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| Transurethral resection of bladder tumor: A systematic review of simulator-based training courses and curricula |
Panagiotis Kallidonisa,*( ),Angelis Peteinarisa,Gernot Ortnerb,Kostantinos Pagonisa,Costantinos Adamoua,Athanasios Vagionisa,Evangelos Liatsikosa,c,Bhaskar Somanid,Theodoros Tokasb
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aDepartment of Urology, University Hospital of Rion, Patras, Greece
bDepartment of Urology and Andrology, General Hospital Hall I.T., Hall in Tirol, Austria
cMedical University of Vienna, Vienna, Austria
dDepartment of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK |
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Abstract Objective: Transurethral resection of bladder tumor is one of the most common everyday urological procedures. This kind of surgery demands a set of skills that need training and experience. In this review, we aimed to investigate the current literature to find out if simulators, phantoms, and other training models could be used as a tool for teaching urologists. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews. Fifteen out of 932 studies met our inclusion criteria and are presented in the current review. Results: The UroTrainer (Karl Storz GmbH, Tuttlingen, Germany), a virtual reality training simulator, achieved positive feedback and an excellent face and construct validity by the participants. The inspection of bladder mucosa, blood loss, tumor resection, and procedural time was improved after the training, especially for inexperienced urologists and medical students. The construct validity of UroSim® (VirtaMed, Zurich, Switzerland) was established. SIMBLA simulator (Samed GmbH, Dresden, Germany) was found to be a realistic and useful tool by experts and urologists with intermediate experience. The test objective competency model based on SIMBLA simulator could be used for evaluating urologists. The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it. The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity, and 60% of participants would like to use the simulators in the future. The 5-day multimodal training curriculum “Boot Camp” in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project. Conclusion: Simulators and courses or curricula based on a simulator training could be a valuable learning tool for any surgeon, and there is no doubt that they should be a part of every urologist's technical education.
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Received: 22 February 2022
Available online: 20 January 2024
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Corresponding Authors:
*E-mail address: pkallidonis@yahoo.com (P. Kallidonis).
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| Study protocol | Question: simulation options for training in transurethral resection surgery of the bladder tumor | | Population | • Simulation trainers and/or curricula for transurethral surgery of the bladder tumor
• Cadaveric, in vivo, in vitro and virtual reality
• Non-technical skills training | | Intervention | • Transurethral resection of bladder tumor (bipolar or monopolar)
• Transurethral laser-assisted resection or vaporesection of the bladder tumor | | Comparison and outcomes | • Evaluation and reporting of results related to the below factors:
- Efficacy-learning curve-impact to training
- Face, content and construct validation
- Cost-effectiveness | | Search option | • Databases to search: PubMed, Scopus, Cochrane Library of Systematic Reviews, and EMBASE
• Manual search is acceptable. Articles in peer reviewed journals and abstracts from major congresses (EAU, WCE, AUA, and SIU)
• Language: English | | Eligibility criteria | • Any study evaluating cadaveric, in vivo, in vitro, and virtual reality simulators and/or curricula for training in transurethral resection surgery of the bladder tumor | | Search keyword | • Simulat?, train?, curricull?, transurethral, TUR?, vaporesect?, laser, bladder |
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The study protocol (Open Science Framework [www.osf.io]; online in August 2020).
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| Simulator | Specification | Study | Participant, n | Design | Structure | Evaluation | Face validity | Content validity | Construct validity | Specific feature and result | | UroTrainer (Karl Storz GmbH, Tuttlingen, Germany) | • VR
• Simulator consists of a personal computer, a workstation with an integrated mechatronic unit (haptic feedback), and two monitors
• Images (generated by a central software) created by digitized video footage of surgeries and data of cross-sectional imaging
• Choice of 0°, 30°, 70°, or 120° angle endoscope
• Hardware for filling, emptying, and flushing | • Reich et al. 2006 [9] | Overall, 36
Medical student, 24
- Resident, 12 | • Prospective, observational, comparative | • 1 h introduction and 2 h of supervised training in order to achieve certain goals during cystoscopy and bladder tumor resection
• 1-week period between the 1 h and the 2 h of supervised training | • Qualitative and quantitative survey and computer-generated parameters | N/A | N/A | N/A | • Medical student (improvement)
- Bladder mucosa inspected (60%-79%)
- Blood loss (52%-100%)
- Tumor resection (49%-65%)
- Surgery time (96-176 s) | | • Kruck et al. 2011 [19] | • Overall, 30
- Novice, 15
- Expert, 15 | • Prospective, observational, comparative | • 10 min of instruction on the simulator and in the principles of TURBT
• 10 min of hands-on training on the simulator
• Novice: five standardized 5-min TURBTs
• Expert: five times using the VR-PDD-TURBT 5-min program using white light visualization with and without PDD assistance | • Qualitative and quantitative survey and computer-generated parameters | N/A | N/A | N/A | • Comparison between the first and the last session
- Novice: improvement for inspected bladder mucosa (36.8% vs. 54.3%, p<0.05), resection rates (26.5% vs. 52.0%, p<0.05)
- Expert: improvement for bladder mucosa inspected (52.2% vs. 62.7%, p=0.003), resection rate using the PDD (43.8% vs. 57.1%, p=0.002) | | • Neumann et al. 2019 [20] | • Overall (medical student), 51
- Group A, 25
- Group B, 26 | • Prospective, observational, comparative | • Initial VR-UC and VR-TURBT task
• Group A: video-based tutorial by a skilled expert
• Group B: training using a VR program for 30 min | • Qualitative and quantitative survey and computer-generated parameters | N/A | N/A | N/A | • Final VR cystoscopy and VR-TURBT, Group B compared to Group A
- Time (mean: 2.7 min vs. 3.9 min, p=0.007)
- Scope movement (mean: 529 mm vs. 857 mm, p=0.005)
- Accidental bladder injury (mean: 0.88 vs. 3, p=0.003) | | • Schout et al. 2009 [18] | • Overall, 104 (urologists and residents) | • Prospective, observational, comparative | • One VR-TURBT completion between 2006 and 2008 and after surgery evaluation with questionnaires | • Qualitative and quantitative survey | ✔ | ✔ | N/A | • 64 of the TURBT participants (30% experts and 70% novices)
• Mean scores for evaluation: 5.6 to 8.2 (SD 1.4-2.5)
• Willingness to purchase: inexperienced residents (<10 surgeries) were more willing to purchase than experienced (>10 surgeries) (p<0.040) | | • Schulz et al. 2019 [21] | • Overall, 22
- Novice, 15
- Expert, 7 | • Prospective, observational, comparative | • 4 TURBTs
• Self-assessment before and after the surgeries
• Evaluation with questionnaires | • Qualitative and quantitative survey | ✔ | N/A | ✔ | • Construct validity: consultants had greater validity than residents
- Overall scores (p<0.001)
- Safety (p=0.004)
- Visualization (p=0.001)
• Benefit of the training: 4.6 out of 5 | | UroSim® (VirtaMed, Zurich, Switzerland) | • High-fidelity, VR
• Basic unit
• Screen
• Tactile feedback
• Prerecorded cases | • Rafi et al. 2020 [11] | • Overall, 60
- Novice, 30
- Expert, 30 | • Cross-sectional prospective study | • Instructive video of the simulator and how it is used
• 15 min hands-on training
• TURBT of three tumors completion | • Qualitative and quantitative survey | N/A | N/A | ✔ | • Construct validity: experts had greater validity than novices
- Overall scores (p<0.001)
- Tumor resection
- Bleeding control
- Safety
- Visualization | | SIMBLA TURBT simulator (Samed GmbH, Dresden, Germany) | • High-fidelity
• Basic unit (Resection-Trainer LS10-31 2.0) in which the SIMBLA operation case is placed
• Resectable bladder material with anatomical structures and embedded tumors
• Basic unit and resectoscope connected to a continuous irrigation flow system
• Real-life instruments | • de Vries et al. 2016 [12] | • Overall, 76
- Novice, 25
- Intermediate, 26
- Expert, 25 | • Prospective, observational, comparative | • Evaluation of TNA
- 21 identified procedural steps
- 17 technical and non-technical pitfalls
• Validity evaluation
- Bladder map-order of resection
- One complete tumor resection
- One resection until 2 to 3 mm below the surface of the bladder wall
- Presence of the tutor or video recording
- Quality of tumor resection assessed by tutor
- Questionnaire immediately after surgery | • Quantitative and quantitative survey | ✔ | ✔ | ✔ | • TNA: cover by SIMBLA
- 13 of 21 identified procedural steps
- 8 of 17 technical and non-technical pitfalls
• Face validity
- Overall realism: 8/10
- Content validity
1) Most useful: learning eye-hand coordination (score: mean 8 [range 6-10])
2) Least useful: learning to avoid complications (score: mean 6.5 [range 3-9])
• Construct validity (both TURBT cases)
- Resection time: experts shorter than novices (both p<0.05)
- Bladder perforations: novices more than intermediates (p=0.007 and p=0.002) and experts (p=0.002 and p=0.06)
- Overall performance: novices lower than intermediates and experts (both p<0.05) | | • de Vries et al. 2018 [13] | • Overall, 76
- Expert, 25
- Resident, 51 | • Prospective, observational, comparative, multi-central | • Test objective competency-TURBT (51 items divided into 3 phases)
- Preparatory, n=15
- Procedural, n=21
- Completion, n=15
• Evaluation
- TURBTs in simulated setting, n=2
- Assessment by 2 raters
- Questionnaire after surgery | • Quantitative and quantitative survey | N/A | N/A | N/A | • Test objective competency (TURBT): valid by 93% of assessors | | “Homemade’’ TUR-simulator | • Synthetic
• 7 cm of a 30 feet garden hose
• Suprapubic tube
• Tupperware? box (Frankfurt, Germany)
• Catheter plugs
• Silicone gel
• Real-life instruments | • Bach et al. 2009 [10] | • Overall, 11
- Student, 3
- Resident, 3
- Fellow, 2
- Consultant, 3 | • Prospective, observational, comparative | Testing different types of meat to reach realism during TURBT
• Flexible cystoscopies with standard tasks, n=5 | • Qualitative and quantitative survey | N/A | N/A | N/A | • Flexible cystoscopy: average time reduction 50.96%; pork and chicken were more realistic than other types of meat | | AUSTEG porcine model | • Porcine model
• Ex vivo porcine bladders
• Inside out eversion
• Bladder tumor creation with sutures
• Real instruments | • Teoh et al. 2019 [14] | • Overall, 46
- Junior surgeon (<4 years of urology training), 20
- Senior surgeon (>20 years of urology training), 20
- Excluded data, 6 | • Prospective, observational, comparative | • Pre-task questionnaire
• Piecemeal and en bloc resection;
• Assessed by faculty members of the AUSTEG
• Post-task questionnaire | • Qualitative and quantitative survey | ✔ | ✔ | ✔ | • Face validity: useful for training purpose (score: mean±SD 4.30±0.65)
• Content validity: training model was very realistic (score: mean±SD 4.73±0.45)
• Construct validity: senior surgeons > junior (total score: mean±SD 48.05±6.47 vs. 42.70±6.94, p=0.021) | | TURB Mentor? VR simulator (3D Systems/Simbionix, Cleveland, OH, USA) | • VR
• Monitor
• Case
• Real instruments | • Bube et al. 2019 [15] | • Overall, 49
- Novice, 11
- Intermediate, 21
- Expert, 17 | • Prospective, observational, comparative | • Three consecutive TURB modules: total simulator score ([resected pathology]×[inspection of the bladder]/time) | • Qualitative and quantitative survey | N/A | N/A | N/A | • Pass or fail threshold mean score: 22.0
• Mean score:
- Novice: 15.9
- Intermediate: 25.6
- Expert: 30.6 |
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Overview of different simulators for transurethral bladder tumor procedures.
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The Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart. TURBT, transurethral resection of bladder tumor.
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