SURGICAL SKILLS EDUCATION IN UROLOGY DOES IT MATTER? Conflict of - - PowerPoint PPT Presentation

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

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

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

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

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

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

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

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

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

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

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access Laparoscopy Robotics

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

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

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

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 Conclusion

Interns who trained on UroMentor outperformed controls

Schout et al. Transfer of cysto-urethroscopy skills from virtual-reality simulator to the operating room. A randomized control trial. BJU Int 2009

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access Laparoscopy Robotics

Ureteroscopy – surgical simulation

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)

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

Ureteroscopy – Surgical Simulation

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

Ureteroscopy – surgical simulation

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

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

Ureteroscopy – surgical simulation

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

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

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

Ureteroscopy – surgical simulation

Established:

Face validity Content validity

Not established

Criterion validity

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

Ureteroscopy – surgical simulation

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

Matsumodo et al. Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills. Int J Urol. 2006.

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

Matsumodo et al. Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills. Int J Urol. 2006.

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access 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 transurethral prostate resection trainer. J Urol 2004; 172: 1953-1957

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)

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access 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

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

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

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

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

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access 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

Brewin et al. Face, content and construct validation of the first virtual reality laparoscopic nephrectomy simulator. BJU Int 2009.

Conclusions

Face, content and construct validity established Good training tool for Lap Radical Nephrectomy Need predictive studies

Brewin et al. Face, content and construct validation of the first virtual reality laparoscopic nephrectomy simulator. BJU Int 2009.

Types of Surgical Simulation in Urology

Cystoscopy Ureteroscopy TURP/TURBT PCNL with Renal Access 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

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

16 novices (no surgical training) 32 intermediates (median 0 robotic cases) 15 experts (median 315 robotic cases)

Results

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

Results

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

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

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

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

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

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

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

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

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 controlled study. J Urol 2002. 1243-1247

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

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

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 percutaneous renal collecting systm access skills using a computer based hybrid virtual reality srugical simulator: phase I. J Urol 2006

11.

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

• f 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?