Predictive Validation of a Robotic Virtual Reality Simulator: The Tube 3 module for Practicing Vesicourethral Anastomosis in Robot-Assisted Radical Prostatectomy

A Systematic Review of New Imaging Technologies for Robotic Prostatectomy: From Molecular Imaging to Augmented Reality

New imaging technologies play a pivotal role in the current management of patients with prostate cancer. Robotic assisted radical prostatectomy (RARP) is a standard of care for localized disease and through the already imaging-based console subject of research towards combinations of imaging technologies and RARP as well as their impact on surgical outcomes. Therefore, we aimed to provide a comprehensive analysis of the currently available literature for new imaging technologies for RARP. On 24 January 2023, we performed a systematic review of the current literature on Pubmed, Scopus and Web of Science according to the PRISMA guidelines and Oxford levels of evidence. A total of 46 studies were identified of which 19 studies focus on imaging of the primary tumor, 12 studies on the intraoperative tumor detection of lymph nodes and 15 studies on the training of surgeons. While the feasibility of combined approaches using new imaging technologies including MRI, PSMA-PET CT or intraoperatively applied radioactive and fluorescent dyes has been demonstrated, the prospective confirmation of improvements in surgical outcomes is currently ongoing.

Virtual reality and surgical oncology

More than 80% of people diagnosed with cancer will require surgery. However, less than 5% have access to safe, affordable and timely surgery in low- and middle-income countries (LMICs) settings mostly due to the lack of trained workforce. Since its creation, virtual reality (VR) has been heralded as a viable adjunct to surgical training, but its adoption in surgical oncology to date is poorly understood. We undertook a systematic review to determine the application of VR across different surgical specialties, modalities and cancer pathway globally between January 2011 and 2021. We reviewed their characteristics and respective methods of validation of 24 articles. The results revealed gaps in application and accessibility of VR with a proclivity for high-income countries and high-risk, complex oncological surgeries. There is a lack of standardisation of clinical evaluation of VR, both in terms of clinical trials and implementation science. While all VR illustrated face and content validity, only around two-third exhibited construct validity and predictive validity was lacking overall. In conclusion, the asynchrony between VR development and actual global cancer surgery demand means the technology is not effectively, efficiently and equitably utilised to realise its surgical capacity-building potential. Future research should prioritise cost-effective VR technologies with predictive validity for high demand, open cancer surgeries required in LMICs.

Simulation-based education in urology - an update

Over the past 30 years surgical training, including urology training, has changed from the Halstedian apprenticeship-based model to a competency-based one. Simulation-based education (SBE) is an effective, competency-based method for acquiring both technical and non-technical surgical skills and has rapidly become an essential component of urological education. This article introduces the key learning theory underpinning surgical education and SBE, discussing the educational concepts of mastery learning, deliberate practice, feedback, fidelity and assessment. These concepts are fundamental aspects of urological education, thus requiring clinical educators to have a detailed understanding of their impact on learning to assist trainees to acquire surgical skills. The article will then address in detail the current and emerging simulation modalities used in urological education, with specific urological examples provided. These modalities are part-task trainers and 3D-printed models for open surgery, laparoscopic bench and virtual reality trainers, robotic surgery simulation, simulated patients and roleplay, scenario-based simulation, hybrid simulation, distributed simulation and digital simulation. This article will particularly focus on recent advancements in several emerging simulation modalities that are being applied in urology training such as operable 3D-printed models, robotic surgery simulation and online simulation. The implementation of simulation into training programmes and our recommendations for the future direction of urological simulation will also be discussed.

Association of Suturing Technical Skill Assessment Scores Between Virtual Reality Simulation and Live Surgery

Introduction: Robotic surgical performance, in particular suturing, has been linked to postoperative clinical outcomes. Before attempting live surgery, virtual reality (VR) simulators afford opportunities for training surgeons to learn fundamental technical skills. Herein, we evaluate the association of suturing technical skill assessments between VR simulation and live surgery, and functional clinical outcomes. Materials and Methods: Twenty surgeons completed a VR suturing exercise on the Mimic™ Flex VR simulator and the anterior vesicourethral anastomosis during robot-assisted radical prostatectomy (RARP). Three independent and blinded graders provided technical skill scores using a validated assessment tool. Correlations between VR and live scores were assessed by Spearman's correlation coefficients (ρ). In addition, 117 historic RARP cases from participating surgeons were extracted, and the association between VR technical skill scores and urinary continence recovery was assessed by a multilevel mixed-effects model. Results: A total of 20 (6 training and 14 expert) surgeons participated. Statistically significant correlations for scores provided between VR simulation and live surgery were found for overall and needle driving scores (ρ = 0.555, p = 0.011; ρ = 0.570, p = 0.009, respectively). A subanalysis performed on training surgeons found significant correlations for overall scores between VR simulation and live surgery (ρ = 0.828, p = 0.042). Expert cases with high VR needle driving scores had significantly greater continence recovery rates at 24 months after RARP (98.5% vs 84.9%, p = 0.028). Conclusions: Our study found significant correlations in technical scores between VR and live surgery, especially among training surgeons. In addition, we found that VR needle driving scores were associated with continence recovery after RARP. Our data support the association of skill assessments between VR simulation and live surgery and potential implications for clinical outcomes.

Are basic robotic surgical skills transferable from the simulator to the operating room? A randomized, prospective, educational study

INTRODUCTION

We aimed to assess the transferability of basic robotic skills from the simulator to the operating room (OR) while performing robotic-assisted radical prostatectomy (RARP).

METHODS

Fourteen urology residents were randomized into two groups: group A was required to practice three sessions (nine tasks each) on the simulator, whereas group B was required to practice (same nine tasks) until they reached competency. Both groups were recorded while practicing on the da Vinci Surgical Skills Simulator. Both groups were then recorded while performing bladder mobilization during RARP. Senior residents from both groups were also recorded while performing urethro-vesical anastomosis during RARP. Recordings were assessed blindly using the validated Global Evaluative Assessment of Robotic Skills (GEARS) tool by C-SATS. Spearman's correlation coefficient (rho) was used to assess correlation between GEARS scores from practice sessions on the da Vinci Simulator and the GEARS scores from bladder mobilization and urethro-vesical anastomosis during RARP.

RESULTS

There was no difference in total GEARS scores between the two groups in the OR. Total GEARS scores for "ring and rail 2" and "suture sponge" tasks correlated with the total GEARS scores during urethro-vesical anastomosis (rho=0.86, p=0.007; rho=0.90, p=0.002, respectively). GEARS' efficiency component during "energy and dissection" task on the da Vinci Simulator correlated with GEARS' efficiency component during bladder mobilization (rho=0.62, p=0.03). GEARS' force sensitivity component during "ring and rail 2" and "dots and needles" tasks on the da Vinci Simulator correlated with GEARS' force sensitivity component during bladder mobilization (rho=0.58, p=0.047; rho =0.65, p=0.02, respectively).

CONCLUSIONS

Objective assessments of urology residents on the da Vinci Surgical Skills Simulator tasks ring and rail 2 and suture sponge correlated with their objective assessments of bladder mobilization and urethro-vesical anastomosis. Therefore, basic robotic skills could be transferred from the simulator to the OR.

Current Status of Simulation Training in Urology: A Non-Systematic Review

Simulation has emerged as an effective solution to increasing modern constraints in surgical training. It is recognized that a larger proportion of surgical complications occur during the surgeon's initial learning curve. The simulation takes the learning curve out of the operating theatre and facilitates training in a safe and pressure-free environment whilst focusing on patient safety. The cost of simulation is not insignificant and requires commitment in funding, human resources and logistics. It is therefore important for trainers to have evidence when selecting various simulators or devices. Our non-systematic review aims to provide a comprehensive up-to-date picture on urology simulators and the evidence for their validity. It also discusses emerging technologies and future directions. Urologists should embed evidence-based simulation in training programs to shorten learning curves while maintaining patient safety and work should be directed toward a validated and agreed curriculum.

Creating a low-cost virtual reality surgical simulation to increase surgical oncology capacity and capability

Worldwide, more than 80% of people with cancer will require surgery during their disease course, but less than 25% have access to safe, affordable and timely surgery. Among the barriers to increasing surgical capacity are the time and costs required to train novices. Virtual reality (VR) surgical simulations can reduce the time required for novices to reach surgical proficiency, though their costs may exceed USD $100,000. The goal of this study was to determine if a low-cost system, using commercially available technology designed for in-home computer gaming, could be used to create a realistic VR surgical oncology simulation. Standard commercially available VR software and Oculus Rift hardware have been used to provide high-quality visuals and believable surgeon hand interactions. Near identical VR reproduction of an operating room using 1:1 scale matching of real-world elements, including equipment, instruments, supplies and sounds, maintaining frame rate greater than 60 fps to maintain visual fidelity has been created. Internal anatomy was designed as VR replica of human female pelvic anatomy, including organs, veins and other vessels, peritoneum and connective tissue. Internal anatomy was designed to run at 120 fps and to allow for a realistic abdominal radical hysterectomy simulation. Surgical hands were modelled to scale for those with large and small hands. Multiple hand positions were simulated using Oculus touch hardware. Reconstructing the virtual environment to simulate reality as accurately as possible was done to immerse users in the simulator so that they focus on learning and practise without distractions. Training modules were co-designed by experts in learning sciences, human behaviour, VR and gynaecologic oncology. We have successfully created a low-cost VR simulation to help prepare novice surgeons to perform a radical abdominal hysterectomy surgery procedure. The simulation can be used with commercially available computer gaming hardware that currently costs less than USD $1,500. Low-cost VR simulation has the potential to reduce the time and cost to train surgeons to perform surgical oncology procedures, as well as both improve and audit quality. If effective in real-world clinical trials, such simulations have relevance to multiple surgical procedures and applicability in both resource-limited and high-income settings.