Simulation-based training and assessment in urological surgery

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 procedure-specific 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 text

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 simu-
lation, 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 metho d
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 con-
ducted via full immersion simulation or high-fidelity operating
room sim ulation.
Despite an increase in the popularity of surgical
training models7, these must be rigorously evaluated
in order to demonstrate the validity, acceptability, reli-
a bility, and educational effect of each tool before it is
used in training and assessment. A number of param-
eters against which assessment of simulators must take
place have been defined (BOX1)8,9.
This Review will provide an overview of the differ-
ent 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 realit y simulation
Urolithiasis. The URO Mentor (Simbionix, USA) is a
VR simulator that incorporates a mannequin and com-
puter 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
1MRC Centre for
Transplantation, King’s College
London, 5th Floor Southwark
Wing, Guy’s Hospital, London
SE1 9RT, UK.
2The Urology Centre, Guy’s
and St Thomas’ NHS
Foundation Trust, 1st Floor
Southwark Wing, Guy’s
Hospital, London SE1 9RT, UK.
Correspondence to P.D.
prokarurol@gmail.com
doi:10.10 38 /n rur ol .201 6. 14 7
Published online 23 Aug 2016;
corrected online 31 Aug 2016
Full immersion simulation
An inflatable low-fidelity and
highly immersive operating
room envi ronment utilise d 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.
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 procedure-
specific 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.
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Acceptability
The extent to which a training
tool or assessment procedure
is accepted by the subjects
involved in the assessment.
virtual stones and stricture cases for practicing semirigid
and flexible ureteroscopy (URS). For each task, a range
of objective parameters are recorded. Following devel-
opment, this system has become the most thoroughly
evaluated simulator in urolog y, 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 <0.001)12.
Arandom ized controlled trial17 of 100 novices also
demonstrated good transfer of skills from the VR simu-
lator to the operating theatre (P ≤0.003, beta range
0.30–0.47). Furthermore, face13,21–23, content13,21, con-
struct22–29, concurrent30 and predictive29,31 validity has
been established for ureteroscopy training in a large
number ofstudies.
The URO Mentor is usually combined with the
PERC Mentor (Simbionix, USA), a platform for percu-
taneous nephrolithotomy (PCNL) training, which has
demonstrated face, content, construct, and predictive
validity14,32–36. Two further studies37,38 have used the
simulator in conjunction with live porcine models and
demonstrated the content validity of both modalities.
BPH therapy and TURBT. In contrast to urolithiasis,
many VR simulators have been developed for train-
ing surgeons in transurethral resection of the prostate
(TURP). In 1999, Ballaro etal.39 demonstrated content
validity of the first reported VR simulator for TURP at
Univ ersity Co lleg e Lon don, but conc luded t hat its va lid-
ity was limited by delayed image acquisition and a lack
of haptic feedback. This simulator is not commercially
available and no further reports have been published
since the original paper39. Having been developed over
15years ago, this particular technology is most probably
outdated and not suited for contemporary use.
In 2005, Kallstrom etal.40 introduced a new VR
simulator at University Hospital Linköping, Sweden,
and demonstrated its content validity. The simulator
incorporates a resectoscope, which is used to navigate
through the patient anatomy and perform resection.
Flushing and draining are achieved by the use of appro-
priate taps, and foot pedals are used for coagulation and
resection. A number of studies have since established
face41, content40,41 and construct40–42 validity. This simu-
lator is available commercially as PelvicVision (Melerit
Medical AB, Sweden); however, no further reports have
been published since.
The University of Washington TURP Trainer —
available commercially as SurgicalSIM TURP (METI,
USA) — is another VR simulator developed for training
in TURP. It contains full TURP procedures and provides
a detailed performance evaluation report. The develop-
ers demonstrated both face and content validity with
136 participants43,44. Furthermore, construct validity
was demonstrated between novices, trainees and spe-
cialists44,45 and also similar levels of experience, where
TURP experience among residents strongly correlated
with grams resected (P = 0.043), use of more irrigat-
ing fluid (P = 0.024) and less time spent coagulating
(P = 0.027) on the simulator43 To date, SurgicalSIM
TURP is the most extensively validated TURP simulator
available.
Th e VR s i mulat or UroS im (VirtaMe d AG,
Switzerland) contains preprogrammed cases for a num-
ber of endourological procedures including TURP,
transurethral resection of bladder tumours (TURBT)
and laser training. It also provides a specific cystoscopy
module for systematic bladder visualization. UroSim has
demonstrated face46, content47 and construct46–48 valid-
ity for TURP, and the same platform is also available
as TURPMentor (Simbionix, USA). Kuronen-Stewart
etal.49 evaluated the holmium laser enucleation of
the prostate (HoLEP) module in 53 participants, and
demonstrated face, content and construct validity.
The developers of UroSim, VirtaMed AG, also offer
commercial companies the opportunity to recreate and
adapt the platform for specific procedures and instru-
ments. The MyoSim, an adaptation of the UroSim pro-
duced for Biolitec AG in Germany, simulates cases of
diode laser photoselective vaporization of the prostate
(PVP). Angulo etal.50 des cribe d and demonstrated con-
struct validity of the simulator among 18 parti cipants
of varying levels of experience. The CyberSim, pro-
duced for Quanta System, Italy, simulates cases ofthu-
lium vaporesection of the prostate (ThuVaRP) and
thuliumlaser enucleation of the prostate (ThuLEP).
Saredi etal.51 used the simulator to successfully train
two surgeons for these novel procedures, but they did
not report any validity of the model. Other adaptations
of the UroSim platform include the UroLiftSim, created
for NeoTract, USA, and RezūmSim, NxThera, USA. The
simulators contain a number of cases for novel methods
of treating benign prostatic hypertrophy, UroLift52 and
transurethral thermal water vapour therapy53.
UroSim also inclu des a numb er of preprogram-
medTURBT cases. However, the use of UroSim for
training TURBT remains to be validated. A number of
reports in the literature describe the Uro Trainer (Karl
Storz GmbH, Germany) for cystoscopy and trans-
urethral resection, which is no longer commercially
avail able. The name is now synonymously used with a
custom-produced UroSim made by VirtaMed AG for
Karl Storz.
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
• Pat i en t- sp e ci fi c s im ul a ti on — i n t he f or m of v i rt ua l re a li ty ( V R) s im u la to rs a n d
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
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The GreenLight SIM Virtual Reality System (Boston
Scientific, USA) is a VR platform developed by Shen and
colleagues54. The simulator includes six operative cases
and five part-task exercises including anatomy identi-
fication, sweep speed, tissue-fibre distance, power set-
tings and coagulation. It has been rigorously evaluated
by a number of studies and has shown face55,56, content56,
and construct55–57 validity. The same group also devel-
oped and reported58 a novel VR trainer for intravesical
injection of botulinum toxin, containing six cases with
varying bladder anatomy and three subtasks. However,
this simulator is not commercially available and is yet
to be validated.
Summary. Overall, an increasing number of validated
VR trainers are now available for endourology, the
majority of which are for prostatic procedures. The URO
Mentor and PERC Mentor system is, to date, the most
thoroughly evaluated simulator with the highest level of
evidence, demonstrating all domains of validity. These
data are in contrast to TURP simulators, which have
only demonstrated face, content, and construct validity.
The available platforms offer a wide range of tasks but
their use is limited owing to the high costs associated
withthem.
Augmented reality simulation
As a relatively newer modality, few augmented reality
(AR) platforms are available within endourology. Perk
Tutor (Queen’s University, Canada) is the only described
AR training system, and is used for teaching and assess-
ing percutaneous nephrostomy (PCN) using tracked-
ultrasonography- snapshot (TUSS) technology59,60. Four
urology residents with minimal or no prior experience in
PCN participated in a study as operators, whereby each
operator performed two TUSS-navigated procedures
and two conventional ultrasonography-guided pro-
cedures. TUSS-guided PCN was shown to be superior in
a number of parameters including number of attempts,
time taken and amount of needle motion in tissue, but
the authors made no effort to validate their model, and
it has not been released commercially.
Bench models
A number of bench models have been developed and
validated for endourological procedural simulation,
the majority of which are high-fidelity and costly. The
ETXY Multifunctional Trainer (ProDelphus, Brazil)61
is a bench model, available as two different versions:
ETXY Uro Adam, which includes only male genitalia,
and ETXY Hystero Eve, which includes only female
genitalia. These models can be used for training a num-
ber of procedures. The ETXY Hystero Eve62 has been
used to teach rigid and/or flexible cystoscopy followed
by delivery of intravesical botulinum toxin injections.
Face and content validity of the model has been estab-
lished61 among 61 participants comprising of 14 experts
and 47trainees.
Table 1 | Type s of ava ila ble s imul ato r mo dal iti es
Modality Advantages Disadvantages Best suited for
Virtual -reality
simulation
Reusable, data capture,
objective performance
evaluation, minimal set‑uptime
Cost, maintenance, down-time,
lack ofreal instruments, poor
3D view, poor face validity
Basic skills and familiarization,
cognitive training
Augmented-
reality
simulation
Reusable, data capture,
objective performance
evaluation, minimal set‑uptime
Cost, limited practice, lack of
real ins truments
Procedural skills and
familiarization, cognitive
training
Bench-top
or synthetic
models
Por t ab le , re us a bl e, m i ni ma l
risks, use of real instruments
• Low fidelity: acceptance by
trainees, poor face validity
• High fidelity: cost
Dependent upon fidelity:
low fidelity best for part-task
training, high fidelity best for
procedural simulation
3D-printed
models
Patient-specific models,
minimal risks, use of real
instruments
Cost Difficult cases
Animal tissue Cost-effective, minimal set-up
time
Special facilities needed for
storage, single use, anatomical
differences
Basic surgical skills and
part-task training
Live animals High fidelity, high face validity,
fullprocedures
Cost, special facilities and
personnel needed, ethical
concerns, single use,
anatomical differences
Advanced procedural
knowledge, procedures in
which blood flow is important,
dissection skills
Human cadavers
(fresh frozen, or
thiel-embalmed)
High fidelity, highest face
validity of all models, full
procedures
Cost, availability, single use,
compliance of tissue, infection
risk
Advanced procedural
knowledge, dissection,
continuing medical education
Full-immersion
simulation
Cost effective, reusable,
minimal set-up time, portability
Limited realism Team training, crisis
management
High-fidelity
operating room
simulation
Reusable, high fidelity, data
capture, interactivity
Cost, maintenance, and
down-time, limited technical
applications
Team training, crisis
management
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Ureterorenoscopy. A number of URS bench trainers
are available and are in widespread use. The Uro-Scopic
Trainer (Limbs & Things, UK) is the most commonly
used model, and incorporates a pelvis with an attached
urethra, bladder, ureters, and collecting systems. It has
an irrigation and drainage mechanism and can be used
with standard equipment enabling both rigid and flex-
ible ureteroscopy training. Stones can be introduced
within the renal pelvis, ureters or bladder, enabling
stone fragmentation and extraction. It has demonstrated
face23, construct23,63,64, and concurrent30 validity.
The Scope Trainer (Mediskills, UK) is another com-
mercially available high-fidelity bench model with ure-
teral orifices, ureters, collecting systems, a distensible
bladder and a transparent dome for visualization of
instruments. Brehmer etal.65,66 demonstrated the face
and content validity of the model, and participants
agreed that use of the model was similar to the real
procedure. The authors also demonstrated construct
validity in a group of 14 urologists65, in which those sub-
specialized in endourology scored significantly higher
(P = 0.0007). Construct validity was demonstrated in a
second group of 26 residents who showed significant
improvement in skills following training on the model
(P <0.0001). Since then, the developers have also released
the Advanced Scope Trainer, an updated version of the
model in terms of anatomy, which is yet to be validated.
The CREST Endoscopic Urinary Tract Model
(University of Minnesota, USA), is a newer high-fidelity
URS trainer, which provides a lifelike representation of a
complete urinary tract, including the urethra, prostate,
ureters, and kidneys, unlike its competitors. It offers the
most anatomically correct model available, but remains
to be validated67.
Matsumoto etal.63 demonstrated construct validity
of a low-fidelity model, costing just CA$20 and consist-
ing of a penrose drain, inverted cup, moulded latex and
two straws, among 40 medical students. Arandomized
controlled trial compared the low-fidelity model with
the Uro-Scopic Trainer and didactic lectures. Statistically
significant improvements were obser ved in the two
simulation groups compared with didactic lectures
(P <0.05). However, no differences were observed
between the low-fidelity and high-fidelity model groups.
The K-Box (Porgés-Coloplast, France), is an alterna-
tive low-fidelity training model for flexible URS, which
is made of four different boxes to reproduce the upper
urinary tract68. The model enables familiarization of
the movements in flexible URS such as pronation,
supination, forward and backward movement, deflec-
tion, grasping, and releasing. Villa etal.69 conducted
a randomized controlled trial in 16 medical students,
whereby the authors trained one group using the model,
who subsequently outperformed the control group, thus
demonstrating construct validity.
The Cook URS model (Cook Medical, USA) is
another low-fidelity model that is designed for familiar-
ization and training of flexible URS. It has demonstrated
face, content and construct validity among 15 urology
residents70 who underwent a 2-week intensive curricu-
lum and demonstrated significant improvement in skills
performance (P = 0.007) and time taken to complete
tasks (P = 0.001) thereafter.
White etal.71 described and validated the Adult
Ureteroscopy Trainer (Ideal Anatomic Modelling, USA),
another high-fidelity model, which was introduced in
2010. To create the simulator, CT images from a patient
who had difficulty passing renal calculi were used to cre-
ate a model that was then cast in silicone. It contains a
urethral orifice, ureters, and the collection system, and
uses standard URS equipment. URS was performed by
46 participants with varying levels of experience, using
the simulator, who rated it as realistic, easy to use, and
a good training tool71. Expert users outperformed the
other participants on all parameters, including global
score and time of completion. However, the model is no
longer commercially available.
Percutaneous nephrolithotr ipsy. Two bench trainers —
the Perc Trainer (Mediskills) and PCNL Trainer (Limbs
& Things) are commercially available for percutaneous
nephrolithotripsy (PCNL). The former enables the use
of fluoroscopy and ultrasonography, whereas the latter
can only be used with ultrasonography. However, neither
have undergone a formal validation process72,73. A newer
experimental bench model for training without fluoros-
copy, i-PERC (Hospital de Especialidades, Mexico), was
described in 2015. Maldonado-Alcaraz etal.74 recruited
30 novices and trained them in PCNL using the i-PERC.
Participants demonstrated improvement over 20 ses-
sions, thereby demonstrating construct validity. The
Fluoro-Less C-arm Trainer (SimPORTAL, Minneapolis,
USA) has also demonstrated face and content validity for
PCNL training in a study of 14 urologists75, and consists
of two video cameras mounted on a mini C-arm capa-
ble of tilting and rainbow movements. The images pro-
duced are processed by a computer programme to create
a simulated X-ray image. The model is accompanied by
an anatomically accurate silicon flank model for needle
insertion. A further study76 investi gated t he impa ct of it s
use in a 2-day training course among 23 residents, who
were assessed by experts before and after training. There
was significant improvement in upper pole renal access
Box 1 | Definitions of validity
• Face validity* — Opinions, including of nonexperts, regarding the realism of
thesimulator
• Content validity* — Opinions of experts about the simulator and its appropriateness
for training
• Construct validity
- Within one group — Ability of the simulator to assess and differentiate between the
level of experience of an individual or group measured over time
- Between groups — Ability of the simulator to distinguish between different levels
ofexperience
• Concurrent validity — Comparison of the new model against the older and gold
standard, usually by Objective Structured Assessment of Technical Skills (OSATS)
• Predictive validity — Correlation of performance with operating room performance,
usually measured by OSATS
* Face and content validity are assessed using surveys and are generally considered to be
subjective and offer the lowest level of evidence among these criteria.
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Table 2 | Available trainin g models for endourological techn iques
Name of model Institution/manufacturer Type of
model
Procedures Validation
URO Mentor Simbionix, Israel VR UCS, bladder biopsy Face11–14, Content13,14,
Construct11,12,15–20
URS Face13,21–23, Content13,21,
Construct22–29, Concurrent30,
Predictive29,31
PERC Mentor Simbionix, Israel VR PCNL Face14,34,36, Content38, Construct32–36,
Predictive33,36
Pel v icV i sio n Melerit Medical AB,
Sweden
VR TURP Face41, Content40,41, Construct40–42
SurgicalSIM TURP METI, USA VR TURP Face44, Content44, Construct43–45
UroSim/TURPSim VirtaMed AG, Switzer land VR TURP Face46, Content47, Construct46–48
TURBT None
HoLEP Face49, Content49, Construct49
MyoSim VirtaMe d AG, Switze rland VR Diode PVP Construct50
CyberSim VirtaMe d AG, Switze rland VR Thulium None51
GreenLight simulator Boston Scientific, USA VR GL PVP Face55,56, Content56, Construct55–57
ETXY Multifunctional
Tra i n e r
ProDelphus, Brazil Bench UCS, BOTOX injections Face61, Content61
UCS, URS Face62,84, Content62,84, Construct62,84
Pen ro s e dr ai n University of Toronto,
Canada
Bench URS Construct63
Scope Trainer Mediskills, UK Bench URS Face65, Content65, Construct65,66
Cook URS Model Cook Medical, USA Bench URS Face70, Construct70
Uro-Scopic Trainer Limbs & Things, UK Bench UCS, URS Face23, Construct23,63,64,
Concurrent30
The Kidney Box (K-Box) Porg es -C o lo pl a st , Fr an ce Bench URS Construct69
Endoscopic Urinary Tract
Model
SimPORTAL, University
ofMinnesota, USA
Bench UCS, URS None67
Per c Tra in er Mediskills, UK Bench PCNL None73
PCNL Trainer Limbs & Things, UK Bench PCNL None72
C-Arm Trainer SimPORTAL, University
ofMinnesota, USA
Bench PCNL Face75, Content75, Construct76
Bristol TURP Trainer Limbs & Things, UK Bench TURP Face14,77,183, Content14,77,183,
Construct14,77,183
Bristol TURBT Model Limbs & Things, UK Bench TURBT Face14, Content14, Construct14
Resection Trainer SAMED GmbH, Germany Bench TURBT Face78, Content78, Construct78
Holmium Surgical
Simulator
Kansai Medical University,
Japan
Bench HoLEP Face80, Content80
Por ci n e ur in ar y t ra ct NA Animal URS Face62,84, Content62,84, Construct62,84
Por ci n e ki dn ey ± chicken
carcass
NA Animal PCNL Face88,90
Live porcine NA Animal URS Face62,84, Content62,84, Construct62,84
Boar urinary tract NA Animal UCS, bladder biopsy Construct83
Fresh frozen cadavers NA Cadaver UCS92,95, BOTOX injections92,
bladder biopsy92, URS92,93, TURP92,
GL PVP94, HoLEP94, ThuVARP94
Face92–94, Content92–94, Construct93,95
Thiel-embalmed
cadavers
NA Cadaver URS96,97, TURP96 Face96,97, Content96,97
BOTOX, botulinum toxin; GL, GreenLight; HoLEP, Holmium laser enucleation of the prostate; NA, not applicable; PCNL, percutaneous nephrolithotomy;
PVP,photoselective vaporization of the prostate; ThuVARP, Thulium vapouresection of the prostate; TURBT, transurethral resection of bladder tumour;
TURP,transurethral resection of the prostate; UCS, urethrocystoscopy; URS, ureterorenoscopy; VR, virtual reality.
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(P = 0.0015) but none in lower pole access. Participants
perceived the model as “very helpful” for learning PCNL
access (mean score of 5.4/6).
TURP and TURBT. The Bristol TURP Traine r (Limbs &
Things, UK) is a disposable bench model, placed within a
sealed plastic chamber, which gives trainees the opportu-
nity to perform TURP. Face, content, and construct valid-
ity of the model have been demonstrated77. The Bristol
TURBT Trainer is a similar model that offers training
forTURBT. Khan etal.14 evaluated both models within
a centralized training programme and demonstrated
face, content, and construct validity. Expert and trainee
surgeons felt the models were good training tools, but
thought that their realism was limited by the lack of bleed-
ing. The Resection-Trainer (Samed GmbH, Dresden,
Germany), is a similar model comprising of a base unit
and a prostate or bladder substrate made ofresectionable
material. Face, content, and construct validity78 of the
model have been demonstrated for TURBT in 76 parti-
cipants. All three models have the advantage of enabling
use of real instruments and irrigation.
HoLEP. The BPH Model and Holmium Surgical
Simulator (Kansai Medical University, Japan) consists of
a hypertrophied prostate model, which can be fitted and
installed into a box simulator and can be used with stand-
ard endoscopy equipment and a holmium laser79. It ena-
bles real fluid management and can be replaced after each
procedure. However, being a synthetic model, it is limi-
ted by supply of models, although refills can be ordered.
Ayd in etal.80 evaluated this model in a group of 36
urologists and demonstrated its face and contentvalidity.
Summary. Bench models in endourology have mainly
offered urolithiasis training. Only a select number have
been developed and validated for other endourological
procedures. Thus, urolithiasis trainers have, in gen-
eral, been more robustly validated. A majority of the
models have demonstrated face, content, and construct
validity, among which the Uro-Scopic Trainer has the
highest level of evidence and is the only model to also
demonstrate concurrent validity. Newer models such as
the K-Box and the CREST model might also be highly
effective tools67, but evidence to demonstrate their valid-
ity is not available. Evidence regarding PCNL models
is especially sparse, and further efforts should be made
to evaluate their validity. As the majority of the avail-
able PCNL simulators are high-fidelity models, they are
associated with a high costs, which could limit their use.
Rapid prototyping (3D printing)
Rapid prototyping, also known as 3D printing, is a manu-
facturing technology that allows accurate reproduction of
3D structures using CT data. Originally introduced in the
mechanical engineering field, it has also garnered interest
as a tool for assessment and preoperative surgical plan-
ning. Bruyere etal.81 pro duced a 3D-printed kidney model
of a patient scheduled to undergo PCNL, using abdominal
CT images of the patient, in order to enable surgeons to
train on the patient-specific model before performing the
operation. Rapid prototyping is a relatively new concept,
which will be useful in preparing numerous models of
variable cases and stages ofdifficulty.
Animal models
A limited number of animal models have been developed
for endourology training. In 2008, Schout etal.82 created
a model consisting of a plastic box in which a pig bladder
can be easily installed and removed, using a removable
metal plate and plastic holder. The model enables train-
ing in numerous procedures, including flexible and rigid
cystoscopy, biopsy, TURBT, and cystolitholapaxy. Real-
time instruments, connected to a light source and a cam-
era, are used. The authors report practical usefulness but
the model lacks formal validation. A high-fidelity train-
ing model using boar urinary tract suspended in a frame
was developed by Grimsby and colleagues83. To test the
durability of the model, two first-year urology residents
were invited to participate in a training activity. They
underwent a training curriculum including cystoscopy,
foreign body retrieval, and bladder biopsy. In each of the
assigned tasks, both residents demonstrated a percent
improvement ranging from 13% to 97% in time taken
to complete.
The use of porcine renoureteral tissue and live anaes-
thetized pigs as part of a wider curriculum has demon-
strated face, content, and construct validity for semirigid84
and flexible URS62. In a similar study85 20 urologi sts were
trained using fresh porcine kidneys with attached ure-
ters. This model demonstrated construct validity, with
reduced time to completion plateauing at the sixth train-
ing attempt. A number of studies have described the use
of foam-wrapped86, silicone-covered87 or insitu38 porcine
kidney for PCNL training. Zhang etal.88 reported face
validity of the use of porcine kidneys in a study of 42
urologists. Another three studies89–91 placed the porcine
kidney into a chicken carcass to simulate the posterior
tissue layers in humans. Hammond etal.90 demonstrated
face validity of this model among urology residents.
Overall, studies on animal models have been limi-
ted, and the only validated models are for urolithiasis
training. Porcine renoureteral tissue has proven to be
a very effective and useful model for URS training, as
demonstrated by several studies of appropriate size
and quality62,84,85. Porcine tissue has also demonstrated
face, content, and construct validity for URS, but
onlyface validity for PCNL. Live pig models have also
demonstrated face validity but their use is limited by
ethicalconsiderations.
Human cadavers
The British Association of Urological Surgeons (BAUS)
Human Cadaver Training Programme was described
in 2015 — a comprehensive curriculum using fresh
frozen cadavers (FFCs), which also includes a Core
Endourology module92. Junior residents performed
rigid cystoscopy and bladder biopsy, flexible cystoscopy,
botulinum toxin injections, semirigid and flexible URS,
and TURP. All procedures were rated >4 or for realism
on a five-point Likert scale by both novice (n = 75) and
expert (n = 27) participants. Another study93 used FFCs
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to train 12 certified urologists in flexible URS technique.
The authors established face and content validity among
participants and faculty, and showed a statistically sig-
nificant change in time taken to perform the procedure
(3.56 ± 2.0 min (range 1.21–7.46) versus 1.76 ± 1.54 min
(range 1.00–6.34) (P = 0.008)), thereby demonstrating
construct validity. A further study94 described the use
of FFCs for laser prostatectomy, including GreenLight
Laser photoselective vaporization of the prostate
(GreenLight PVP), HoLEP, and ThuVaRP, and reported
face and content validity of the model for all techniques.
Furthermore, construct validity of FFCs has also been
demonstrated for cystoscopy in a group of 29 obstetric
residents95. Several studies have also reported the use of
thiel-embalmed cadavers (TECs). Rai etal.96 and Mains
etal.97 demonstrated face and content validity of TECs
for URS, with the former study also demonstrating
validity of the model forTURP.
Cadavers have always been used for surgical train-
ing. However, the evidence supporting their use is limi-
ted by small studies of poor quality, many of which are
survey studies92,96,97. TECs have been shown to demon-
strate superior efficacy for tissue quality, elasticity, and
handling98 and are generally assumed to be more real-
istic than FFCs, but this assumption is yet to be proven
in well-designed studies. Nevertheless, both the expert
and participants involved in these studies highly rec-
ommended cadaveric training and suggest they be used
asmasterclasses.
Laparoscopic urology
Owing to restrictions in working times and its technically
demanding nature, laparoscopic surgery is associated
with a steep learning curve. Simulation has been widely
adopted to overcome this challenge. An overwhelming
number of simulators for acquiring basic laparoscopic
skills are available, in the form of VR and box trainers99,
which have been thoroughly evaluated by many studies. In
contrast, procedure-specific models are fewer in number
and lack comprehensive validation studies (TAB L E  3).
Virtual realit y simulation
The Procedicus MIST (Mentice, Sweden) is a laparo-
scopic nephrectomy simulator, which has demonstrated
face, content, and construct validity in a group of eight
experts, 10 trainees and 10 novices100. Validity was also
demonstrated among 33 participants when the plat-
form was used in a centralized training programme14.
However, in 2010, Wijn etal.101 reported failure of
Procedicus MIST to demonstrate construct validity
in a larger cohort (n = 64). The model has not been
commercially available since.
The LAP Mentor (Simbionix, USA) and LapSim
(Surgical Science, Sweden) are commercially avail-
able VR simulators, which include programmes to
train in basic camera and laparoscopic skills as well as
procedure- specific modules, one of which is nephrec-
tomy. The simulators have been validated for basic
skills102–107, but the nephrectomy modules have not yet
been scientifically evaluated.
Dry-lab models
Dry laboratories utilize a variety of synthetic bench
models as opposed to animal and cadaver models,
other wise termed wet-lab models, and virtual reality;
several dry-lab models have been produced for use
within box- trainers. The Partial Nephrectomy dry-lab
model (University of California Irvine, USA) is a kid-
ney model made from polyvinyl alcohol with an incor-
porated tumour. It has demonstrated face and content
Table 3 | Available trainin g models for laparoscopic urology
Name of model Institution / manufacturer Type of
model
Procedures Validation
Procedicus MIST
Nephrectomy
Mentice, Sweden VR LAPN Face100, Content100,
Construct100
LapMentor Simbionix, Israel VR LAPN None
LapSim Surgical Science, Sweden VR LAPN None
Partial Nephrectomy
Renal Model
University of California Irvine
Medical Center, USA
Bench LAPN Face108, Content108,
Construct109,110
Hydrogel model Cleveland Clinic, USA Bench Ureteral
reimplantation
Face113, Content113,
Construct113
Latex UV model McMaster University, Canada Bench UVA Face114, Predictive114
Rabbit model NA Animal LAPN Construct116
Por ci n e bl ad de r NA Animal Pyeloplasty Construct123
Chicken crop model NA Animal Pyeloplasty Construct117
Por ci n e in te st i ne m od e l NA Animal UVA Construct124
Chicken chest model NA Animal UVA Construct118
Chicken skin model NA Animal UVA Content121, Construct121
Live pig NA Animal UVA Face114
LAPN, laparoscopic-assisted partial nephrectomy; NA, not applicable; UVA, urethrovesical anastomosis; VR, virtual reality.
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validity in a group of five urology fellows108. Two fur-
ther studies109,110 used the model in a high-fidelity oper-
ating theatre environment and demonstrated construct
validity with eight and nine subjects, respectively.
A disposable, low-cost, high-fidelity, physical renal
pelvis–ureter tissue analogue model for pyleo plasty
training has been developed and validated, with face,
content, and construct validity demonstrated in a
group of 31 urologists111. A similar model built for
paediatric pyeloplasty using 3D printing technology
has demonstrated face validity among 22 novices and
four experts112. None of these models are commercially
available, and are solely for training purposes at the
institutions by which they were developed.
Tu ni t s ky etal.113 developed a d ry-lab model for m ini-
mally invasive ureteral reimplantation from hydrogel,
and demonstrated face, content, and construct validity
of the model in 20 subjects. A randomized controlled
trial114 evaluated a latex task-specific simulator for ure-
throvesical anastomosis (UVA) and demonstrated its
face and predictive validities. Anaesthetized pigs were
used to assess surgical performance, and the study
showed that the groups who trained on the model
outperformed the control arm.
Animal models
Animal models provide the mainstay of laparoscopic
procedural training in urology. A range of exvivo and
invivo models have proven to be useful. Although
studies conducted on these models have been of accept-
able quality, they generally include only low numbers
of participants; efforts should be made to address this
concern with the involvement of more residents in
validationstudies.
Animal models within laparoscopic box-trainers
have been used to simulate partial nephrectomy and
pyeloplasty. Among proposed animal models, rabbits
have been validated as models for improving basic
surgical skills including suturing, knot-tying and dis-
section115. Molinas etal.116 used live rabbits to train 10
medical students and 10 gynaecologists to perform
laparoscopic nephrectomy. Each participant performed
20 procedures, at the end of which duration of surgery
and rates of complications were significantly reduced.
Gynaecologists achieved shorter operating times than
students for the first and last procedures (P <0.0001 and
P = 0.0001, respectively) and severe complications were
more frequent in the student group (P = 0.0003).
Jiang etal.117 described a chicken crop and oesopha-
gus model to simulate the human renal pelvis and ureter,
respectively, for UVA. Construct validity of this model
was demonstrated in 15 participants, in which experi-
enced participants outperformed intermediates and
novices. Laguna etal.118 assessed the effectiveness of
the chicken-chest model for laparoscopic UVA training
and demonstrated basic construct validity. However, the
model failed to reflect the different levels of experience
among the most experienced subjects. Similarly, Nadu
etal.119,120 developed the chicken-skin model, in which
chicken skin was transformed into a 4-cm long tube
over a 16F catheter (imitating the urethra), with another
piece of skin folded over itself to simulate a bladder, and
showed that using the model enabled trainees to acquire
laparoscopic UVA skills in addition to developing other
fundamental skills such as manual dexterity. This model
was shown to have both construct and content validity
for UVA in a study carried out by Yang and Bellman121.
The chicken-gizzard model has also been proposed
and used to perform UVA, but has not undergone
anyvalidation122.
The porcine model has also been used for laparoscopic
procedural training. Teber etal.123. used porcine bladders
to train five laparoscopic surgeons in pyeloplasty. Over
five sessions, time for completion decreased by 20.8%
(P = 0.01), thereby demonstrating construct validity.
The porcine-intestine model has been used for laparo-
scopic UVA and has demonstrated construct validity124.
Jiang etal.125 proposed the posterior chicken trunk and
porcine colon segment as a more effective, realistic,
andcheaper alternative to the chicken-skin model for
laparoscopic UVA training. The use of anaesthetized pigs
to assessUVA performance has also demonstrated face
validity in a study of 28participants114.
Robot-assisted urological surgery
Robot-assisted surgery, as a relatively new but rap-
idly evolving subspecialty, is well suited to simulation.
Currently, VR simulators comprise the majority of avail-
able training tools (TAB L E  4). However, recognition of the
importance of structured training curricula is driving
innovation in AR, dry-lab, and wet-lab models.
VR simulators
A relatively large number of VR simulators are com-
mercially available, the majority of which have under-
gone extensive validation. The principle VR simulators
available in robotic surgery are the Robotic Surgical
Simulator (Simulated Surgical Systems, USA), the
dV-Trainer (Mimic Technologies, USA), the SimSurgery
Educationa l Plat form (SE P) Robot (SimSurger y,
Norway), the da Vinci Skills Simulator (dVSS; Intuitive
Surgical, USA), the ProMIS (CAE Healthcare, Canada)
and the RobotiX Mentor (Simbionix, USA) (TABLE4).
The dVSS is the only simulator to work directly
with the da Vinci robot. The dVSS backpack is attached
directly onto the console, enabling the user to practice
operating on the da Vinci robot in a virtual environ-
ment. The disadvantage of this arrangement is that the
simulator can, therefore, only be used when the robot is
free, which greatly limits training time. First introduced
in 2011, it runs the Mimic Msim software which pro-
vides basic and advanced training modules. The dVSS
has undergone extensive evaluation, demonstrating
face126–130, content126–133, construct128–130, concurrent126
validity. A single study has also shown predictive valid-
ity in uro logical surgery, with dVSS training significantly
improving performance on exvivo models134.
The dV-Trainer is a standalone simulator with
mobile foot pedals. However, the hand controls differ
from those of the da Vinci system, with the master con-
trollers connected via two tension cables as opposed to
the jointed arms of the da Vinci robot. The dV-Trainer
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runs its own Mimic Msim software like the dVSS.
The first prototype was released in 2007 and it is now
themost validated robotic simulator. Face126,135–143, con-
tent126,127,135–137,139–141,143 and construct126,127,135–137,140,142–144
validity have been established in multiple studies.
Studies have also assessed predictive validity using
dry-lab performance as a surrogate for robotic profi-
ciency. Three studies have shown equivalent improve-
ment compared to dry-lab training138,145,146 whereas one
showed improved performance compared with a con-
trol group, who did not receive any simulation train-
ing147. Kang etal.143 developed the Tube 3 module, a VR
module teaching anastomosis of two tubes, in prepara-
tion for UVA. The authors demonstrated face, content,
and construct validity among 20 parti cipants. A further
small study by Kim etal.148 recruited 11 robotic novices
and trained them using this module over seven sessions.
Using th e d a Vinci ro bot, the parti cipa nts the n p er-
formed anastomosis on synthetic double-layered bowel
(Limbs & Things, UK) and, later, on another synthetic
UVA model (3-Dmed, USA), thereby demonstrating a
basic level of concurrent and predictive validities. The
utility of both the dVSS anddV Trainer simulators
have been extensively validated. The freestanding dV
Tr ai ne r me a ns i t ca n be w i de ly u s ed , wi t ho ut b e in g li mi -
ted by the availability of the da Vinci console; however,
training outcomes seem to be largely similar between
the twomodels.
The Robotic Surgical Simulator (RoSS) was devel-
oped by the Roswell Park Cancer Institute and the
Univ ersit y of Buf falo. The Ro SS is a st andalone s imu-
lator that emulates the controls of the da Vinci robot.
Studies have confirmed face149, content150, and con-
struct151,152 validity, although not as extensively as for
the dV-Tr ai ne r or dVS S . Th e R oS S c ur re nt ly in co rp o-
rates the Fundamental Skills of Robotic Surgery (FSRS)
curriculum. Composed of four modules (basic console
training, psychomotor Skills, basic surgical skills, and
intermediate surgical skills), the FSRS curriculum aims
to teach novice trainees basic robotic surgical skills153.
However, it is currently only available in the USA.
The RobotiX Mentor was released in 2014. This free-
standing simulator provides 3D vision and free-floating
hand controls. It offers the Fundamentals of Robotic
Surgery (FRS) curriculum, as well its own basic suturing
modules, which have shown face, content, and construct
validity154. Modules for hysterectomy, lobectomy, vagi-
nal cuff closure and inguinal hernia repair are available;
aprostatectomy module has also been developed but is
not yet validated.
The SEP-robot (SimSurgery, USA) uses two motion-
tracked hand controls that mimic — rather than replicate
Table 4 | Available trainin g models for robotic urolo gy
Name of model Institution / manufacturer Type of
model
Procedures Validation
dV Trainer Mimic Technologies, USA VR Basic Skills Face126,135–143, Content126,127,135–137,139–141,143,
Construct126,127,135–137,140,142–144, Predictive145,147
Tub e -3 Mimic Technologies, USA VR UVA Face143, Content143, Construct143,
Concurrent148, Predictive148
Maestro AR Mimic Technologies, USA AR RAPN161, RARP Face161, Content161, Construct161
dVSS Intuitive Surgical, USA VR Basic Skills Face126–130, Content126–133, Construct128–130,
Concurrent126
RoSS/HoST Simulated Surgical Systems,
USA
AR/VR Basic Skills (FSRS)149–152,
UVA162, RARP, cystectomy,
lymph node dissection
Face149,162, Content150, Construct151,152,
Concurrent162
RobotiX Mentor Simbionix, USA VR Basic Skills Face154, Content154, Construct154
SimSurgery Educational
Platform
SimSurgery, Norway VR Basic Skills Face155, Content155, Construct14,155–157
ProMISTM CAE Healthcare, Canada VR/
Bench
Basic Skills Face158, Content158, Construct158–160
Mimic dry-lab Exercises Mimic Technologies, USA Bench Basic skills Face160, Content160, Construct160
RARP dry-lab models The Methodist Hospital, USA Bench Basic skills for RARP Construct163
SIMPLE-PN University of Rochester, USA Bench RAPN Face164, Content164, Construct164,
Concurrent165
Porcine kidney with
styrofoam ball
NA Animal RAPN Face167, Content167, Construct167,
Concurrent134, Predictive134
Por ci n e ge ni to u ri na r y mo de l NA Animal RARP Face168, Content168, Construct168
Fresh frozen cadavers NA Cadaver RARP169,171, RAPN171,
cystectomy171, lymph node
dissection171
Face169,171, Content171, Construct171
AR, augmented reality; dv-Trainer, da Vinci Trainer; dVSS, da Vinci Skills Simulator; ERUS, EAU Robotic Urology section; FSRS, Fundamental Skills of Robotic
Surgery; GU, genitourinary; HoST, Hands-on Surgical Training; RAPN, robot-assisted partial nephrectomy; RARP, robot-assisted radical prostatectomy;
RoSS,Robotic Surgical Simulator; UVA, urethrovesical anastomosis; VR, virtual reality.
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Educational impact
The extent to which test results
and feedback contribute to
improve the learning strategy
on behalf of the trainer and
thetrainee
— robotic control arms. Like the da Vinci robot, a clutch
is incorporated, but the video feed is displayed by a 2D
screen as opposed to the 3D video provided by the above
simulators. Gavazzi etal.155 initially demonstrated face,
content, and construct validity of the platform and three
further studies supported the construct validity14,156,157.
Incontrast, van der Meijden etal.157 felt the system
required further development to improve its educational
value. To date, there have been no further updates on
the SEP system and its use remains limited despite its
commercial availability.
Although the ProMIS simulator was originally
designed for standard laparoscopic surgery, it has
also been successfully used with robotic instruments.
ProMIS is a hybrid VR simulator and box trainer with
motion tracking technology that enables the user to
interact with virtual and physical models. Face158,
content158 and construct158–160 validity for robotic
training have been demonstrated, but its use remains
limited.
Robotic VR simulators have, in general, been shown
to be useful in basic skills acquisition, with many high-
quality studies conducted. The most comprehensive
evaluation has been performed on the dV-Tra in er
followed by the dVSS, which uses the same software.
Moving forwards, further research on the optimal inte-
gration of virtual reality simulation within the robotic
surgical curricula is now required. Further studies with
high levels of participation should be conducted to
evaluate the existing procedural modules in detail.
Augmented reality simulators
The Maestro AR system (Mimic Technologies, USA),
which was released in 2014, provides procedure- specific
training through manipulation of a 3D anatomical
video161. Currently, the only urological module is for
partial nephrectomy, for which the authors have demon-
strated face, content, construct, and concurrent validity
in a group of 42 participants161. Further modules includ-
ing prostatectomy and low anterior resection have been
developed, but are yet to be validated.
An AR procedure-specific training programme
using Hands-on Surgical Training (HoST), for use on
the RoSS has been developed for prostatectomy, cystec-
tomy, and lymph node dissection. Chowriappa etal.162
demonstrated face and concurrent validity of the UVA
module in a group of 52 fellows and residents. Alongside
the full procedural training VR modules developed
fortheRobotiX Mentor, such procedure specific AR
training is an expanding area of simulation, which offers
the potential for bridging the gap between basic simula-
tion training and advanced wet lab and modular training
within the operating room.
Results from the further validation of these training
programmes are required to hopefully support or refute
such possibilities.
Dry-lab models
A number of dry-lab models have been developed for use
with the da Vinci Surgical System. However, in compari-
son to VR simulators, relatively few models have been
validated for robotic surgery. Ramos etal.160 validated
three dry-lab models reverse engineered from the Mimic
Msim VR software. The three basic skills models demon-
strated face, content, and construct validity. Similarly,
Goh etal.163 developed four training exercises (suturing,
dissection, peg transfer, and needle driving) for robot-
assisted radical prostatectomy (RARP) with construct
validity initially proven within a small cohort. Further
comparison with VR and wet-lab models revealed a
strong correlation between all three modalities133.
SIMPLE-PN (Simulate d Inanim ate Model for
Physical Learning Experience-Partial Nephrectomy)
model (University of Rochester, USA) is a procedure-
specific training model for robot-assisted part ial
nephrectomy (RAPN). Using a 3D-printed replica kid-
ney and tumour, it provides simulation to perform the
steps of RAPN. Face, content, and construct validity
were demonstrated using objective parameters of ischae-
mia time, blood loss, positive margins, and estimated
blood loss164. Comparison of procedural metrics includ-
ing operative time, blood loss and warm ischaemia time
during RAPN on the SIMPLE model and live surgery
has been used to show concurrent validity165. However,
the small sample size of both studies (n = 8) mean that
further validation is required. Patient 3D-printed models
have also been created to enable exact patient- specific
simulation just before surgery166 but these require
educational evaluation.
Animal models
Both exvivo and invivo animal models have been used
for robotic training. Unfortunately, few studies have
documented their educational value. Hung etal.167
described a tissue model for RAPN training consisting
of a porcine kidney and a polystyrene ball to mimic a
tumour. Face, content, and concurrent validity were
established among 46 participants — 24 novices,
9intermediates, and 13 experts. Further analysis during
a larger trial supported its concurrent validity134. This
study also analysed use of a porcine bowel and bladder
for resection and cystostomy closure training, respec-
tively. However, only concurrent validity was confirmed
during the trial134.
Tissue models for RARP have also been created.
An exvivo model from a female porcine genitourinary
tract has been shown, surprisingly, to provide effective
simulation of the key steps of RARP. Fallopian tubes are
used to simulate the seminal vesicles and dorsal venous
complex while the introitus is used as the prostate. Face,
content and construct validity of the model were demon-
strated168. Exvivo tissue models (chicken and porcine)
alongside invivo porcine models were used as part of the
European Association of Urology (EAU) robotic training
curriculum. Although specific data pertaining to their
use as wet lab models are not available, the curriculum
was shown to be effective overall, with good educational
impact and acceptability169,170.
Human cadavers
As with animal models, validation of the effectiveness of
cadaveric training in robotic surgical training is lacking.
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Cost effectiveness
The extent to which a training
and assessmenttool provides
maximum value for money.
Cadaveric training was incorporated into the validated
EAU robotic training curriculum169,170 and R aison etal.171
demonstrated face, content, and construct validity in a
study of 16 intermediate and four expert participants.
Open surgery
Open surgery remains a challenge for surgical simulation;
unlike the wide range of systems available for minimally
invasive procedure training, only a limited number of
training models and simulators are available(TABL E  5 ).
Bench models
Up to 10 high-fidelity bench models are commercially
available for simple and suprapubic urinary catheteriza-
tion. However, none of these models have undergone any
scientific evaluation thus far, and they are very costly. In
contrast, a number of low-fidelity models for suprapubic
catheterization (SPC) have been described and validated
in the literature. Singal etal.172 develop ed a mo del consi st-
ing of a bony pelvis, a bladder, a fat layer, and a skin layer
to teach general surgery residents. The authors demon-
strated face and content validity among 25 parti cipants,
and cost effectiveness (US$31.28). Another model, devel-
oped by Hossack and colleagues173, consisting of an
abdominal wall from a simple box and a bladder from
a party balloon, has demonstrated face validity, is easily
reproducible and costs AU$2.67 per resident. UroEmerge
(St Bartholomew’s Hospital, UK)174 is an other l ow- fidelity
model consisting of a 3-litre bag of irrigation fluid,
injected and then tied with two tourniquets to simulate a
full bladder, within a plastic box, covered by an abdomi-
nal open and closure pad simulating abdominal skin and
the rectus sheath. SPC insertion using this model was
assessed in 36 participants, who were assessed before and
after training, showing that they performed considerably
better after usingUroEmerge.
Adult male circumcision models have also been
reported in the literature. The Adult Circumcision
Tr ai ne r (L i mb s & Th in g s, U K) 175 consists of an anatom-
ical penile piece and a synthetic double-layered bowel,
to simulate the foreskin. The authors demonstrated
face and content validity among 55 trainees and 32
trainers. The cost of the penile model is UK£112 and
the foreskin material is £8, the latter being able to be
used twice. Abdulmajed etal.176 used a similar penile
model (Pharmabotics, UK) and the same foreskin mat-
erial to simulate adult male circumcision. The authors
also described the use of the model for simulating other
penile procedures including penile ring-block local
anaesthetic injection, paraphimosis reduction and pri-
apism aspiration. They demonstrated face and content
validity for all these procedures among 12 trainees and
their trainers. The latter model costs £22 and can be used
approximately four times. As a result, the latter model
is far more cost-effective and enables a greater number
of procedures to be performed, with individual cost
approximating at £5.50 per trainee for all the procedures.
Bench models for vasectomy have also been devel-
oped. The No-Scalpel Vasectomy Simulator (Advanced
Meditech, USA) demonstrated face validity in a group of
four urology residents, who stated the model improved
their level of confidence in performing the procedure177.
Park etal.178 developed a low-fidelity model consisting
of a realistic scrotal sac made from silicone rubber with
two spherical testes attached to spermatic cords. The
authors demonstrated face and content validity in a
group of six urology residents and found it to be a useful
tool for novices learning the procedure.
Table 5 | Available trainin g models for open urology
Name of model Institution or manufacturer Type of
model
Procedures Validation
SPC Training Model Northwestern University Feinberg
School of Medicine, USA
Bench UC, SPC Face,
Content172
SPC Training Model Western Hospital, Melbourne,
Australia
Bench UC, SPC Face173
UroEmerge SPC Model St Bartholomew’s and The Royal
London Hospitals, UK
Bench SPC Construct,
Predictive174
Advanced
Catheterisation Trainer
Limbs & Things, UK Bench SPC None
Adult Circumcision
Tra i n e r
Limbs & Things, UK Bench Circumcision Face175,
Content175
Pen i le M od el + foreskin Pharmabotics, UK (penis), Limbs &
Things, UK (foreskin)
Bench Circumcision, penile
ring block, paraphimosis
reducti on, priapis m aspiration
Face176,
Content176
Non-Scalpel
Vas e ct o my S i mu la t or
Advanced Meditech, USA Bench Va s e ctom y Face177
Fresh frozen cadavers NA Cadaver Andrology92, emergency
procedures92
Face92,
Content92,
Construct
Thiel-embalmed
cadavers
NA Cadaver Renal transplantation179 Face179
NA, not applicable; SPC, suprapubic catheterization; UC, urinary catheterization.
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Crisis resource management
training
(CRM training). Simulation
training to enhance cognitive,
interpersonal, communication
and team-working skills during
emergency scenarios.
In summary, a variety of synthetic models have been
described for open urological surgery However, the val-
idation studies have been of low quality and in a limited
number of participants. Nevertheless, these are the only
models for use in the training of suchprocedures.
Human cadavers
The BAUS curriculum92 for cadaveric training has used
FFCs for a number of common operations including
circumcision, vasectomy, hydrocele repair, testicular
fixation, and radical orchidectomy. Cadavers have also
been used for training in emergency urological pro-
cedures including open cystostomy, management of
bladder perforation, transureteroureterostomy, ureteric
reimplantation, open surgical packing of the pelvis,
and emergency nephrectomy. Face and content validity
of FFCs has been shown for common and emergency
urological operations in a group of 75 residents and 27
experts92. Similarly, Cabello etal.179 demonstrated the use
of TECs in renal transplantation and demonstrated face
validity among 28 subjects. However, face and content
validity is generally considered to be only a low level of
evidence and further studies are needed to prove the
usefulness of cadavers for such training.
Nontechnical skills and team training
Considerable attention has been given to the devel-
opment of technical skills in the simulation envi-
ronment. Three distinct categories of nontechnical
skills are described in the literature: cognitive skills,
personal resource factors, and social skills180 (FIG.1).
A number of different concepts have been used for
integration of nontechnical skills and team training
inurology109,110,181–183.
A centralized training programme with crisis resource
management training (CRM training) was carried out with
33 training specialists and five nurses in a simulated ward
setting14. Using an interactive human patient mannequin,
up to six different clinical scenarios were enacted, followed
by debriefing, and demonstrated constructvalidity.
Brunckhorst etal.181 conducted a randomized con-
trolled trial in which one group of participants received
ureteroscopy and nontechnical skills training through a
curriculum using full immersion simulation (Imperial
College London, UK), a low-fidelity inflatable operating
environment, and the control group received a stand-
ardized 30min didactic teaching for both arms. The
randomized group outperformed the control arm in all
aspects, including nontechnical skills, thereby demon-
strating construct validity. Furthermore, the researchers
showed a strong correlation between technical and non-
technical skills182. Brewin etal.183 also used this concept
for training in TURP scenarios and demonstrated face,
content, and construct validity.
Two studies have used high-fidelity operating room
simulation within a simulated laparoscopic operat-
ing room (Karl Storz, Germany) using the Partial
Nephrectomy dry-lab model (University of California,
USA)109,110. The researchers executed a partial nephrec-
tomy scenario with complications, in which the
high-fidelity operating room team training simulation
demonstrated face, content, and construct validation in
both technical skills and nontechnical skills. TeamSim
(Surgical Science, Sweden) is another example of a team
training package whereby a virtual operating room can
be created alongside the LapSim for procedural training;
however, it remains to be validated.
Team training is also a very important concept
in robot-assisted surgery owing to the set-up of the
operating room: the surgeon is at the console, away
from the patient and, therefore, relies on assistants for
the safety of the patient. The Xperience Team Trainer
(XTT; Mimic Technologies) has been developed to train
both the surgeon and the assistant. XTT is currently
used alongside generic skills modules, but procedure-
specific modules will, hopefully, also be developed. The
platform has demonstrated face, content, construct, and
concurrentvalidity184.
Curricular training
A number of studies have used individual simulators
and developed curricula instead of simply opportunis-
tic use of VR simulators. In endourology, Hudak etal.45
used the SurgicalSIM TURP simulator and Bright
etal.46 used the UroSim to design and validate TURP
curricula using each of the respective VR simulators.
Similarly, Aydin etal.56 and Kuronen-Stewart etal.49
developed GreenLight PVP and HoLEP curricula with
the GreenLight Simulator and UroSim, respectively. In
laparoscopic surgery, Brewin etal.100 have developed and
validated a VR curriculum with the Procedicus MIST for
retroperitoneal laparoscopic nephrectomy.
The Fundamentals of Laparoscopic Surgery (FLS)
skills curriculum, the validity of which is well demon-
strated for training and assessment, has been adapted
into a number of urology-specific curricula includ-
ing the Program for Laparoscopic Urological Skills
(PLUS)185,186, BasicLaparoscopic UrologicSurger y
Figure 1 | Components of nontechnical skills.
Threedistinct categories of nontechnical skills have been
described in the literature including cognitive skills,
personal resource factors, and social skills.
Nature Reviews | Urology
Cognitive skills
• Decision making
• Planning
• Situation
awareness
Social skills
• Communication
• Teamwork
• Leadership
Personal
resource
factors
• Stress
• Fatigue
Nontechnical
skills
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(BLUS) skills programme187 and the European Basic
Laparoscopic Urological Skills (E-BLUS) programme188.
Sweet etal.187demonstrated face, content, and construct
validity and acceptability of BLUS in a group of 116 parti-
cipants including practicing urologists, fellows, residents,
and medical students. Similarly, the PLUS curriculum has
also demonstrated face, content, and construct validity,
although among a relatively lower number of just 50 par-
ticipants185, and has established itself as reliable method of
assessment186. Results of the E-BLUS assessment revealed
that the laparoscopic skills level among European res-
idents is very low188 and, hence, training using the for-
mer two curricula might help residents to reach a level of
competency in these skills.
Despite the large number of individual training
models and validation studies available, each model has
its strengths and drawbacks. Thus, models should be
used in combined curricula that address specific learning
needs. Furthermore, nontechnical skills training should
also be integrated into such curricula. Brunckhorst
etal.181 developed a training curriculum incorporating
various platforms for ureteroscopy and nontechnical
skills within a full simulation environment, performing
a randomized controlled trial in which medical students
who were trained with the curriculum outperformed the
controlgroup.
A similar curriculum, only including technical skills,
was described for semirigid84 and flexi ble URS62, whereby
a modular three-stage curriculum was developed, which
began with theoretical knowledge. Participants then used
the ETXY Uro Adam to perform urethrocystoscopy, ure-
teral orifice cannulation, and a semirigid ureteroscopy
case. These procedures were followed by laser lithotripsy
and basket removal of stones on a porcine renoureteral
unit. Finally, participants repeated task one on a live por-
cine model. Face, content, and construct validity of both
curricula weredemonstrated.
The EAU Section of Robotics (ERUS) has devel-
oped a training curriculum for RARP189. This 12-week
programme was developed based on an expert panel
discussion and used to train 10 fellows from major
European teaching institutions. The curriculum includes
e- learning, 1week of structured simulation-based train-
ing (VR, synthetic, animal, and cadaveric platforms), and
supervized modular training. Eight training surgeons
took part in the programme and face validity, feasibility,
acceptability, and educational impact of the curricula
weredemonstrated.
Future work and recommendations
Early simulators have had the advantage of increased
scientific evaluation in contrast to newly developed
simulators, which have not had as thorough evalu-
ation. Consequently, greater emphasis must be placed
on validating the more recently developed simulators.
Furthermore, efforts should be made to identify the best
aspects of each training model and procedure-specific
simulation curricula should be developed and validated,
employing different modalities, with the inclusion of
nontechnical skills training, as exemplified by the studies
carried out by Brunckhorst and colleagues181.
Patient-specific simulation, in the form of VR and
3D-printed bench models, have also become more freely
available in recent years190–192. A newly developed laparo-
scopic renal VR simulator that uses abdominal CT scans
to create cases from patient-specific data has been devel-
oped to enable surgeons to prepare for cases preopera-
tively191,192. Similarly, an increasing number of models are
now being produced using 3D printing technology81,112,164.
Although 3D printing might be too costly for use in every
patient, such concepts can be advantageous in complex
and unusual cases. At the advanced phase of training,
a library of such cases could enable a large number of
surgeons to prepare for complex surgeries.
In light of the current evidence, we recommend a
training pathway for institutions and training boards
who offer simulation training for residents (FIG.2). Where
institutions do not offer structured simulation training,
residents are recommended to individually follow their
development through the proposed curriculum. Globally,
urological training takes >5years193,194 and the suggested
curriculum can prepare residents in the simulation envi-
ronment, before gaining real-life experience in each
procedure, at all stages of training for both technical and
nontechnical skills.
Proposed curriculum
The curriculum we recommend is progressive, and
trainees should develop their skills in each subspecialty
accordingly. Specific procedures have been selected at
each level, in accordance with the current traditional
training curricula. At the early phase, trainees should
make use of the currently available bench models for
acquisition of skills in SPC, circumcision, and scrotal
procedures. Although the use of animal models has not
been reported in the literature, they are widely utilized for
scrotal surgery training, and can also be used. These skills
should be further developed in cadaveric masterclasses at
the early or intermediate phase, depending upon the level
of experience trainees have gained. As they represent
the only currently available modality, human cadavers
should be used for training in female and reconstructive
surgery and emergency procedures at the advanced level
of training.
Skill acquisition in endourology should begin with
the use of bench and VR models for cystoscopy, botuli-
num toxin injections, URS, transurethral resection, and
related laser procedures. Cases with appropriate level of
difficulty should be selected at both the early and inter-
mediate phases of training. HoLEP and PCNL training
should begin at the intermediate phase, in preparation
for performing them in patients at the advanced phase.
URS training should also use validated VR and bench
models at each stage, with the selection of appropri-
ate cases. Animal and cadaver workshops should be
utilized to refine skills, as a final step in preparing for
allprocedures.
Laparoscopic training should begin with generic skills
acquisition on VR and dry-lab models at the early stage
of training. At the intermediate stage, procedure- specific
VR, dry-lab and exvivo animal models should be used,
followed by wet-lab training on live animals and/or
Feasibility
The extent to which a training
and assessment process is
capable of being carried out.
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cadavers at the advanced stage, if permitted by ethics
and the available facilities. Similarly, generic skills acqui-
sition in robotic surgery should begin on VR and dry-lab
models at the intermediate phase followed by procedural
training in the advanced phase.
VR training is recommended as the initial phase of
training for each procedure, as it is the modality which
least resembles actual surgery. However, VR simulators
can be very beneficial for trainees in grasping con-
cepts, familiarizing with instruments, and in cognitive
preparation. Of the available VR simulators, the URO
Mentor and PERC Mentor hold the highest level of evi-
dence and recommendation for urolithiasis, UroSim
and SurgicalSIM TURP for TURP and the dv-Trainer
for robotics195. Bench models should be used next as they
enable the use of real instruments and irrigation and
those with the highest level of evidence and recommen-
dation, among the available models, are the Uro-Scopic
Trainer for ureteroscopy and the Bristol TURP Trainer
for TURP195. Exvivo animal models should comprise
the next phase of training, owing to their similarity with
human tissue, several of which have been mentioned
to be effective previously. Live animal and/or cadaveric
simulation should be used as the final stage of each pro-
cedural training as they have the highest face validity and
are costly. The restricted availability of cadavers could be
improved through coordinated use for multiple teaching
sessions across different specialties196. Nontechnical
skills using CRM and full immersion simulation should
also be used at each step to prepare trainees for common
scenarios in the operating room.
Conclusions
Urosimulation has made considerable progress in the last
few decades, with increasing numbers of new models being
developed and validated. High numbers of procedure-
specific models have been reported for endourology, the
majority of which are VR and bench models. Training
modalities for laparoscopic and robot-assisted urological
surgery are mainly geared towards generic skills acquisi-
tion with a selected few procedure-specific dry-lab and
exvivo anima l models and VR and A R platforms, respec-
tively. In contrast, very few simulators have been produced
and validated for open urological surgery, with cadaveric
simulation reported as the main modality of training.
Furthermore, newer simulation modalities such as aug-
mented reality and 3D printing are also rapidly gaining
popularity. Efforts should continue to use the currently
available models in a curricular approach, with the inclu-
sion of nontechnical skills training. In light of the current
evidence, the proposed generic and supplementary simu-
lation curriculum for urological training should help to
enhance operating-room experience and reduce many of
its associated challenges.
Figure 2 | Recommended simulation training pathway. The curriculum offers the systematic use of validated training
tools and curricula at various stages. Human cadaveric simulation is suggested as masterclass workshops to refine skills.
BOTOX, botulinum toxin; HoLEP, holmium laser enucleation of the prostate; OR, operating room; PCNL, percutaneous
nephrolithotomy; PVP, photoselective vaporization of the prostate; SPC, suprapubic catheterization; TURP, transurethral
resecti on of the prost ate; UCS, ure throcystosc opy; URS, uret erorenoscopy ; VR, virtual reality.
Nature Reviews | Urology
Technical skills
Nontechnical skills
Skill stage
General nontechnical skills
• Consenting a patient
• Explanation of procedure etc.
Crisis resource management
• Common urological emergencies
in the ward setting
Full immersion simulation
• Common procedure‑specic R
scenarios  TURP and URS
Crisis resource management
• Common urological emergencies
in the ward setting
Full immersion simulation
• Common procedure‑specic
R scenarios — laparoscopic
procedures
Crisis resource management
• Common urological emergencies
in the ward setting
Full immersion simulation
• Common procedure‑specic R
scenarios — robot-assisted surgery
General Urology
• SPC, circumcision, scrotal surgery,
• Bench and animal models
• Human cadavers (masterclass)
Endourology
• UCS, BT, TURP, PVP and URS
• Bench and VR models
• Appropriate cases
Laparoscopy
• Generic skills
• VR and dry‑lab training
General Urology
• SPC, circumcision, scrotal surgery
• Bench and animal models
• Human cadavers (masterclass)
Endourology
• TURP, PVP, oP, URS, PC
• Bench and VR models
• Human cadavers (masterclass)
Laparoscopy
• Procedural skills
• VR and dry‑lab training
Robotics
• Generic skills
• VR and dry‑lab training
Open surgery
• Emergency procedures
• Female and reconstructive surgery
• Human cadavers
Endourology
• oP, URS, PC
• Bench and VR models
• Human cadavers (masterclass)
Laparoscopy
• Procedural skills
• Wet-lab training
Robotics
• Procedural skills
• Dry-lab and wet-lab training
AdvancedIntermediateEarly
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Autho r contri butions
A.A. and N.R. researched data for the article and wrote the
manuscript. All authors contributed to discussions of content
and reviewed or edited the article before submission.
Competing interests statement
The authors declare no competing interests.
Review criteria
A broad search was performed on Medline and EMBASE
databases to identify English language articles between
January 1990 and May 2016. The reference lists of the
identi fied articles were screened for further relevant studies.
Abstracts from the American Urology Association (AUA),
European Association of Urology (EAU), World Congress of
Endourology (WCE), and the British Association Urological
Surgeons (BAUS) meetings were also searched in their respec-
tive journals. The identified models were also searched on
Google to determine their commercial availability and details.
Definitions of validity were based on the definitions of
McDougall etal.8 and van No rtwick etal.9.
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