The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Survival and Long-term Effects of Kidney-sparing Surgery Versus Radical Nephroureterectomy on Kidney Function in Patients with Upper Urinary Tract Urothelial Carcinoma.

Background: Current European Association of Urology (EAU) guidelines discriminate between high- and low-risk upper urinary tract urothelial carcinoma (UTUC) to determine treatment by means of radical nephroureterectomy (RNU) or kidney-sparing surgery (KSS). Objective: To compare long-term oncological outcomes and renal function for patients with UTUC treated by RNU versus KSS. Design setting and participants: A retrospective cohort study, including 186 renal units with nonmetastatic UTUC treated in a tertiary referral centre between 2010 and 2021, was conducted. Intervention: RNU, ureterorenoscopy, percutaneous tumour resection, and segmental ureteral resection. Outcome measurements and statistical analysis: Recurrence-free survival, metastasis-free survival (MFS), overall survival (OS), cancer-specific survival (CSS), and renal function were analysed by means of the log-rank test and the independent-sample t test. Results and limitations: OS was 71.1% for the RNU group and 81.9% for the KSS group. In a cohort matched for propensity weight based on EAU risk stratification progression-free survival (PFS; RNU 96.0%; KSS 86.0%), MFS (RNU 72.0%; KSS 84.0%), CSS (RNU 84.0%; KSS 86.0%), and OS (RNU 76.0%; KSS 76.0%) were all similar between both groups. No significant differences in renal function were seen at 2 and 5 yr after the intervention. Although this series represents the largest cohort of (high-risk) UTUC patients treated by means of KSS to date, it is not suitable for performing a multivariate analysis. Conclusions: PFS, MFS, CSS, and OS were all comparable when analysing the RNU and KSS groups. Similar results for groups with evenly distributed risk factors and a large percentage of high-risk disease suggest that current risk stratification might not be accurate in discriminating low-risk from high-risk disease. Patient summary: In this report, we looked at outcomes for upper urinary tract urothelial carcinoma in a specialised hospital. We conclude that kidney-sparing surgery and radical nephroureterectomy have comparable outcomes and that risk factors for worse outcome might not be identified correctly.

How to evaluate a flexible ureterorenoscope? Systematic mapping of existing evaluation methods.

OBJECTIVES: The objective of this study was to identify, map and review scope-related and user-related parameters used to evaluate the quality of flexible ureterorenoscopes. Thereby identifying key items and variability in grading systems. METHODS: A literature search of four databases (MEDLINE [Ovid], EMBASE [Ovid], Web of Science, Google scholar and the Cochrane Library) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines encompassing articles published up to August 2020. A total of 2386 articles were screened. RESULTS: A total of 48 articles were included in this systematic scoping review. All studies had a prospective design. Five key items in the assessment of flexible ureterorenoscopy were distinguished: 'Manoeuvrability' (87.5%), 'Optics' (64.6%), 'Irrigation' (56.3%), 'Handling' (39.6%) and 'Durability' (35.4%). After regrouping, every key item could be divided into specific subcategories. However, the quality assessment showed a wide variation in denomination, method of measurement, circumstances of measurement, tools used during measurements, number of measurements performed, number of observers, and units of outcomes. CONCLUSION: The research field regarding quality assessment of ureterorenoscopes is heterogeneous. In this systematic scoping review we identified five key parameters: Manoeuvrability, Optics, Irrigation, Handling and Durability, used to grade flexible ureterorenoscopes. However, within these categories we found a wide variety in terms of method of measurements. A standardised, uniform grading tool is required to assess and compare the quality of flexible ureterorenoscopes in the future.

Lessons from Literature: Nephrostomy Versus Double J Ureteral Catheterization in Patients with Obstructive Urolithiasis-Which Method Is Superior?

Purpose: To review the literature on optimal methods of drainage for obstructive urolithiasis in adult patients, comparing percutaneous nephrostomy (PCN) with retrograde ureteral catheterization (Double J [JJ]) regarding success of procedure, efficacy, complications, quality of life (QoL), and costs. Methods: Web of Science and the Medline, Embase, Emcare, and Cochrane controlled trial databases were searched for all relevant publications until November 2018. A review protocol was created, using the PRISMA statement. Two reviewers independently screened the titles and abstracts in Endnote X8, using criteria as stated in the research protocol. A total of 1108 abstracts were screened of which 9 were included in the qualitative synthesis. Level of evidence of the studied articles varies between 1b and 2c. Results: Both JJ and PCN have high success rates (80%-100% and 99%-100%, respectively). No major complications were reported in both groups. Procedural and fluoroscopy times are significantly shorter for JJ than for PCN (31-33 minutes vs 35-49 minutes and 5 minutes vs 7 minutes, respectively). Time to clinical improvement did not differ. In the JJ group, analgesics were used more frequently than in the PCN group. Data regarding procedural costs were contradictory, but overall the PCN group was associated with higher costs. In pregnant women, PCN placement appears to be significantly more effective than placement of JJ. A significant decrease between pre- and postintervention QoL was found with patients receiving a JJ. Back pain was reported more frequently in the PCN group, urinary symptoms were more common in the patients with a JJ. Conclusions: Both PCN and JJ have comparable success rates for patients with obstructive urolithiasis and procedure-related complications are rare. Overall, higher rates of sepsis, longer hospital stay, and higher costs were found in the PCN group, but that could be explained by patient selection. Patients with JJ experienced a lower QoL and experience more lower urinary tract symptoms.

Development and validation of the TOCO-TURBT tool: a summative assessment tool that measures surgical competency in transurethral resection of bladder tumour.

BACKGROUND: The current shift towards competency-based residency training has increased the need for objective assessment of skills. In this study, we developed and validated an assessment tool that measures technical and non-technical competency in transurethral resection of bladder tumour (TURBT). METHODS: The 'Test Objective Competency' (TOCO)-TURBT tool was designed by means of cognitive task analysis (CTA), which included expert consensus. The tool consists of 51 items, divided into 3 phases: preparatory (n = 15), procedural (n = 21), and completion (n = 15). For validation of the TOCO-TURBT tool, 2 TURBT procedures were performed and videotaped by 25 urologists and 51 residents in a simulated setting. The participants' degree of competence was assessed by a panel of eight independent expert urologists using the TOCO-TURBT tool. Each procedure was assessed by two raters. Feasibility, acceptability and content validity were evaluated by means of a quantitative cross-sectional survey. Regression analyses were performed to assess the strength of the relation between experience and test scores (construct validity). Reliability was analysed by generalizability theory. RESULTS: The majority of assessors and urologists indicated the TOCO-TURBT tool to be a valid assessment of competency and would support the implementation of the TOCO-TURBT assessment as a certification method for residents. Construct validity was clearly established for all outcome measures of the procedural phase (all r > 0.5, p < 0.01). Generalizability-theory analysis showed high reliability (coefficient Phi ≥ 0.8) when using the format of two assessors and two cases. CONCLUSIONS: This study provides first evidence that the TOCO-TURBT tool is a feasible, valid and reliable assessment tool for measuring competency in TURBT. The tool has the potential to be used for future certification of competencies for residents and urologists. The methodology of CTA might be valuable in the development of assessment tools in other areas of clinical practice.

High educational impact of a national simulation-based urological curriculum including technical and non-technical skills.

BACKGROUND: Although simulation training is increasingly used to meet modern technology and patient safety demands, its successful integration within surgical curricula is still rare. The Dutch Urological Practical Skills (D-UPS) curriculum provides modular simulation-based training of technical and non-technical basic urological skills in the local hospital setting. This study aims to assess the educational impact of implementing the D-UPS curriculum in the Netherlands and to provide focus points for improvement of the D-UPS curriculum according to the participants. METHODS: Educational impact was assessed by means of qualitative individual module-specific feedback and a quantitative cross-sectional survey among residents and supervisors. Twenty out of 26 Dutch teaching hospitals participated. The survey focussed on practical aspects, the D-UPS curriculum in general, and the impact of the D-UPS curriculum on the development of technical and non-technical skills. RESULTS: A considerable survey response of 95 % for residents and 76 % for supervisors was obtained. Modules were attended by junior and senior residents, supervised by a urologist, and peer teaching was used. Ninety percent of supervisors versus 67 % of residents judged the D-UPS curriculum as an important addition to current residency training (p = 0.007). Participants' aggregated general judgement of the modules showed a substantial percentage favorable score (M ± SE: 57 ± 4 %). The impact of training on, e.g., knowledge of materials/equipment and ability to anticipate on complications was high, especially for junior residents (77 ± 5 and 71 ± 7 %, respectively). Focus points for improvement of the D-UPS curriculum according to the participants include adaptation of the training level to residents' level of experience and focus on logistics. CONCLUSION: The simulation-based D-UPS curriculum has a high educational impact. Residents and supervisors consider the curriculum to be an important addition to current residency training. Focus points for improvement of the D-UPS curriculum according to the participants include increased attention to logistics and integration of a spiral learning approach.

The Simbla TURBT Simulator in Urological Residency Training: From Needs Analysis to Validation.

OBJECTIVE: To investigate the value of the physical Simbla Transurethral Resection of a Bladder Tumor (TURBT) simulator as an educational tool within urological residency training, by means of a training needs analysis (TNA) and assessment of its feasibility, acceptability, and face, content, and construct validity. METHODS: To analyze the training needs for TURBT, procedural steps and pitfalls were identified and the TNA was completed during an expert consensus meeting. Participants (n = 76) were divided into three groups based on their experience in TURBT: novices, intermediates, and experts. Participants performed two standardized TURBT procedures on the simulator. Face validity and content validity, as well as feasibility and acceptability, were assessed with a quantitative survey. Construct validity was assessed by comparing the performance of novices, intermediates, and experts on resection time, quality of tumor resection, and overall performance. RESULTS: Of the 21 procedural steps and 17 pitfalls defined in TNA, 13 steps and 8 pitfalls were covered by the Simbla. Participants rated the Simbla's overall realism (face validity) with a score of 8 of 10 (range 6-9). The simulator was judged to be most useful (content validity) for learning eye-hand coordination: score 8 (6-10). All aspects regarding realism and usefulness were rated above the acceptability threshold of 6/10. Intermediates (100%) and experts (96%) considered the Simbla to be a useful educational tool within the urological curriculum. Resection time was longer for novices than for experts (p < 0.05; construct validity). In addition, the overall performance of novices was rated lower compared with intermediates and experts, and novices showed more irradical resections and bladder perforations (all p < 0.05). CONCLUSIONS: The Simbla TURBT simulator is a valid, feasible, and acceptable educational tool for training procedural skills and may be implemented in the urological curriculum to complement learning in clinical practice. TNA is valuable in defining training objectives and evaluating the educational value of a simulator.

High acceptability of a newly developed urological practical skills training program.

BACKGROUND: Benefits of simulation training are widely recognized, but its structural implementation into urological curricula remains challenging. This study aims to gain insight into current and ideal urological practical skills training and presents the outline of a newly developed skills training program, including an assessment of the design characteristics that may increase its acceptability. METHODS: A questionnaire was sent to the urology residents (n = 87) and program directors (n = 45) of all Dutch teaching hospitals. Open- and close-ended questions were used to determine the views on current and ideal skills training and the newly developed skills training program. Eight semi-structured interviews were conducted with 39 residents and 15 program directors. All interviews were audiotaped, fully transcribed, and thereafter analyzed. RESULTS: Response was 87.4% for residents and 86.7% for program directors. Residents appeared to be still predominantly trained 'by doing'. Structured practical skills training in local hospitals takes place according to 12% of the residents versus 44% of the program directors (p < 0.001). Ideally, residents prefer to practice certain procedures on simulation models first, especially in endourology. The majority of residents (92%) and program directors (87%) approved of implementing the newly developed skills training program (p = 0.51). 'Structured scheduling', 'use of peer teaching' and 'high fidelity models' were indicated as design characteristics that increase its acceptability. CONCLUSIONS: Current urological residency training consists of patient-related 'learning by doing', although more practice on simulation models is desired. The acceptability of implementing the presented skills-training program is high. Design characteristics that increase its acceptability are structured scheduling, the use of peer teaching and high fidelity models.

Patient Safety Risks of Basic Urological Procedures Performed by Junior and Senior Residents.

OBJECTIVE: To investigate the current performance of urological residents regarding basic urological procedures in relation to patient safety issues and the identification of specific training needs. DESIGN: Observational data of 146 urethrocystoscopies (UCSs), 27 transrectal ultrasounds of the prostate (TRUSs), 38 transrectal ultrasound-guided prostatic biopsies (TRUSPs), and 30 transurethral resections of bladder tumor (TURBTs) were collected. Performance was evaluated using scoring lists including details on completeness of procedural steps, level of independence, time, and the incidence of unintended events. The causal factors contributing to the unintended events were identified by 2 expert urologists and classified according to the recognized PRISMA method. SETTING: This study was performed in 5 teaching hospitals in the Netherlands. PARTICIPANTS: We included 11 junior residents and 5 senior residents in urology in the final study cohort. RESULTS: Senior residents showed a lower degree of completeness in material usage than junior residents did during UCS (p < 0.01) and in preparation, material usage, and procedure during TRUSP (all p < 0.05). In UCS and TURBT, senior residents received significantly less feedback than junior residents did (both p < 0.01). Incidence of unintended events for junior vs senior residents was 11% and 4% in UCS, 0% and 7% in transrectal ultrasound of the prostate, 36% and 62% in TRUSP, and 41% and 23% in TURBT, respectively. Overall, unintended events were mainly caused by human factors, in particular, verification and skills-based issues. CONCLUSION: Present performance of basic urological procedures involves a high percentage of unintended events, especially in TRUSP and TURBT, which are mainly caused by human factors and are a potential threat for patient safety. Junior residents are less independent but more thorough in the performance of UCS and TRUSP than senior residents are. Targeted skills training including assessment should be implemented before privileges for independent practice are granted to reduce the incidence of unintended events and optimize patient safety.

Results of the European Basic Laparoscopic Urological Skills examination.

BACKGROUND: In 2011, the European Basic Laparoscopic Urological Skills (E-BLUS) examination was introduced as a pilot for the examination of final-year urologic residents. OBJECTIVE: In this study, we aimed to answer the following research questions: What level of laparoscopic skills do final-year residents in urology have in Europe, and do the participants of the E-BLUS pass the examination according to the validated criteria? DESIGN, SETTING, AND PARTICIPANTS: Participants of the examination were final-year urology residents from different European countries taking part in the European Urology Residents Education Program in 2011 and 2012. SURGICAL PROCEDURE: The E-BLUS exam consists of five tasks validated for the training of basic urologic laparoscopic skills. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Performances of the tasks were recorded on DVD and analysed by an objective rater. Time and number of errors made in tasks 1-4 were noted. Furthermore, all expert laparoscopic urologists were asked to score participants on a global rating scale (1-5) based on three items: depth perception, bimanual dexterity, and efficiency. Participants were asked to complete a questionnaire on prior training and laparoscopic experience. RESULTS AND LIMITATIONS: Seventy DVD recordings were analysed. Most participants did not pass the time criteria on task 4 (90%), task 2 (85.7%), task 1 (74.3%), and task 5 (71.4%). Task 3 was passed by 84.3%. The overall quality score was passed by 64%. When combining time and quality, only three participants (4.2%) passed the examination according to the validated criteria. According to the questionnaire, 61% did not have the opportunity to train in laparoscopic skills. CONCLUSIONS: The results of the E-BLUS examination show that the level of basic laparoscopic skills among European residents is low. Although quality of performance is good, most residents do not pass the validated time criteria. Regular laparoscopic training or a dedicated fellowship should improve the laparoscopic level of residents in urology.

da Vinci skills simulator for assessing learning curve and criterion-based training of robotic basic skills.

OBJECTIVE: To answer 2 research questions: what are the learning curve patterns of novices on the da Vinci skills simulator parameters and what parameters are appropriate for criterion-based robotic training. MATERIALS AND METHODS: A total of 17 novices completed 2 simulator sessions within 3 days. Each training session consisted of a warming-up exercise, followed by 5 repetitions of the "ring and rail II" task. Expert participants (n = 3) performed a warming-up exercise and 3 repetitions of the "ring and rail II" task on 1 day. We analyzed all 9 parameters of the simulator. RESULTS: Significant learning occurred on 5 parameters: overall score, time to complete, instrument collision, instruments out of view, and critical errors within 1-10 repetitions (P <.05). Economy of motion and excessive instrument force only showed improvement within the first 5 repetitions. No significant learning on the parameter drops and master workspace range was found. Using the expert overall performance score (n = 3) as a criterion (overall score 90%), 9 of 17 novice participants met the criterion within 10 repetitions. CONCLUSION: Most parameters showed that basic robotic skills are learned relatively quickly using the da Vinci skills simulator, but that 10 repetitions were not sufficient for most novices to reach an expert level. Some parameters seemed inappropriate for expert-based criterion training because either no learning occurred or the novice performance was equal to expert performance.

Program for laparoscopic urological skills assessment: setting certification standards for residents.

AIM: There is growing pressure from the government and the public to define proficiency standards for surgical skills. Aim of this study was to estimate the reliability of the Program for Laparoscopic Urological Skills (PLUS) assessment and to set a certification standard for second-year urological residents. METHODS: Fifty participants were assessed on performance time and performance quality to investigate the reliability of the PLUS assessment. Generalisability coefficient of 0.8, on a scale of 0 to 1.0, was considered to indicate good reliability for assessment purposes. Pass/fail standards were based on laparoscopic experience: Novices, intermediates, and experts (>100 procedures). The pass/fail standards were investigated for the PLUS performances of 33 second-year urological residents. RESULTS: Fifteen novices, twenty-three intermediates and twelve experts were included. An inter-trial reliability of >0.80 was reached with two trials for each task. Inter-rater reliability of the quality measurements was 0.79 for two judges. Pass/fail scores were determined for the novice/intermediate boundary and the intermediate/expert boundary. Pass rates for second-year residents were 63.64% and 9.09%, respectively. CONCLUSION: The PLUS assessment is reliable for setting a certification standard for second-year urological residents that serves as a starting point for residents to proceed to the next level of laparoscopic competency.

[Erectile dysfunction and incontinence after prostatectomy. Treating the complications of surgery for prostate cancer]. / Erectiestoornis en incontinentie na prostatectomie. Behandeling van complicaties van chirurgie bij prostaatkanker.

After having undergone a radical prostatectomy, 1 out of 5 men is dissatisfied about the functional results particularly because of complications like erectile dysfunction and urinary incontinence; these complications frequently do occur. During the first postoperative year, patient counselling and guidance are necessary aspects of the management of urinary incontinence and erectile dysfunction. In order to prevent irreversible erectile dysfunction, it is important that the patient resumes sexual activity soon after the operation; if necessary, a phosphodiesterase-5 (PDE-5) inhibitor or intracavernosal injection therapy may be used. Treatment of urinary incontinence in the first postoperative year consists of pelvic floor exercises and guidance on the use of collection devices, penile clamps or condom catheters. If urogenital functional disorders persist after one year, in a way that significantly affects patient's quality of life, the implantation of an erectile prosthesis or - depending on the amount of urine loss - a sling or sphincter prosthesis is indicated.

Designing simulator-based training: an approach integrating cognitive task analysis and four-component instructional design.

Most studies of simulator-based surgical skills training have focused on the acquisition of psychomotor skills, but surgical procedures are complex tasks requiring both psychomotor and cognitive skills. As skills training is modelled on expert performance consisting partly of unconscious automatic processes that experts are not always able to explicate, simulator developers should collaborate with educational experts and physicians in developing efficient and effective training programmes. This article presents an approach to designing simulator-based skill training comprising cognitive task analysis integrated with instructional design according to the four-component/instructional design model. This theory-driven approach is illustrated by a description of how it was used in the development of simulator-based training for the nephrostomy procedure.

Analysis of pitfalls encountered by residents in transurethral procedures in master-apprentice type of training.

BACKGROUND AND PURPOSE: Today's simulators are frequently limited in their possibilities to train all aspects of endourological procedures. It is therefore indicated to first make an inventory of training needs before (re)developing simulators. This study examined pitfalls encountered by residents in real-time transurethral procedures. MATERIALS AND METHODS: First, difficulties that residents encounter in transurethral procedures (transurethral resection of the bladder tumor [TURBT], transurethral resection of the prostate [TURP], ureterorenoscopy [URS]) were identified by asking urologists and residents to complete an open questionnaire. Based on their answers a list of pitfalls was designed and tested in 28 pilot observations. Then, two raters (interrater agreement 0.72, 0.70, and 0.75 for TURBT, TURP, and URS, respectively) categorized all observed procedure-related interactions between residents and supervisors in 80 procedures as (1) (type of ) pitfall or (2) no pitfall. RESULTS: Pitfalls most frequently encountered were as follows: (1) planning/anticipation on new situations (median 27.3%, 29.3%, and 31.8% of total pitfalls in TURBT, TURP, and URS, respectively); (2) handling of instruments (11.5%, 10.6%, and 20.0% for TURBT, TURP, and URS); (3) irrigation management for TURBT (7.7%), depth of resection for TURP (8.9%), and use of X-ray for URS (13.3%). CONCLUSION: Designers of endourological simulators should include possibilities to train planning/anticipation on new situations, handling of instruments in all transurethral procedures, and irrigation management in TURBT, depth of resection in TURP, and timing usage of X-ray in URS.

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

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). CONCLUSION: 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.

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

OBJECTIVE: 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 < or = 0.003, beta range 0.30-0.47). There was no effect of training for participants with a specific preference for a surgical speciality in two of five GRS scores. Participants from CHE obtained higher GRS 3 scores than those from UMCG. Significantly more UMCG trainees indicated having had stress than those from CHE (P < 0.001). 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.

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

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.

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

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.

How useful and realistic is the uro trainer for training transurethral prostate and bladder tumor resection procedures?

PURPOSE: We evaluated the face and content validity (novice and expert opinions of realism and usefulness) of the Uro Trainer (Karl Storz GmbH, Tuttlingen, Germany), a simulator for transurethral resection procedures, to ascertain whether it is justifiable to continue the validation process by performing prospective experimental studies. MATERIALS AND METHODS: Between 2006 and 2008, 104 urologists and urology residents performed a transurethral bladder tumor resection and/or transurethral prostate resection procedure on the Uro Trainer, and rated simulator usefulness and realism on a 10-point scale (1-not at all useful/realistic/poor, 10-very useful/realistic/excellent). Participants were classified as experts (more than 50 procedures performed) or novices (50 or fewer procedures performed). Because the literature offered no guidelines for interpreting our data, we used criteria from other studies to interpret the results. RESULTS: A total of 161 questionnaires were analyzed from 97 (21% experts, 79% novices) and 64 (30% experts, 70% novices) participants who performed transurethral prostate resection and transurethral bladder tumor resection procedures, respectively. Mean usefulness, realism and overall scores varied from 5.6 to 8.2 (SD 1.4-2.5). Measured by validity criteria from other studies, Uro Trainer face and content validity was unsatisfactory, with ratings on only 3%, 5% and 8% of the parameters interpreted as positive, moderately acceptable and good, respectively. CONCLUSIONS: Measured against criteria from other validation studies, Uro Trainer face and content validity appears to be unsatisfactory. Modification of the simulator seems advisable before further experimental validation studies are initiated. The lack of general guidelines for establishing face and content validity suggests a need for consensus about appropriate methods for evaluating the validity of simulators.