See Like an Expert: Gaze-Augmented Training Enhances Skill Acquisition in a Virtual Reality Robotic Suturing Task.

Introduction: The da Vinci Skills Simulator (DVSS) is an effective platform for robotic skills training. Novel training methods using expert gaze patterns to guide trainees have demonstrated superiority to traditional instruction. Portable head-mounted eye-trackers (HMET) offer the opportunity for eye tracking technology to enhance surgical robotic simulation training. Objective: To evaluate if training guided by expert gaze patterns can improve trainee performance over standard movement training techniques during robotic simulation. Methods: Medical students were recruited and randomized into gaze training (GT, n = 9) and movement training (MT, n = 8) groups. First, the participants reviewed an instructional video, with the GT group emulating expert gaze patterns and the MT group (n = 8) standard movement-based instruction. Training consisted of 10 repetitions of "Suture Sponge 3" on the DVSS while wearing HMET; the first three repetitions were followed by group-appropriate video coaching (gaze vs movement feedback), while the remaining repetitions were without feedback. Finally, two multitasking repetitions with a secondary bell-counting task were completed. Primary outcomes included DVSS scores during training and multitasking. Secondary outcomes included metrics collected from the HMET (gaze patterns and gaze entropy). Results: Total score, efficiency, and penalties improved significantly over the training in both groups; the GT group achieved higher scores on every attempt. Total scores in the GT group were higher than the MT group postvideo review (20.3 ± 21.8 vs 3.0 ± 6.2, p = 0.047), after coaching repetitions (61.8 ± 18.8 vs 30.1 ± 26.2, p = 0.01), and at the last training attempt (73.0 ± 16.5 vs 63.1 ± 17.4, p = 0.247). During multitasking, the GT group maintained higher total scores (75 ± 10.1 vs 63.3 ± 15.3, p = 0.01), efficiency (86.3 ± 7.4 vs 77.4 ± 11.2, p = 0.009), and superior secondary task performance (error: 6.3% ± 0.06 vs 10.7% ± 0.11, p = 0.20). Gaze entropy (cognitive-load indicator) and gaze pattern analysis showed similar trends. Conclusion: Gaze-augmented training leads to more efficient movements through adoption of expert gaze patterns that withstand additional stressors.

The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory.

BACKGROUND: There is a significant need for a non-biohazardous, educational platform to equip and maintain the surgical skills required by urology trainees and low-volume implanters for inflatable penile prosthetic (IPP) placement. AIM: To design and develop an anatomic, hydrogel-based simulation platform for training and evaluate IPP placement using modern education theory. METHODS: The backward design concept was used as a framework in the design and development of an IPP simulation platform. Steps included delineating requirements from a physicians' perspective, translating requirements into engineering tasks (deliverables), developing a prototype, and pilot validation. Using a combination of 3-dimensional printing and hydrogel casting, a genitourinary tract model was constructed to replicate the appropriate steps of IPP placement guided by expert feedback. Full-immersion IPP simulations were performed through both infrapubic and penoscrotal approaches by 4 expert surgeons under operative conditions. Questionnaires evaluating the simulation's realism, value as a training tool, and further recommendations were completed. OUTCOMES: Using backward design educational pedagogy, a high-fidelity, full-procedural IPP simulation was fabricated and verified as an adequate educational tool for training and assessment. RESULTS: An expert consensus on the anatomic landmarks, steps and substeps, instruments, and errors to be included in the model was reached using a hierarchical task analysis and was successfully translated into a prototype hydrogel model. Experts performed all appropriate steps of IPP surgery and rated the simulation highly in terms of its realism and value as a training tool. On average, experts agreed that the model could function as a training tool, assessment tool, prerequisite for IPP accreditation, and requirement before live surgery. Experts stated they would have their trainees ideally complete an average of 1.75 models before live surgical training. All experts believed an operative checklist would be an ideal assessment tool. Witthaus MW, Saba P, Melnyk R, et al. The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory. J Sex Med 2020;17:2299-2306.

A history of urolithiasis risk in space.

INTRODUCTION: The development of renal stones in space would not only impact the health of an astronaut but could critically affect the success of the mission. MATERIALS AND METHODS: We reviewed the medical literature, texts and multimedia sources regarding the careers of Dr. Abraham Cockett and Dr. Peggy Whitson and their contributions to the study of urolithiasis in space, as well as the studies in between both of their careers that helped to further characterize the risks of stone formation in space. RESULTS: Dr. Abraham T. K. Cockett (1928-2011) was Professor and Chair of the Department of Urology at the University of Rochester and served as AUA President (1994-1995). In 1962, Dr. Cockett was one of the first to raise a concern regarding astronauts potentially forming renal stones in space and suggested multiple prophylactic measures to prevent stone formation. Many of the early studies in this field used immobilized patients as a surrogate to a micro-gravity environment to mimic the bone demineralization that could occur in space in order to measure changes in urinary parameters. Dr. Peggy A. Whitson (1960-), is a biochemistry researcher and former NASA astronaut. She carried out multiple studies examining renal stone risk during short term space shuttle flights and later during long-duration Shuttle-Mir missions. CONCLUSION: From the early vision of Dr. Cockett to the astronaut studies of Dr. Whitson, we have a better understanding of the risks of urolithiasis in space, resulting in preventive measures for urolithiasis in future long duration space exploration.

Incorporation and validation of clinically relevant performance metrics of simulation (CRPMS) into a novel full-immersion simulation platform for nerve-sparing robot-assisted radical prostatectomy (NS-RARP) utilizing three-dimensional printing and hydrogel casting technology.

OBJECTIVES: To incorporate and validate clinically relevant performance metrics of simulation (CRPMS) into a hydrogel model for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). MATERIALS AND METHODS: Anatomically accurate models of the human pelvis, bladder, prostate, urethra, neurovascular bundle (NVB) and relevant adjacent structures were created from patient MRI by injecting polyvinyl alcohol (PVA) hydrogels into three-dimensionally printed injection molds. The following steps of NS-RARP were simulated: bladder neck dissection; seminal vesicle mobilization; NVB dissection; and urethrovesical anastomosis (UVA). Five experts (caseload >500) and nine novices (caseload <50) completed the simulation. Force applied to the NVB during the dissection was quantified by a novel tension wire sensor system fabricated into the NVB. Post-simulation margin status (assessed by induction of chemiluminescent reaction with fluorescent dye mixed into the prostate PVA) and UVA weathertightness (via a standard 180-mL leak test) were also assessed. Objective scoring, using Global Evaluative Assessment of Robotic Skills (GEARS) and Robotic Anastomosis Competency Evaluation (RACE), was performed by two blinded surgeons. GEARS scores were correlated with forces applied to the NVB, and RACE scores were correlated with UVA leak rates. RESULTS: The expert group achieved faster task-specific times for nerve-sparing (P = 0.007) and superior surgical margin results (P = 0.011). Nerve forces applied were significantly lower for the expert group with regard to maximum force (P = 0.011), average force (P = 0.011), peak frequency (P = 0.027) and total energy (P = 0.003). Higher force sensitivity (subcategory of GEARS score) and total GEARS score correlated with lower nerve forces (total energy in Joules) applied to NVB during the simulation with a correlation coefficient (r value) of -0.66 (P = 0.019) and -0.87 (P = 0.000), respectively. Both total and force sensitivity GEARS scores were significantly higher in the expert group compared to the novice group (P = 0.003). UVA leak rate highly correlated with total RACE score r value = -0.86 (P = 0.000). Mean RACE scores were also significantly different between novices and experts (P = 0.003). CONCLUSION: We present a realistic, feedback-driven, full-immersion simulation platform for the development and evaluation of surgical skills pertinent to NS-RARP. The correlation of validated objective metrics (GEARS and RACE) with our CRPMS suggests their application as a novel method for real-time assessment and feedback during robotic surgery training. Further work is required to assess the ability to predict live surgical outcomes.

Bladder oxidative stress in sleep apnea contributes to detrusor instability and nocturia.

PURPOSE: Obstructive sleep apnea is associated with voiding symptoms in humans and animals, and yet its effects on the urinary tract are poorly understood. We examined bladder structure and function, markers of oxidative damage and the redox survival pathway in a rat model of obstructive sleep apnea to identify changes. MATERIALS AND METHODS: To model obstructive sleep apnea we used a rat oxycycler system to create cyclical interruption in breathing oxygen, thereby producing intermittent hypoxemia. Male Sprague Dawley® rats were divided into an obstructive sleep apnea, a sham treated and a control group of 8 each. After 8-week exposure to obstructive sleep apnea conditions we assessed daytime and nighttime rat voiding behavior in metabolic cages. Cystometrograms were done and bladder tissue was processed for biochemical assays, enzyme-linked immunosorbent assay and transmission electron microscopy. RESULTS: Increased urinary frequency and total urine output developed in rats exposed to obstructive sleep apnea conditions. Cystometric changes included detrusor instability, bladder noncompliance and increased spontaneous contractions. These changes were associated with bladder oxidative stress characterized by significant increases in tissue levels of malondialdehyde and advanced oxidation protein products. Obstructive sleep apnea activated cell survival signaling manifested by increased expression of PI3K and phosphorylated Akt1. Transmission electron microscopy revealed marked ultrastructural damage to subcellular elements. CONCLUSIONS: Intermittent hypoxia in obstructive sleep apnea causes oxidative stress with ultrastructural and functional changes in the bladder. Sleep apnea related nocturia/voiding symptoms could be the result of these direct changes. Untreated sleep apnea has significant health consequences. Identifying urinary oxidative stress products in patients with nocturia may be useful as an economical noninvasive biomarker to identify undiagnosed obstructive sleep apnea.