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Background: Virtual reality (VR) training is widely used for surgical training, supported by comprehensive, high-quality validation. Technological advances have enabled the development of procedural-based VR training. This study assesses the effectiveness of procedural VR compared to basic skills VR in minimally invasive surgery. Methods: 26 novice participants were randomised to either procedural VR (n= 13) or basic VR simulation (n= 13). Both cohorts completed a structured training programme. Simulator metric data were used to plot learning curves. All participants then performed parts of a robotic radical prostatectomy (RARP) on a fresh frozen cadaver. Performances were compared against a cohort of 9 control participants without any training experience. Performances were video recorded and assessed blindly using GEARS post hoc. Results: Learning curve analysis demonstrated improvements in technical skill for both training modalities although procedural training was associated with greater training effects. Conclusions: This trial has shown that a structured programme of procedural VR simulation is effective for robotic training with technical skills successfully transferred to a clinical task in cadavers. Further work to evaluate the role of procedural-based VR for more advanced surgical skills training is required.

Background: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH. Methods: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants. Results: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n= 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P= 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P= 0.0004). No significance differences were achieved in the circle cutting (P= 0.18) or needle guidance tasks (P= 0.32). The RCH group experienced significantly lower workload (P= 0.014) due to lower levels of distraction (P= 0.047). Conclusions: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice. Trial registration: ISRCTN 83733979

To evaluate all simulation models for ophthalmology technical and non-technical skills training and the strength of evidence to support their validity and effectiveness. A systematic search was performed using PubMed and Embase for studies published from inception to 01/07/2019. Studies were analysed according to the training modality: virtual reality; wet-lab; dry-lab models; e-learning. The educational impact of studies was evaluated using Messick’s validity framework and McGaghie’s model of translational outcomes for evaluating effectiveness. One hundred and thirty-one studies were included in this review, with 93 different simulators described. Fifty-three studies were based on virtual reality tools; 47 on wet-lab models; 26 on dry-lab models; 5 on e-learning. Only two studies provided evidence for all five sources of validity assessment. Models with the strongest validity evidence were the Eyesi Surgical, Eyesi Direct Ophthalmoscope and Eye Surgical Skills Assessment Test. Effectiveness ratings for simulator models were mostly limited to level 2 (contained effects) with the exception of the Sophocle vitreoretinal surgery simulator, which was shown at level 3 (downstream effects), and the Eyesi at level 5 (target effects) for cataract surgery. A wide range of models have been described but only the Eyesi has undergone comprehensive investigation. The main weakness is in the poor quality of study design, with a predominance of descriptive reports showing limited validity evidence and few studies investigating the effects of simulation training on patient outcomes. More robust research is needed to enable effective implementation of simulation tools into current training curriculums.

Background: The advent of Virtual Reality technologies presents new opportunities for enhancing current surgical practice. Studies suggest that current techniques in endoscopic surgery are prone to disturbance of a surgeon’s visual-motor axis, influencing performance, ergonomics and iatrogenic injury rates. The Microsoft®HoloLens is a novel head-mounted display that has not been explored within surgical innovation research. This study aims to evaluate the HoloLens as a potential alternative to conventional monitors in endoscopic surgery. Materials and methods: This prospective, observational and comparative study recruited 72 participants consisting of novices (n= 28), intermediate-level (n= 24) and experts (n= 20). Participants performed ureteroscopy, within an inflatable operating environment, using a validated training model and the HoloLens mixed-reality device as a monitor. Novices also completed the assigned task using conventional monitors; whilst the experienced groups did not, due to their extensive familiarity. Outcome measures were procedural completion time and performance evaluation (OSATS) score. A final evaluation survey was distributed amongst all participants. Results: The HoloLens facilitated improved outcomes for procedural times (absolute difference, − 73 s; 95% CI − 115 to − 30; P= 0.0011) and OSAT scores (absolute difference, 4.1 points; 95% CI 2.9–5.3; P< 0.0001) compared to conventional monitors. Feedback evaluation demonstrated 97% of participants agreed or strongly agreed that the HoloLens will have a role in surgical education (mean rating, 4.6 of 5; 95% CI 4.5–4.8). Furthermore, 95% of participants agreed or strongly agreed that the HoloLens is feasible to introduce clinically and will have a role within surgery (mean rating, 4.4 of 5; 95% CI 4.2–4.5). Conclusion: This study demonstrates that the device facilitated improved outcomes of performance in novices and was widely accepted as a surgical visual aid by all groups. The HoloLens represents a feasible alternative to the conventional setup, possibly by aligning the surgeon’s visual-motor axis.

Background Training for robot-assisted thoracic lobectomy remains an issue, prompting the development of virtual reality simulators. Our aim was to assess the construct and face validity of a new thoracic lobectomy module on the RobotiX Mentor, a robotic surgery simulator. We also aimed to determine the acceptability and feasibility of implementation into training.Methods This prospective, observational, and comparative study recruited novice (n = 16), intermediate (n = 9), and expert (n = 5) participants from King's College London, the 25th European Conference on General Thoracic Surgery, and the Society of Robotic Surgery conference 2018. Each participant completed two familiarization tasks followed by the Guided Robotic Lobectomy module and an evaluation questionnaire. Outcome measures were compared using Mann-Whitney Utests.Results Construct validity was demonstrated in 12/21 performance evaluation metrics. Significant differences between groups were found in all metrics including: time taken to complete module, vascular injury, respect for tissue, number of stapler firings, time instruments out of view, number of instrument collisions, and number of movements. Participants deemed aspects of the simulator (mean 3/5) and module (3/5) as realistic and rated the simulator as both acceptable (3.8/5) and feasible (3.8/5) for robotic surgical training.Conclusions Face validity, acceptability, and feasibility were established for the thoracic lobectomy module of the RobotiX Mentor simulator. Moderate evidence of construct validity was also demonstrated. With further work, this simulation module could help to reduce the initial part of the learning curve for trainees and decrease the risk of errors during live training.

The complexity of the operating room requires a surgeon to have both technical ability and an array of nontechnical skills. The emphasis on technical skills during surgical training is well established, however it is deficiencies in nontechnical skills that have been identified as the main cause of errors in the operating room.

To conduct a systematic review of orthopedic training and assessment simulators with reference to their level of evidence (LoE) and level of recommendation.

Otolaryngology is a highly technical and demanding specialty and the requirements for surgical trainees to acquire proficiency remains challenging. Simulation has been purported to be an effective tool in assisting with this. The aim of this systematic review is to identify the available otolaryngology simulators, their status of validation, and evaluation the level of evidence behind each training model and thereby establish a level of recommendation.

Simulation has become widely accepted as a supplementary method of training. Within urology, the greatest number of procedure-specific models and subsequent validation studies have been carried out in the field of endourology. Many generic-skills simulators have been created for laparoscopic and robot-assisted surgery, but only a limited number of procedure-specific models are available. By contrast, open urological simulation has only seen a handful of validated models. Of the available modalities, virtual reality (VR) simulators are most commonly used for endourology and robotic surgery training, the former also employing many high-fidelity bench models. Smaller dry-lab and ex vivo animal models have been used for laparoscopic and robotic training, whereas live animals and human cadavers are widely used for full procedural training. Newer concepts such as augmented-reality (AR) models and patient-specific simulators have also been introduced. Several curricula, including one recommended within, have been produced, incorporating various different training modalities and nontechnical skills training techniques. Such curricula and validated models should be used in a structured fashion to supplement operating room training.

Little integration of technical and nontechnical skills (e.g., situational awareness, communication, decision making, teamwork, and leadership) teaching exists within surgery. We therefore aimed to (1) evaluate the relationship between these 2 skill sets within a simulation-based environment and (2) assess if certain nontechnical skill components are of particular relevance to technical performance.

Current training modalities within ureteroscopy have been extensively validated and must now be integrated within a comprehensive curriculum. Additionally, non-technical skills often cause surgical error and little research has been conducted to combine this with technical skills teaching. This study therefore aimed to develop and validate a curriculum for semi-rigid ureteroscopy, integrating both technical and non-technical skills teaching within the programme. Delphi methodology was utilised for curriculum development and content validation, with a randomised trial then conducted (n= 32) for curriculum evaluation. The developed curriculum consisted of four modules; initially developing basic technical skills and subsequently integrating non-technical skills teaching. Sixteen participants underwent the simulation-based curriculum and were subsequently assessed, together with the control cohort (n= 16) within a full immersion environment. Both technical (Time to completion, OSATS and a task specific checklist) and non-technical (NOTSS) outcome measures were recorded with parametric and non-parametric analyses used depending on the distribution of our data as evaluated by a Shapiro–Wilk test. Improvements within the intervention cohort demonstrated educational value across all technical and non-technical parameters recorded, including time to completion (p< 0.01), OSATS scores (p< 0.001), task specific checklist scores (p= 0.011) and NOTSS scores (p< 0.001). Content validity, feasibility and acceptability were all demonstrated through curriculum development and post-study questionnaire results. The current developed curriculum demonstrates that integrating both technical and non-technical skills teaching is both educationally valuable and feasible. Additionally, the curriculum offers a validated simulation-based training modality within ureteroscopy and a framework for the development of other simulation-based programmes.

To evaluate the urology human cadaver training program developed by the British Association of Urological Surgeons.

Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training.

Although a number of simulators have been introduced for prostate surgery, none have undergone validation for holmium laser enucleation of the prostate training. This study was carried out to assess the face and content validities as well as feasibility and acceptability of the new prostatic hyperplasia model and prostate surgery simulator for holmium laser enucleation of the prostate.

It is estimated that the risk of women acquiring a urinary tract infection (UTI) in their lifetime is greater than 50%. Within a year of successful treatment in a primary care setting, the risk of a recurrent UTI is high: 53% of women older than 55 years and 36% of younger women. A recurrent UTI can be either a relapse or reinfection. A relapse refers to reinfection with the same bacterial strain within 2 weeks of completing treatment. In contrast, reinfections refer to symptomatic infections occurring more than 2 weeks after treatment or after sterile intervening culture. Most cases are caused by reinfection with the original pathogen. Recurrent UTIs are widely defined as 2 or more episodes in the last 6 months or 3 or more episodes in the last 12 months, documented by culture. Patients with recurrences can be recognized through history and examination. Classic symptoms of cystitis include frequency, polyuria, dysuria, pelvic discomfort or pressure, and hematuria. Both management and prevention of recurrent UTI are of utmost significance to clinicians.This article provides an overview of recurrent UTIs and their management, using current information from systematic reviews, randomized controlled trials, and clinical guidelines. A literature search was conducted using MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews databases. Current guidelines on management of recurrent UTIs were obtained through use of a Google search. The authors recommend a pathway for the management of recurrent UTIs, based on the latest evidence.The criterion-standard test for definitive diagnosis of responsible uropathogens is urine microscopy and culture of midstream urine samples. Escherichia coliis the responsible pathogen for both sporadic and recurrent UTI in 70% to 95% of cases. Other causative organisms include Staphylococcus saprophyticus(10%–15% of cases) as well as Klebsiella pneumoniaeand Proteus mirabilis. Current prevention strategies include eliminating lifestyle and other risk factors that increase the risk of acquiring recurrent UTI, antibiotic prophylaxis (continuous, postcoital, and self-initiated), as well as nonantibiotic measures.There is considerable variation in risk factors for recurrent UTI between premenopausal and postmenopausal women. Behavioral risk factors predominate in premenopausal women and include frequency of sexual intercourse, new partners, and use of spermicides or diaphragms. Nonbehavioral risk factors in this age group include maternal history, a previous case of UTI before 15 years of age, and a shorter distance between the urethra and anus. Risk factors in postmenopausal women include cystocele, urogenital surgery, estrogen deficiency, high postvoid residual volume, and a previous UTI. Older women also have a relative depletion of vaginal lactobacilli and an increase in vaginal E. colicompared with premenopausal women.After complete resolution of the acute infection with antibiotic therapy, postcoital prophylaxis, continuous prophylaxis, or self-start empiric treatment may be selected.Trimethoprim, trimethoprim/sulfamethoxazole, nitrofurantoin, and fluoroquinolones are commonly used prophylactic antimicrobial agents. Although nonantibiotic prevention strategies (estrogens, cranberry, vitamin C [ascorbic acid], and methenamine salts) can be considered, there is no strong evidence that any of these measures can be used routinely or as an alternative to antibiotics. Research results are promising for emerging preventive therapies currently under trial, which include vaccinations, d-mannose, and Lactobacillusand other probiotics.To summarize, the authors provide a management pathway for evaluation and treatment that is based on current evidence and guidelines. Although it is important to identify and address risk factors, the most effective method of management remains use of individualized antibiotic prophylaxis. Nonantibiotic prevention strategies (estrogens, cranberry, vitamin C, and methenamine salts) can be considered. However, there is no strong evidence that any of these measures can be used routinely or as an alternative to antibiotics. Preliminary research is promising for a number of emerging therapies (vaccination, d-mannose, and probiotics), but further basic science and randomized controlled trials are needed before any of these therapies can be recommended.