Training novice robot surgeons: Proctoring provides same results as simulator-generated guidance.

To understand the influence of proctored guidance versus simulator generated guidance (SGG) on the acquisition dexterity skills in novice surgeons learning RAS (robot assisted surgery). Prospective non-blinded 3-arm randomised controlled trial (RTC). Exclusion criteria: previous experience in RAS or robotic surgery simulation. The participants were assigned to three different intervention groups and received a different form of guidance: (1) proctored guidance, (2) simulator generated guidance, (3) no guidance, during training on virtual reality (VR) simulator. All participants were asked to complete multiple questionnaires. The training was the same in all groups with the exception of the intervention part. Catharina Hospital Eindhoven, The Netherlands. A total of 70 Dutch medical students, PhD-students, and surgical residents were included in the study. The participants were randomly assigned to one of the three groups. Overall, all the participants showed a significant improvement in their dexterity skills after the training. There was no significant difference in the improvement of surgical skills between the three different intervention groups. The proctored guidance group reported a higher participant satisfaction compared to the simulator-generated guidance group, which could indicate a higher motivation to continue the training. This study showed that novice surgeons. Significantly increase their dexterity skills in RAS after a short time of practicing on simulator. The lack of difference in results between the intervention groups could indicate there is a limited impact of "human proctoring" on dexterity skills during surgical simulation training. Since there is no difference between the intervention groups the exposure alone of novice surgeons to the robotic surgery simulator could possibly be sufficient to achieve a significant improvement of dexterity skills during the initial steps of RAS learning.

Structured robot-assisted surgery training curriculum for residents in Urology and impact on future surgical activity.

To gain insight into the availability of training for robot assisted surgery (RAS) and the possibility to perform RAS during Dutch residency curriculum and to analyze the effects on surgical skills by the introduction of an advanced course in RAS for residents. A combination of a validated snap shot survey and a prospective cohort study. Structured advanced RAS training including virtual reality (VR) simulation, dry and wet lab facility at ORSI academy (Belgium). A snap-shot survey has been sent to all the residents and specialists in Urology graduated during the years 2017-2020 in Netherlands. Among residents, only last year residents (5th and 6th year) have been considered for the RAS training. Although most of the residents (88.2%) and young urologists (95%) were asked to follow a basic training or meet basic requirements before starting RAS, the requirements set by the educators were different from center to center. Some of them were required to attend only an online course on RAS, whereas others were asked to achieve threshold scores at VR simulator and participate in a standardized course at a training institute. The attendance to a structured advanced course in RAS showed a significant increase in surgical skills. Our study shows residents in urology are allowed to perform RAS during their residency though the criteria for starting RAS differ significantly amongst the teaching hospitals. To guarantee a basic level of skills and knowledge a structured, (multi-step) training and certification program for RAS should be implemented.

Validation and implementation of surgical simulators: a critical review of present, past, and future.

BACKGROUND: In the past 20 years the surgical simulator market has seen substantial growth. Simulators are useful for teaching surgical skills effectively and with minimal harm and discomfort to patients. Before a simulator can be integrated into an educational program, it is recommended that its validity be determined. This study aims to provide a critical review of the literature and the main experiences and efforts relating to the validation of simulators during the last two decades. METHODS: Subjective and objective validity studies between 1980 and 2008 were identified by searches in Pubmed, Cochrane, and Web of Science. RESULTS: Although several papers have described definitions of various subjective types of validity, the literature does not offer any general guidelines concerning methods, settings, and data interpretation. Objective validation studies on endourological simulators were mainly characterized by a large variety of methods and parameters used to assess validity and in the definition and identification of expert and novice levels of performance. CONCLUSION: Validity research is hampered by a paucity of widely accepted definitions and measurement methods of validity. It would be helpful to those considering the use of simulators in training programs if there were consensus on guidelines for validating surgical simulators and the development of training programs. Before undertaking a study to validate a simulator, researchers would be well advised to conduct a training needs analysis (TNA) to evaluate the existing need for training and to determine program requirements in a training program design (TPD), methods that are also used by designers of military simulation programs. Development and validation of training models should be based on a multidisciplinary approach involving specialists (teachers), residents (learners), educationalists (teaching the teachers), and industrial designers (providers of teaching facilities). In addition to technical skills, attention should be paid to contextual, interpersonal, and task-related factors.

Linking surgical skills to postoperative outcomes: a Delphi study on the robot-assisted radical prostatectomy.

OBJECTIVE: To develop an assessment instrument for the evaluation of surgical videos to elucidate the association between surgical skills and postoperative outcomes after a robot-assisted radical prostatectomy (RARP). DESIGN: A Delphi study consisting of two consecutive online surveys and a consensus group meeting. SETTING: Urology departments of general, teaching and university hospitals in the Netherlands. PARTICIPANTS: All Dutch urologists with a specialization in RARP. RESULTS: Of 18 invited experts, 12 (67%) participated in the first online survey. In the second round, 9 of the 18 invited experts participated (50%). The Delphi meeting was attended by 5 of the 18 (27%) invited experts. The panel identified seven surgical steps with a possible association to postoperative outcomes. The experts also expected an association between adverse postoperative outcomes and the frequency of camera removals, the number of stitches placed, the amount of bleeding, and the extent of coagulation. These factors were incorporated into an assessment instrument. CONCLUSIONS: Experts in the field of RARP achieved consensus on 7 surgical steps and 4 aspects of the RARP procedure that may be related to adverse postoperative outcomes. The resulting assessment instrument will be tested in future research to determine its validity.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands.

BACKGROUND: Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands. METHODS: Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire. RESULTS: A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines. CONCLUSIONS: A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Impact of comorbidity on treatment and prognosis of prostate cancer patients: a population-based study.

This study investigates the independent influence of serious comorbidity and age on treatment and survival of prostate cancer patients diagnosed between 1995 and 2002 in the southern part of the Netherlands. Eight percent of patients<60 years had two or more concomitant diseases versus 27% of those aged 80 years or older. The number of patients undergoing radical prostatectomy or curative radiotherapy decreased significantly with increasing age. The proportion of patients aged 60-69 years undergoing prostatectomy decreased significantly from 32% of patients without comorbidity to 17% of patients with two or more comorbid conditions and from 8% to 3%, respectively, of those aged 70-79 years. The risk of dying was significantly higher for patients with two or more comorbid conditions compared to patients without comorbidity. Serious comorbidity led to less aggressive treatment and negatively affected the prognosis of prostate cancer patients aged 60-79 years.

The use of a memokath prostatic stent for obstructive voiding symptoms after brachytherapy.

INTRODUCTION: Brachytherapy may be complicated by serious obstructive voiding symptoms (OVS). Only conservative treatment options are available in the first 6 months after brachytherapy. We evaluated safety, efficacy and patient tolerance of the Memokath prostatic stent (MPS). MATERIAL AND METHODS: A MPS was placed in 10 patients with OVS after brachytherapy. Evaluation included uroflowmetry, international prostate symptom score (IPSS), prostate volume and urethrocystoscopy before and 3 months after placement of the stent. RESULTS: Both the IPSS and uroflowmetry results significantly improved after stent insertion. The mean IPSS decreased from 29/5 to 11/1 and the mean Qmax from the uroflowmetry improved from 4.7 to 11.2 ml/s. The 5 patients who were catheter dependent voided spontaneously with a mean Qmax of 15 ml/s. Two stents migrated towards the bladder, and those patients needed a second stent which was placed without complications. Removal of the stent was easy to perform. Adverse effects were minor with perineal pain and irritative voiding symptoms occurring in 5 patients mainly in the first weeks after insertion. This did not negatively influence quality of life and all patients were more satisfied with the stent than without. CONCLUSIONS: The MPS provides a safe, effective, and completely reversible treatment for patients with OVS after brachytherapy and was well tolerated.

Virtual reality laparoscopic nephrectomy simulator is lacking in construct validity.

BACKGROUND AND PURPOSE: Several training models have been developed to improve surgeons' operative skills as well as patient outcomes. Before implementing these models in training programs, their usefulness and accuracy need to be assessed. In this study, we examined the ability of a laparoscopic nephrectomy (LN) virtual reality (VR) simulator to distinguish between different levels of expertise (construct validity). METHODS: Twenty-two novices (no LN experience), 32 intermediates (<10 LN procedures performed) and 10 experienced urologists (> or =10 LN procedures performed) performed the same retroperitoneal task on the LN VR simulator (Mentice, Sweden) three times, performing a practice task before and after the second time. Outcome parameters were time, blood loss, path length, and total score (combination of 62 different parameters). RESULTS: No significant differences were found between intermediate and experienced participants. Task 3 performance showed no significant difference between any of the groups. Both intermediates and experienced participants were significantly faster than novices on the first two tasks and had a better total score. Learning curves of intermediate and experienced participants were flat after task two. CONCLUSIONS: The LN-VR simulator did not distinguish between intermediate and experienced participants. The analysis of the learning curves suggests that the tasks measured dexterity in using the simulator rather than an actual improvement of operative skills. We conclude that the LN-VR simulator does not have sufficient construct validity and is therefore, in its present form, not suitable for implementation in a urologic training program.