate the usability of the phantom as a valuable educational tool, and the dynamic feature expands its use as a versatile endoscopic training platform.

Fellowship training in endourology: Impact on percutaneous nephrolithotomy access patterns.

Percutaneous nephrolithotomy (PCNL) remains the treatment of choice for kidney stones larger than 2 cm. Few studies have examined the reasons why some urologists obtain their own PCNL access while others prefer to have interventional radiology (IR) obtain access. The objective of this study was to investigate what factors influence this decision. A survey was posted to the American Urological Association's (AUA) Young Urologist Community. Descriptive statistics and exploratory analyses were used to summarize practice trends and motivating factors. All 99 respondents began practicing within the past 11 years. Ninety-two currently perform PCNLs and 47% of them obtain their own access. Endourology fellowship-trained physicians were more likely to currently obtain their own access (75%) compared to urologists who completed non-endourology fellowships (75% vs. 23%, p=0.58) and non-fellowship-trained urologists (75% vs. 45%, p=0.01). Logging >50 cases during training also predicted physicians obtaining their own access and having a larger annual number of PCNL cases. The most common motivator for obtaining one's own access was preference to control their own access point (95%). Urologist-obtained PCNL access was associated with greater training experience (endourology fellowship) and current annual PCNL case volume. Urologist-reported factors that influenced the decision to obtain one's own access include control of access, comfort level, and both physician and patient convenience. By identifying the factors that influence practice patterns, we may better address barriers, improve education to make urologistobtained PCNL access feasible even without fellowship training, and ultimately improve outcomes and quality of care.

Endourological Training Using 3D-Printed Bladder Phantoms: Development and Prospective Evaluation.

Background: To create and evaluate a realistic, anatomically accurate, and user-friendly bladder phantom for reproducible endourological training purposes and endoscope mastery. Materials and Methods: The anatomy of full bladders was mapped from human computed tomography datasets. After a 3D model development process, content evidence and response process evidence (RPE) of the phantom were evaluated using the system usability scale (SUS), 5-point Likert scale questionnaires, and task execution of experienced urologists (U) and endoscopy-naive medical students (MS) in two training sessions (first vs second). Required validation cohort sizes (1:10) of the evaluating urologists (n = 12) and students (n = 115) were precalculated. Time measurements were recorded. Students were additionally evaluated by a validated global psychomotor assessment score (GPSS). Group comparisons were calculated by the Mann-Whitney U test. All tests were two sided with p < 0.05 considered statistically significant. Results: Content evidence was assessed by urologists with an "excellent" SUS score of 89.4 ± 5.9 and an average "agreement" of ≥4 pts in the Likert scale questionnaires. RPE was assessed by intra- and intergroup time comparison for the execution of endoscopic tasks (cystoscopy [CY], guidewire insertion, and tumor biopsy). For CY, U: first 17.6 ± 4.4 seconds vs second 12.4 ± 2.0 seconds, p = 0.002; MS: first 56.6 ± 28.2 seconds vs second 28.6 ± 14.7 seconds, p < 0.001; U vs MS: first U 17.6 ± 4.4 seconds vs first MS 56.6 ± 28.2 seconds, p < 0.001, second U 12.4 ± 2.0 seconds vs second MS 28.6 ± 14.7 seconds, p < 0.001. Significant time differences were documented for all tasks and sessions (p < 0.001). Additionally, significant GPSS differences were recorded between the sessions (GPSS: first 20.4 ± 5.1 pts vs second 24.7 ± 4.0 pts, p < 0.001). Conclusions: Our low-fidelity 3D-printed bladder, called BladCap, is an easy-to-assemble, inexpensive, and robust phantom. We present data, which establish construct validity to support use as a clinical training device.

Simulation Training in Endo-urology: a New Opportunity for Training in Senegal

Teaching of surgery has long relied on live practice. The advent of endo-urology and laparoscopy have favored the development of simulation. The purpose of this study was to evaluate the role of simulation in the development of a center of excellence center in Senegal. Simulation has become the standard for surgical training students in Europe and the USA, allowing for a better and faster learning. The routine practice of minimally invasive surgery in urology along with a high number of residents should favor the use of simulation in this setting. The experts achieved a higher percentage of prostate tissue resection within the allotted time for this procedure. The quality of the control of hemostasis evaluated on a basic procedure and during a resection is significantly better in the expert group. The satisfaction survey was conducted at the end of the seminar.

A Novel Simulated Training Platform and Study of Performance Among Different Levels of Learners in Flexible Cystoscopy.

The aims of this study were to test a novel simulation platform suitable for flexible cystoscopy using a standard scope, to assess the platform's proposed use as a training tool for flexible cystoscopy, and to assess the user experience through surveyed response. Thirty-one urologists (11 novices, 20 experts) were evaluated using a novel light-based bladder model and standard flexible cystoscope. Time to complete full inspection of the simulated bladder was measured, and the scope trajectory was recorded. Participants also completed a survey of the training platform. Thirty participants completed a simulated inspection of a portable bladder model with a mean ± SD time for 153.1 ± 76.1 seconds. One participant failed to complete. Novice urologists (defined as those having completed less than 50 flexible cystoscopies in clinic) had a mean ± SD time of 176.9 ± 95.8 seconds, whereas with experts, this decreased to 139.3 ± 60.7 seconds. Dynamic trajectory maps identified "blind spots" within each user's cystoscopy performance. In a poststudy follow-up, 27 participants considered the tool valuable or extremely valuable for training, whereas 19 participants considered that the tool either very well or excellently replicated the clinical setting. All participants ranked the tool as very good or excellent for overall quality of training. Advances in electronic technology make portable low-cost models a potential low-cost alternative to endourology training platforms. In providing a quantifiable measure of user performance, the tool may shorten the learning curve in flexible cystoscopy and, potentially, reduce clinical errors and provide quantifiable measures for further clinical training.

Benefits and Limitations of Transurethral Resection of the Prostate Training With a Novel Virtual Reality Simulator.

Profound endourological skills are required for optimal postoperative outcome parameters after transurethral resection of the prostate (TURP). We investigated the Karl Storz (Tuttlingen, Germany) UroTrainer for virtual simulation training of the TURP. Twenty urologists underwent a virtual reality (VR) TURP training. After a needs analysis, performance scores and self-rated surgical skills were compared before and after the curriculum, the realism of the simulator was assessed, and the optimal level of experience for VR training was evaluated. Statistical testing was done with SPSS 25. Forty percent of participants indicated frequent intraoperative overload during real-life TURP and 80% indicated that VR training might be beneficial for endourological skills development, underlining the need to advance classical endourological training. For the complete cohort, overall VR performance scores (P = 0.022) and completeness of resection (P < 0.001) significantly improved. Self-rated parameters including identification of anatomical structures (P = 0.046), sparing the sphincter (P = 0.002), and handling of the resectoscope (P = 0.033) became significantly better during the VR curriculum. Participants indicated progress regarding handling of the resectoscope (70%), bleeding control (55%), and finding the correct resection depth (50%). Although overall realism and handling of the resectoscope was good, virtual bleeding control and correct tissue feedback should be improved in future VR simulators. Seventy percent of participants indicated 10 to 50 virtual TURP cases to be optimal and 80% junior residents to be the key target group for VR TURP training. There is a need to improve training the TURP and VR simulators might be a valuable supplement, especially for urologists beginning with the endourological desobstruction of the prostate.

Validation of a High-End Virtual Reality Simulator for Training Transurethral Resection of Bladder Tumors

The oncological outcome in patients with bladder cancer (BC) significantly correlates with the quality of transurethral resection of bladder tumors (TUR-BT). Virtual reality (VR) training simulators have been developed to improve surgical skills. We evaluated the advantages and limitations of the novel Uro Trainer (UT) (Karl Storz GmbH, Germany) with respect to training for TUR-BT. Participants underwent VR training based on 4 different TUR-BT cases accompanied by self-assessment and evaluation questionnaires. Results were compared between experienced endourologists and novices, and furthermore, correlated with self-rated capabilities for content and construct validity. Student's t tests, Pearson's correlation, and chi-squared tests were performed for statistical evaluation. The study was performed at the tertiary care urological department of the Ludwig-Maximilians-University, Munich, Germany. A total of 22 urological physicians, including residents and consultants, were included in the study. There is a need to improve TUR-BT training as 27.3% of the participants had already experienced overtaxing situations during TUR-BT and only a few reported of high satisfaction with the classical "see one-do one" teaching mode. Construct validity was demonstrated, as consultants achieved significantly higher overall scores (p < 0.001) and safety (p = 0.004) and visualization (p = 0.001) subscores. Interestingly, the self-assessed capability to perform a TUR-BT correlated significantly (p = 0.01) with overall UT scores. Significant progress of self-rated abilities was shown for several parameters, including inspection (p = 0.046) and resection (p = 0.026). Although participants indicated improvements in several procedural skills and overall benefit of the VR training with the UT was rated 4.6 on a 5-point scale by consultants, limitations of the UT were demonstrated predominantly for tissue feedback and authenticity of different tissue layers. The novel VR simulator showed a high face and construct validity, and therefore has a great potential to complement endourological training.

Face, Content, and Construct Validations of Endoscopic Needle Injection Simulator for Transurethral Bulking Agent in Treatment of Stress Urinary Incontinence

Endoscopic injection of urethral bulking agents is an office procedure that is used to treat stress urinary incontinence secondary to internal sphincteric deficiency. Validation studies important part of simulator evaluation and is considered important step to establish the effectiveness of simulation-based training. The endoscopic needle injection (ENI) simulator has not been formally validated, although it has been used widely at University of California, Irvine. We aimed to assess the face, content, and construct validity of the UC, Irvine ENI simulator. Dissected female porcine bladders were mounted in a modified Hysteroscopy Diagnostic Trainer. Using routine endoscopic equipment for this procedure with video monitoring, 6 urologists (experts group) and 6 urology trainee (novice group) completed urethral bulking agents injections on a total of 12 bladders using ENI simulator. Face and content validities were assessed by using structured quantitative survey which rating the realism. Construct validity was assessed by comparing the performance, time of the procedure, and the occlusive (anatomical and functional) evaluations between the experts and novices. Trainees also completed a postprocedure feedback survey. Effective injections were evaluated by measuring the retrograde urethral opening pressure, visual cystoscopic coaptation, and postprocedure gross anatomic examination. All 12 participants felt the simulator was a good training tool and should be used as essential part of urology training (face validity). ENI simulator showed good face and content validity with average score varies between the experts and the novices was 3.9/5 and 3.8/5, respectively. Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.9-3.8/5). However, the bladder does not bleed, and sometimes thin. Experts significantly outperformed novices (p < 001) across all measure of performance therefore establishing construct validity. The ENI simulator shows face, content and construct validities, although few aspects of simulator were not very realistic (e.g., bleeding).This study provides a base for the future formal validation for this simulator and for continuing use of this simulator in endourology training.