Survey Of Virtual Reality Urologic Simulators

Surgical simulation modules have been classified according to whether they train the technical components of a procedure or strictly the cognitive components. Basic skills trainers train basic psychomotor and/or visual spatial skills that are proposed to translate into improved skills in clinical application. Simple task trainers focus on a specific construct within the context of a procedure like trocar insertion. Many of the existing box trainer physical models are examples of simple task simulators. Complex task trainers focus on a more complicated construct such as percutaneous access to the kidney or the renal hilar dissection and transection. Complete procedure modules allow the user to do cases from start to finish and may include simple and complex task trainers as submodules. The UW transurethral resection of the prostate simulator and the ureteroscopic module for UroMentor are examples of such trainers. Cognitive training modules are designed to provide for training and assessment of medical decision making and interactive mental surgical rehearsal and are less focused on the visual-spatial/psychomotor components. The following is a review of known current applications.

Digital Rectal Examination Simulators

Digital rectal examination for prostate cancer is an important basic skill for any urology training program. The gold standard method of teaching prostate cancer detection is either on patients with a repeat examination being done by the trainer or with a physical model simulator like the one provided by Merck, Heath Edco,g "prostate training kit." Unlike many of the other skill sets in urology where visual feedback dominates over tactile feedback, with digital rectal examination, the sense of touch is paramount. Using a silicon graphics inc. workstation, four prostates were modeled, which were similar to the Merck physical models, and a PHANToM haptic interface was used to provide force feedback.

Medical students had a 67% correct diagnosis rate of malignant versus nonmalignant cases compared with 56% for urology residents. Residents felt the content (force feedback) lacked realism and concurrent validity was not demonstrated, as residents were able to correctly identify malignancy on the Merck trainer (gold standard) 96% of the time (39).

Pugh et al. designed a pelvic examination simulator that also uses force feedback, which is now owned and distributed by Medical Education Technologies Inc. (METI).h It will soon include a digital rectal exam module.

Percutaneous Access

Percutaneous access is a skill set that requires excellent visual-spatial awareness and experience.

Simbionix designed a module on the UroMentor platform called PercMentori that attempts to train these skills. It provides a mannequin and a needle that is tracked as it enters the virtual anatomy. The kidney exhibits respiratory variation and the trainee has

SWaco, Texas, U.S.A. hSarasota, Florida, U.S.A. 'Simbionix, Lod, Israel.

One of the oldest cognitive "simulators" is the surgical atlas.

When designed and studied in coordination with their technical skills trainer counterparts, cognitive trainers may actually be able to determine not only if an error has occurred but also dissect whether it was an error in cognition, psychomotor skills, or visual spatial orientation.

to navigate the needle into the calyx and slip a wire past the virtual stone. The user learns c-arm manipulation and can either use the standard fluoroscopic view or the anatomical view as a teaching aid. Metrics include time to task, injury to blood vessels, perforation of the collecting system, amount of contrast used, and rib injuries. Matsumoto et al. presented data in abstract form showing that novice residents from two residency programs who train on the simulator have fewer attempts, use less fluoroscopy, and have fewer errors on the simulator than those who do not train between trials. Content, construct, concurrent and predictive validity studies are currently lacking but are underway. Training in ultrasound-guided access and percutaneous lithotripsy/nephrolithotomy currently are not features of this simulator, but would add substantially to this product.

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