Virtual Reality Training in Urology

Virtual Reality Training in Urology he report by Lucas et al in this issue of The Journal (page 2588) illuminates an important issue confronting urological residency programs—that of developing a coherent surgical skills curriculum during an era of rapidly changing surgical practice and technological innovation. Although this problem is having a direct impact on residency training programs now, it will increasingly affect all practicing urologists as the need to acquire new skills and demonstrate surgical competence gains prominence. A thorough review of the state of urological simulation was recently presented by Wignall et al, who noted that a variety of factors have decreased resident participation in surgical procedures including reduced duty hours, economic and medicolegal considerations, as well as the need for experienced surgeons to perform major portions of new procedures before becoming comfortable with passing on cases to the resident.1 As a field in its infancy, skills acquisition and simulator research suffer from a lack of standards in methodology and means of evaluation. Lucas et al are to be commended for using a recognized standard, Objective Structured Assessment of Technical Skills, which allows the evaluation of differing systems using common methodology.2 Another problem plaguing validation studies is that they are often performed among members of a single service at a single institution. This setup limits the number of subjects recruited and reduces the generalizability of results. The lack of an organized network of simulation validation centers hampers our ability to pass judgment on available devices. The validation process for simulators is lengthy. To gain acceptance new simulators must prove to be appropriate and reasonable (face validity), the contents of the tested procedure must be relevant to the subject assessed (content validity), the results of the new tool must correspond to an established tool (criterion validity) and the test must discriminate among groups of different skill levels (concurrent validity). Ultimately we want to know the predictive validity— how do the results of training on a simulator predict the performance of real-world surgical procedures? No virtual reality simulator has been shown to improve the performance of actual urology procedures. In addition, most of the simulators have been validated on novices and have proven that novices gain skills faster with simulators than with no training. What has not been proven is whether these devices sufficiently enhance performance beyond the skills achieved using low fidelity simulators (eg box or pelvic trainers) to justify the exponentially greater costs. Low fidelity systems using common fruits, vegetables and meats inside cardboard boxes have been proven to help novices gain basic skills.3,4 Low fidelity systems are characterized by a lack of realism, a lack of feedback, and no built-in evaluation and mentoring system, thus requiring increased involvement of senior staff to monitor trainee progress. On the other hand,

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0022-5347/08/1806-2305/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION

many virtual reality trainers do not challenge higher level residents who have acquired basic skills. At our program we continue to perform regular animal labs to present educational opportunities for senior residents. Creating simulators that challenge upper level residents and experienced urologists is a task for the future. The availability of simulation is another issue confronting training programs. In a recent survey of junior urology residents representing 71 training programs we found that only 28% of the programs offered a comprehensive laparoscopic curriculum. Residents in 19% of the programs reported no simulation training was available. Even when a simulation experience is accessible more than half the respondents use the devices less than once a month or not at all.5 Clearly programs need to offer a curriculum that includes skills training, residents need to be informed of the importance of skills training, and carrot and stick need to be applied to assure compliance. For reasons of economics the current approach to surgical simulation development favors the creation of expensive, complex trainers located in specialized centers that are often not available to residents when time is available. This problem is magnified by restrictions on resident duty hours. Allocating large portions of education budgets to a single aspect of residency training may not be wise. The current systems incur huge costs. First and foremost is the capital outlay for the simulators, with price tags in the tens of thousands of dollars. Maintenance is critical, including dayto-day maintenance on quirky proprietary devices as well as costly software and hardware upgrades. Technicians need to be hired to maintain machines located in simulation centers and to help with record keeping. These costs are borne by residency programs facing budget cuts from decreased government support and increased pressure on attending staff to maintain clinical productivity at the cost of resident training. Furthermore, the technology is changing so rapidly that the $100,000 robotic simulator purchased today may not be relevant in 5 years when a new generation of robotic technology emerges. Residency directors do not want to be stuck with a Walkman in the era of the iPod. The ideal trainer is readily available at home and in the workplace, is inexpensive, provides feedback and evaluation, allows for increase in technical skills as goals are achieved and is upgradable. A Web based system would be ideal for delivering this training. Preferably curricula would be standardized across training programs. A basic laparoscopy curriculum is already available as Fundamentals of Laparoscopic Surgery from the Society of American Gastrointestinal and Endoscopic Surgeons. The American Urological Association has initiated the process of creating a core curriculum and has taken the initiative of developing a laparoscopic handbook available online.6 More cooperation among urology programs and among

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Vol. 180, 2305-2306, December 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.09.069

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VIRTUAL REALITY TRAINING IN UROLOGY

specialties needs to develop so that a network of educators/researchers can be created to validate new systems. A core curriculum of basic endoscopic and laparoscopic skills could be shared by Urology, Gynecology and General Surgery services. Individual specialty specific modules could be developed by teams of educators, validated online through a dedicated network of research centers and then distributed to subscribers. Coordination of such an effort will require resources and leadership from the top levels of academic surgeons. Noah Schenkman* Department of Urology University of Virginia Medical Center Charlottesville, Virginia REFERENCES 1.

Wignall GR, Denstedt JD, Preminger GM, Cadeddu JA, Pearle MS, Sweet RM et al: Surgical simulation: a urological perspective. J Urol 2008; 179: 1690.

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Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C et al: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 1997; 84: 273. 3. Hammond L, Ketchum J and Schwartz BF: A new approach to urology training: a laboratory model for percutaneous nephrolithotomy. J Urol 2004; 172: 1950. 4. Hammond L, Ketchum J and Schwartz BF: Accreditation Council on Graduate Medical Education technical skills competency compliance: urologic surgical skills. J Am Coll Surg 2005; 201: 454. 5. Ehdaie B, Tracy C, Cung B and Schenkman NS: Survey of urology residents for availability of laparoscopic and robotic training. Unpublished data. 6. Collins S, Lehman DS, McDougall EM, Clayman RV and Landman J: AUA Handbook of Laparoscopic and Robotic Fundamentals. Available at http://www.auanet.org/residents/ basiclapguide.pdf.

* Financial interest and/or other relationship with Intuitive Surgical.