Transurethral resection of bladder tumor:A systematic review of simulator-based training courses and curricula

Pngiotis Kllionis,Angelis Peteinris ,Gernot Ortner ,Kostntinos Pgonis ,Costntinos Amou ,Athnsios Vgionis ,Evngelos Litsikos,c,Bhskr Somni,Theooros Toks

a Department of Urology,University Hospital of Rion,Patras,Greece

b Department of Urology and Andrology,General Hospital Hall I.T.,Hall in Tirol,Austria

c Medical University of Vienna,Vienna,Austria

d Department of Urology,University Hospital Southampton NHS Foundation Trust,Southampton,UK

KEYWORDS Simulator;Train;Curriculum;Transurethral resection;Vaporesection;Laser;Bladder

Abstract Objective: Transurethral resection of bladder tumor is one of the most common everyday urological procedures.This kind of surgery demands a set of skills that need training and experience.In this review,we aimed to investigate the current literature to find out if simulators,phantoms,and other training models could be used as a tool for teaching urologists.Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews.Fifteen out of 932 studies met our inclusion criteria and are presented in the current review.Results: The UroTrainer (Karl Storz GmbH,Tuttlingen,Germany),a virtual reality training simulator,achieved positive feedback and an excellent face and construct validity by the participants.The inspection of bladder mucosa,blood loss,tumor resection,and procedural time was improved after the training,especially for inexperienced urologists and medical students.The construct validity of UroSim® (VirtaMed,Zurich,Switzerland) was established.SIMBLA simulator(Samed GmbH,Dresden,Germany)was found to be a realistic and useful tool by experts and urologists with intermediate experience.The test objective competency model based on SIMBLA simulator could be used for evaluating urologists.The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it.The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity,and 60% of participants would like to use the simulators in the future.The 5-day multimodal training curriculum “Boot Camp” in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project.

1.Introduction

Bladder tumor is the 6th most common neoplasm worldwide[1].Its incidence is 26.5 per 100 000 among men and 5.5 per 100 000 among women [1].Transurethral resection of bladder tumor(TURBT)is one of the most common everyday procedural activities for a urologist.These endoscopic procedures are challenging and have a certain level of difficulty.The inspection of bladder mucosa,the total resection of tumor,and the careful hemostasis are some steps that need experience and practice in order to be done correctly and safely.The past “see one do one” teaching model used to prepare the residents for their first cases does not fall in line with the new surgical status that requires training,in order to avoid compromising the quality of the services provided to the patients.In the United States,approximately 53 million dollars are invested annually for extending the time that residents are trained in the operation room [2].It is mentioned that 100 TURBT cases is the minimum for a resident to achieve dignified surgical and oncological skills [3].The increasing number of these cases in combination with the limited operation room time and the economic issues associated are some of the reasons why the learning curves must be shortened[3].The second axis is the effect that the existing condition has on the patients.The inability of the total resection of a tumor may lead to an incomplete or delayed staging.In addition,good hemostasis and protection of the ureteric orifices during surgery could minimize the complications and hospital stay [4].

The training models and courses give doctors the opportunity to train in a similar scheme to realistic situations.In that way,trainee surgeons also come to terms with the operative tools and their ergonomy.This kind of surgical training is an excellent way to reduce the learning curve and familiarize the surgeons with the difficulties of lower urinary tract procedures.In addition,it is an important way to standardize the training of surgeons.This can be achieved by the creation of programs(curricula)for doctors at the same level with the goal not only to educate theoretically,but also to provide technical skills for the surgical practice.These curricula could be the base for the standardization of the quality surgical education[5].We herein systematically reviewed the literature to elucidate the current status of the training models and protocols for TURBT.The simulators and phantoms that are used alone or as a part in courses and curricula and their role in a urologist’s surgical education were the basic questions of this review.

2.Materials and methods

2.1.Evidence acquisition

2.1.1.Search strategy,eligibility criteria,and endpoints

PubMed,Scopus,Cochrane Library of Systematic Reviews,and EMBASE were screened from January 1990 to October 2021.The study complied with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines office for conducting systematic reviews[6,7].Eligible was any study evaluating cadaveric,in vivo,in vitro,and virtual reality(VR)simulators and/or curricula for training in TURBT.Any study without the presentation of a phantom or a simulator during a course or a curriculum was excluded from our investigation.The study protocol was published online in August 2020 in Open Science Framework (www.osf.io) and could be also reviewed in Table 1.

Table 1 The study protocol (Open Science Framework[www.osf.io];online in August 2020).

2.2.Data extraction

The studies were screened by two reviewers (Peteinaris A and Ortner G) independently depending on the inclusion criteria and relevant data on study characteristics(Table 2).The inclusion criteria of all studies in this review were simulators or phantoms for TURBT,courses or curricula about transurethral surgeries.Any discrepancies among the investigators were solved by the senior investigators (Kallidonis P and Somani B).

3.Results

After the screening of 932 publications,15 studies were considered eligible to be included in the review,of which 11 studies looked into training simulators for TURBT,one described training curricula,and three referred to training courses and their evolution.Fig.1 shows the flowchart of the study.Our investigation presented the existence of a wide variety of phantoms and simulators.For a more structured and understandable analysis,we presented data on eligible studies after categorizing them to the followingtypes: VR simulators,low-fidelity simulators,and highfidelity simulators.Low-fidelity simulator is considered a simulator that is not very close to real learning environment conditions,and high-fidelity simulator is the one that is very close to real learning environmental conditions [8].Uro-Trainer(Karl Storz GmbH,Tuttlingen,Germany)was sorted as a VR simulator [9].The “homemade” simulator by Bach et al.[10]and UroSim®(VirtaMed,Zurich,Switzerland)were classified as low-fidelity simulators [11].The SIMBLA TURBT simulator (Samed GmbH,Dresden,Germany),the “porcine model” of the Asian Urological Surgery Training and Education Group,and the TURB Mentor™VR simulator(3D Systems/Simbionix,Cleveland,OH,USA) were classified as high-fidelity simulators [12-14].The search of the literature for the existence of simulator-based courses and curricula revealed a possible examination tool and two different educational programs.The evolution of the second program is also presented[15-17].

4.Discussion

4.1.Simulators and phantoms

4.1.1.VR simulators

The UroTrainer is a VR simulator for transurethral training that offers a software of many anatomical and pathologic variations for diagnostic and surgical interventions with haptic force feedback [18].The simulator consists of a personal computer,a workstation with an integrated mechatronic unit(haptic feedback)and two monitors.The images are displayed and generated by a central software.The images of the urethra and the bladder were created by digitized video footage of surgeries,as well as from data of cross-sectional imaging (MRI and CT).The first monitor reflects the surgeon’s view,while the second presents a sagittal,axial,or coronal view of the overall situation.The surgeon can choose 0°,30°,70°or 120°angle optical endoscope.Filling,emptying,and flushing with irrigant are performed with genuine hardware incorporated into the instruments.The simulator was used and tested by urologists in a two-phase study.In the first phase of the study,the machine was used by urologists with different level of experience during workshops and congresses.Feedback of about eighteen questions was sent by more than 150 urologists.Although the learning curve was not long,there was a correlation with the level of experience of the surgeon.In the second phase,the machine was evaluated by 24 medical students and 12 residents.The assessment was a 1 h introduction and 2 h of supervised training to achieve certain goals during cystoscopy and bladder tumor resection.There was a week between the first and the second hour of supervised training.The researchers found that there was an improvement for the medical students for the inspection of bladder mucosa,blood loss,tumor resection,and surgery time.Residents’performance was stable,although they had better scores for the tumor resection.It seemed that UroTrainer could be a helpful learning tool for the medical students,representing a sample of physicians without experience,achieving a significantly better score at the second time they used the UroTrainer [9].

The UroTrainer was also used for a comparison of the surgical performance of two groups of urologists before and after the use of the device.Fifteen novices had five attempts of using white light trying the VR-TURBT resection and 15 experts had five attempts VR-TURBT resections with white light and photodynamic cystoscopy using the Uro-Trainer.Each attempt lasted 5 min.Before the task,there was a 10-min lesson with instructions for the simulator and a 10-min hands-on experience.Comparing the first with the last TURBT session,the novices had an improvement for the inspected bladder mucosas and their resection rates.The experienced surgeons had a better bladder mucosa inspection and resection rate using the photodynamic diagnostics.The remarkable higher score of the 15 novices showed that UroTrainer could be a reliable teaching solution [19].

Figure 1 The Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart.TURBT,transurethral resection of bladder tumor.

In addition,UroTrainer’s utility was evaluated by the surgical performance of medical students [20].Fifty one medical novices were divided into two groups.The difference between the two training groups was that the first one had theoretical instructions and the second one a hands-on trial with the UroTrainer.Every medical student had a VR-cystoscopy and VR-TURBT task.After that,the first group had a tutorial video by an expert urologist about tool handling,bleeding control,cystoscopy,and tumor resection performance.The second group had a 30-min hands-on experience with the UroTrainer about cystoscopy,tumor resection,and bleeding control.In the end,both groups had a final VR-cystoscopy and TURBT.The results showed no difference for the cystoscopy task between the two groups.As for the TURBT,the second group had a better score for the time needed to complete the resection and for the accidental bladder injury.This proves that technical education offered by training with VR simulators can be useful for urologists with any level of experience [20].

Similarly,the UroTrainer was tested by urologists of different level of expertise.Novice and expert urologists performed a TURBT and/or a transurethral prostate resection using UROTrainer[18].After that,they had to rate how useful and realistic the device was on a 10-point scale.Only 64 participants performed a TURBT (30% experts and 70% novices),and the mean scores for the usefulness,realism,and overall performance varied from 5.6 to 8.2 (standard deviation 1.4-2.5).

In another study,22 urologists with different levels of expertise(15 novices and 7 experts)used the UroTrainer for performing four TURBT procedures [21].The assessment of the participants was completed with questionnaires before and after surgery and self-interaction.As for construct validity,the experts had better overall,safety,and visualization scores.A significant correlation of the UroTrainer scores and the self-assessment capability was also found.The positive face and construct validity showed that Uro-Trainer has tremendous potential as a learning tool.

4.1.2.Low-fidelity simulators

A study proposing and evaluating a low-fidelity simulator was recognized in the current review.A “homemade” transurethral surgery-simulator made of a 7 cm hose,one suprapubic tube,three catheter plugs,one silicone gel,and a Tupperware™box was presented[10].This simulator was tested by 11 urologists (three students,three residents,two fellows,and three consultants).They used real instruments during training with the simulator.The authors observed that the pork and beef were close enough to reality where it concerned the feedback during cutting.The 11 urologists had to perform a task using flexible cystoscopy for five attempts.The mean duration of flexible cystoscopy was better by almost 51% on the last attempt compared to the first one.The most impressive fact about this simulator was its low cost,which was under$40.It seems that it could be used for the familiarization of the basic urological procedures for the new doctors [10].

A cross-sectional prospective study was conducted by Rafi et al.[11]investigating the construct validity of UroSim®.The participants were 30 experienced and 30 novice urologists.This simulator consisted of a basic unit and a screen,and original instruments were used.All the participants had the opportunity to watchan instructive video of the simulator and 15 min hands-on with the UroSim®.After that,every participant had to complete the task of removing three bladder tumors (prerecorded case),and the results of the surgical performance were analyzed by the simulator.The differences on the performance between the two groups were significant regarding the resection time,bleeding control,safety,and visualization.Most of the novices were unable to complete the resection of the third tumor due to its location in the bladder dome.Construct validity of the simulator was well-demonstrated and it could be considered a reliable training solution for teaching psychomotor skills required for TURBT[11].

4.1.3.High-fidelity simulators

The SIMBLA TURBT simulator is a high-fidelity simulator according to de Vries et al.[12].The operation case was placed on the basic unit of the simulator.The bladder substrate of resectable material(with anatomical structures and tumors)is placed inside the case.Real instruments are used for training.To investigate its utility as an educational tool,76 urologists (25 novices,26 intermediates,and 25 experts)used the SIMBLA TURBT simulator for two standardized procedures.A committee of eight expert urologists established a training needs analysis,to investigate SIMBLA adequacy as a training tool.The score determined by the participants for face validity and content validity was eight out of ten.All intermediates and most experts found the SIMBLA simulator as a realistic and useful educational tool.As for the construct validity,novices had longer resection time,more incomplete resections,more bladder injuries,and lower total score compared to the intermediates and experts.It made sense that novices had lower scores due to lack of operational experience.The high score for face and content validity showed that SIMBLA simulator could probably be a useful learning tool for endourology procedures [12].

In an attempt to examine the usefulness of SIMBLA simulator as a part of an evaluation process,the test objective competency,TURBT tool was presented[13].This tool was designed by expert urologists and included three different phases for the assessment of a TURBT procedure.The three phases were the preparatory,the procedural,and the completion phase.Seventy-six urologists took part in this experiment.Each one had an instructional lesson for the use of SIMBLA simulator.After that,they had to complete two standardized TURBTs.Each surgery was rated by two different independent urologists.The most raters and urologists that took part in this survey found that this tool could be a valid competency assessment for this kind of procedure.It was also found that the format with two surgeries and two raters was reliable and that construct validity was well established regarding at least the procedural phase.This model could be used for the evaluation of urologists,but it would be probably better if there was a more standardized way of rating,as the subjectivity of the raters could introduce biases [13].

The Asian Urological Surgery Training and Education Group developed a porcine model for training in TURBT[14].For this training model,porcine bladders were used,a cystostomy was created near the bladder neck and the endoluminal surface was brought inside out.The mucosa was elevated with a surgical instrument and then tied with a suture for the creation of the “tumor”.After the reversion of the bladder to its normal position and the saturation of the cystostomy,the bladder was inserted into a training box.The box had a hole for the insertion of real instruments.This model was tested by 40 urologists and divided into two groups consisting of junior and senior surgeons.The division was based on the criterion if the duration of their training was more or less than 4 years.Questionnaires for face-validity were completed before the task.For content validity after the task and for the construct validity,a global rating scale was used.In the end,mean scores of ＞4.0 and ＞4.5 out of 5 were achieved for the pre-and the post-task questionnaires,respectively.Additionally,the seniors had a better total score and better scores in eight out of 11 tasks compared to the juniors[14].The score results were expected based on the experience of the participants.The creation of this model seems easy and inexpensive,and could be a reliable solution for transurethral surgery training [14].

In the following prospective observational trial,the researchers attempted to develop a simulator-based test based on the TURB Mentor™VR simulator,the TURBEST[15].This device is a VR simulator and consists of a screen and a case.The resectoscope was inserted in the case during the procedure.In addition,physical equipment including a resectoscope,a loop electrode,water valves,camera and light cable,and a foot pedal with a cutting and coagulation current was used.The TURBEST included three consecutive TURBT modules.In this trial,49 doctors participated (11 novices,21 intermediates,and 17 experienced) divided by their experience in transurethral surgeries.The researchers created a total simulator score([resected pathology]×[inspection of the bladder]/time).The mean scores were 15.9 for the novices,25.6 for the intermediates,and 30.6 for the experts.The pass or fail threshold was the mean score of 22.0.The idea of a standard procedure for the technical evaluation of urologists is excellent and this model could be used and modified suitably for any other aspect of training and evaluation [15].

4.2.Courses and curricula

The Simulation and Technology Enhanced Learning Initiative Project is a centralized,multimodal,and simulation-based training-program [16].It was created to establish a new training way for urologists.The program included technical and non-technical modules.Thirty-three urologists participated and performed a multimodal simulation training program with VR simulators for the technical skills part.The participants also completed modules for crisis management,decision making,communication,and team work for the non-technical skills part.For this project,a bench top model for transurethral procedures was used.In the current publication,there is no information given for the simulator.The participants performed this multimodal simulation training program.As for the face and content validity,90% found this model realistic and useful and the sessions well organized,with 60% participants suggesting that it was a good idea to be able to use the simulators again.As for the construct validity,seniors had a better overall performance.Most of the participants found that VR simulators were close to reality,and many of them would like to have the opportunity to use the simulators again.This study demonstrated that the technical training of urologists is inevitably connected with this kind of technology [16].

The researchers of the following review present a pilot 5-day training course for urology specialty trainees during the 3rd year of their residency [17].This simulator-based boot camp includes technical and non-technical skills training enhanced by a 5-day multi-modal training scheme.In this program,16 junior urologists participated.In order to rotate through the different modules,they were divided into four groups.Each group had four trainees.The aim of the majority of the modules was to enhance the experience of the participants,especially for some technical skills and secondary for non-technical skills.TURB-Mentor™was used for the urologists’ training.The participants completed a questionnaire before the course about their surgical experience and the level of confidence that they have in order to complete a procedure.The post-course evaluation of this program was at 6 weeks and 3 months later.The simulators’ score was 4.8 out of 5,which was the highest,although all the sections of the course received a feedback score higher than 4.5 out of 5.The level of confidence of the participants was 3 out of 5 before the course and 4 out of 5 after the course.It remained at the level of 5 for most of them after 6 weeks and 3 months.It is important for a urologist to feel safe and capable of performing the basic procedures,especially at the beginning of the specialty and it can be achieved by this kind of course.In that way,the novices not only acquire the basic knowledge and surgical skills,but also have the same standard level of education with other colleagues from different centers.Additionally,this model can be used for evaluating the doctors for technical and non-technical skills at every stage of their training in order to ensure the existence of a satisfactory level for every stage,creating a high standard of education for everyone [17].

After 1 year,the course participants’ number increased to 33.The modules were similar and the way of rotating through them was once again by teams.There was an evaluation of technical and non-technical skills before and after the course.The results showed that there was significant improvement of the endourological skills (16.7% before and 62.0% after the course).It seems that this type of course has a positive effect at the learning curve of the endourological procedures and providing a safe environment for the improvement of surgical skills and knowledge [22].

After 2 years,the participants in the same course increased to 48.The main body of the course remained the same (eight modules with slightly different activities).There was also a pre-and post-course questionnaire.The feedback assessments of the course were immediately after the course and after 3 months.The mean level of confidence of the participants for a TURBT procedure was 3 out of 5 before the course and 4 out of 5 immediately after the “Boot Camp” and 3 months later.The annual character and the growing number of participants can modify and improve the content of the course.A training or valuating program like this could be considered by other countries for resident training [23].

5.Conclusion

The aim of this review was to present and evaluate the existing training schemes and to our knowledge,this is the first one to investigate this topic.The choice of the best simulator or phantom or training programme is not considered to be the objective of this research.In addition,validation criteria tend to be subjective,especially regarding face and content validity of the simulators.It seems that simulators and technology-assisted techniques could assist urologists familiarize with endourology procedures and reduce learning curves,limiting the procedural time and the possible surgical complications.In that way,when used as a part of a course,they could upgrade the level of surgical education.In addition,the use of training simulators as a part of training curricula could create a new standard of quality for the education and clinical practice of young urologists.

Author contributions

Study concept and design: Panagiotis Kalidonis,Theodoros Tokas.

Data acquisition: Gernot Ortner,Vagionis Athanasios,Angelis Peteinaris.

Data analysis: Athanasios Vagionis,Gernot Ortner.

Drafting of manuscript: Angelis Peteinaris,Kastantinos Pagonis,Costantinos Adamou.

Critical revision of the manuscript: Theodoros Tokoas,Evangelos Liatsikos,Bhaskar Somani.

Conflicts of interest

The authors declare no conflict of interest.