URO MENTOR CLINICAL VALIDATIONS

Assessment of percutaneous renal access skills during Urology Objective Structured Clinical Examinations (OSCE).

Noureldin YA1, Elkoushy MA2, Andonian S3.

1Department of Surgery, Division of Urology, McGill University Health Center, Montreal QC; ; 2 Department of Urology, Benha University Hospital, Benha University, Benha, Egypt;\

Can Urol Assoc J. 2015 Mar-Apr;9(3-4):E104-8. doi: 10.5489/cuaj.2482.

INTRODUCTION: The first objective was to assess percutaneous renal access (PCA) skills of urology postgraduate trainees (PGTs) during the Objective Structured Clinical Examinations (OSCEs). The second objective was to determine whether previous experience with percutaneous nephrolithotomy (PCNL) improved performance.

METHODS: After obtaining ethics approval, we recruited PGTs from two urology programs in Quebec between postgraduate years (PGY-3 to PGY-5). Each trainee was asked to answer a short questionnaire regarding previous experience in endourologic procedures. After a 3-minute orientation on the PERC Mentor simulator (Simbionix, Cleveland, OH), each trainee was asked to perform task 4, where they had to correctly access all of the renal calyces and pop the balloons in a normal left kidney model. We collected and analyzed data from the questionnaire and the performance report generated by the simulator.

RESULTS: In total, 13 PGTs participated in this study. PGTs had performed a median of 200 (range: 50-1000) cystoscopies, 50 (range: 10-125) TURBTs, 30 (range: 0-100) TURPs, 5 (range: 0-50) laser prostatectomies, and 50 (range: 2-125) ureteroscopies prior to this OSCE. PGTs with previous PCNL experience (8/13) had performed a mean of 18.6 ± 6.3 PCNLs. PGTs with previous PCNL experience performed significantly better in terms of shorter fluoroscopy time (10 ± 1.5 vs. 5.1 ± 0.7 min; p = 0.04), fewer attempts required for successful puncture of the pelvi-calyceal system (PCS) (21 ± 2.3 vs. 13 ± 1.8; p = 0.02), and had significantly lower complications in terms of fewer infundibular injury (7.4 ± 1.5 vs. 2 ± 0.4; p = 0.004) and fewer PCS perforations (11 ± 1.7 vs. 4.5 ± 1.2; p = 0.01).

CONCLUSION: It is feasible to use the PERC Mentor simulator during OSCEs to assess PCA skills of urology PGTs. PGTs who had previous PCNL experience performed significantly better with fewer complications.


Simulation-based ureteroscopy training: a systematic review.

Brunckhorst O1, Aydin A1, Abboudi H1, Sahai A1, Khan MS1, Dasgupta P1, Ahmed K2.

1MRC Centre for Transplantation, King’s College London, King’s Health Partners, London, United Kingdom; Department of Urology, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners, London, United Kingdom.

2MRC Centre for Transplantation, King’s College London, King’s Health Partners, London, United Kingdom; Department of Urology, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners, London, United Kingdom. Electronic address: kamran.ahmed@kcl.ac.uk.

J Surg Educ. 2015 Jan-Feb;72(1):135-43.

OBJECTIVE: Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training.

DESIGN: The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases.

RESULTS: In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study.

CONCLUSIONS: Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice.


Training for percutaneous renal access on a virtual reality simulator.

Zhang Y, Yu CF, Liu JS, Wang G, Zhu H, Na YQ.

Wu Jieping Urology Center, Peking University Shougang Hospital, Beijing 100144, China.

Chin Med J (Engl). 2013 Apr;126(8):1528-31.

BACKGROUND: The need to develop new methods of surgical training combined with advances in computing has led to the development of virtual reality surgical simulators. The PERC Mentor(TM) is designed to train the user in percutaneous renal collecting system access puncture. This study aimed to validate the use of this kind of simulator, in percutaneous renal access training.

METHODS: Twenty-one urologists were enrolled as trainees to learn a fluoroscopy-guided percutaneous renal accessing technique. An assigned percutaneous renal access procedure was immediately performed on the PERC Mentor(TM) after watching instruction video and an analog operation. Objective parameters were recorded by the simulator and subjective global rating scale (GRS) score were determined. Simulation training followed and consisted of 2 hours daily training sessions for 2 consecutive days. Twenty-four hours after the training session, trainees were evaluated performing the same procedure. The post-training evaluation was compared to the evaluation of the initial attempt.

RESULTS: During the initial attempt, none of the trainees could complete the appointed procedure due to the lack of experience in fluoroscopy-guided percutaneous renal access. After the short-term training, all trainees were able to independently complete the procedure. Of the 21 trainees, 10 had primitive experience in ultrasound-guided percutaneous nephrolithotomy. Trainees were thus categorized into the group of primitive experience and inexperience. The total operating time and amount of contrast material used were significantly lower in the group of primitive experience versus the inexperience group (P = 0.03 and 0.02, respectively).

CONCLUSIONS: The training on the virtual reality simulator, PERC Mentor(TM), can help trainees with no previous experience of fluoroscopy-guided percutaneous renal access to complete the virtual manipulation of the procedure independently. This virtual reality simulator may become an important training and evaluation tool in teaching fluoroscopy-guided percutaneous renal access.


Endourological simulator performance in female but not male medical students predicts written examination results in basic surgery.

Schlickum M, Felländer-Tsai L, Hedman L, Henningsohn L.

Division of Orthopedics, Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.

Scand J Urol. 2013 Feb;47(1):38-42. doi: 10.3109/00365599.2012.693538. Epub 2012 Jul 2.

OBJECTIVE: The objective of this study was to examine the correlation between endourological simulator performance and demonstrated theoretical knowledge in the basic surgical sciences.

MATERIAL AND METHODS: In total, 158 fourth year medical students participated in the study, 83 females and 75 males, all surgical novices. All students performed the flexible endoscopic task Hall of Fame in the urological simulator URO Mentor™. Later during the same semester all students took the final theoretical examination in surgery.

RESULTS: In female medical students a significant correlation was found between surgical simulator performance and the examination results (r = -0.22, p = 0.04). There was no statistically significant correlation when looking at the total study population (r = -0.04, p = 0.58) or when looking at male medical students (r = 0.01, p = 0.9).

CONCLUSION: Female medical students completing an endourological simulator task more efficiently passed the theoretical examination in the basic surgical sciences with significantly higher scores than females with low efficiency in the urological simulator. There are likely to be several explanations for this correlation, such as motivation and a lower amount of current video gaming experience.


Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity.

Shamim Khan M, Ahmed K, Gavazzi A, Gohil R, Thomas L, Poulsen J, Ahmed M, Jaye P, Dasgupta P.

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital Simulation and Interactive Learning (SaIL) Centre, Guy’s & St Thomas NHS Foundation Trust Department of Urology, Aalborg Denmark and King’s College Hospital, London, UK.

BJU Int. 2012 Aug 29.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and what does the study add? A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programs that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants – South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres).

Objectives: To establish the feasibility and acceptability of a centralized, simulation-based training-program. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills.

Materials and Methods: For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Simbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales.

Results: In total 33, three specialist registrars of different grades and five urological nurses participated in the present study.  Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized.  A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills.

Conclusions: A centralized simulation program that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.


Use of a virtual reality simulator to improve percutaneous renal access skills: a prospective study in urology trainees.

Papatsoris AG, Shaikh T, Patel D, Bourdoumis A, Bach C, Buchholz N, Masood J, Junaid I.

Endourology and Stone Services and The Urology Simulation Centre, Department of Urology, Bart’s and The London NHS Trust, London, UK.

Urol Int. 2012;89(2):185-90. doi: 10.1159/000337530. Epub 2012 Jul 6.

OBJECTIVES: This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees.

METHODS: A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees’ performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training.

RESULTS: Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training.

CONCLUSIONS: We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.


The following abstract was presented at the 27th Annual Congress of the European Association of Urology, February 24-28, 2012, Paris, France

Acceleration of competency in renal access skills by using Virtual Reality Perc-Mentor Trainer

Zaman, F., Bach, C., Kumar, P., Kachralis, S., Buchholz, N., Masood, J., Junaid, I.

Barts and the London NHS Trust, Dept. of Urology, London, United Kingdom

Introduction & Objectives: Education and Training in surgery enter into a new era. The traditional model of see one, do one and teach one is no longer an optimal approach to gain surgical skills. Especially in endourology video-endoscopy has changed everything, surgeons don’t operate on patients, they operate on their images. Minimally Invasive Surgery (MIS) requires a new specific set of technical skills. However, training in MIS in the UK has been inadequate because of a shortage of designated training centre with appropriate facilities and recognized expert trainers. Currently, trainees are expected to learn in a shortened period of time. Training on patients has increasingly been challenged by high profile medico-legal cases underlining clinical governance issues. The European Working Time Directive and financial pressure on the NHS further put pressure on surgical training.

In this study we assessed the improvement of renal access performance of trainees by using a structured assessment tool on Virtual Reality (VR) Perc-Mentor.

Material & Methods: 14 Specialist Registrars without previous renal access experience were. The set-task involved puncturing lower pole renal calyx and passing wire into the ureter. Following initial attempt and assessment, participants were given 120 minutes supervised training over two sessions and asked to repeat the task. Assessment criteria were – time taken for procedure, number of puncture, fluoroscopy time, organ injury and safe completion of the procedure.

Results Training on PERC-Mentor demonstrated significant reduction of time to perform the procedure (p<0.0001). Mean initial time was 18.2 minutes whereas post-training time was 6.3 minutes, a 65% reduction in the procedure time. Puncture attempts, errors and organ injury were also reduced.

Conclusions: Our study demonstrates that training on VR Perc-Mentor enhances percutaneous renal access skills. This trainer may become an integral part of endourology training , revalidation and certification in the future.


Effect of distraction on the performance of endourological tasks: a randomized controlled trial.

Persoon MCvan Putten KMuijtjens AMWitjes JAHendrikx AJScherpbier AJ. Urology Department, Catharina Hospital, Eindhoven.

BJU Int. 2010 Sep 3.

Study Type – Therapy (case series) Level of Evidence

Objective: To establish the effect of distraction on the performance of cystoscopy and basic endourological tasks by using a virtual reality (VR) simulator.

Subjects and Methods: A total of 86 third-year medical students from Maastricht University, who had no previous experience in performing the tasks on a VR simulator, were randomly assigned to an intervention or control group.  All participants performed three endourological tasks on the VR simulator. Participants in the intervention group were distracted 1 min into the third task. The distraction consisted of being asked to answer questions about a medical case that had been presented to all the participants before the hands-on session. After two adequate verbal responses the conversation was terminated.  Number of traumata, number of missed lesions in the bladder and time to completion were measured by the VR simulator.

Results: Number of traumata and missed lesions, as well as time to completion were significantly higher in the intervention than in the control group with effect sizes (using Cohen’s categorization) of 0.48, 0.41 and 0.50 respectively.  Nevertheless, only 9.5% of the participants in the intervention group reported feeling burdened by the distraction.

Conclusions: Distraction during the performance of endourological skills results in significantly poorer performance by medical students on all the variables measured in a controlled learning environment.  Most students do not realize they are affected by distraction.  Further research is needed to determine the impact of distraction on more experienced participants and on patient safety.


Acquisition of flexible cystoscopy skills on a virtual reality simulator by experts and novices.

Schout BM, Muijtjens AM, Hendrikx AJ, Ananias HJ, Dolmans VE, Scherpbier AJ, Bemelmans BL.

VU University Medical Centre, Amsterdam, the Netherlands.

BJU Int. 2010 Jan;105(2):234-9. Epub 2009 Jul 6.

Objective: To assess the construct validity of the URO Mentor (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices’ performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor? METHODS: Thirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were ‘test tasks’ to evaluate participants’ performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts’ and novices’ performances, with P < 0.05 considered to indicate statistical significance. Effect sizes (ES) were calculated to quantify the practical significance of the results; ES of 0.10, 0.30, and 0.50 were considered small, medium and large, respectively. RESULTS: Novices’ performances showed a significant improvement with large ES in time (linear trend of learning curve P < 0.001, ES 0.66) and mean GRS score (linear trend P < 0.001, ES 0.84, quadratic trend P = 0.018, ES 0.24). There was a medium improvement for trauma (linear trend P < 0.001, ES 0.40) and a small improvement in areas inspected (linear trend P = 0.032, ES 0.21). That the 95% confidence intervals of the measures on the first task of experts and novices did not coincide indicates that differentiation between experts and novices on the four variables measured can be achieved using the URO Mentor. CONCLUSIONS: Training on the URO Mentor appears to result in a medium to large improvement of novices’ performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.


Percutaneous renal access training: content validation comparison between a live porcine and a virtual reality (VR) simulation model.

Mishra S, Kurien A, Ganpule A, Muthu V, Sabnis R, Desai M.

Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.

BJU Int. 2010 Dec;106(11):1753-6.

Objective: To compare the content validity (realism and usefulness) of percutaneous renal access (PRA) obtained on a live porcine model and a high-fidelity computer-based surgical simulator (PERC Mentor, Simbionix; Lod, Israel) in our skills laboratory for trainees interested in PRA training, so as to determine which of the two is a more appropriate and effective training model.

Materials and Methods:  In all, 24 ‘experts’ performed PRA in a live porcine model and using the PERC Mentor. • The porcine model access required a live anaesthetized pig with a pre-placed ureteric catheter. The access was done with flouroscopic guidance using a 22-G ‘skinny’ needle (Cook Medical, Bloomington, IN, USA).  Then the specific task of PRA using a similar case scenario was done using the PERC Mentor.  The experts rated the models using a questionnaire based on a 5-point Likert scale, consisting of 10- and three-items of realism and usefulness, respectively.

Results: Of the 10 items of realism assessed, the porcine model was rated as better than the PERC Mentor for ‘overall realism’, ‘movement of the kidney’, ‘tactile feedback of perinephric space’, ‘fluoroscopic realism’ and ‘complications encountered’ (All P < 0.001).  It was inferior to the PERC Mentor for ‘orientation to the flank’, ‘aspiration’, ‘repetitive performance’ and ‘organisational feasibility’ (All P < 0.001).  ’Tactile feedback of successful access’ was similar in both models (mean [sd] points, 4.24 [0.7] vs 4.6 [0.5]). • Of the three items of usefulness, ‘overall usefulness’ (4.6 [0.6] vs 4.65 [0.5]) and ‘use as a training tool’ (4.32 [0.5] vs 4.75 [0.4]) was similar; however, the porcine model was a much better assessment tool (P < 0.001).

Conclusions: Both models have relative advantages and disadvantages. The live porcine model is a more realistic assessment tool for PRA. The specific advantage of the PERC Mentor is of repetitive tasking and easier set up feasibility.  The overall usefulness was same for both the models.


The effect of a low-fidelity model on cystoscopic skill training: a single-blinded randomized controlled trial.

Persoon MC, Schout BM, Muijtjens AM, Hendrikx AJ, Witjes JA, Scherpbier AJ.

Urology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.

Simul Healthc. 2010 Aug;5(4):213-8.

Introduction: Models for training urological procedures without burdening patients are available at varying costs. We examined the value of training on a low-fidelity model in addition to training on a high-fidelity simulator in a cystoscopy training program.

Methods: Thirty-two medical students were randomized to an intervention and a control group. The former started by performing cystoscopy on a low-cost, low-fidelity, glass globe model before moving on to training on the URO Mentor (UM), a computerized simulator. The control group took part in the same UM training program but not in the low-fidelity training. Performance on UM was assessed by a global rating score, percentage of correctly inspected areas of the bladder (% inspected areas), time, and number of traumas caused.

Results: The intervention group had generally higher scores. Its global rating score on task 1 was significantly higher than that of the control group (Mann-Whitney U test, P = 0.046, effect size 0.6) and the group also scored higher, albeit not significantly, on time and % inspected areas. All students said they valued training with UM, but the appreciation of the intervention group was stronger (mean 8.9 vs. 8.1 on a scale from 1 to 10, P = 0.017, effect size 1.8).

Conclution: A low-fidelity glass globe model seemed to be an inexpensive educational tool to practice the first steps of cystoscopy. It may reduce training time on the UM simulator. The combined use of a low- and high-fidelity training model may provide an optimal learning effect.


Validation of virtual reality simulation for percutaneous renal access training.

Mishra S, Kurien A, Patel R, Patil P, Ganpule A, Muthu V, Sabnis RB, Desai M.

Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.

J Endourol. 2010 Apr;24(4):635-40.

Objective: The objective of this study was to assess the face, content, construct, convergent, and predictive validities of virtual reality-based simulator in acquisition of skills for percutaneous renal access.

Materials and Methods:  A cohort of 24 participants comprising novices (n = 15) and experts (n = 9) performed a specific task of percutaneous renal puncture using the same case scenario on PERC Mentor. All objective parameters were stored and analyzed to establish construct validity. Face and content validities were assessed by having all experts fill a standardized questionnaire. All novices underwent further repetition of the same task six times. The first three were unsupervised (pretest) and the later three after the PERC Mentor training (posttest) to establish convergent validity. A subset of five novice cohorts performed percutaneous renal access in an anesthetized pig before and after the training on PERC Mentor to assess the predictive validity. Statistical analysis was done using Student’s t-test (p <or= 0.05=”” statistically=”” significant).<=”” p=””>

Results The overall useful appraisal was 4 in a scale of 1 to 5 (1 is poor and 5 is excellent). Experts were significantly faster in total performance time 187 +/- 26 versus 222 +/- 29.6 seconds (p < 0.005) and required fewer attempts to access 2.00 +/- 0.20 versus 2.8 +/- 0.4 (p < 0.001), respectively. The posttest values for the trained novice group showed marked improvement with respect to pretest values in total performance time 42.7 +/- 6.8 versus 222 +/- 29.6 seconds (p < 0.001), fluoroscopy time 66.9 +/- 10.20 versus 123.3 +/- 19.40 seconds (p < 0.0001), decreasing number of perforation 0.8 +/- 0.3 versus 1.3 +/- 0.2 (p < 0.001), and number of attempts to access 1.3 +/- 0.10 versus 2.00 +/- 0.20 (p < 0.001), respectively. Access without complication was attained by all five when compared with one with three complications (baseline vs. post training group, respectively) in the porcine model.

Conclusion: All aspects of validity were demonstrated on virtual reality-based simulator for percutaneous renal access.


Transfer of cysto-urethroscopy skills from a virtual-reality simulator to the operating room: a randomized controlled trial.

Schout BM, Ananias HJ, Bemelmans BL, d’Ancona FC, Muijtjens AM, Dolmans VE, Scherpbier AJ, Hendrikx AJ.

Catharina Hospital Eindhoven, Eindhoven, the Netherlands.

BJU Int. 2009 Nov 12.

Objectives: To assess whether real-time cysto-urethroscopy (CUS) performance improves by simulator-based training (criterion or predictive validity), addressing the research question ‘Does practical skills training on the URO Mentor (UM, Simbionix USA Corp., Cleveland, OH, USA) virtual-reality simulator improve the performance of flexible CUS in patients’. SUBJECTS AND

Methods: Participants (71 interns from Catharina Hospital Eindhoven, CHE, and 29 from University Medical Centre Groningen, UMCG) were randomized to carry out CUS in a patient after training on the UM (UM-trained, 50) or without training on UM (control, 50). The assessment of real-time performance consisted of scoring on a Global Rating Scale (GRS) by supervisors unaware of training status. Data were analysed using stepwise multiple linear regression. The effect size (ES) indication for correlations was used to interpret the magnitude of a standard regression coefficient (beta); an ES of 0.10, 0.30 and 0.50 were considered small, moderate and large, respectively. The study was approved by the Medical Review Ethics Committees of the participating hospitals. RESULTS Overall, the group that received training performed significantly better than the controls (P Conclusions: The results showed that interns who had trained on UM outperformed controls for a CUS procedure in a patient. Training for CUS on the UM is to be recommended for learning to respect tissue, procedural knowledge, flow of procedure and forward planning. Use of the UM to train interns with a specific interest in a surgical speciality in handling instruments, and time and motion, seems to be of limited value.


The virtual reality endourologic simulator is realistic and useful for educational purposes.

Dolmans VE, Schout BM, de Beer NA, Bemelmans BL, Scherpbier AJ, Hendrikx AJ. Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
J Endourol. 2009 Jul;23(7):1175-81.

Purpose: To examine the educational value of URO Mentor, a virtual reality simulator for endourologic procedures, by establishing its face and content validity.

Materials and Methods: Eighty-nine urologists and residents in urology performed a urethrocystoscopy task (bladder inspection, biopsy, and coagulation) or a ureterorenoscopy task (manipulation of a distal ureter stone) using the URO Mentor. They completed an evaluation questionnaire about these tasks. Questionnaire bias related to task performance on URO Mentor was analyzed as well (Hawthorne effect).

Results: The overall rating of the URO Mentor was 7.3 on a 10-point scale (1 = poor, 10 = excellent). Regression analysis showed that ratings were not related to previous experience or task performance using the URO Mentor. Of all subjects, 25% rated the realism of URO Mentor as >or=3.5 on a five-point scale, and 82% rated its usefulness as an educational tool as >or=3.5 on a five-point scale. More than 73% of all participants said they would purchase a URO Mentor if financial means were available; participants who needed more time to complete the task were less positive in their answers to this question.
Conclusions: URO Mentor appears to be a realistic and useful training model for endourologic procedures.


The following abstract was published and presented as part of the poster session at the European Association for Endoscopic Surgery (EAES) Meeting, September 13 – 16, 2006 in Berlin, Germany.

The Virtual Reality Simulator the URO Mentor is a Realistic and Valid Training Model: Determination of Face Validity

Dolmans VEMG, Schout Barbara , De Beer NAM, Hendrikx AJM
Catharina Hospital Eindhoven, Eindhoven, The Netherlands

Introduction. At the moment more and more training models become available for training in urology. In order to know whether such models improve learning curves of residents and contribute to the educational program, these models need to be validated. We are performing a validation study on the URO Mentor, a virtual reality simulator which simulates endourologic procedures. Face validity is one aspect of the validation process. It addresses the question: “To what degree does the URO Mentor resemble reality as judged by a specific (target) population?”.

Aim: To determine face validity of the URO Mentor virtual reality simulator in order to investigate realism and usefulness of this educational tool. Methods. We questioned 70 urologists and residents after they performed a urethrocystoscopic task (bladder inspection, biopsy and coagulation) or a ureterorenoscopic task (stone manipulation of a distal ureter stone). We also investigated possible questionnaire bias related to performance on the URO Mentor.

Results: The overall appraisal was 7.2 in a scale of 1 to 10 (1 is poor, 10 is good). A regression analysis showed that this judgment is independent of age, experience or task performance (p>0.05). Of all interviewees, 86% considered working with the URO Mentor as realistic. Usefulness was judged from average to very useful by 89% of the urologists and residents. On average, over 73% would consider purchasing a URO Mentor if financial means were available, but subjects who caused more traumata during the task were less likely to answer positively to this question.

Conclusion: According to our study, the URO Mentor is a realistic and useful training model for educational purposes.


Acquisition of flexible cystoscopy skills on a virtual reality simulator by experts and novices.

Schout BM, Muijtjens AM, Hendrikx AJ, Ananias HJ, Dolmans VE, Scherpbier AJ, Bemelmans BL.
VU University Medical Centre, Amsterdam, the Netherlands.
BJU Int. 2009 Jul 6

Objectives: To assess the construct validity of the URO Mentor(TM) (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices’ performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor

Methods: Thirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were ‘test tasks’ to evaluate participants’ performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts’ and novices’ performances, with P < 0.05 considered to indicate statistical significance. Effect sizes (ES) were calculated to quantify the practical significance of the results; ES of 0.10, 0.30, and 0.50 were considered small, medium and large, respectively.

Results: Novices’ performances showed a significant improvement with large ES in time (linear trend of learning curve P < 0.001, ES 0.66) and mean GRS score (linear trend P < 0.001, ES 0.84, quadratic trend P = 0.018, ES 0.24). There was a medium improvement for trauma (linear trend P < 0.001, ES 0.40) and a small improvement in areas inspected (linear trend P = 0.032, ES 0.21). That the 95% confidence intervals of the measures on the first task of experts and novices did not coincide indicates that differentiation between experts and novices on the four variables measured can be achieved using the URO Mentor.

Conclusions: Training on the URO Mentor appears to result in a medium to large improvement of novices’ performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.


Development of a standardized curriculum for teaching cystoscopic skills using a computer-based endourologic simulator

Gettman MT, Le CQ, Rangel LJ, Slezak JM, Bergstralh EJ, Krambeck AE.
Department of Urology, Division of Biostatistics, Mayo Medical School and Mayo Clinic, Rochester, MN 55906, USA.
Simul Healthc. 2009 Summer;4(2):92-7.

Introduction: Educational opportunities with simulation are now available to teach endoscopic skills outside the clinical setting. The goal of this study is to assess the learning curve and subjective impressions of cystoscopic tasks performed by untrained subjects on a computer-based simulator using a standardized curriculum.

Methods: We evaluated ten novice subjects on a computer-based cystoscopic simulator (URO Mentor, Simbionix, Lod, Israel) during a standardized cystoscopy skills course developed for the study. All trainees performed three basic cystoscopic tasks as part of the curriculum. Subjects were evaluated until a steady state of performance was observed. Subjectively, participants assessed their performance and opinions regarding the computer-based simulator.

Results: Among the ten novice subjects (five men, five women), a median of six training sessions were required to achieve a steady state of performance. Significant performance improvements were noted with additional simulator time (P<0.001), however, the rate of improvement declined with time. Regression analysis of completion times revealed significant gender effects for one cystoscopic task. At study end, gender performance differences for any task were not significant. Uniformly, novices felt that URO Mentor was easy to use and provided an overall realistic training experience.

Conclusions: In this study a computer-based simulator was successfully incorporated into a training curriculum for cystoscopy education. For simulated tasks performed with rigid and flexible cystoscopes, a median of six training sessions was necessary. Objectively, performance on the testing scenarios significantly increased with experience. Subjectively based on nonvalidated criteria, comfort level, and perceived competency increased significantly from the pre- to postcourse evaluations.


Analysis of a computer based simulator as an educational tool for cystoscopy: subjective and objective results

Gettman MT, Le CQ, Rangel LJ, Slezak JM, Bergstralh EJ, Krambeck AE.
Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota 55906, USA.
J Urol. 2008 Jan;179(1):267-71.

Purpose:Resident education in cystoscopy has traditionally relied on clinical instruction. However, simulators are now available outside the clinical setting. We evaluated a simulator for flexible and rigid cystoscopy

Materials and Methods: We evaluated 30 novice and 27 expert cystoscopists on a computer based cystoscopic simulator (UroMentor, Simbionix, Lod, Israel). All subjects performed 5 trials of 3 basic cystoscopic tasks. The objective measurement was procedure time, and subjective measures were assessment of the simulator and individual tasks by the cystoscopist. Repeated measures analyses were performed using mixed effects regression models.

Results: There was a significant difference in median age between novice and expert cystoscopists at 46 (range 25 to 63) and 35 (range 28 to 68) years old, respectively (p = 0.014). Experts completed simulations significantly faster than novices in all trials. For the first trial median times (novice vs expert) were 300 vs 68 seconds (p <0.001) for guide wire placement, 650 vs 179 seconds (p <0.001) for bladder examination and 119 vs 71 seconds (p <0.001) for bladder lesion fulguration. At the fifth trial median times (novice vs expert) were 57 vs 31 seconds (p = 0.001) for guide wire placement, 164 vs 67 seconds (p <0.001) for bladder examination and 55 vs 40 seconds (p = 0.007) for bladder lesion fulguration. Subjective task evaluations were lower in novice subjects but improved after training. Subjective simulator evaluations were more favorable in novice subjects.

Conclusions: Objectively, expert and novice performance of cystoscopic tasks can be distinguished with the UroMentor. Subjective assessments suggest ongoing refinement of the simulator as a learning tool for cystoscopic skills training.


Analysis of a Computer Based Simulator as an Educational Tool for Cystoscopy: Subjective and Objective Results.

Gettman MT, Le CQ, Rangel LJ, Slezak JM, Bergstralh EJ, Krambeck AE.
Departments of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota.
J Urol. 2007 Nov 12

Purpose: Resident education in cystoscopy has traditionally relied on clinical instruction. However, simulators are now available outside the clinical setting. We evaluated a simulator for flexible and rigid cystoscopy.
Materials and Methods: We evaluated 30 novice and 27 expert cystoscopists on a computer based cystoscopic simulator (UroMentor, Simbionix, Lod, Israel). All subjects performed 5 trials of 3 basic cystoscopic tasks. The objective measurement was procedure time, and subjective measures were assessment of the simulator and individual tasks by the cystoscopist. Repeated measures analyses were performed using mixed effects regression models.

Results: There was a significant difference in median age between novice and expert cystoscopists at 46 (range 25 to 63) and 35 (range 28 to 68) years old, respectively (p = 0.014). Experts completed simulations significantly faster than novices in all trials. For the first trial median times (novice vs expert) were 300 vs 68 seconds (p <0.001) for guide wire placement, 650 vs 179 seconds (p <0.001) for bladder examination and 119 vs 71 seconds (p <0.001) for bladder lesion fulguration. At the fifth trial median times (novice vs expert) were 57 vs 31 seconds (p = 0.001) for guide wire placement, 164 vs 67 seconds (p <0.001) for bladder examination and 55 vs 40 seconds (p = 0.007) for bladder lesion fulguration. Subjective task evaluations were lower in novice subjects but improved after training. Subjective simulator evaluations were more favorable in novice subjects.

Conclusions: Objectively, expert and novice performance of cystoscopic tasks can be distinguished with the UroMentor. Subjective assessments suggest ongoing refinement of the simulator as a learning tool for cystoscopic skills training.

Percutaneous Renal Access Simulators

Stern J, Zeltser IS, Pearle MS.
Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.
J Endourol. 2007 Mar;21(3):270-3.

Percutaneous renal access is an integral step in percutaneous renal drainage and percutaneous nephrolithotomy. Urologists are increasingly obtaining access themselves, as this eliminates reliance on a second “surgeon” and increases flexibility with respect to procedure timing and the location of the access tract. Surprisingly few models have been developed to train urologists in percutaneous renal access. Harvested porcine kidney/ureter units mounted so they can be viewed radiographically and accessed by needle puncture through material simulating the human flank have been incorporated into two models. The PERC Mentor (Simbionix; Lod, Israel) is a virtual-reality simulator developed specifically for training in percutaneous renal puncture. Hands-on intraoperative training continues to be the primary method for learning percutaneous renal access. However, bench model and simulator-based education offer a useful adjunct.


The Virtual Reality Simulator the URO Mentor is a Realistic and Valid Training Model: Fetermination of Face Validity

Chout, B M.A.; Dolmans, V E.M.G.; De Beer, N A.M.; Hendrikx, A J.M.

Catharina Hospital Eindhoven, Eindhoven, The Netherlands

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
Fall 2006 – Volume 1 – Issue 3 – p 192

Introduction: At the moment more and more training models become available for training in urology. In order to know whether such models improve learning curves of residents and contribute to the educational program, these models need to be validated. We are performing a validation study on the URO Mentor, a virtual reality simulator which simulates endourologic procedures. Face validity is one aspect of the validation process. It addresses the question: “To what degree does the URO Mentor resemble reality as judged by a specific (target) population?”.

Aim: To determine face validity of the URO Mentor virtual reality simulator in order to investigate realism and usefulness of this educational tool. Methods. We questioned 70 urologists and residents after they performed a urethrocystoscopic task (bladder inspection, biopsy and coagulation) or a ureterorenoscopic task (stone manipulation of a distal ureter stone). We also investigated possible questionnaire bias related to performance on the URO Mentor.

Results: The overall appraisal was 7.2 in a scale of 1 to 10 (1 is poor, 10 is good). A regression analysis showed that this judgment is independent of age, experience or task performance (p>0.05). Of all interviewees, 86% considered working with the URO Mentor as realistic. Usefulness was judged from average to very useful by 89% of the urologists and residents. On average, over 73% would consider purchasing a URO Mentor if financial means were available, but subjects who caused more traumata during the task were less likely to answer positively to this question.
Conclusion: According to our study, the URO Mentor is a realistic and useful training model for educational purposes.


The following abstract was published and presented as part of the poster session at the European Association for Endoscopic Surgery (EAES) Meeting, September 13 – 16, 2006 in Berlin, Germany. The poster won a price for best poster presentation in the education category.

Determination of Construct Validity of the URO Mentor, a Virtual Reality Simulator for Endourological Procedures

Schout, BMA, Dolmans Valerie, De Beer NAM, Hendrikx AJM
Catharina Hospital Eindhoven, Eindhoven, The Netherlands

Results: Experts are significantly faster (Wilcoxon, p<0.0005) and cause less traumata (p=0.015) during the first task when compared to novices. Data show a decrease in total performance time over runs, which is significant for all tasks compared with the first one (p=0.0010). The number of traumata is significantly smaller during the fourth and fifth tasks, compared to the first task (p=0.023).

Methods: Ten interns (novices) and 21 urologists (experts) performed a cystoscopy task with biopsy taking and coagulation of the biopsy site on the URO Mentor. Novices performed this task 5 times, experts once. Afterwards they filled in a questionnaire.

Conclusion: This pilot study shows the URO Mentor can distinguish between novices and experts and proves there is a significant improvement in total time and number of traumata after training, thus demonstrating construct validity. Further study is needed to distinguish between true task learning and the effect of learning how to use the URO Mentor.
Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills.

Matsumoto ED, Pace KT, D’A Honey RJ.
Division of Urology, McMaster University, Hamilton, Ontario, Canada.
Int J Urol. 2006 Jul;13(7):896-901.

Aim: Virtual reality (VR) simulators are now commercially available for various surgical skills training. The Uro Mentor VR Ureteroscopy Simulator by Symbionix is one system that may revolutionize the way we assess and teach surgical residents. Surgical educators may no longer have to depend on the operating room as the sole venue for teaching residents technical skills. We validated performance on this new system with previously developed assessment tools and compared it to performance on a high fidelity ureteroscopy bench model.

Methods: Urology residents (n = 16) were assessed on their ability to perform cystoscopy, guidewire insertion, semirigid ureteroscopy and basket extraction of a distal ureteric stone on the VR simulator. A blinded examiner assessed subject performance using a checklist, global rating scale and a pass/fail rating. In addition, computer-generated parameters including time to complete task, scope and instrument trauma and the number of attempts to insert a guidewire were analysed. Performance on the VR simulator was compared to performance on a high fidelity ureteroscopy bench model.

Results: Senior residents (n =  scored significantly higher on their global rating scale (29.4 +/- 2.5 vs 20.8 +/- 0.9, P = 0.005), checklist (19.1 +/- 1.1 vs 15.2 +/- 0.9, P = 0.02), pass/fail rating (chi(2) = 7.3, P = 0.007) and required less time to complete the task (352.9 +/- 55.7 s vs 576.8 +/- 67.4 s., P = 0.02) than the junior residents (n =  on the VR simulator. Junior residents also had a significantly higher incidence of scope trauma (4 vs 0.6, P = 0.02). No significant differences were noted in instrument trauma and the number of attempts to insert the guidewire. Global rating scale performance on the VR simulator correlated well to performance on the high fidelity ureteroscopy bench model (r = 0.7, P = 0.002) as did time to complete task (r = 0.7, P = 0.004).

Conclusions: The Uro Mentor VR Ureteroscopy Simulator is a useful tool in assessing resident endourological skills. Performance on the VR simulator is comparable to a validated high fidelity ureteroscopy bench model. Future studies will assess the utility of VR simulators in surgical skills.


Validation of Computer-Based Training in Ureterorenoscopy

Knoll T, Trojan L, Haecker A, Alken P, Michel MS.
Department of Urology, University Hospital Mannheim, Germany.
BJU Int. 2005 Jun;95(9):1276-9.

Objectives: To evaluate the outcome of training both urological novices and experts, using the recently developed UroMentor (Simbionix Ltd, Israel) trainer, that provides a realistic simulation of rigid and flexible ureterorenoscopy (URS).
Subjects and methods: Twenty experienced urologists (total number of previous flexible URSs 21-153) were monitored during simulated flexible URS for treating a lower calyceal stone, and the outcome was correlated with individual experience. A score was compiled based on the variables recorded, including total operation time, stone contact time, complications such as bleeding or perforation, and treatment success. A further five urological residents with no endourological experience were trained on the UroMentor in rigid URS for ureteric stone treatment. Their acquired clinical skills were subsequently compared to those of five urological residents who received no simulator training.
Results: All 20 experienced urologists disintegrated the stone on the simulator, and the score achieved was related to their personal experience; there was a significant difference in performance in those with < 40 and > 80 previous flexible URSs. For the five urological residents with no endourological experience, simulator training improved their skills, and comparison with urological residents who had received no simulator training showed advantages for the trained residents. After being trained on the simulator, the group performed better in the first four URSs on patients.
Conclusions: Individual experience correlates with individual performance on the simulator. Simulator training was helpful in improving clinical skills. Although the distribution of computer-based simulators is limited by high prices, virtual reality-based training has the potential to become an important tool for clinical education.


Virtual Ureteroscopy Predicts Ureteroscopic Proficiency of Medical Students on a Cadaver

Ogan K, Jacomides L, Shulman MJ, Roehrborn CG, Cadeddu JA, Pearle MS.
Department of Urology, University of Texas Southwestern Medical Center, Dallas, 75390, USA.
J Urol. 2004 Aug;172(2):667-71.

Purpose: Training on a virtual reality (VR) simulator has been shown to improve the performance of VR endoscopic tasks by novice endoscopists. However, to our knowledge the translation of VR skills into clinical endoscopic proficiency has not been demonstrated. We established criterion validity for a VR ureteroscopy simulator by evaluating VR trained subjects in a cadaver model.

Materials and Methods: A total of 32 participants, including 16 medical students and 16 urology residents, were evaluated at baseline on a VR ureteroscopy simulator (Uromentor, Simbionix, Lod, Israel), performing simple diagnostic ureteroscopy. The students then underwent 5 hours of supervised training on the simulator. Two weeks later all participants were reevaluated (VR2) on the simulator when repeating the initial task. Each participant was then assessed on the performance of a similar diagnostic ureteroscopy in a male cadaver.

Results: In medical students VR2 and cadaver performances correlated closely for several measured parameters (total time for task completion and overall global ratings score). In contrast, there was little correlation between the 2 performances in residents. Indeed, performance on the cadaver correlated more closely with the training level than VR2 scores. Despite VR training medical students were unable to perform cadaver ureteroscopy comparably to residents.
Conclusions: For novice endoscopists performance on the simulator after training predicted operative (cadaver) performance and, thus, it may be useful for the education and assessment of physicians in training. However, VR training is unable to override the impact of clinical training, although it may help shorten the learning curve early in training.


Use of a Virtual Reality Simulator for Ueteroscopy Training

Jacomides L, Ogan K, Cadeddu JA, Pearle MS.
Department of Urology, The University of Texas Southwestern Medical Center , Dallas, 75390, USA .
J Urol. 2004 Jan;171(1):320-3; discussion 323.

Purpose: Virtual reality surgical simulators may shorten operative time and reduce the potential for iatrogenic injury by providing training outside the operating room. We hypothesized that training on a virtual ureteroscopy (VU) simulator would allow novice endoscopists to overcome the initial learning curve before entering the operating room.
Materials and Methods: We evaluated 16 medical students on their ability to perform specific ureteroscopic tasks on a VU simulator. The students trained on the simulator for a total of 5 hours over multiple sessions using different training modules and then were retested on the initial module. Likewise, 16 urology residents with varying degrees of endoscopic experience were assessed on the same test module twice, without additional simulator training.
Results: The students improved task completion time from 17.4 to 8.7 minutes (p <0.05), while the residents performed the task in 7.6 minutes at baseline and 6.7 minutes at the second trial. Stratification of residents by years of urology training revealed that the mean completion time for the students after training did not differ statistically from that of first year residents who had performed a median of 14 clinical ureteroscopies. Furthermore, the subjective performance scores of the students were comparable to those of the first year residents.
Conclusions: Novice medical students trained on a VU simulator improved task completion time by 50% after training, and performed comparably to residents who had completed nearly 1 year of urology training. VR training may allow beginning urology residents to shorten the initial learning curve associated with ureteroscopy training, although this hypothesis requires further validation.


Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator

Wilhelm DM, Ogan K, Roehrborn CG, Cadeddu JA, Pearle MS.
Department of Urology and The Southwestern Center for Minimally Invasive Surgery, The University of Texas Southwestern Medical Center at Dallas, 75390-9110, USA.
J Urol. 2003 Aug;170(2 Pt 1):692.

Background: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists.
Study design: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest).
Results: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p < 0.001), and evaluator assessment (p < 0.001). Comparing the posttest results of the control and trained arms, we found significantly better posttest scores in the trained group for the following parameters: ability to perform the task (p = 0.035), overall performance (p = 0.004), and total evaluator score (p < or = 0.001).
Conclusions: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.


Validation of a Flexible Cystoscopy Course

Shah J, Montgomery B, Langley S, Darzi A.
Academic Surgical Unit, Imperial College School of Medicine, St. Mary’s Hospital, London, UK.
BJU Int. 2002 Dec;90(9):833-5

Objectives: To examine the instructional effectiveness of a course for nurses wishing to learn flexible cystoscopy, using a virtual reality flexible cystoscopy simulator to measure the outcome.

Subjects and methods: Fourteen urology nurse practitioners with no previous experience of cystoscopy were taught the basic techniques of flexible cystoscopy. They then had supervised group instruction during which they practised flexible cystoscopy on an inanimate latex model, and were taught how to handle the cystoscope, followed by unsupervised practice, including use of the virtual reality (VR) simulator (URO Mentor, Simbionix, Israel). They then undertook a cystoscopy task on the simulator; within the bladder there were 10 flags (numbered 1-10) at key positions. By visualizing and photographing each of the flags the subject would have visualized the entire bladder mucosa. The number of flags seen was thus used as a measure of how much of the bladder mucosa was examined. The VR simulator also measured the total procedure time. After a day of training the subjects were reassessed and the changes in performance evaluated. Subjects were also asked their opinion of the use of VR for flexible cystoscopy.
Results: The median (range) time to complete the procedure before the course was 3.33 (2-5.5) min and the number of flags seen 7 (6-9). After the course, the median time decreased to 2.85 (1.5-4.42) min and the number of flags seen increased to 8 (6-9). The change in time was significant (P = 0.03) but the difference in the number of flags was not (P = 0.12). All 14 subjects enjoyed the use of VR for learning flexible cystoscopy; they all reported that they were more confident in handling a flexible cystoscope and in undertaking flexible cystoscopy.

Conclusions: The virtual reality simulator was an effecctive tool for teaching flexible cystoscopy.


Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator

Wilhelm, D.M., Ogan, K., Roehrborn, C.G., Cadeddu, J.A. and Pearle,M.S.
J.Am.Coll.Surg., 195:675-681, 2002.

The article shows that students trained on a VR simulator, the URO MENTOR™, demonstrated statistically significant improvement on repeat testing while a control group showed no improvement. The authors claim that endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the OR.


 A Randomized, Prospective Blinded Study Validating the Acquisition of Ureteroscopy Skills Using a Computer Based Virtual Reality Endourological Simulator

James D. Watterson, Darren T. Beiko, James K Kuan and John D. Denstedt
The Journal of Urology, November 2002; Vol, 168, 1928-1932.

The article shows that the use of the URO MENTOR™ resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. In addition, correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the uroteroscopy simulator for the assessment of uroteroscopy skills.


The following abstracts on topics involving the URO Mentor™ simulator were published and presented at the 20th World Congress on Endourology and SWL, 18th Basic Research Symposium, September 19-22, 2002 in Genoa, Italy

The articles were presented as part of the poster session and were also selected for presentation in the plenary session of “Highlights of Basic Research Symposium”. The full abstracts are available in the Journal of Endourology Abstracts, volume 16, Supplement1, September 2002:

(P16-27) Laparoscopic & Endourologic Simulators for Training

Steiner, Charles, Inderbir S. Gill, Ran Cohen, Inbal Mazor.

The abstract discusses a study designed to investigate the efficacy of an endourologic simulator and a laparoscopic surgical simulator as part of a formal training course. Residents were divided into 2 groups after being initially scored on basic endourologic and laparoscopic skills in the inanimate trainer and an acute porcine model. One group then underwent 8 hours of training on each of the two simulators and the second group received more classic training involving observation and training on the inanimate trainer. Preliminary results indicate significantly superior technical skill acquisition for the group trained on the simulators.

P3-3 The URO Mentor Virtual Reality (VR) Ureteroscopy Simulator as a Valid Tool for Assessing Endourological Skills

Pace, Kenneth, Edward D. Matsumoto, Solieman Bilgasem, and R. John Honey.

The abstract discusses a study conducted to validate performance on the URO MENTOR with previously developed assessment tools and to compare it to performance on a high fidelity ureteroscopy bench model. Performances of senior and junior residents were scored and compared, leading to the conclusions that simulator performance is comparable to a validated high fidelity ureteroscopy bench model and that the simulator is a useful tool in assessing resident endourological skills.

P3-4 Acquisition of Ureteroscopy Skills Using a Computer-Based Virtual Reality Endourological Simulator: Validation of the URO Mentor Simulator

Watterson, James D., Beiko, Darren T. Kuan, James K. Denstedt, John D.

The abstract discusses a study conducted using the URO MENTOR simulator to evaluate and validate its use in the acquisition of basic ureteroscopic skills. 20 novices were assessed in the study, which demonstrated the utility of a virtual reality ureteroscopy simulator in endourological training. The study concluded that use of the simulator leads to rapid acquisition of ureteroscopic skills in trainees with no prior surgical training and that the simulator is a valid tool for assessment of ureteroscopic skills.

P3-5 Comparison of Residents and Inexperienced Medical Students on an Endoscopic Virtual Reality Simulator

Jacomides, Luicas, Kenneth Ogan, Jeffrey A. Cadeddu, and Margaret S. Pearle.

The study examined first and second year medical students as well as urology residents with varied experience. A portion of the medical students who were given training on the virtual ureteroscopy simulator were found to improve their task completion time by 50% after training, and in fact to better the time of first year residents with some actual ureteroscopy experience.

P3-6 Assessment of Basic Elements of Human Performance Predicts Ureteroscopics Skills in the Virtual Environment

Jeffery A. Cadeddu, David Wilhelm, MD Kenneth Ogan, MD Margaret S.l Pearle, MD George V. Kondraske, Ph.D.

In this study the URO MENTOR simulator was used as a means for measurement of ureteroscopic skills. The study was designed to assess the impact of basic elements of human performance (BEP) on endoscopic performance. Measurements of BEP were compared to ureteroscopy and laser lithotripsy in the URO MENTOR, and were found predictive of VR ureteroscopic performance.


The following abstracts on topics involving the URO Mentor™ simulator were published and presented at the AUA exhibition in Orlando, Florida, May 26 – 29, 2002. The full abstracts are available in the Proceedings of the AUA Exhibition:

Abstract ID 101952: State-of-the-art Endourological Training Using Computer-Based Virtual Reality Simulation.

James D Watterson, Darren T Beiko, James K Kuan, John D Denstedt.

The abstract , which has been accepted for publication by the Journal of Urology, discusses a study designed to evaluate the use of a computer-based ureteroscopy simulator (URO Mentor™) in the acquisition of basic ureteroscopic skills. Twenty novice trainees were divided randomly into 2 groups and then tested for skill level. Subsequent to the first testing one group received mentored training on the simulator, the second group did not. Both groups were statistically analyzed, and the conclusions reached were that use of the simulator resulted in the rapid acquisition of basic ureteroscopy skills and proved the effectiveness of the simulator as an instructional tool.

Abstract ID 100693: Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator.

David M Wilhelm, Kenneth Ogan, Jeffery A Cadeddu, Margaret S Pearle, Dallas, TX; Stephen Y Nakada, Sean P hedican, Madison, WI.

The abstract, which has been submitted to the Journal of American Surgery, discusses a study designed to evaluate the effect of supervised training using a state of the art virtual reality genitourinary endoscopy simulator on performance of basic endoscopic skills in novice endoscopists. Evaluation of 20 medical students performing a simulator case was compared with their subsequent performance after half of them received training on the simulator. Results suggest that students trained on the virtual reality simulator demonstrated statistically significant improvement on repeat testing while the control group showed no improvement. The authors summarized that endourologic training using the simulator facilitates performance of basic endourologic tasks and may translate into better performance in the operating room.

Abstract ID 104606: The URO Mentor: A New Computer Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological Procedures

Maurice S Michel, Thomas Knoll, Kai U Kuhrmann, Peter Alken.

The abstract describes the URO Mentor™ simulator with details on the software employed, and a description of features and benefits. The authors believe that the URO Mentor opens new perspectives for computer based urological training systems and methods.

The same findings were published lately in BJU international:

The URO Mentor: Development and Evaluation of a New Computer-Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological Procedures.

M. S. Michel, T. Knoll, K. U. Kohrmann and P. Alken, Department of Urology, University Hospital Mannheim, Germany.

British Journal of Urology International (2002), 89, 174-177.

This article provides a thorough description and evaluation of the URO Mentor simulator with particular emphasis on the features and benefits of training with the simulator. Among the benefits enumerated in the article are: a reduction in complications, reduction in procedure times, shorter training periods and the continuous monitoring of competence.


The URO Mentor: Development and Evaluation of a New Computer-Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological procedures

Michel MS, Knoll T, Kohrmann KU, Alken P.
Department of Urology, University Hospital Mannheim , Germany.
BJU Int. 2002 Feb;89(3):174-7.

Objectives: To overcome the current disadvantages of traditional training methods for ureterorenoscopy and percutaneous nephrolitholapaxy, using the URO Mentor (Simbionix, Tel Aviv, Israel ) computer-assisted simulator.
Methods: The URO Mentor device for training and quality control in ureterorenoscopy was developed using virtual reality, multimedia technology and intelligent tutoring systems. The central software system features a proprietary visualization engine (the SVE) which allows real-time simulation by offering a high-level object-orientated application program interface (written in C++) available for use with either Microsoft, DirectX 7 or OpenGL as platforms. The SVE includes general procedures to allow two- (2D) and three-dimensional (3D) rendering, collision detection, collision correction, 3D morphing, 2D image manipulation, texture mapping, ‘bump’ mapping, video texture, X-ray rendering, special effects (blood, smoke, stone fragments and more) and reflections.
Results: The system allows a complete training session on a wide range of procedures by offering different types of cases and virtual patients, and features a full representation of the endourological procedures under direct vision and by using interactive fluoroscopy with a contrast agent. The supported tools include: baskets, graspers, intracorporal lithotripters, guidewires, catheters, stents, biopsy and dilatation devices. The endourological procedures that can be performed are lithotripsy, tumour resection, treatment of strictures and obstructions, stent placement and biopsies.
Conclusions: The URO Mentor introduces a new generation of mannequin equipped with a special haptic device, providing trainees with an unparalleled life-like sensation while training for diagnostic and therapeutic endourological procedures. By bringing key advances into urological simulation (e.g. with the real-time X-ray renderer) and by integrating in a single system both high-quality simulation and learning tools, the URO Mentor provides new perspectives for computer-based urological training systems and methods.


Interactive Multimedia Training

Maurice Stephan Michel Knoll, Kai Uwe Koehrmann, Peter Alken.
Deutsches Arzteblatt/PraxisComputer 4/2002.


The URO mentor: Continuous Development and Evaluation of an Intelligent Computer Based Training System for Ureterorenoscopy and PNL

Presented as a Poster at the EUA exhibition on May, 2001, Geneva, Switzerland
Michel M.S., Knoll T., Frede T., Kohrmann K.U. and Alken P.
Department of Urology, University Hospital, Mannheim, Germany,
http://www.ma.uni-heidelberg.de/inst/uro/
Abstract: Rapid developments in the urological field, as an expanding knowledge base and emerging new techniques require continuing urological education to achieve life long learning and to keep the urologists up to date. Consequently, specific training is necessary to guarantee qualification of the urologists. The goal of the development of the URO mentor (Simbionix, Israel) is to overcome the current drawbacks of traditional training methods for ureterorenoscopy and PNL procedures.
A computer-assisted simulator for training and quality control in ureterorenoscopy and PNL was developed using virtual reality, multimedia technology and intelligent tutoring systems. The software system is the heart of the simulator system. It features the proprietary visualization engine – SVE. SVE makes real-time simulation possible by offering a high level object oriented API (Application Program Interface) written in C++, available for use with either Microsoft® DirectX 7® or OpenGL as platforms. SVE includes general procedures that allows for: 2D and 3D rendering, collision detection, collision correction, 3D morphing, 2D image manipulation, texture mapping, bump mapping, video texture, X-ray rendering, special effects (blood, smoke, stone fragments and more) reflections.
The system allows for a full training session on a wide range of procedures by offering different types of cases and different types of virtual patients. The URO Mentor simulator features full representation of the endourological procedures under direct vision and by using interactive fluoroscopy with a contrast agent. The supported Tools include: baskets, graspers, intracorporal lithotripters, guide wires, catheters, stents, biopsy devices, dilation devices. The following endourological procedures can be performed: lithotripsy, tumor resections, treatment of strictures and obstructions, stent placement, biopsies.
The URO Mentor introduces a new generation mannequin equipped with a special haptic device, providing trainees with an unparalleled true-to-life sensation while training for diagnostic and therapeutic endourological procedures. By bringing key advances in the area of urological simulation–with the real-time x-ray renderer for instance–and by integrating in a single system both high quality simulation and learning tools, the URO Mentor opens new perspectives for computer based urological training systems and methods.

Materials & Methods:
URO mentor proprietary technology features:

  • three-dimensional computer modeling
  • 3D visualization engine
  • an innovative and friendly user interface
  • scope and tool tracking technologies
  • electronic devices including I/O cards
  • specially designed haptic devices for realistic force feedback.

The simulated view:
It is a revolutionary technique for building computer modeling of human organs – a non-rigid, elasto-dynamic object. The realtime rendered images simulate stretching, deflation and inflation, contraction and perforation.
The Software Engine and SVE:
The Simulation System is the heart of the software system. It features the proprietary Simbionix Visualization Engine – SVE. SVE makes real-time simulation possible by offering a high level object oriented API (Application Program Interface) written in C++, available for use with either Microsoft® DirectX 7® or OpenGL as platforms.
SVE includes general procedures that allows for:

  • 2D and 3D Rendering
  • collision detection
  • collision correction
  • 3D Morphing
  • 2D Image Manipulation
  • texture mapping
  • bump mapping
  • video texture
  • X-ray rendering
  • special effects (blood, smoke, stone fragments and more)
  • reflections

Introduction and Objectives: The Simbionix URO Mentor introduces a new generation mannequin equipped with a special haptic device, providing trainees with an unparalleled true-to-life sensation while training for diagnostic and therapeutic endourological procedures. One of the great advantages of the system is the clear picture it affords the trainee at every stage of the endoscopic procedure by giving complete and realistic three-dimensional simulation of the anatomy of the urinary system. The goal of the development of the URO mentor (Simbionix, Israel) is to overcome the current drawbacks of traditional training methods for ureterorenoscopy and PNL procedures.
Conclusion: The concept of the simulator as a training tool is well established, notably in aviation. It is also used for the annual evaluation of pilots prior to their final approval by the authorities. The airline industry has demonstrated that the use of such simulators has improved pilot skill. Pilots are trained on simulators in order to reduce mistakes which may be critical and cost lives.
It is therefor natural that simulators should be used for training in the medical field as well. In recent years advanced simulation technology has been introduced into medicine in several fields such as laparoscopy, cardiology, and anesthesiology. Performing an endoscopy requires skill and training. For each type of procedure there is a minimum number of attempts necessary to achieve competence.
Different organizations have their recommendations for the minimal number of procedures needed for competence.
Many supervising physicians find that they have insufficient time to spend overseeing procedures. Any device which saves time would be valuable. The most obvious example of such a device would be an endoscopic simulator, which would enable the trainee to learn and be tested quickly and safely.
The URO mentor system allows a full training session on a wide range of procedures by offering different types of cases and different types of virtual patients. The simulator features full representation of the endourological procedures under direct vision and by using interactive fluoroscopy with a contrast agent. The supported tools include: baskets, graspers, intracorporal lithotripters, guide wires, catheters, stents, biopsy devices, dilation devices. The following endourological procedures can be performed: lithotripsy, tumor resections, treatment of strictures and obstructions, stent placement, biopsies.
Bearing in mind the simulators already available, the increased public awareness of medical legal issues, and the limited time of supervising physicians, endoscopic training is likely to undergo changes.
Trainees will start their training on a computer-based simulator. Since it is always available, the trainee can practice as long as it is needed and at that time which is convenient for him.
The virtual mentor that exists in such a simulator will constantly improve the trainee’s performance. The URO mentor simulator is ideal for this purpose.
Advanced training in therapeutic procedures can also be done with an ex vivo model. However, the use of such a model requires early planning. The pig kidney and ureter needs to be obtained and prepared. Further more the use of X-Rays is limited.
In the very near future the URO mentor simulator will provide the option for PCNL and TUR-P as well as TUR-B. Once this happens, the need for animal models is expected to decline.
In addition, as with flight simulators, computer-based simulators will make continuous monitoring of competence possible. Accurate recording of successes and failures throughout professional life would help individuals recognize areas where they need improvement, and would also help healthcare organizations to identify impaired practitioners.


Training in Endourology – The Role of Simulators

J.M.C.H. de la Rosette MD Ph.D., European Urology Today, June 2001

The changing face of EndoUrology training received special attention at the EAU Congress with an exhibition of a new computerized, interactive EndoUrology simulator in the Technology Garden
Both in past and present training in EndoUrology has focused primarily on three stages of learning. Stage one entails the review of textual material on the urinary collecting system anatomy and on the procedures involved in diagnostic and therapeutic activities. In addition to the library work, trainees may view video films, where available, of actual procedures, which have been performed on patients. Stage two has the trainee present at actual procedures where he may observe the techniques required for performance of endourology procedures. And, the third stage involves the performance by the trainee of actual procedures on patients while under the supervision of a specialist during the entire procedure.
More recently in some programs the three-staged training may be supplemented by the use of mechanical or animal simulators. The mechanical simulators have a very short-term usefulness in familiarizing the trainee with the anatomy. The animal simulators are useful in providing a more true-to-life feel, however are problematic from both the point of view of the use of animals for this purpose and the time and cost of setting up an animal simulator workshop. Yet, both have the benefit of providing the trainee with an opportunity to gain the hand-eye coordination and the skills required for endourological procedures without risk to the patient. The new generation of EndoUrology training simulators, which are now becoming available, address the issues of patient safety, cost effectiveness, gaining of skills and more.
Instructors may find that their trainees spend more time on performing procedures while they spend a good deal less time supervising them. The teaching of a difficult procedure will no longer be dependent upon finding a patient suffering from that particular problem. With the URO Mentor simulator the instructor may select any case desired as well as any number of cases or repetitions of cases. Computerized simulators employing the latest in video imaging and sensor technology, give medical experts and trainees the opportunity to practice procedures from the most basic to both the rare and difficult without risk to patients and without the need for animals or animal parts. The practice venue is readily available at all times.
During the presentation and demo at the EAU meeting in Geneva, it was shown how performance evaluation is also improved via the new simulators. Video recording of performed procedures, and computer tracking of performance time provide the instructor with objective means for trainee evaluation as well as information over time, which enables the tracking of trainee improvement. Even the trainee may follow his own progress and identify areas in which he may choose to engage in additional practice. And, the opportunity to practice is as available as is time on the simulator.
The new simulators provide the trainee with an amazingly true-to-life experience. Within minutes he may find himself immersed in an actual patient case, performing a procedure on the simulator mannequin, having forgotten the fact that his patient, though quite sophisticated, is far from flesh and blood. The images he sees on the video monitor are the same as those he would see in an actual procedure room in the hospital. And yet, the beginning trainee may rest assured that he can’t hurt anyone if his skills are not yet up to far.
Attendees at the XVI Congress of the European Association of Urology also had the opportunity to try out the new EndoUrology Training Simulator at the Technological Garden booth, which proved to be a popular addition to the congress this year attracting large numbers of visitors. Simulators such as the URO Mentor will undoubtedly soon play expanding roles in endourology training. The ability to design a tailor made training program, to assign cases to trainees on a remote basis, and to review the computerized evaluation and record of performance make the simulator an invaluable part of any training, accreditation or CME program.