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

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. CONCLUSION: 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.

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.

The current role of medical simulation in american urological residency training programs: an assessment by program directors.

PURPOSE: Although medical simulation opportunities are increasingly available, resident training to date has involved primarily hands-on, subjective assessments. The role of simulation and computer based training for urology residents remains unknown. We evaluated the current status of medical simulation among urological training programs in the United States. MATERIALS AND METHODS: An anonymous questionnaire was developed and mailed to the program director at the 119 Accreditation Council for Graduate Medical Education accredited United States urology training programs, and consisted of 17 questions documenting the prior experience of the responder to medical simulation as well as the current status of simulation at their institution. An additional 14 questions sought the responders' opinion of medical simulation in urology training programs. RESULTS: The questionnaire was returned by 41 program directors (35%). Among respondents, access to a laparoscopy simulator was 76%. In comparison, reported access to cystoscopy, ureteroscopy, transurethral resection and percutaneous access simulators was 16%, 21%, 8% and 12%, respectively. Respondents indicated that these simulators were good educational tools, realistic and easy to use. Unanimous agreement was reported for simulation training in residency and that simulators allow practice in a controlled environment. Disagreement was reported about the cost effectiveness, validity and ability of simulators to replace hands-on instruction in the operating room. CONCLUSIONS: Among responders a high level of access to laparoscopic simulators for urology residents is coupled with low levels of access to other endoscopic trainers. Urology residency program directors unanimously recognize a role for simulation training in residency, although the extent to which they may be incorporated remains to be resolved.

Laparoscopic and robotic radical prostatectomy.

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.

Evaluation of microporous polysaccharide hemospheres for parenchymal hemostasis during laparoscopic partial nephrectomy in the porcine model.

OBJECTIVES: We evaluated the efficacy of Microporous Polysaccharide Hemospheres (MPH) for parenchymal hemostasis during laparoscopic partial nephrectomy (LPN) in the porcine model. METHODS: Six female farm pigs underwent a transperitoneal right lower-pole LPN during occlusion of the renal hilum. Renal parenchyma was excised using cold Endoshears. MPH was applied to the defect and the hilar clamp released. Animals were kept alive for one week. Before sacrifice, left LPN was similarly performed using MPH. Study variables included blood loss, number of MPH applications, hilar clamp time, hemostasis time, perioperative complications, and abnormalities noted at sacrifice. RESULTS: Hemostasis was achieved in all kidneys solely by using MPH. The average excised specimen represented 5.6% (range, 3.6 to 8.5) of renal weight. Mean hilar clamp and hemostatic times were 12.8 minutes (range, 6 to 18) and 2 minutes (range, 1 to 3), respectively. Hemostasis occurred after one MPH application in 8 kidneys (67%). In 3 kidneys, additional MPH powder was required to treat minor residual bleeding. In the remaining kidney, a second standard MPH application was required for hemostasis. No operative complications were encountered. No hematomas or residual MPH was found at necropsy; however, small urinomas were found in 2 of 6 kidneys. CONCLUSIONS: In the experimental porcine model, this initial study suggests that MPH provides effective parenchymal hemostasis during laparoscopic resection of an exophytic kidney lesion.

Angiotropism of human prostate cancer cells: implications for extravascular migratory metastasis.

OBJECTIVES: To report several samples of invasive human prostate cancer showing angiotropism, and to use human prostate cancer cells stably expressing green fluorescence protein (GFP) in in vitro and in vivo models to assess the dissemination pathway of prostate cancer cells. MATERIALS AND METHODS: Malignant melanoma and prostate carcinoma cells can migrate along anatomical structures such as nerves; previous studies showed that melanoma cells can be perivascular, on the outside of the endothelium, i.e. they are angiotropic, which suggests the hypothesis that melanoma cells also may migrate along vascular channels, termed 'extravascular migratory metastasis' (EVMM). Thus we examined histologically 10 human prostatic carcinoma specimens for the presence of angiotropism. In vitro, the PC-3 prostate cancer cells were co-cultures with capillary-like structures. In vivo, PC-3 cells were implanted on the chick chorio-allantoic membrane (CAM). RESULTS: Histologically, in all 10 cases, angiotropism was detected at least focally within the tumour or at the advancing front of the tumour. In vitro, the PC-3 cells spread along the external surface of the vascular tubules; in vivo, PC-3 cells formed a cuff around some vessels a few millimetres beyond the tumour, showing angiotropism. Histopathology of the CAM confirmed the perivascular location of tumour cells and the absence of tumour cells within the vessel lumina. CONCLUSION: The presence of angiotropic tumour cells in human invasive prostate cancers, associated with the angiotropism of GFP prostate cancer cells cultivated in vitro and in vivo in angiogenic models, raises the possibility that some prostate tumour cells may migrate along the external surface of vessels as a mechanism of spread, i.e. EVMM.