jeff mckay scott bagnell surgical skills … · surgical skills education in urology – does it...

SURGICAL SKILLS EDUCATION IN

UROLOGY – DOES IT MATTER?

Jeff McKay

Scott Bagnell

Conflict of Interest Statement

No conflict of interests to state

Outline

1. Definitions

2. Do we need surgical simulation? Why?

3. Types of surgical simulation in urology

4. Strengths/weaknesses of simulation

5. Implementing simulation curriculum into

residency program

Definitions

Simulator

Device that enables operator to reproduce or represent test

conditions or phenomena likely to occur in actual

performance

Fidelity

How “realistic” is the simulator

Low or High-fidelity

Merrium-Webster Online Dictionary. Avail at www.merrium-

webster.com

Fidelity

Low fidelity ureteroscopy trainer

High fidelity ureteroscopy

trainer

Matsumoto et al. The effect of bench model fidelity on endourological skills: a randomized

controlled study. J Urol 2002. 1243-1247

Definitions

Virtual Reality

Artificial environment which is experienced through sensory

stimuli provided by a computer and in which one’s actions

partially demonstrate what happens in the environment

Merrium-Webster Online Dictionary. Avail at www.merrium-

webster.com

Virtual Reality simulators

VALIDATION

Validity

Instrument appropriately measures what it was intended to

measure

Subjective and objective benchmarks

Wignall et al. Surgical simulation: a urological perspective. J Urol 2008. 179; 1690-1699

Subjective Validity Assessment

Face validity

Test seems reasonable and appropriate

Content validity

Assures contents of test cover relevant areas


Objective Validity Assessment

Criterion validity

Correlation of results of tool with established tool

Predictive validity

- Extent which scores on new test predict future clinical performance

Construct validity

Used if no clear standard exists for comparison


Objective Structured Assessment of Technical

Skills Examination

Best measure of operative performance

Checklists & global rating scales for evaluation of

tasks

Few simulators have undergone rigorous tests that

would fully validate use for training or proficiency

assessment


Outline

1. Definitions





residency program

Need for Surgical Simulation in Urology

Decreasing opportunities for residents to learn in OR

Limited work hours

Financial constraints – surgical efficiency

Fear of litigation

Increasingly complex cases

Practising surgeons often learning new skills

*Anastakis et al. Evaluating the effectiveness of a 2-year curriculum in surgical skills center.

Am J Surg 2003; 185: 378

Barriers to Surgical Simulation

Small market

Few simulators validated for teaching

High cost of software design

High cost of simulators at centres

Selecting and retaining suitable faculty

1. Wignall et al. Surgical Simulation: A Urological Perspective. J Urol 2007

2. Forster et al. Surgical simulators in urological training – views of UK

training programme directors BJU Int 2011.

Outline

1. Definitions





residency program

Types of Surgical Simulation in Urology

Cystoscopy

Ureteroscopy

TURP/TURBT

PCNL with Renal Access

Laparoscopy

Robotics

Cystoscopy – Surgical simulation

Schout et al. Transfer of cysto-urethroscopy skills from virtual-reality simulator to

the operating room. A randomized control trial. BJU Int 2009

Cystoscopy – surgical simulation

100 interns randomized



Cystoscopy – surgical simulation



Cystoscopy – Surgical simulation Conclusion

Interns who trained on UroMentor outperformed controls




Cystoscopy

Ureteroscopy

TURP/TURBT


Laparoscopy

Robotics

Ureteroscopy – surgical simulation


Research QUESTION:

Does bench model fidelity affect surgical skills?

40 4th year med students randomized to:

1. Didactic session (7)

2. Low fidelity bench model practice (16)

3. High fidelity bench model practice (17)



Ureteroscopy – Surgical Simulation

Matsumoto et al. The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol 2002. 1243-1247


Conclusion:

1. Low-fidelity and high-fidelity significantly improved GRS

and pass rate

2. Low fidelity had similar results to high fidelity at a much

cheaper cost




20 2nd year medical students randomized to:

1. Control (untrained) group

2. Test (trained) group

Watterson et al. A randomized, prospective blinded study validating the acquisition of ureteroscopy

skills using a computer based virtual reality endourological simulator. J Urol 2002

URO Mentor – VR Simulation



Results

Watterson et al. A randomized, prospective

blinded study validating the acquisition of

ureteroscopy skills using a computer based

virtual reality endourological simulator. J Urol

2002


Established:

Face validity

Content validity

Not established

Criterion validity




16 Urology residents assessed on basket extraction of

distal ureteric stone using UroMentor VR simulator

Performance on VR simulator compared to high fidelity

bench model (UroScopic Trainer)

Matsumodo et al. Virtual reality ureteroscopy simulator as a valid tool

for assessing endourological skills. Int J Urol. 2006.

VR simulator vs high fidelity bench model

Results

Results of VR Simulator

Correlation with performance on high fidelity bench model

from previous study



Conclusions

UroMentor is a useful tool for the assessment of

resident performance

Predictive validity and content validity as performance

correlated with UroScopic trainer

Future studies needed to correlate performance in the

OR




Cystoscopy

Ureteroscopy

TURP/TURBT


Laparoscopy

Robotics

TURP – Surgical Simulation

URO-Trainer

VR simulator SurgicalSIM

TURP simulator

Simbionix TURP trainer

TURP – Surgical Simulation

• Version 1.0 of VR based TURP simulator

• 72 board certified urologists

• 19 novices

Participants:

• Completed pre-task questionnaire

• Viewed training video

• Performed pre-compiled 5-minute resection task

Results

Sweet et al. Face, content and construct validity of the University of Washington virtual reality

transurethral prostate resection trainer. J Urol 2004; 172: 1953-1957

Conclusions

Face, content, construct validity for v1.0 of Univ of

Washington TURP Simulator

Need predictive validity study to complete validation

Integration of simulator into training is appropriate

Not validated for assessment until more rigorous

validation complete

Sweet et al. Face, content and construct validity of the University of Washington virtual reality


TURBT Simulation

24 medical students

12 residents in urology

Results

Reich et al. High-level virtual reality simulator for endourologic procedures of lower urinary

tract. Urol 2006. 67(6)

Conclusions

Face, content and construct validity achieved

Results of this study support need for prospective RCT

for predictive validity

TURP model to be added in the future

Reich et al. High-level virtual reality simulator for endourologic procedures of lower urinary

tract. Urol 2006. 67(6)


Cystoscopy

Ureteroscopy

TURP/TURBT


Laparoscopy

Robotics

PERC RENAL ACCESS & PCNL TRAINERS

PERC Mentor

63 subjects

• 31 medical students

• 31 residents

• 1 fellow

Global Rating Scale

Knudsen et al. A randomized, controlled, prospective study validating the acquisition of

percutaneous renal collecting systm access skills using a computer based hybrid virtual

reality srugical simulator: phase I. J Urol 2006

Results - PercMentor




Conclusions

Training on Perc mentor was beneficial in learning and

performing steps of renal collecting system access

using VR model

Face, content and convergent validity established

Predictive ability to be tested in Phase II using live

porcine model





Cystoscopy

Ureteroscopy

TURP/TURBT


Laparoscopy

Robotics

Laparoscopy – Surgical Skills

CORRECT USE OF

BOX TRAINERS

INCORRECT USE

OF BOX TRAINERS

Laparoscopy – Surgical Skills

Laparoscopy – low fidelity

12 Urology residents

• 6 into training group

• 6 into non-training group

Traxer et al. The impact of intense laparoscopic skills training on the operative performance of

urology residents. J Urol 2001 166;1658-1661

No significant difference

between groups

Traxer et al. The impact of intense laparoscopic skills training on the operative performance of urology

residents. J Urol 2001 166;1658-1661

Laparoscopy – VR simulation

Brewin et al. Face, content and construct validation of the first virtual reality

laparoscopic nephrectomy simulator. BJU Int 2009.

• 8 expert urological laparoscopic surgeons

• 10 trainee urologists (performing or observing)

• 10 novice urologists (observation)

Results



Conclusions

Face, content and construct validity established

Good training tool for Lap Radical Nephrectomy

Need predictive studies




Cystoscopy

Ureteroscopy

TURP/TURBT


Laparoscopy

Robotics

Robotics – surgical simulation

Da Vinci Robot surgical simulator

Hung et al. Face, content and construct validity of a novel robotic surgery simulator. J Urol 2011

Robotics – Surgical simulation


16 novices (no surgical training)

32 intermediates (median 0 robotic cases)

15 experts (median 315 robotic cases)

Results


Conclusion

Face, content and construct validity of da Vinci Skills

simulator established

Predictive studies need to be completed

Further software development with procedure based

modules to augment usefulness for advanced training


Outline

1. Definitions





residency program

Strengths & Weaknesses

Strengths

Safe way to practice without compromising patient care

Gain familiarity with procedure before assisting

Muscle memory to aid in OR

Cost – some low fidelity models cheap and portable

Possible use for assessment in the future

Weaknesses

Cost

Predictive validity still needs to be determined for many

simulators

Some simulators may not be realistic

Adequate training and supervision for simulation

Strengths & Weaknesses

Outline

1. Definitions





residency program

Simulation in Urology

Positive transfer of skills from simulation to OR1

USA urology training programs2:

68% have simulation education centres

88% of urological depts have access to these

- 76% laparoscopy

- 16% cystoscopy

- 21% ureterorenoscopy

- 12% percutaneous renal access

- 8% TURP

1Laguna et al. How far will simulators be involved into training? J Endourol 2011 2Le et al. The current role of medical simulation in american urological residency programs:

an assessment by program directors. J Urol 2007

Implementing Simulation in Residency Training

Surgical simulation should be complementary to

standard surgical training

Future holds updated software, new simulators, new

technologies

No ideal curricula or model currently exists

Future of Surgical Simulation at DALHOUSIE

Simbionix TURP Simulator

Outline

1. Definitions





residency program

References 1. Merrium-Webster Online Dictionary. Avail at www.merrium-webster.com

2. Matsumoto et al. The effect of bench model fidelity on endourological skills: a randomized


3. *Anastakis et al. Evaluating the effectiveness of a 2-year curriculum in surgical skills center.

Am J Surg 2003; 185: 378

4. Forster et al. Surgical simulators in urological training – views of UK training programme

directors BJU Int 2011.

5. Schout et al. Transfer of cysto-urethroscopy skills from virtual-reality simulator to the

operating room. A randomized control trial. BJU Int 2009

6. Watterson et al. A randomized, prospective blinded study validating the acquisition of

ureteroscopy skills using a computer based virtual reality endourological simulator. J Urol

2002

7. Matsumodo et al. Virtual reality ureteroscopy simulator as a valid tool for assessing

endourological skills. Int J Urol. 2006.

8. Sweet et al. Face, content and construct validity of the University of Washington virtual reality


References cont’d

9. Reich et al. High-level virtual reality simulator for endourologic procedures of lower urinary

tract. Urol 2006. 67(6)

10. Knudsen et al. A randomized, controlled, prospective study validating the acquisition of



11. Traxer et al. The impact of intense laparoscopic skills training on the operative performance

of urology residents. J Urol 2001 166;1658-1661

12. Brewin et al. Face, content and construct validation of the first virtual reality laparoscopic

nephrectomy simulator. BJU Int 2009

13. Hung et al. Face, content and construct validity of a novel robotic surgery simulator. J Urol

2011

14. Laguna et al. How far will simulators be involved into training? J Endourol 2011

15. Le et al. The current role of medical simulation in american urological residency programs:

an assessment by program directors. J Urol 2007

Questions?

jeff mckay scott bagnell surgical skills … · surgical skills education in urology – does it...

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