URO Mentor Research Articles

The SIMULATE ureteroscopy training curriculum: educational value and transfer of skills

ObjectiveDifferent simulation modalities may be utilised in a curricular fashion to benefit from the strengths of each training model. The aim of this study is to evaluate a novel multi-modality ureterorenoscopy (URS) simulation curriculum in terms of educational value, content validity, transfer of skills and inter-rater reliability.MethodsThis international prospective study recruited urology residents (n = 46) with ≤ 10 URS experience and no prior simulation training. Participants were guided through each phase of the expert-developed SIMULATE URS curriculum by trainers and followed-up in the operating room (OR). Video recordings were obtained during training. A post-training evaluation survey was distributed to evaluate content validity and educational value, using descriptive statistics. Performance was evaluated using the objective structured assessment of technical skills (OSATS) scale to measure improvement in scores throughout the curriculum. Pearson’s correlation coefficient and Cohen’s kappa tests were utilised to investigate correlation and agreement between raters.ResultsParticipants reported gaining OR-transferrable skills (Mean: 4.33 ± 0.67) and demonstrated marked improvement in throughout the curriculum, transferred to the OR for both semi-rigid URS (p = 0.004) and flexible URS (p = 0.007). 70% of participants were successfully followed-up in the OR (n = 32). No differences were identified with the additional use of fresh frozen cadavers (p = 0.85, p = 0.90) and the URO Mentor VR simulator (p = 0.13, p = 0.22). A moderate level of correlation was noted on the video OSATS assessments, between two expert assessors (r = 0.70), but a poor agreement with the live rating.ConclusionThe SIMULATE URS training curriculum received high educational value from participants, who demonstrated statistically significant improvement with consecutive cases throughout the curriculum and transferability of skills to the OR in both semi-rigid and flexible URS.

The role of cognitive training in endourology: A randomized controlled trial

IntroductionCognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior. MethodsThis prospective, comparative study recruited 59 medical students and randomized them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomized to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received. ResultsThis study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (p=0.017, p=0.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (p=0.0125). Other parameters analyzed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training. ConclusionThis study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

El papel de la formación cognitiva en la endourología: un ensayo controlado aleatorizado

IntroductionCognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior. MethodsThis prospective, comparative study recruited 59 medical students and randomised them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomised to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received. ResultsThis study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (P=.017, P=.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (P=.0125). Other parameters analysed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training. ConclusionThis study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

MP20-06 VALIDATION OF THE SIMULATE URETERORENOSCOPY TRAINING CURRICULUM

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment II1 Apr 2016MP20-06 VALIDATION OF THE SIMULATE URETERORENOSCOPY TRAINING CURRICULUM Abdullatif Aydin, Ahmed Al-Jabir, Mohammed Husnain Iqbal, Haleema Aya, Pranav Osuri, Nicholas Raison, James Brewin, Craig McIlhenny, Nicholas Rukin, Jake Patterson, Howard Marsh, Ranan Dasgupta, Azhar Khan, Shahid Khan, Stephen Brown, Azi Samsuddin, John McCabe, Muhammad Shamim Khan, Prokar Dasgupta, and Kamran Ahmed Abdullatif AydinAbdullatif Aydin More articles by this author , Ahmed Al-JabirAhmed Al-Jabir More articles by this author , Mohammed Husnain IqbalMohammed Husnain Iqbal More articles by this author , Haleema AyaHaleema Aya More articles by this author , Pranav OsuriPranav Osuri More articles by this author , Nicholas RaisonNicholas Raison More articles by this author , James BrewinJames Brewin More articles by this author , Craig McIlhennyCraig McIlhenny More articles by this author , Nicholas RukinNicholas Rukin More articles by this author , Jake PattersonJake Patterson More articles by this author , Howard MarshHoward Marsh More articles by this author , Ranan DasguptaRanan Dasgupta More articles by this author , Azhar KhanAzhar Khan More articles by this author , Shahid KhanShahid Khan More articles by this author , Stephen BrownStephen Brown More articles by this author , Azi SamsuddinAzi Samsuddin More articles by this author , John McCabeJohn McCabe More articles by this author , Muhammad Shamim KhanMuhammad Shamim Khan More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2775AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A number training models and modalities have been utilised and validated for ureterorenoscopy (URS) training. Recent developments in surgical education suggest that training using a range of simulators within a curriculum may be much more effective for training. Furthermore, emphasis has also been placed on training non-technical skills. The aim of this study is to validate the newly-developed SIMULATE URS simulation training curriculum. METHODS A comprehensive training curriculum was developed using the Delphi process. On completion of the development process, 15 junior residents were invited for a 3-day intense training course, using the curriculum. The following simulators were utilised in the training curriculum: The URO-Mentor virtual reality simulator, Uro-Scopic Trainer and Advanced Scope Trainer dry-lab models, Fresh Frozen Cadavers and Full Immersion Simulation. Participants were taught and assessed, using OSATS, by faculty members. They were all invited for an evaluation survey following the training programme. RESULTS Participants rated that the training significantly improved their skills (mean: 4.5/5) and that they gained transferrable skills (mean: 4.6/5). A One-way ANOVA test revealed significant improvement in both semi-rigid URS (p=0.0032) and flexible URS (p=0.0003) skills, with consecutive cases throughout the curriculum. Improvement was also seen in Non-technical skills with consecutive scenarios (p=0.0037). Flexible URS (mean: 4.3/5) and stone fragmentation (mean: 4.3/5) were rated to be the strongest aspects of the URO Mentor. In contrast, both the dry-lab models scored the highest with regards to instrument handling, laser stone fragmentation and stone extraction. C-arm control was the most highly rated aspect of fresh frozen cadavers (mean: 4.7/5). CONCLUSIONS The SIMULATE URS curriculum revealed face, content and construct validity. Participants will be followed up in the operating room for transfer validity and will compared to an arm with no simulation experience, as part of the on-going randomised controlled trial. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e214 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Abdullatif Aydin More articles by this author Ahmed Al-Jabir More articles by this author Mohammed Husnain Iqbal More articles by this author Haleema Aya More articles by this author Pranav Osuri More articles by this author Nicholas Raison More articles by this author James Brewin More articles by this author Craig McIlhenny More articles by this author Nicholas Rukin More articles by this author Jake Patterson More articles by this author Howard Marsh More articles by this author Ranan Dasgupta More articles by this author Azhar Khan More articles by this author Shahid Khan More articles by this author Stephen Brown More articles by this author Azi Samsuddin More articles by this author John McCabe More articles by this author Muhammad Shamim Khan More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Simulation-Based Ureteroscopy Training: A Systematic Review

Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training. The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases. In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study. Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice.

MP73-19 URETEROSCOPY SIMULATION - A SYSTEMATIC REVIEW OF CURRENT TRAINING MODALITIES

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2014MP73-19 URETEROSCOPY SIMULATION - A SYSTEMATIC REVIEW OF CURRENT TRAINING MODALITIES Oliver Brunckhorst, Abdullatif Aydin, Hamid Abboudi, Muhammad Khan, Prokar Dasgupta, and Kamran Ahmed Oliver BrunckhorstOliver Brunckhorst More articles by this author , Abdullatif AydinAbdullatif Aydin More articles by this author , Hamid AbboudiHamid Abboudi More articles by this author , Muhammad KhanMuhammad Khan More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2372AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Various simulation models are available for training and assessment of ureteroscopy and they are a common adjunct to OR training. This systematic review aims to: 1. Identify the available simulators for diagnostic and therapeutic ureteroscopy; 2. Explore the evidence for their effectiveness using the characteristic criterion; and 3. Recommend a curriculum based on the available literature. METHODS This study was performed using the guidelines set out by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A literature search was performed using the PubMed, EMBASE and Cochrane Library Databases for research articles describing the validation and training of simulators in ureteroscopy. RESULTS 20 out of a 527 potentially relevant articles were included. Three high-fidelity bench models are available. The Uro-Scopic Trainer has proven face, construct and concurrent validity whilst the Scope Trainer has undergone content, construct and predictive validity. The Adult Ureteroscopy Trainer, has demonstrated face, content and construct validity. The URO mentor is the one virtual reality system available. Extensive validation via ten studies shows face, content, construct, concurrent and predictive validity. All but the Adult Ureteroscopy Trainer have an established educational impact proven. A cost effective non-commercially available low-fidelity model has demonstrated educational impact comparable to its high fidelity counterpart at teaching novices at 185 times less the price. Additionally three studies have described the use of porcine ex-vivo models for training, however validation studies are lacking. With current levels of evidence the simulators could now be incorporated into a formalised curriculum for validation. However, small sample sizes coupled with the lack of randomised controlled studies leaves room for further investigation. Cost-effectiveness and non-technical skills of ureteroscopy simulations requires further scrutiny. CONCLUSIONS Simulators need rigorous validation to justify the high cost associated with them and current models require strengthening of evidence. The next step for the ureteroscopy simulators is incorporation into a formalized and validated curriculum integrated with a non-technical skills aspect. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e872 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Oliver Brunckhorst More articles by this author Abdullatif Aydin More articles by this author Hamid Abboudi More articles by this author Muhammad Khan More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1488 HIGH FIDELITY TRAINING MODELS FOR FLEXIBLE URETEROSCOPY (URS): IS NON- VIRTUAL REALITY (NON-VR) MODEL EQUALLY EFFECTIVE AS A VIRTUAL REALITY (VR) MODEL?

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment1 Apr 20111488 HIGH FIDELITY TRAINING MODELS FOR FLEXIBLE URETEROSCOPY (URS): IS NON- VIRTUAL REALITY (NON-VR) MODEL EQUALLY EFFECTIVE AS A VIRTUAL REALITY (VR) MODEL? Rajan Sharma, Shashikant Mishra, Abraham Kurien, Arvind Ganpule, Veeramani Muthu, Ravindra Sabnis, and Mahesh Desai Rajan SharmaRajan Sharma Nadiad, India More articles by this author , Shashikant MishraShashikant Mishra Nadiad, India More articles by this author , Abraham KurienAbraham Kurien Nadiad, India More articles by this author , Arvind GanpuleArvind Ganpule Nadiad, India More articles by this author , Veeramani MuthuVeeramani Muthu Nadiad, India More articles by this author , Ravindra SabnisRavindra Sabnis Nadiad, India More articles by this author , and Mahesh DesaiMahesh Desai Nadiad, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1446AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The higher the fidelity of the model, the better it is supposed to be. The cost of high fidelity model especially Virtual reality (VR) model is prohibitive. We assessed whether cheaper available non-Virtual reality (non-VR) high fidelity models are effective enough?φ METHODS 21 participants with no experience of flexible URS underwent dry lab simulation practice on a high fidelity non-VR (Uro-scopic trainer TM and Endo-Urologie-Modell TM ) and high fidelity VR model (URO mentor TM) labelled as stations A, B, C respectively. The participants were divided into three batches of 7 each with rotation on each of the model for 30 minutes. Task at the three models were standardised by an expert ureteroscopist to keep uniform complexity levels. At the end of each rotation, skills were measured by global rating scores (GRS) and pass rating. The evaluator assigned a value of 1 to 5 for each of the seven tasks on GRS. Face validity questionnaire measured nine realistic domains. Participants filled a 10 point Likert's scale questionnaire for face validity of the models. RESULTS The GRS improved statistically at evaluation done after second rotation (p < 0.001 for all batches). This was observed in all batches irrespective to the starting training model; whether VR or non-VR. The GRS improvement at third rotation was not significant when compared to second (p = 0.62, 0.29, 0.20 for stations A, B, C respectively), although significant when compared with first (p <0.001 for all batches). Pass ratings also improved significantly for all training models when third and first rotations were compared (p <0.05 for all batches). At the end of 2nd rotation, the batch which trained on VR model initially had more improvement in pass rating but failed to attain significance statistically (X2 >3.84 at 0.05 confidence interval). Face validity results were similar in all domains except realistic flexible ureteroscope domain (non-VR model > VR model) and respiratory movement domain (VR model > non-VR model). CONCLUSIONS All the models used for training flexible URS were effective with respect to increasing GRS and pass rating scores. The advantage of using a non-VR based model is its higher realism of the real time flexible endoscope which makes training on these models attractive. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e596-e597 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rajan Sharma Nadiad, India More articles by this author Shashikant Mishra Nadiad, India More articles by this author Abraham Kurien Nadiad, India More articles by this author Arvind Ganpule Nadiad, India More articles by this author Veeramani Muthu Nadiad, India More articles by this author Ravindra Sabnis Nadiad, India More articles by this author Mahesh Desai Nadiad, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgical Simulation Tasks Challenge Visual Working Memory and Visual‐Spatial Ability Differently

New strategies for selection and training of physicians are emerging. Previous studies have demonstrated a correlation between visual-spatial ability and visual working memory with surgical simulator performance. The aim of this study was to perform a detailed analysis on how these abilities are associated with metrics in simulator performance with different task content. The hypothesis is that the importance of visual-spatial ability and visual working memory varies with different task contents. Twenty-five medical students participated in the study that involved testing visual-spatial ability using the MRT-A test and visual working memory using the RoboMemo computer program. Subjects were also trained and tested for performance in three different surgical simulators. The scores from the psychometric tests and the performance metrics were then correlated using multivariate analysis. MRT-A score correlated significantly with the performance metrics Efficiency of screening (p = 0.006) and Total time (p = 0.01) in the GI Mentor II task and Total score (p = 0.02) in the MIST-VR simulator task. In the Uro Mentor task, both the MRT-A score and the visual working memory 3-D cube test score as presented in the RoboMemo program (p = 0.02) correlated with Total score (p = 0.004). In this study we have shown that some differences exist regarding the impact of visual abilities and task content on simulator performance. When designing future cognitive training programs and testing regimes, one might have to consider that the design must be adjusted in accordance with the specific surgical task to be trained in mind.

Comparative performance of high-fidelity training models for flexible ureteroscopy: Are all models effective?

Objective:We performed a comparative study of high-fidelity training models for flexible ureteroscopy (URS). Our objective was to determine whether high-fidelity non-virtual reality (VR) models are as effective as the VR model in teaching flexible URS skills.Materials and Methods:Twenty-one trained urologists without clinical experience of flexible URS underwent dry lab simulation practice. After a warm-up period of 2 h, tasks were performed on a high-fidelity non-VR (Uro-scopic Trainer™; Endo-Urologie-Modell™) and a high-fidelity VR model (URO Mentor™). The participants were divided equally into three batches with rotation on each of the three stations for 30 min. Performance of the trainees was evaluated by an expert ureteroscopist using pass rating and global rating score (GRS). The participants rated a face validity questionnaire at the end of each session.Results:The GRS improved statistically at evaluation performed after second rotation (P<0.001 for batches 1, 2 and 3). Pass ratings also improved significantly for all training models when the third and first rotations were compared (P<0.05). The batch that was trained on the VR-based model had more improvement on pass ratings on second rotation but could not achieve statistical significance. Most of the realistic domains were higher for a VR model as compared with the non-VR model, except the realism of the flexible endoscope.Conclusions:All the models used for training flexible URS were effective in increasing the GRS and pass ratings irrespective of the VR status.

The Effect of a Low-Fidelity Model on Cystoscopic Skill Training

Models for training urological procedures without burdening patients are available at varying costs. We examined the value of training on a low-fidelity model in addition to training on a high-fidelity simulator in a cystoscopy training program. Thirty-two medical students were randomized to an intervention and a control group. The former started by performing cystoscopy on a low-cost, low-fidelity, glass globe model before moving on to training on the URO Mentor (UM), a computerized simulator. The control group took part in the same UM training program but not in the low-fidelity training. Performance on UM was assessed by a global rating score, percentage of correctly inspected areas of the bladder (% inspected areas), time, and number of traumas caused. The intervention group had generally higher scores. Its global rating score on task 1 was significantly higher than that of the control group (Mann-Whitney U test, P = 0.046, effect size 0.6) and the group also scored higher, albeit not significantly, on time and % inspected areas. All students said they valued training with UM, but the appreciation of the intervention group was stronger (mean 8.9 vs. 8.1 on a scale from 1 to 10, P = 0.017, effect size 1.8). A low-fidelity glass globe model seemed to be an inexpensive educational tool to practice the first steps of cystoscopy. It may reduce training time on the UM simulator. The combined use of a low- and high-fidelity training model may provide an optimal learning effect.

Transfer of cysto‐urethroscopy skills from a virtual‐reality simulator to the operating room: a randomized controlled trial

Study Type – Therapy (RCT) Level of Evidence 1bOBJECTIVETo assess whether real‐time cysto‐urethroscopy (CUS) performance improves by simulator‐based training (criterion or predictive validity), addressing the research question ‘Does practical skills training on the URO Mentor (UM, Simbionix USA Corp., Cleveland, OH, USA) virtual‐reality simulator improve the performance of flexible CUS in patients’.SUBJECTS AND METHODSParticipants (71 interns from Catharina Hospital Eindhoven, CHE, and 29 from University Medical Centre Groningen, UMCG) were randomized to carry out CUS in a patient after training on the UM (UM‐trained, 50) or without training on UM (control, 50). The assessment of real‐time performance consisted of scoring on a Global Rating Scale (GRS) by supervisors unaware of training status. Data were analysed using stepwise multiple linear regression. The effect size (ES) indication for correlations was used to interpret the magnitude of a standard regression coefficient (β); an ES of 0.10, 0.30 and 0.50 were considered small, moderate and large, respectively. The study was approved by the Medical Review Ethics Committees of the participating hospitals.RESULTSOverall, the group that received training performed significantly better than the controls (P ≤ 0.003, β range 0.30–0.47). There was no effect of training for participants with a specific preference for a surgical speciality in two of five GRS scores. Participants from CHE obtained higher GRS 3 scores than those from UMCG. Significantly more UMCG trainees indicated having had stress than those from CHE (P &lt; 0.001).CONCLUSIONSThe results showed that interns who had trained on UM outperformed controls for a CUS procedure in a patient. Training for CUS on the UM is to be recommended for learning to respect tissue, procedural knowledge, flow of procedure and forward planning. Use of the UM to train interns with a specific interest in a surgical speciality in handling instruments, and time and motion, seems to be of limited value.

Acquisition of flexible cystoscopy skills on a virtual reality simulator by experts and novices

To assess the construct validity of the URO Mentor (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices' performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor? Thirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were 'test tasks' to evaluate participants' performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts' and novices' performances, with P < 0.05 considered to indicate statistical significance. Effect sizes (ES) were calculated to quantify the practical significance of the results; ES of 0.10, 0.30, and 0.50 were considered small, medium and large, respectively. Novices' performances showed a significant improvement with large ES in time (linear trend of learning curve P < 0.001, ES 0.66) and mean GRS score (linear trend P < 0.001, ES 0.84, quadratic trend P = 0.018, ES 0.24). There was a medium improvement for trauma (linear trend P < 0.001, ES 0.40) and a small improvement in areas inspected (linear trend P = 0.032, ES 0.21). That the 95% confidence intervals of the measures on the first task of experts and novices did not coincide indicates that differentiation between experts and novices on the four variables measured can be achieved using the URO Mentor. Training on the URO Mentor appears to result in a medium to large improvement of novices' performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.

The Virtual Reality Endourologic Simulator Is Realistic and Useful for Educational Purposes

To examine the educational value of URO Mentor, a virtual reality simulator for endourologic procedures, by establishing its face and content validity. Eighty-nine urologists and residents in urology performed a urethrocystoscopy task (bladder inspection, biopsy, and coagulation) or a ureterorenoscopy task (manipulation of a distal ureter stone) using the URO Mentor. They completed an evaluation questionnaire about these tasks. Questionnaire bias related to task performance on URO Mentor was analyzed as well (Hawthorne effect). The overall rating of the URO Mentor was 7.3 on a 10-point scale (1 = poor, 10 = excellent). Regression analysis showed that ratings were not related to previous experience or task performance using the URO Mentor. Of all subjects, 25% rated the realism of URO Mentor as >or=3.5 on a five-point scale, and 82% rated its usefulness as an educational tool as >or=3.5 on a five-point scale. More than 73% of all participants said they would purchase a URO Mentor if financial means were available; participants who needed more time to complete the task were less positive in their answers to this question. URO Mentor appears to be a realistic and useful training model for endourologic procedures.

Development of a Standardized Curriculum for Teaching Cystoscopic Skills Using a Computer-Based Endourologic Simulator

Educational opportunities with simulation are now available to teach endoscopic skills outside the clinical setting. The goal of this study is to assess the learning curve and subjective impressions of cystoscopic tasks performed by untrained subjects on a computer-based simulator using a standardized curriculum. We evaluated ten novice subjects on a computer-based cystoscopic simulator (URO Mentor, Simbionix, Lod, Israel) during a standardized cystoscopy skills course developed for the study. All trainees performed three basic cystoscopic tasks as part of the curriculum. Subjects were evaluated until a steady state of performance was observed. Subjectively, participants assessed their performance and opinions regarding the computer-based simulator. Among the ten novice subjects (five men, five women), a median of six training sessions were required to achieve a steady state of performance. Significant performance improvements were noted with additional simulator time (P<0.001), however, the rate of improvement declined with time. Regression analysis of completion times revealed significant gender effects for one cystoscopic task. At study end, gender performance differences for any task were not significant. Uniformly, novices felt that URO Mentor was easy to use and provided an overall realistic training experience. In this study a computer-based simulator was successfully incorporated into a training curriculum for cystoscopy education. For simulated tasks performed with rigid and flexible cystoscopes, a median of six training sessions was necessary. Objectively, performance on the testing scenarios significantly increased with experience. Subjectively based on nonvalidated criteria, comfort level, and perceived competency increased significantly from the pre- to postcourse evaluations.

Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills

Virtual reality (VR) simulators are now commercially available for various surgical skills training. The Uro Mentor VR Ureteroscopy Simulator by Symbionix is one system that may revolutionize the way we assess and teach surgical residents. Surgical educators may no longer have to depend on the operating room as the sole venue for teaching residents technical skills. We validated performance on this new system with previously developed assessment tools and compared it to performance on a high fidelity ureteroscopy bench model. Urology residents (n = 16) were assessed on their ability to perform cystoscopy, guidewire insertion, semirigid ureteroscopy and basket extraction of a distal ureteric stone on the VR simulator. A blinded examiner assessed subject performance using a checklist, global rating scale and a pass/fail rating. In addition, computer-generated parameters including time to complete task, scope and instrument trauma and the number of attempts to insert a guidewire were analysed. Performance on the VR simulator was compared to performance on a high fidelity ureteroscopy bench model. Senior residents (n = 8) scored significantly higher on their global rating scale (29.4 +/- 2.5 vs 20.8 +/- 0.9, P = 0.005), checklist (19.1 +/- 1.1 vs 15.2 +/- 0.9, P = 0.02), pass/fail rating (chi(2) = 7.3, P = 0.007) and required less time to complete the task (352.9 +/- 55.7 s vs 576.8 +/- 67.4 s., P = 0.02) than the junior residents (n = 8) on the VR simulator. Junior residents also had a significantly higher incidence of scope trauma (4 vs 0.6, P = 0.02). No significant differences were noted in instrument trauma and the number of attempts to insert the guidewire. Global rating scale performance on the VR simulator correlated well to performance on the high fidelity ureteroscopy bench model (r = 0.7, P = 0.002) as did time to complete task (r = 0.7, P = 0.004). The Uro Mentor VR Ureteroscopy Simulator is a useful tool in assessing resident endourological skills. Performance on the VR simulator is comparable to a validated high fidelity ureteroscopy bench model. Future studies will assess the utility of VR simulators in surgical skills training.

The virtual reality simulator the URO Mentor is a realistic and valid training model: determination of face validity.

At the moment more and more training models become available for training in urology. In order to know whether such models improve learning curves of residents and contribute to the educational program, these models need to be validated. We are performing a validation study on the URO Mentor, a virtual reality simulator which simulates endourologic procedures. Face validity is one aspect of the validation process. It addresses the question: “To what degree does the URO Mentor resemble reality as judged by a specific (target) population?”. We questioned 70 urologists and residents after they performed a urethrocystoscopic task (bladder inspection, biopsy and coagulation) or a ureterorenoscopic task (stone manipulation of a distal ureter stone). We also investigated possible questionnaire bias related to performance on the URO Mentor. The overall appraisal was 7.2 in a scale of 1 to 10 (1 is poor, 10 is good). A regression analysis showed that this judgment is independent of age, experience or task performance (p0.05). Of all interviewees, 86% considered working with the URO Mentor as realistic. Usefulness was judged from average to very useful by 89% of the urologists and residents. On average, over 73% would consider purchasing a URO Mentor if financial means were available, but subjects who caused more traumata during the task were less likely to answer positively to this question. We conclude that, according to our study, the URO Mentor is a realistic and useful training model.

Determination of construct validity of the URO Mentor, a virtual reality simulator for endourological procedures.

Residents learn operative skills by an apprentice-type of training. Due to ethical concerns this type of training is no longer acceptable. Nowadays skills labs are arising with different type of training models. Selection of models is mostly based on their costs and looks. Proper validation studies are necessary to use models in an evidence-based manner. This study determines the construct validity of the URO Mentor, a virtual reality simulator for endourological procedures. Construct validity answers the question: “Can the simulator distinguish between novices and experts?”. Ten interns (novices) and 21 urologists (experts) performed a cystoscopy task with biopsy taking and coagulation of the biopsy site on the URO Mentor. Novices performed this task 5 times, experts once. Afterwards they filled in a questionnaire. Experts are significantly faster (Wilcoxon, p<0.0005) and cause less traumata (p=0.015) during the first task when compared to novices. Data show a decrease in total performance time over runs, which is significant for all tasks compared with the first one (p=0.0010). The number of traumata is significantly smaller during the fourth and fifth tasks, compared to the first task (p=0.023). This pilot study shows the URO Mentor can distinguish between novices and experts and proves there is a significant improvement in total time and number of traumata after training, thus demonstrating construct validity. Further study is needed to distinguish between true task learning and the effect of learning how to use the URO Mentor.

Validation of a flexible cystoscopy course.

To examine the instructional effectiveness of a course for nurses wishing to learn flexible cystoscopy, using a virtual reality flexible cystoscopy simulator to measure the outcome. Fourteen urology nurse practitioners with no previous experience of cystoscopy were taught the basic techniques of flexible cystoscopy. They then had supervised group instruction during which they practised flexible cystoscopy on an inanimate latex model, and were taught how to handle the cystoscope, followed by unsupervised practice, including use of the virtual reality (VR) simulator (URO Mentor, Simbionix, Israel). They then undertook a cystoscopy task on the simulator; within the bladder there were 10 flags (numbered 1-10) at key positions. By visualizing and photographing each of the flags the subject would have visualized the entire bladder mucosa. The number of flags seen was thus used as a measure of how much of the bladder mucosa was examined. The VR simulator also measured the total procedure time. After a day of training the subjects were reassessed and the changes in performance evaluated. Subjects were also asked their opinion of the use of VR for flexible cystoscopy. The median (range) time to complete the procedure before the course was 3.33 (2-5.5) min and the number of flags seen 7 (6-9). After the course, the median time decreased to 2.85 (1.5-4.42) min and the number of flags seen increased to 8 (6-9). The change in time was significant (P = 0.03) but the difference in the number of flags was not (P = 0.12). All 14 subjects enjoyed the use of VR for learning flexible cystoscopy; they all reported that they were more confident in handling a flexible cystoscope and in undertaking flexible cystoscopy. The virtual reality simulator was an effecctive tool for teaching flexible cystoscopy.

A Randomized Prospective Blinded Study Validating Acquistion of Ureteroscopy Skills Using A Computer Based Virtual Reality Endourological Simulator

Surgical simulation has emerged in the last decade as a potential tool for aiding acquisition of technical skills, including anesthesia protocols, trauma management, cardiac catheterization and laparoscopy. We evaluate and validate the use of a computer based ureteroscopy simulator (URO Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic skills. We assessed 20 novice trainees for the ability to perform basic ureteroscopic tasks on a computer based ureteroscopy simulator. Participants were randomized to receive individualized mentored instruction or no additional training, and subsequently underwent post-testing. Pre-training and post-training improvement in performance was assessed by objective simulator based measurements. Subjective overall performance was rated using a validated endourological global rating scale by an observer blinded to subject training status. Demographics and pre-test scores were similar between groups. Post-testing revealed a significant effect of training on objective and subjective measurements. Spearman rank correlation demonstrated a significant association between objective simulator based measurements and the endourological global rating scale. Use of a computer based ureteroscopy simulator resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. Results of this study demonstrate the use of a virtual reality ureteroscopy simulator in endourological training. Correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the ureteroscopy simulator for the assessment of ureteroscopic skills.