availableatwww.sciencedirect.com
journalhomepage:www.europeanurology.com
Review–Endo-urology
UpdateonTrainingModelsinEndourology:AQualitativeSystematicReviewoftheLiteraturebetweenJanuary1980andApril2008
BarbaraM.A.Schouta,b,*,AdJ.M.Hendrikxa,AlbertJ.J.A.Scherpbierb,BartL.H.BemelmanscaCatharinaHospitalEindhoven,Eindhoven,TheNetherlandsVUMedicalCentreAmsterdam,Amsterdam,TheNetherlandscMaastrichtUniversity,Maastricht,TheNetherlands
bArticleinfo
Articlehistory:
AcceptedJune12,2008PublishedonlineaheadofprintonJune25,2008Keywords:SystematicReviewTrainingModelUrologyValidationBladderProstateKidneyUreter
Abstract
Context:Interestintheuseofsimulatorsinurologicalskillstrainingisontheincrease.Toensureeffectiveimplementationoftrainingmodels,anoverviewofthenatureandvalidityoftheavailablemodelsisoftheessence.
Objective:Toobtainanoverviewoftrainingmodelsandtheirvaliditybyperformingaqualitativesystematicreviewoftheliterature.
Evidenceacquisition:StudieswereidentifiedthroughsearchesofPubMed,theCochraneLibrary,andWebofSciencebetweenJanuary1980andApril2008usingtwosearchstrategies:‘‘urologyand(trainingorsimulat*ormodel)’’andcombinationsofthesetermswith‘‘prostate,’’‘‘kidney,’’‘‘bladder,’’or‘‘ureter.’’Studieswereincludedifthey(1)describedoneormoretrainingmodels,and/or(2)examinedthevalidityoftrainingmodels.Studiesinundergraduateeducationandoftrainingmodelsforphysicalexaminationwereexcluded.ValidationstudieswerescoredaccordingtoKirkpatrickandOxfordCentreforEvidence-BasedMedicine(OCEBM)levelsofevi-dence.
Evidencesynthesis:Forty-fivearticles(outoftheinitiallistof4753retrievedarticles,0.9%)wereincluded,describing30typesoftrainingmodelsand54validationstudies.Thelargestnumberofmodelshasbeendescribedforureterorenoscopy(ninetypes).Onlythreerandomisedcontrolledtrials(RCTs),receivinga1bOCEBMlevelofevidencescore,werefound.Studiesinvestigatingtheimpactofsimulatortrainingonperfor-manceinpatients(criterionBvalidity)werescarce.Thenumberofparticipantsinexperimentalstudiesrangedfrom7to136.
Conclusions:Duetogrowinginterestintrainingmodelsinurology,itisincreasinglyurgenttodeterminewhichofthesemodelsaremostvaluableforpostgraduatetraining.Becausethevalidationstudiespublishedsofararefewinnumber,havelowevidencelevels,andarecomposedofonlyafewRCTs,itisimportantthatmorerandomisedcontrolledvalidationstudiesincludinglargernumbersofparticipantsareperformed.
#2008EuropeanAssociationofUrology.PublishedbyElsevierB.V.Allrightsreserved.
*Correspondingauthor.CatharinaHospitalEindhoven,UrologyDepartment,P.O.Box1350,5602ZAEindhoven,TheNetherlands.Tel.+31402397040;Fax:+31402396021.E-mailaddress:barbara.schout@cze.nl(BarbaraM.A.Schout).
0302-2838/$–seebackmatter#2008EuropeanAssociationofUrology.PublishedbyElsevierB.V.Allrightsreserved.
doi:10.1016/j.eururo.2008.06.036
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1.Introduction
‘‘Seeone,doone,teachone!’’Fordecadesthishasbeentheadageofpostgraduatepracticalskillstraining.Itcapturesthewayinwhichmanyoftoday’sdoctorsacquiredtheirtechnicalcompetenceandwentontobecomeexcellentsurgeons.How-ever,today’spatientsareverydifferentfromthoseofearlierdays,andtomorrow’spatientswillbedifferentstill;itisageneraltrendforpatientstobecomemoreassertiveanddemanding.Thereislesswillingnessamongthemtoberecruitedas‘‘trainingmodels’’foruntrainedjuniordoctors’firstattemptsatperformingaprocedure.
Inhealthcare,itisnotonlythepatientswhoarechanging;operationtechniquesarealsoevolvingcontinuously.Overthelastdecades,theapplica-tionsofendoscopictechniqueshaveexpanded,andtheuseofminimallyinvasivetechniquesinurologyhasspreadrapidly,ashastheconcomitantneedfortrainingandqualificationinthesecomplicatedtechniques.Furthermore,legalandethicalconcernsaboutlearningonthepatienthavebecomeamajortopicofinterest.Thereisagrowingrealisationthatalargepartofthelearningcurveofproceduresdoesnotnecessarilyrequirepractisingonpatientsandthatitmaybeevenbettertotrainonamodelfirst.Thequestionofhowtotrainnovicesinurologicalpracticalskills,promptedbytheboominthedevelopmentoftrainingmodelsandskillslabora-tories,isurgentlyawaitingananswer.Whentheansweris‘‘byusingmodels,’’theinevitablenextquestioniswhichconsiderationsshouldprevailinselectingamodel.Sometimesitseemsthathospi-talsallowtheirchoicestobedirectedpredominantlybyfinancialconsiderationsandoutwardappear-ance.Unfortunately,thoseresponsibleforprocuringteachingmaterialsrarelyconsiderhoweffectiveamodelisinshorteningtrainees’learningcurvesand,
eveniftheydo,theywillfindthemselvesfacedwithadisconcertinglackofconvincingresearchevidencetoprovideasolidfoundationforananswer.Becauseitisofparamountimportancethattrainingmodelsandskillslaboratoriesareimplementedinastruc-turedmannerandbasedonevidenceoftheabilityof(oftenexpensive)trainingmodelstoactuallyimprovenovices’performanceinpatients,valida-tionoftrainingmodelsmustbegivenpriorityinurologicalskillstraining[1].
Theresearchquestionofthisstudywaswhattypesofendourologictrainingmodelshavebeendescribedintheliteratureandtowhatextenttheyhavebeenvalidated.Wefocusedonendourologictrainingmodels,meaningmodelsconcerningintra-luminalminimallyinvasiveurologicalsurgery.Wemappedthecurrentknowledgeaboutthesetrainingmodelsbymakinganinventoryofstudiesdescribingandvalidatingthesemodelsbasedonaqualitativesystematicreviewoftheliterature.Theresultscanbeusedbyurologistsandurologytraineestoguidewell-foundedchoicesofmodelsforskillstrainingwhilealsoofferingsuggestionsforwhichtypeofresearchinthisareashouldhavethehighestpriority.2.
2.1.
Methods
Selectioncriteria
Articleswereselectedforinclusioniftheydescribedanendourologicaltrainingmodeland/orsubjectedamodeltotestingofface,content,construct,orcriterionvalidity.DefinitionsofthesevaliditytermsaredescribedinTable1andwerebasedonthedefinitionsbyMcDougall[1].Becausethedefinitionsandimplicationsofvalidityinthearticlesshowedconsiderablevariation,wejudgedthedescriptionsinthestudiesbasedonthedefinitionsofvalidityinTable1.Articlesaboutundergraduateskillstrainingandphysicalexaminationmodelswereexcluded.
Table1–DefinitionsofvalidityKindofvalidity*FacevalidityContentvalidityConstructvalidity
A:withinonetraineeB:betweengroups
Criterionvalidity
A:concurrentvalidityB:predictivevalidity
SubcategoryDefinition
Opinionofnonexpertsaboutthesimulator
Opinionofexpertsaboutthesimulator(anditsappropriatenessforpostgraduatetraining)
Abilityofsimulatortodistinguishbetweendifferentlevelsofexperience,measuredwithinonetraineeovertime
Abilityofsimulatortodistinguishbetweendifferentlevelsofexperience,measuredbetweengroupswithdifferentlevelsofexperienceComparisonofnewmodelwitholdmodel/techniquebyOSATS
Correlationoftrainees’performanceonthemodelwithoperatingroomperformancemeasuredbyOSATS
*Abbreviation:OSATS,ObjectiveStructuredAssessmentofTechnicalSkills.
KindsofvaliditydefinedbyauthorsbasedondefinitionsofMcDougalletal[1].
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2.2.Searchmethods
WesearchedthePubMed,CochraneLibrary,andWebofSciencedatabasesforEnglish-languagearticlespublishedbetweenJanuary1980andApril2008describingurologicaltrainingmodelsand/orvalidationstudiesofthesemodels.Ourfirstsearchstrategyusingthesearchterms‘‘urologyand(trainingorsimulat*ormodel)’’wasfollowedbycombinationsoftwooftheterms‘‘training,’’‘‘simulat*’’and‘‘model’’with‘‘prostate,’’‘‘kidney,’’‘‘bladder,’’or‘‘ureter.’’Weexaminedthetitlesandabstracts—ifavailable—oftheretrievedarticlestodetermineiftheymettheinclusioncriteria.Ofthearticlesthatdid,wealsoexaminedthetitlesandabstractsofthepaperslistedinthereferences.Abstractsofcongresseshavenotbeensearchedbecausetheyprovidedincompletedata.
2.3.Dataextraction
Aftertworesearchers(BSandAS)haddecidedontheinclusionandexclusionoftheselectedarticlesandresolvedanydifferencesofopinion,theincludedarticleswereretrievedinfull.Potentiallyrelevantarticlesfromreferencesofincludedarticleswerealsoretrievedandsubjectedtotheinclusion/exclusionprocedure.
2.4.Dataanalysis
Ourevaluationofthequalityofthevalidationstudieswasbasedonthemethods,therandomisationstrategy,blindingofjudges,measurestominimisebias,samplesize,andpowertomeasurea‘‘trueeffect.’’Duetodifferencesbetweenstudies,theresultscouldnotbepooledacrossstudies.ValidationstudieswereratedonthebasisoftheOxfordCentreforEvidence-BasedMedicine(OCEBM)levelsofevidenceandKirkpatricklevelsofevidence[2,3].
3.
Results
3.1.
Descriptionofstudies
Outof4753initiallyretrievedarticles,includingnumerousduplicates,45articlesmettheinclusioncriteria(0.9%).Ofthese45,41articlesconcernedthedescriptionofamodeland24concernedoneormorevalidationstudies.Themostfrequentreasonforexclusionwasthatthearticledidnotaddress‘‘training’’and/or‘‘model’’(50%)and‘‘(endo)urology’’(33%).Table2summarisestheincludedarticles.
3.2.
Descriptionofmodels1980–2008
Forty-onearticlesdescribed30typesoftrainingmodels(Table3),mostofwhichwereforureteror-enoscopy(URS).Forthisprocedure,19articlesdescribed27modelsof9differenttypes.Transur-ethralresectionofbladdertumour(TURBT)wastheleastpopular,withonlyonearticledescribingonemodel.
3.2.1.Urethrocystoscopy
Mostofthemodelsdesignedforureterorenoscopicand/ortransurethralproceduresalsoenableperfor-manceofa(flexibleand/orrigid)cystoscopyprocedure.Twooutofsixdifferentmodelswereespeciallydesignedforcystoscopy(pumpkin,greenpepper)[4].Thefourothermodels—thevirtualreality(VR)simulatorsfromtheGeorgeWashingtonUniversityMedicalCenter,Storz(KarlStorzGmbH,Tuttlingen,Germany),Simbionix(Cleveland,OH,US),andtheporcineliverinapumpkinfromtheSouthernIllinoisUniversitySchoolofMedicine—allowedperformanceofacystoscopyprocedureaswellasureterorenoscopicand/orothertransure-thralprocedures[4–13].
3.2.2.
Ureterorenoscopy
ThemostfrequentlydescribedURSmodel(ninetimes)istheUROMentor(Simbionix),acomputer-basedVRmodelofferingsemirigidandflexibleURSmodulesaswellasrigidandflexibleure-throcytoscopy(UCS)modules[6,10,12,15,16,18,21,22,27].Thesecondmostdescribedmodel(fivetimes)istheUro-Scopictrainer(Limbs&Things[L&T],Bristol,UK).Thishigh-fidelitybenchmodelcreatesthepossibilityoftrainingwithreal-timeinstrumentsasusedintheoperatingroom[13,15,18–20].
3.2.3.
Transurethralresectionofbladdertumour
WefoundonlyonearticledescribingatrainingmodelfortheTURBTprocedure;namely,theUROTrainer(Storz),whichofferstrainingofdiagnosticsofbladdertumoursaswellasresectionandcoagulation[7].
3.2.4.
Transurethralresectionofprostate
ThefirsttopublishadescriptionofaVRsimulatorfortransurethralresectionoftheprostate(TURP)procedureswereBallaroetalandGomesetalin1999[28,29].Sweetetalfocusedonimplementingbleeding,somethingnootherresearchgroupbeforethemhadmanagedtoachieve.TheycreatedaVR-TURPmodeldescribedbyOppenheimeretalinwhichbleedingimageschangeaccordingtothefluidflowstate[32,33].TheVRmodeldevelopedbyGomesetalandKumaretalcanbeclassifiedas‘‘augmentedreality’’:acombinationofVR(objectiveparameters)andabenchmodel(hapticfeedback)[29,31].Kallstrometalaimedtointroducehapticfeedbackintheirself-developedVRsimulator[30].ThismodelmayalsobethefirstTURPsimulatortoenableperformanceofanentiresurgicalprocedurewithoutinterruptionforchangingthesoftwaremodule.
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Table2–SummaryofincludedstudiesArticle
Ballaroetal[28]Brehmeretal[45]Brehmeretal[14]Bruyereetal[40]Chouetal[15]Earpdesa[37]Gettmanetal[11]Gomesetal[29]Hackeretal[41]Hammondetal[4]Hammondetal[38]Hozneketal[16]Jacomidesetal[46]Kallstrometal[30]Knolletal[43]Knudsenetal[36]Kumaretal[31]Kuoetal[17]Lagunaetal[18]Manyaketal[5]
Matsumotoetal[20]Matsumotoetal[19]Matsumotoetal[21]Micheletal[6]Nedasetal[27]Oganetal[22]
Oppenheimeretal[32]Premingeretal[23]Rashidetal[47]Reichetal[7]Shahetal[8]Shahetal[24]Shahetal[9]Sternetal[42]
Strohmaieretal[25]Strohmaieretal[39]Sweetetal[33]Sweetetal[34]Sweet[53]
Trindadeetal[35]Wattersonetal[44]Wattersonetal[12]Wignalletal[13]Wilhelmetal[10]Wilsonetal[26]
YearofDescriptionofpublicationmodel*1999
20052002200820062003200819992007200520042006200420052005200620022001200220022002200120062002200420042001199620072006200220012002200720012005200220042007198120022007200820021991
101111111111010111111111111101111111111101111
Kindofprocedure
TURP
URSPNLURSPercUCSTURPPerc
UCS,URS,PercPerc
TURP,URS,PercTURPPercTURPURSURSUCSURSURSURS
UCS,URSURSURSTURPURS
UCS,TURBTUCS
URS,TURPUCSPercURSPercTURPTURPTURPTURP
UCS,URS
UCS,URS,TURP,PercUCS,URSURS
Validationstudies(no.)
123020200010222200013214020118203000030020020
Kindof
validationstudy
Content
ConstructA,constructB
Content,constructB,criterionB2xcriterionA
ConstructA,constructB
Face
ConstructA,constructBContent,constructAConstructB,criterionBConstructA,constructB
Content
3xcriterionA
ConstructA,constructBConstructB
2xface,2xcontentConstructB,criterionB
ContentConstructB
2xcontent,4xconstructA,2xconstructBFace,constructA
2xconstructA,constructB
Face,content,constructB
ConstructA,constructB
ConstructA,constructB
Abbreviations:TURP,transurethralresectionofprostate;TURBT,transurethralresectionofbladdertumor;URS,ureterorenoscopy;PNL,percutaneousnephrolitholapaxy;Perc,percutaneous;UCS,urethrocytoscopy.*0=no,1=yes.
3.2.5.Percutaneousaccessand/orlitholopaxy
3.3.Validationstudies1980–2008
Sevenoutoftheninetypesofpercutaneousmodelsweresuitableforpractisingpercutaneousmanoeuvres,includingpuncture,tractdilatation,introductionofnephroscope,lithotripsy,andendo-pyelotomy[4,13,37–41].Theothertwomodelswerelimitedtopercutaneousrenalpuncture[13,16,36,42].
Twenty-fourarticlesdescribed54studiesvalidatingtrainingmodelsforendourologicalprocedures.Moststudies(31outof54,57%)focusedonconstructvalidity(theabilitytodistinguishbetweendifferentlevelsofexperience).Themostimportantstepinthevalidationprocess,whichisthetransferfromthe
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Table3–Overviewofdescriptionofmodels,1980–2008Typeofmodel
UrethrocystoscopyVirtualrealityVirtualrealityVirtualreality
Bench(highfidelity)Organic:pumpkin,greenpepper
Animal,porcineliverinpumpkinUreterorenoscopyVirtualrealityVirtualreality
Manufacturer
GeorgeWashingtonUniversityMedicalCenter,Washington,DC,USSimbionix
Storz
Limbs&Things
SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
DukeUniversityMedicalCenter,Durham,NC,USSimbionix
Manyak[5]
Describedby
Shah[8,9],Wilhelm[10],Michel[6],Gettman[11],Watterson[12]Reich[7],Wignall[13]
Watterson[12],Wignall[13]Hammond[4]Hammond[4]
Bench(lowfidelity)Bench(highfidelity)Bench(highfidelity)Animal,porcinekidneyAnimal,porcinekidneyAnimal,porcinekidneyHuman,uterusTURBT
VirtualrealityTURP
Virtualreality
VirtualrealityVirtualreality
VirtualrealityandlatexAnimal,caninecadaverPercaccess/litholapaxyVirtualrealityBenchBench
Bench/rapidprototypingAnimal,porcinekidneyAnimal,porcinekidneyAnimal,porcinekidneyAnimal,porcinekidneyinchickencadaverAnimal,porcinekidneyinchickencadaver
UniversityofToronto,Ontario,CanadaLimbs&Things
Mediskills
KlinikumCoburg,Germany
SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
UniversityofCalifornia,Irvine,CA,US
UniversityMedicalCenter,Shreveport,LA,USStorz
UniversityCollege,London,UK
UniversityofWashington,Seattle,WA,USUniversityHospitalLinkoping,Sweden
ImperialCollegeofScience,Medicine,London,UKUniversityofCalifornia,CA,US
SimbionixMediskills
Limbs&Things
UniversityHospitalofTours,Tours,FrancePetropolisSchoolofMedicine,RiodeJaneiro,Brazil
KlinikumCoburg,Germany
SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
UniversityHospitalMannheim,Germany
Preminger[23],Shah[24],Kuo[17]Laguna[18],Michel[6],
Wilhelm[10],Nedas[27],Ogan[22],
Chou[15],Matsumoto[21],Hozneck[16],Watterson[12]
Matsumoto[20],Wignall[13]
Matsumoto[19,20],Laguna[18],Chou[15],Watterson[12],Wignall[13]Brehmer[14],Watterson[12]Strohmaier[25],Watterson[12]Hammond[4]Chou[15]Wilson[26]Reich[7]
Ballaro[28],Shah[24],Oppenheimer[32],Wignall[13],Sweet[33,34,53],Hozneck[16]Kallstrom[30],Wignall[13]
Gomes[29],Kumar[31],Sweet[53],Wignall[13]Trindade[35]
Knudsen[36],Stern[42],Wignall[13]Hozneck[16]Wignall[13]Bruyere[40]Earpdesa[37]
Strohmaier[39],Stern[42]Hammond[4],Hozneck[16]Hammond[38],Stern[42]
Hacker[41],modifiedfromHammond[38]
Abbreviations:TURBT,transurethralresectionofbladdertumour;TURP,transurethralresectionoftheprostate;Perc,percutaneous.
simulatortothepatient,orcriterionvalidityB,wasaddressedinthreestudies[14,22,43].
Onlythreearticlesreportedonprospectiverandomisedcontrolledtrials[10,20,44].ThesethreeconcernedmodelsfortheURSprocedure,twoVRandonebenchmodel,andreceivedthehighestOCEBMlevelofevidence.
3.3.1.Urethrocystoscopy
Faceandcontentvaliditystudies,concerningonlyVRsimulators,yieldedpositiveresults,althoughtwostudiesfailedtostatetheprecisenumberofparticipants(Table4)[5–8].ShahetalandGettmanetalconcludedthattheUROMentor(UM,Simbionix)hasprovenconstructvaliditybasedon
1252Table4–Validationstudiesonurologicaltrainingmodels,1980–2008:urethrocystoscopyTrainingmodel
Virtualreality–GeorgeWashingtonUniversityMedicalCenter,
Washington,DC,US
Typeofvalidation
FaceContent
Author
–
Manyaketal(2002)[5]
No.ofparticipants
–8
Outcome*–
‘‘Despiteanimperfectinitialvisualpresentation,thesimulationdidgenerallyduplicatetheexperienceofurologicendoscopy’’–––
‘‘All14subjects...feltthat...theyweremoreconfidentinhandlingaflexiblecystoscopeandinundertakingflexiblecystoscopy’’
‘‘Experiencedendourologicalinstructorsand
thetraineesreportedthattheUMsimulates...inreal-timewithahighdegreeofrealism,supportedbyarealistichapticfeedback’’
‘‘ExperiencedendourologicalinstructorsandthetraineesreportedthattheUMsimulates...inreal-timewithahighdegreeofrealism,supportedbyarealistichapticfeedback’’
Yes,time(p=0.03);no,numberofflags(p=0.12)Yes,time(p=0.005);no,numberofflags(p=0.05)Yes,time(p=0.02);no,numberofflags(nopvalue)Yes,time(p<0.001)
Yes,timeandnumberofflagson(p=0.01;p=0.03)Yes,time(p0.01)––
–
‘‘TheUTiscapableofauthenticsimulationofavarietyoflowerurinarytractprocedures’’Yes,mucosainspected(p<0.05)No,mucosainspected(nopvalue)No,mucosainspected(nopvalue)––
LevelofLevelofevidenceevidence(OCEBM)(Kirkpatrick)
–
5
–1
ConstructAConstructBCriterionA
Virtualreality–
UROMentor(UM)
Face
–––
Shahetal(2002)[8]
–––14
–––5
–––1
europeanurology54(2008)1247–1261Micheletal(2002)[6]?51
ContentMicheletal(2002)[6]?51
ConstructA
ConstructBCriterionACriterionB
Virtualreality–UROTrainer(UT)
FaceContentConstructAConstructBCriterionACriterionB
Shahetal(2002)[8]Shahetal(2002)[9]Shahetal(2002)[9]
Gettmanetal(2008)[11]Shahetal(2002)[9]
Gettmanetal(2008)[11]––
–
Reichetal(2006)[7]Reichetal(2006)[7]Reichetal(2006)[7]Reichetal(2006)[7]––
14107571757–––>150241236––
2b2b2b2b3b2b–––52b2b3b––
2b2b2b2b2b2b–––12b2b2b––
*Abbreviation:OCEBM,OxfordCentreforEvidence-BasedMedicine.Forexperiments:construct/criterionvalidityproven?
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significantdifferencesbetweendifferentlevelsofexperienceintimeperformances.They,however,didnotinvestigateotheraspectsofperformance[11],nordidtheyfindsignificantdifferencesinotheraspectsofperformancesuchasinvestigatedmucosa[8,9].
3.3.2.Ureterorenoscopy
Table5showstheresultsofthe26validationstudiesoftwoVRmodelsandthreebenchmodelsfortheURSprocedure.Ingeneral,theauthorsconcludethattheUROMentor(UM),aswellastheLimbs&Things(L&T)andMediskillsbenchmodels,can
Table5–Validationstudiesonurologicaltrainingmodels,1980–2008:ureterorenoscopy
Trainingmodel
Typeofvalidation
Author
No.ofparticipants
Outcome*LevelofLevelof
evidenceevidence
(OCEBM)(Kirkpatrick)
–5
–1
Virtualreality–DukeUniversityMedicalCenter,Durham,NC,US
FaceContent
–
Premingeretal1996[23]
–>300
ConstructAConstructBCriterionACriterionB
Virtualreality–UROMentor(UM)
Face
––––
Michel
etal2002[6]
––––?
–
>98%:simulationwasrepresentativeoftrueflexibleureteroscopyandwouldserveasavaluabletrainingexperienceforurologicsurgeonsunfamiliarwiththisprocedure––––
‘‘ExperiencedendourologicalinstructorsandthetraineesreportedthattheUMsimulates...in
real-timewithahighdegreeofrealism,supportedbyarealistichapticfeedback’’
‘‘ExperiencedendourologicalinstructorsandthetraineesreportedthattheUMsimulates...in
real-timewithahighdegreeofrealism,supportedbyarealistichapticfeedback’’
Yes,OSATS,time,numberofattempts(nopvalues)Yes,time(p<0.05);yes,fluoroscopy,attemptsatcannulation,instrumenttrauma(nopvalues)Yes,totaltime,insertguidewire,abilityto
performtask,overallperformance,globalrating,self-evaluation(p=0.002,p=0.039,p<0.001,p=0.001,p<0.001,p<0.001);no,trauma,
perforations,fragmentationtime(nopvalues)
––––5
––––1
Content
Michel
etal2002[6]
?51
ConstructA
Wattersonetal2002[44]Jacomidesetal2004[46]
1016
42b
2b2b
ConstructB
Wilhelm
etal2002[10]Wattersonetal2002[44]
1120
Yes,OSATS,timetocannulate,attemptsatcannulation,overalltime(p<0.001,p=0.02,p=0.01,p=0.01);no,simulatorresets,tietobladderneck,timetoureteralorifice(p=0.06,p=0.39,p=0.22)
Yes,clearanceofstone(p<0,01),meanoperationtime(p<0.05);no,x-rayexposuretime,timeofprogressiontostonecontact,andbleedingevents(nopvalue)Yes,time(p<0.05)
Yes,fluoroscopy,trauma(p<0.01)
Yes,overallperformance,abilitytoperformtask,globalrating(p=0.004,p=0.035,p<0.001);no,totaltime(p=0.461);no,insertguidewire,trauma,perforations,fragmentationtime,self-evaluation(nopvalues)
Yes,fluoroscopytime,trauma,overallOSATS(trainedstudents>residentsp<0.01,p<0.01,p=0.03);no,time(residents>trainedstudents,p<0.01);no,numberofURSattempts(p=0.45)Yes,checklistscore,OSATS,time,scopetrauma,percentpassing(p=0.02,p=0.002,p=0.02,p=0.02,p=0.007)
2b1b
2b2b
Knoll
etal2005[43]Jacomidesetal2004[40]
2032
3b3b
2b2b
CriterionACriterionB
Wilhem
etal2002[10]Ogan
etal2004[22]Matsumotoetal2006[21]Chou
etal2006[15]Knoll
etal2005[43]Ogan
etal2004[22]
23321616?32
1b3b3b
2b2b2b2b3
No,meanOSATS(p=0.38)
Yes,time(p<0.05);no,complications(nopvalue)Yes,totaltime,overallOSATS(p=0.022,p=0.01);no,fluoroscopytime,numberofURSattempts(p=0.826,p=0.892)
2b2b
3b2b
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Table5(Continued)
Trainingmodel
Typeofvalidation
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Author
No.ofparticipants
Outcome*LevelofLevelofevidenceevidence(OCEBM)(Kirkpatrick)
––2b3b
––32b
Bench–Limbs&Things
FaceContentConstructAConstructB
––
Matsumotoetal2001[19]Matsumotoetal2001[19]Matsumotoetal2002[20]Chou
etal2006[15]–
––––
Matsumotoetal2002[20]Matsumotoetal2002[20]–
–
Brehmeretal2002Brehmeretal2005Brehmeretal2002Brehmeretal2005–
Brehmeretal2002
––1717
CriterionA33
––
Yes,OSATS,checklistscore,passrating,time(p=0.001,p=0.001,p=0.011,p<0.001)Yes,seniorresidentsbetterthanjunior
residentsforOSATS,passrating,andtime(p<0.01,p=0.03,p<0.01);no,checklistscore(p=0.11)No,OSATS,checklist,scores,passrating,totaltime(p=0.08,p=0.17,p=0.95,p=0.80)No,meanOSATS(p=0.38)
2b2b
CriterionB
Bench–UniversityofToronto,Ontario,Canada
FaceContentConstructAConstructBCriterionACriterionA
16–––––3323
–
––––
No,OSATS,checklist,scores,passrating,totaltime(p=0.08,p=0.17,p=0.95,p=0.80)Yes,OSATS,checklist,scores,passrating,
totaltime(p=0.012,p=0.006,p=0.001,p=0.013)–
–
‘‘Allparticipantsfoundthebenchmodelproceduresimilartorealsurgery’’
Yes,task-specificchecklist,globalscore
andtotalscore(p<0.0001,p<0.0001,p<0.0001)No,nosignificantdifferencebetweengroups(nopvalue)
Yes,task-specificchecklist,globalscore,totalscore(nopvalues)–
Meanscoreonpatients17.6;onmodel,also17.6
2b–––––1b1b
2b–––––2b2b
CriterionB
Bench–Mediskills
FaceContentConstructAConstructB
––14
[14]
26
[45]
14
[14]
26
[45]
–14
[14]
––553b2b–2b
––112b2b–3
CriterionACriterionB
*Abbreviations:OCEBM,OxfordCentreforEvidence-BasedMedicine;OSATS,ObjectiveStructuredAssessmentofTechnicalSkills.Forexperiments:construct/criterionvalidityproven?
discriminatebetweendifferentlevelsofexpertise(constructAandB)[10,14,19,21,22,43–46].Matsumotoetaldidnotfindsignificantdifferencesbetweentheperformanceofgroupstrainedonahigh-fidelitymodel($3700)andlow-fidelitymodel($20).Theonlyresearchgroupthatdescribedastudyaboutthetransferfromsimulatortothepatientusingamalecadaver(criterionB)inaprospectiveexperimentwasOganetal[22].Matsumotoetal,Wattersonetal,andWilhelmetalweretheonlystudiestoscore1boftheOCEBMlevelsofevidence[10,20,44].
3.3.3.
Transurethralresectionofbladdertumour
TheUROTrainerhasonlybeeninvestigatedbyReichetal(Table6)[7].Theyconductedseveralcontentvaliditystudies,whichresultedinimprovementandfurtherdevelopmentofthemodel.Positiveresultsonconstructvaliditywerefoundinastudyamong24medicalstudents(novices)and12residents(experts).
3.3.4.
Transurethralresectionofprostate
validitybutdidnotdescribethequestionnairenorreportresultsinnumbersorfigures[28].Kallstrometaladministereda10-itemquestionnairetoinvestigatecontentvalidityandfoundscoresonsimulatorcharacteristicsrangingfrom4to8(1=poor,10=verygood)[30].Thesamplesinbothstudiesweresmall:threeandnine,respectively.Sweetetalconductedarelativelylargeface,content,andconstructvalidityBstudyamong19novicesand72expertsshowingthattheUniversityofWashingtonVRtrainercandiscriminatebetweenlevelsofexperience(p<0.05on9differentobjectiveparameters)[34].Rashidetalinvestigatedaspecialkindofconstructvalidity;namely,differencesinabilitylevelsingroupswith‘‘similar’’experience[47].Theyfoundthatprimaryproficiencymetricswereassociatedwithspecificfactors(eg,fluiduse,cutsattissue,hitsoncuttingpedal)ineachparticipantgroup.
3.3.5.
Percutaneousaccessand/orlitholopaxy
TheresultsofthevalidationstudiesofTURPmodelsarereportedinTable7.BallaroetalstudiedcontentHammondetalexaminedthefacevalidityofapercutaneousmodeltheyhaddevelopedand
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Table6–Validationstudiesonurologicaltrainingmodels,1980–2008:transurethralresectionofbladdertumourTrainingmodel
Typeofvalidation
FaceContent
Author
No.ofparticipants
–>150
Outcome*LevelofLevelofevidenceevidence(OCEBM)(Kirkpatrick)
–5
–1
Virtualreality–UROTrainer(UT)–
Reichetal(2006)[7]
ConstructA
Reichetal(2006)[7]Reichetal(2006)[7]
2412
ConstructBCriterionACriterionBReichetal(2006)[7]––36––
–
‘‘TheUTiscapableofauthenticsimulationofavarietyoflowerurinarytractprocedures’’
Yes,tumourstreated,totaltime,bloodloss(p<0.05)
Yes,tumourstreated;no,
totaltime,bloodloss(nopvalue)Yes,tumourstreated,blood–loss;no,totaltime(nopvalue)–
2b2b3b––
2b2b2b––
*Abbreviation:OCEBM,OxfordCentreforEvidence-BasedMedicine.Forexperiments:construct/criterionvalidityproven?
reportedahighdegreeofsatisfactionwiththeeffectivenessofthismodel,butprovidednoinfor-mationaboutthequestionnaireortheparticipants(Table8)[38].KnudsenetalinvestigatedconstructAandBvalidityinastudywith63participantsanddemonstratedthattrainingonthePERCMentor(Simbionix)significantlyimprovedtheperformanceofnovices[36].
cide.However,authorsofarticlesonvalidationstudiesshouldalwaysdefineexactlywhattheymeanbyaspecificvalidityterm.
4.1.
Descriptionofmodels
4.Discussion
Between1980and2008,atotalof45articlesdescribed41modelsforendourologicalproceduresandreported54validationstudiesofthesemodels.Theonlystudiesthatcanbeclassifiedasrandomisedcontrolledtrials(RCTs)arethreeofthevalidationstudies[10,20,44].ThisnumberisverylowcomparedtothenumberofRCTsingeneralsurgeryandgeneralmedicine.InasystematicreviewofRCTsoftrainingtechniquesinvolvingatleastsomeelementsofsurgicalsimulation,Sutherlandetalreported30RCTspublishedbetween1998and2005[48].Asystematicsearchoftheliteraturebetween1998and2006forstudiesofmedicalsimulatorsbyLynaghetalyielded44RCTs,24(54%)ofwhichconcernedlaparoscopicskills[49].OnlytwoRCTs,WattersonetalandMatsumotoetal,addressedendourologicalskillswithinthispaper[20,44].
Insurgicalsimulation,noclearconsensusexistsontheexactdefinitionofthetermsofface,content,construct,andcriterionvalidity[1,12,50].Intheincludedarticles,theuseofthesetermsvaried,and,therefore,wedescribedthedefinitionsweusedinTable1andjudgedthedescriptionsinthestudiesonthesedefinitionsaccordingly.Studiesconcerningvalidationofsimulatorsarehighlyreproduciblebecausethecontentandmethodsofstudiescoin-
Surprisingly,onlyonetypeofmodelfortheTURBTprocedurewasdescribed,incontrasttoUCS,URS,TURP,andPercprocedures,withsix,nine,five,andninetypesofmodels,respectively.Itispossiblethatothermodelsexistthathavenotbeenstudied,butanotherplausibleexplanationseemstobethatTURBTmodelsaremoredifficulttodevelopbecauseoftheenormousvariationoftumoursinpatients.
Fifteenarticlesweremerelydescriptive,reportingnoattemptsatvalidationofthemodel.Ideally,articlespresentingnewlydevelopedmodelsshouldaddressalltypesofvalidation.However,forpropervalidationstudies,asufficientlylargenumberofparticipantsisrequired,makingcollaborationwithotherresearchgroupsaprerequisite.Urologybeingasmallspecialtywithfewtraineesinonehospital(comparedto,forexample,generalsurgery),itseemsadvisabletostartbypublishingadescriptivearticleofanewlydevelopedmodelandafterthatproceedtoconductaprospectiverandomisedmulticentrestudy.
AninterestingfindingisthatitwasuniversitiesthatdevelopedthefiveTURPmodelswithoutinvolvementofcommercialcompanies,whereas30%(threeoutofnine)oftheURSmodelsweredevelopedbyacommercialcompany.Commercialcompanies’interestsareprimarilyfinancial,andtheirtargetsdonotalwayscoincidewithurologists’educationalgoals.Ifamodelisdevelopedcommer-cially,itisparamountthatthisbedoneinclosecollaborationwithaurologyresearchgroup.
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Table7–Validationstudiesonurologicaltrainingmodels,1980–2008:transurethralresectionofprostateTrainingmodel
Typeofvalidation
Face
Author
No.ofparticipants
19
Outcome*LevelofLevelofevidenceevidence(OCEBM)(Kirkpatrick)
5
1
Virtualreality–UniversityofWashington,Seattle,WA,US
Sweetetal[34]Sweetetal[34]
Content72
ConstructAConstructB
–
Sweetetal[34]
–91
‘‘Overallparticipatingurologistsandtraineesbelievedthatversion1.0of
theUWTURPsimulatorwasacceptable’’93%thinkthattheUWTURPsimulatorwouldbeusefulasatrainingtool;onaLikertscale(1=totally
unacceptable,5=totallyacceptable),urologistsscored3.38–
Yes,orientationtime,gramsresected,cuttingtime,cutsattissue,coagulationtime,grams/cuts,totalfluid,bloodloss,fluiduse/grams,bloodloss/grams(p<0.0001,p<0.0001,p<0.0001,p<0.0001,p=0.002,p=0.002,
p=0.002,p=0.016,p=0.020,p=0.032)Yes,coagulationtime,orientationtime,cuttingtime,bloodloss,
gmresected,tissuecuts(p<0.05)
41
–2b–1
CriterionACriterionB
Virtualreality–University
College,London,UK
FaceContent
Rashidetal[47]––
–
Ballaro(1999)[28]
136–––3
––
–
Expertsagreedthatthesimulator‘‘allowedtheusertopracticeinspectionandresectionoftheprostateglandwithahighdegreeofrealism,althoughlimitedbydelayedimagesandlackofhapticfeedback’’––––
–
Judgmentofanatomy,handling,
vision,perforation,strategy,realism,flexibility,instrumentation,overallopinion,usefulnessvarybetween4and8
Yes,resectedvolume,bloodloss,distancetheresectoscopetipwasmoved,timeduring
whichtherewashighpressure,amountofabsorbedirrigation
fluid(p<0.001,p<0.001,p<0.001,p<0.005,p<0.005)–––
–––5
–––1
ConstructAConstructBCriterionACriterionB
Virtualreality–
UniversityHospitalLinkoping,Sweden
FaceContent
––––
–
Kallstrom(2005)[30]
–––––9
–––––5
–––––1
ConstructA
Kallstrom(2005)[30]
72b2b
ConstructBCriterionACriterionB––––––––––––
*Abbreviation:OCEBM,OxfordCentreforEvidence-BasedMedicine.Forexperiments:construct/criterionvalidityproven?.
4.2.Validationstudies
TheTURPprocedureprovedtobeoneofthefavouritesintermsofthedevelopmentanddescrip-tionofmodels.Paradoxically,TURPmodelshaveso
fargivenrisetoonly7validationstudies(comparedto26studiesconcerningURSand14forUCS),4ofwhichaddressedonlyfaceorcontentvalidity,achievinglowOCEBMratingsandKirkpatricklevelsofevidence.Onemightwonderwhetherthese
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Table8–Validationstudiesonurologicaltrainingmodels,1980–2008:percutaneousaccessandlitholopaxyTrainingmodel
Typeofvalidation
Face
Author
No.ofparticipants
?
Outcome*LevelofLevelofevidenceevidenceOCEBM)(Kirkpatrick)
5
1
Animal–SouthernIllinoisUniversitySchoolofMedicine,Springfield,IL,US
Hammond
etal(2004)[38]
ContentConstructAConstructBCriterionACriterionB
Virtualreality–PercMentor
FaceContentConstructA
–––––––
Knudsenetal[36]
–––––––?
‘‘Anonymousevaluationformssubmittedbyalltraining
sessionparticipantsrevealedahighdegreeofsatisfactionwiththeeffectivenessof
thismodelfortheapplicationofpercutaneousrenalaccess
andnephrolithotomytechniques’’–––––
––
Yes,OSATSscores,totaltime,fluoroscopytime,attemptedneedlepunctures(allp<0.001),bloodvesselinjuries(p=0.003),collectingsystemperforation(p=0.05)
Yes,OSATSscores(p<0.001),totaltime(p<0.001),
fluoroscopytime(p<0.001),attemptedneedlepunctures(p=0.001),bloodvesselinjuries(p<0.001),collectingsystem
perforation(p=0.009)––
–––––––2b
–––––––2b
ConstructB
Knudsenetal[36]
632b2b
CriterionACriterionB––––––––
*Abbreviations:OCEBM,OxfordCentreforEvidence-BasedMedicine;OSATS,ObjectiveStructuredAssessmentofTechnicalSkills.Forexperiments:construct/criterionvalidityproven?
modelsarestillunderdevelopmentorwhethertheresultsof(unpublished)faceandcontentvaliditystudiesmaynothavebeensufficientlypositivefortheresearcherstodecidetoproceedtotestconstructandcriterionvalidity.
StudieswithanOCEBMlevel1scorewerescarce.OnlyMatsumotoetal,Wattersonetal,andWilhelmetalmanagedtoconductRCTsofreasonablequality[10,20,44].However,thestudysampleswerelimitedto33,20,and23participants,respectively.In33outofthetotalof36studiesaddressingconstructandcriterionvalidity,thestudypopulationwasalsosmall,rangingfrom5to36.OnlyRashidetal,Sweetetal,Knudsenetal,andGettmanetalincludedlargernumbersof136,91,63,and57participants,respectively[11,34,36,47].Althougheffectsizesmustbelarge(>0.5)becauseotherwisettestsofdiffer-encesbetweengroupsdonothavesufficientpowertoshowsignificantdifferences,manyarticlesreportedsignificantdifferencesforatleastsomeoftheobjectivecriteriadespitesmallnumbersofparticipants.Thismayimplythattheeffectsoftrainingwithsomemodelsareverystrong.
Inmostofthestudiesofconstructandcriterionvalidity,timewastheonlyobjectiveparameterinvestigated.Thisraisesthequestionofwhetherspeedisthemainobjectiveoftrainingonamodel.Apossibleexplanationofthislimitedfocusisthattimeisaneasyandobjectiveparametertomeasure.Mostexperiments(constructA,B,criterionA,B)involvedVRmodels.Thisseemsattractive,becauseVRmodelscreateobjectiveparametersandareeasytouse.However,bench,animal,orhumanmodelscanalsoyieldobjectiveassessmentsusingObjectiveStructuredAssessmentofTechnicalSkills(OSATS)scoringlists[51].OSATSresultsincludehandlingofinstruments,respectfortissue,andknowledgeofprocedures,allparametersthatappeartobestrongeronrelevancethanjusttime.
Shahetalshowedthatexperts’performanceshowednochangefromtrial1totrial10inthenumberofflagsvisualised(asaparameterof
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inspectedmucosa)butthattheyweresignificantlyfasterattheendofthetraining.Thismeansthatevenexpertshavealearningcurveonthesimulator,whichonemightinterpretas‘‘gettingusedtothesimulator.’’Onemusttaketheseresultsintoaccountininterpretingtheresultsofnovices,whoarefacednotonlywiththelearningcurveofgettingusedtotheprocedureitself,butalsowiththatofthesimulator.
ChouetalandMatsumotoetalstudiedcriterionAvaliditycomparingtheL&TmodelwithaVRmodelandtheUniversityofTorontomodel,respectively[15,20].Neitherarticlereportedanysignificantdifferencesbetweenthetwomodelsunderstudy;however,thisdoesnotautomaticallyimplythatthedifferentmodelsareequivalent.Onecouldimaginethatmorebasicproceduresarebestlearnedonsimplelow-costsimulators,whereasforadvancedprocedures,high-fidelitymodelsarepreferable.Futurestudieswillhavetoshowwhichtypeoftrainingmodelbestfitswhichlearningphaseofwhichprocedure.Indeed,everymodelshouldbevalidatedforeveryprocedureandforeverytask.Thekeyquestionforeachmodeliswhethertrainees’performanceonrealpatientsimprovesbypractisingonthatmodel(criterionBvalidity).Ratherdisappointingly,onlythreestudiesaddressedthiscrucialquestion[14,22,43],althoughthisisquiteunderstandableconsideringthatthisisoneofthemostdifficulttypesofstudytoperform,involvingethicalissuesaswellaslargenumbersofpatientsandtrainingsessions.Theethicalissuesarerelatedtoinformedconsentfromallparticipatingpatients.Obtainingthisislikelynottobestraightforward,becausepatientswantthebestpossibletreatmentandmaywithholdconsentifparticipationentailsarelativeincreaseintheirriskofcomplications.Alternativescanbesoughtinpatientoranimalcadavers,butthosecanneverfullyreplacerealpatients.Thereasonthatlargenumbersofpatientsandtrainingsessionsareneededisthatpatientscannotbestandardised.Inshort,studiestoestablishcriterionBvalidityareintensiveandtimeconsum-ing,but,nonetheless,absolutelyessential.Becauseoftheircomplicatednature,theyareprobablybestperformedinwell-organised,multicentresettingswithapprovalofthelocalethicalcommittees.
Futureinvestigationsshouldfocusonthetransferofskillsfromsimulatortopatient(criterionBvalidity).Moreover,inordertoassesswhethernovicesaresufficientlycompetenttocontinuetheirlearningcurveonthepatient,appropriateassess-mentmethodsneedtobedeveloped,evaluated,andimplemented.AsGallagheretaldescribed,trainingtechnicalskills—usingsimulators—isoneaspectof
asurgicalcurriculum[52].Inaddition,individuals‘‘needtoknowwhattodo,whatnottodo,howtodowhattheyneedtodo,andhowtoidentifywhentheyhavemadeamistake’’[52],andfuturestudiesshouldalsoconsiderthesecognitiveaspectsofacquiringendourologicalskills.Publicationbiasisoneofthelimitationsofthisreview.Becausenegativeresultsarelesslikelytobepublished,wemayhavemissedsome.Anotherlimitationisthatourconclusionsaremostlybasedonnon-rando-misedstudies,becauseoursearchretrievedonlythreeprospectiverandomisedstudies.
Insummary,ourqualitativesystematicreviewshowsthatasurprisinglysmallnumberofmodelswerethesubjectofadescriptivestudy,andvalidationstudieswerefewaswell.Giventhattrainingmodelsshouldbedescribedandsubjectedtovaliditytestingbeforetheireducationalvaluecanreasonablybeestablished[1],wecanonlyconcludethatnoneoftheurologytrainingmodelsdescribedandresearchedbetweenJanuary1980andApril2008canbesaidtohaveprovenvalidityforuseinspecialtytraining.
5.Conclusions
Duetogrowinginterestintrainingmodelsinurology,itisincreasinglyurgenttodeterminewhichofthesemodelsaremostvaluableforpostgraduatetraining.Becausethevalidationstudiespublishedsofararefewinnumber,havelowevidencelevels,andarecomposedofonlyafewRCTs,itisimportantthatmorerandomisedcontrolledvalidationstudiesincludinglargernumbersofparticipantsareper-formed.
Authorcontributions:BarbaraSchouthadfullaccesstoallthedatainthestudyandtakesresponsibilityfortheintegrityofthedataandtheaccuracyofthedataanalysis.
Studyconceptanddesign:Schout,Hendrikx,Scherpbier,Bemel-mans.
Acquisitionofdata:Schout,Scherpbier.
Analysisandinterpretationofdata:Schout,Scherpbier.
Draftingofthemanuscript:Schout,Hendrikx,Scherpbier,Bemelmans.
Criticalrevisionofthemanuscriptforimportantintellectualcontent:Schout,Hendrikx,Scherpbier,Bemelmans.Statisticalanalysis:None.Obtainingfunding:None.
Administrative,technical,ormaterialsupport:Schout.
Supervision:Schout,Hendrikx,Scherpbier,Bemelmans.Other(specify):None.
Financialdisclosures:Icertifythatallconflictsofinterest,includingspecificfinancialinterestsandrelationshipsandaffiliationsrelevanttothesubjectmatterormaterials
europeanurology54(2008)1247–1261
1259
discussedinthemanuscript(eg,employment/affiliation,grantsorfunding,consultancies,honoraria,stockownershiporoptions,experttestimony,royalties,orpatentsfiled,received,orpending),arethefollowing:None.Funding/Supportandroleofthesponsor:None.
Acknowledgementstatement:TheauthorswouldliketothankMerekeGorsiraforhereditorialassistance.
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EditorialCommenton:UpdateonTrainingModelsinEndourology:AQualitativeSystematicReviewoftheLiteraturebetweenJanuary1980andApril2008StavrosGravasDepartmentofUrology,UniversityHospitalofLarissa,Larissa,Greecesgravas2002@yahoo.comWiththeincreasingpressuresonsurgicalperformanceandtheemergenceofnewtechnol-ogies,urologistsandresidentsaredemandingtrainingsystemsthatwillgivethemtheoppor-tunitytopractice,acquire,andmaintaintheirsurgicalcompetence.Endourologicsimulatorshavebeenrecentlyintroducedastrainingtools.Theyhavethepotentialtoreducesurgicalriskrelatedtotheeducationprocess,andtheyallowsurgeonstoacquirefamiliaritywithsurgi-calstepsandtheuseofendoscopictoolsanddevelophand/eyecoordinationbyrepetitivetraininginastress-freeenvironment.Inaddition,thesystemscanbecustomisedtotheneedsofindividualtrainees,andanincreasinglevelofdifficultycanbeapplied.However,thesimulatorsdonotofferreal-timeinteractivityandtactilefeedback,andtheyhaveahighpurchasecost.Nonetheless,simulatorsaregaininginpopular-ity,withmorethan86%ofurologists(irrespectiveoftheiryearofcertification)interestedinthem[1].However,beforeincorporatingsimulationtrain-ingintoroutineeducationalprogrammes,thesesystemsmustbevalidated.Validitymeasureswhetherthetrainingmodelactuallyisteachingorevaluatingwhatitisintendedtoteachormeasure,andthatdifferenttypesofvalidityhavebeendefined,includingface,content,construct,andcriterionvalidity[2].Schoutetalprovideanexcellentoverviewoftrainingmodelsinendourologyandtheirvalidity[3].Becauseofthedifferencesintheevaluatedmodelsandthedesignoftheavailablestudies,itistruethatnostatisticalcombinationofresultsfromtwoormoreseparatestudiescanbedone.Idoagreewiththeconclusionofthissystematicreviewthatvalidationstudiespublishedsofararefewinnumber,havelowevidencelevels,andcompriseonlyafewrandomisedcontrolledtrials(RCTs).Therefore,thevalidityofmostmodelsremainseuropeanurology54(2008)1247–1261
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unproven,stressingtheneedformoreRCTswithasufficientnumberofsubjectsandadequatevalida-tion.Whatwillthefuturebringus?Advancementsincomputingandgraphicalcapabilitiesshouldallowfuturegenerationsofsimulatorstoovercomethepresentdisadvantages.Itisalsolikelythatnewsimulatorswillbeusedforoperativeplanningbyintegratinghigh-resolutioncomputedtomographyandmagneticresonanceimagesofindividualpatientintothetrainingsystem[4].Asaresult,aurologistcouldpractiseavirtualoperationbeforetherealprocedureonthepatient.Lastbutnotleast,someofthemostimportantworkinsimulationtraininghasbeendoneinthefieldoflaparoscopy.Asystematicreviewonlaparoscopicsimulatorswillbealsoverywelcomebytheurologicalcommunitybecauseoftheincreasinginterestinlaparoscopyandrobotics.References[1]delaRosetteJJMCH,GravasS,MuschterR,RassweilerJ,JoyceA,onbehalfofthemembersoftheboardoftheESUT.Presentpracticeanddevelopmentofminimallyinvasivetechniques,imagingandtraininginEuropeanurology:resultsofasurveyoftheEuropeanSocietyofUro-Technology(ESUT).EurUrol2003;44:346–51.[2]McDougallEM.Validationofsurgicalsimulators.JEndourol2007;21:24–7.[3]SchoutBMA,HendrikxAJM,ScherpbierAJJA,Bemel-mansBLH.Updateontrainingmodelsinendourology:aqualitativesystematicreviewoftheliteraturebetweenJanuary1980andApril2008.EurUrol2008;54:1247–61.[4]NedasT,ChallacombeB,DasguptaP.Virtualrealityinurology.BJUInt2004;94:25–7.DOI:10.1016/j.eururo.2008.06.037DOIoforiginalarticle:10.1016/j.eururo.2008.06.036
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