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Objective: Different simulation modalities may be utilised in a curricular fashion to benefit from the strengths of each training model. The aim of this study is to evaluate a novel multi-modality ureterorenoscopy (URS) simulation curriculum in terms of educational value, content validity, transfer of skills and inter-rater reliability., Methods: This international prospective study recruited urology residents (n = 46) with ≤ 10 URS experience and no prior simulation training. Participants were guided through each phase of the expert-developed SIMULATE URS curriculum by trainers and followed-up in the operating room (OR). Video recordings were obtained during training. A post-training evaluation survey was distributed to evaluate content validity and educational value, using descriptive statistics. Performance was evaluated using the objective structured assessment of technical skills (OSATS) scale to measure improvement in scores throughout the curriculum. Pearson's correlation coefficient and Cohen's kappa tests were utilised to investigate correlation and agreement between raters., Results: Participants reported gaining OR-transferrable skills (Mean: 4.33 ± 0.67) and demonstrated marked improvement in throughout the curriculum, transferred to the OR for both semi-rigid URS (p = 0.004) and flexible URS (p = 0.007). 70% of participants were successfully followed-up in the OR (n = 32). No differences were identified with the additional use of fresh frozen cadavers (p = 0.85, p = 0.90) and the URO Mentor VR simulator (p = 0.13, p = 0.22). A moderate level of correlation was noted on the video OSATS assessments, between two expert assessors (r = 0.70), but a poor agreement with the live rating., Conclusion: The SIMULATE URS training curriculum received high educational value from participants, who demonstrated statistically significant improvement with consecutive cases throughout the curriculum and transferability of skills to the OR in both semi-rigid and flexible URS., (© 2021. The Author(s).)

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.

Objective: In the last decade non-technical skills (NTS) have emerged as a vital area for improvement within surgery. This study aims to develop and evaluate a Non-technical Skills for Urological Surgeons (NoTSUS) training curriculum and assessment scale., Methods: This international, longitudinal and observational study began with a 3-round Delphi methodology to refine curriculum contents and rating scale. Sessions with up to four participants were delivered where each candidate undertook an independent scenario within the validated full immersion simulation environment. Candidates were assessed using both the NoTSS (Non-technical Skills for Surgeons) and NoTSUS rating scales by NTS-trained and non-trained experts. A post-training evaluation survey was distributed., Results: 62 participants comprising trainees (n = 43) and specialists (n = 19) undertook the NoTSUS course. The NoTSS and NoTSUS scales correlated well, with a mean difference of 3.3 in the overall total (p = 0.10, r = 0.53). However, there was significant differences in scores between the NoTSS-trained and non-trained raters (n = 28, p = 0.03). A one-way ANOVA test revealed significant improvement throughout the four simulation scenarios in each session (p = 0.02). The NoTSUS curriculum received positive feedback from participants and demonstrated educational value and acceptability., Conclusions: The NoTSUS curriculum has demonstrated high educational value for NTS training aimed at urologists, with marked improvement throughout sessions. Correlation of NoTSUS and NoTSS scales proves its suitability for evaluating NTS in future training. Demonstration of inter-rater reliability indicates that the scale is reliable for use in assessment by expert faculty members. Furthermore, qualitative feedback from participants suggests gain of transferrable skills over the course.

To assess the role of live porcine simulation in robotic surgical skills training. A qualitative and quantitative survey was conducted of participants of a live porcine robotic simulation course undertaken in a regional training centre. Data on participants' experience, robotic surgical ability, the educational impact and outcomes from the course were collected. Thirty-nine participants from four different countries completed the survey. Clinical experience varied; however, prior robotic surgical experience (median 0 cases, range 0-100) and technical ability were low. The perceived usefulness, effectiveness and realism of the training course were all highly scored. Participants rated the most useful course components as port placement and docking, basic robotic skills training and repair of a bladder injury. Training resulted in significant increases in technical ability (p < 0.0001). Following the course, 49% of participants continued to either train or perform robotic surgery. This survey demonstrates that live porcine simulation for robotic surgery is a highly valued, acceptable and feasible form of training. The majority of participants were relatively inexperienced but nonetheless significant improvements in technical ability were reported. The results of this survey support the use of live porcine training for robotic surgery.

Objectives: To report the study protocol for the first international multicentre randomized controlled trial investigating the effectiveness of simulation-based surgical training and the development process for an evidence-based training curriculum, to be delivered as an educational intervention., Participants and Methods: This prospective, international, multicentre randomized controlled clinical and educational trial will recruit urology surgical trainees who must not have performed ≥10 of the selected index procedure, ureterorenoscopy (URS). Participants will be randomized to simulation-based training (SBT) or non-simulation-based training (NSBT), the latter of which is the current sole standard of training globally. The primary outcome is the number of procedures required to achieve proficiency, where proficiency is defined as achieving a learning curve plateau of 28 or more on an Objective Structured Assessment of Technical Skills (OSATS) assessment scale, for three consecutive operations, without any complications. All participants will be followed up either until they complete 25 procedures or for 18 months. Development of the URS SBT curriculum took place through a two-round Delphi process., Results: A total of 47 respondents, consisting of trainees (n = 24) with URS experience and urolithiasis specialists (n = 23), participated in round 1 of the Delphi process. Specialists (n = 10) finalized the content of the curriculum in round 2. The developed interventional curriculum consists of initial theoretic knowledge through didactic lectures followed by select tasks and cases on the URO-Mentor (Simbionix, Lod, Israel) VR Simulator, Uro-Scopic Trainer (Limbs & Things, Bristol, UK) and Scope Trainer (Mediskills, Manchester, UK) models for both semi-rigid and flexible URS. Respondents also selected relevant non-technical skills scenarios and cadaveric simulation tasks as additional components, with delivery subject to local availability., Conclusions: SIMULATE is the first multicentre trial investigating the effect and transferability of supplementary SBT on operating performance and patient outcomes. An evidence-based training curriculum is presented, developed with expert and trainee input. Participants will be followed and the primary outcome, number of procedures required to proficiency, will be reported alongside key clinical secondary outcomes, (ISCRTN 12260261)., (© 2020 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: Virtual reality (VR) and dry-lab simulation have been widely validated for robotic surgical training. Both modalities are used during the early stages of the learning curve, yet, no comparative analysis of the two modalities has been undertaken. This study compares the effectiveness of VR and dry-lab simulation for basic robotic surgical skill training. Methods: A comparative study of 43 robotic novices was undertaken at two centers in the United Kingdom and Italy. Participants were allocated to either VR or dry-lab simulation and completed a robotic simulation training program. On completion, all participants were assessed by performing a urethrovesical anastomosis on a synthetic model. Technical proficiency was measured by two trained raters using the Global Evaluative Assessment of Robotic Skills (GEARS) tool. All participants completed a qualitative posttraining assessment questionnaire. Results: Baseline characteristics were equal between the two groups. Both VR and dry-lab training led to a significant improvement in technical proficiency. Overall mean GEARS scores increased by 5.6 and 2.5 following dry-lab and VR simulation training, respectively ( p  = 0.034). Dry-lab training showed significantly greater improvements than VR simulation, but only after the third training session. Both techniques were highly rated by participants. Conclusions: Both VR and dry-lab simulation were effective in improving robotic surgical skill but were not equal. For more advanced skill training, dry-lab training was found to be superior to VR simulation. Dry-lab training offers specific benefits to robotic surgical training and should remain a principal component of the simulation curriculum.

Background: Tools for assessment of technical skills are a crucial part of surgical education. They provide trainees with quantitative feedback highlighting both proficiency and areas for improvement. For this to be relevant to day-to-day practice, the tools used have to be validated and relevant to each surgical situation. This study aims to evaluate the validity of assessment tools used within surgery., Materials and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted searching the MEDLINE and Embase databases (International Prospective Register of Systematic Reviews: CRD42018104674). Studies utilizing any assessment tool in any surgical specialty were included. Messick's criteria were used for literature evaluation, and the Modified Educational Oxford Centre for Evidence-Based Medicine was used to assess levels of recommendation., Results: A total of 303 studies and 76 tools were included. The most commonly used tool was Objective Structured Assessment Tool Skills (OSATS; n = 137, 45.2%). OSATS was used in conjunction with another tool or tools in an additional 55 studies (18.2%). Seven further tools were used in at least 3 studies. A total of five studies evaluated contained all five aspects of Messick's validity., Conclusions: There are several widely validated tools for assessing technical skills, the most common of which is OSATS. There is an emerging trend for crowdsourcing as a quick, cheap method for assessment of technical skills. This technique has been validated using both GEARS and GOALS. Numerous tools were found to be used only once and demonstrate a tendency for units to create their own tools for a specific task or specialty., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The increasing challenges facing the training of future neurosurgeons have led to continued development of simulation-based training, particularly for neurosurgical subspecialties. The simulators must be scientifically validated to fully assess their benefit and determine their educational effects. In this second part, we aim to identify the available simulators for spine, pediatric neurosurgery, interventional neuroradiology, and nontechnical skills, assess their validity, and determine their effectiveness., Methods: Both Medline and Embase were searched for English language articles that validate simulation models for neurosurgery. Each study was screened according to the Messick validity framework, and rated in each domain. The McGaghie model of translational outcomes was then used to determine a level of effectiveness for each simulator or training course., Results: Overall, 114 articles for 108 simulation-based training models or courses were identified. These articles included 24 for spine simulators, 3 for nontechnical skills, 10 for 9 pediatric neurosurgery simulators, and 12 for 11 interventional neuroradiology simulators. Achieving the highest rating for each validity domain were 3 models for content validity; 16 for response processes; 1 for internal structure; 2 for relations to other variables; and only 1 for consequences. For translational outcomes, 2 training courses achieved a level of effectiveness of >2, showing skills transfer beyond the simulator environment., Conclusions: With increasing simulators, there is a need for more validity studies and attempts to investigate translational outcomes to the operating theater when using these simulators. Nontechnical skills training is notably lacking, despite demand within the field., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The endoscopic stone treatment step 1 (EST s1) protocol has been developed after 2 years of collaborative work between different European Association of Urology (EAU) sections., Objectives: In this study, we added construct validity evidence to the EST s1 curriculum., Materials and Methods: The EST-s1 curriculum includes four standardized tasks: flexible cystoscopy, rigid cystoscopy, semi-rigid URS and flexible URS. Validation was performed during the annual 2016 EUREP meeting in Prague. 124 participants provided information on their endoscopic logbook and carried out these 4 tasks during a DVD recorded session. Recordings were anonymized and blindly assessed independently by five proctors. Inter-rater reliability was checked on a sample of five videos by the calculation of intra-class correlation coefficient. Task-specific clinical background of participants was correlated with their personal performance on the simulator. Breakpoint analysis was used to define the minimum number of performed cases, to be considered "proficient". "Proficient" and "Non-proficient" groups were compared for construct validity assessment. Likert scale-based questionnaires were used to test content and to comment on when the EST-s1 exams should be undertaken within the residency program., Results: 124 participants (105 final-year residents and 19 faculty members) took part in this study. The breakpoint analysis showed a significant change in performance curve at 36, 41, 67 and 206 s, respectively, corresponding to 30, 60, 25 and 120 clinical cases for each of the 4 tasks. EST-s1 was scored as a valid training tool, correctly representing the procedures performed in each task. Experts felt that this curriculum is best used during the third year of residency training., Conclusion: Our validation study successfully demonstrated correlation between clinical expertise and EST-s1 tasks, adding construct validity evidence to it. Our work also demonstrates the successful collaboration established within various EAU sections.

Objective: The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aim to identify the currently available simulators and training courses for neurosurgery, assess their validity, and determine their effectiveness., Methods: Both MEDLINE and Embase were searched for English language articles which validate simulation models for neurosurgery. Each study was screened according to the Messick validity framework and rated in each domain. The McGaghie model of translational outcomes was then used to determine a level of effectiveness (LoE) for each simulator or training course., Results: On screening of 6006 articles, 114 were identified to either validate or determine an LoE for 108 simulation-based training models or courses. Achieving the highest rating for each validity domain were 6 models and training courses for content validity, 12 for response processes, 4 for internal structure, 14 for relations to other variables, and none for consequences. For translational outcomes, 6 simulators or training achieved an LoE >2 and thus showed skills transfer beyond the simulation setting., Conclusions: With the advent of increasing neurosurgery simulators and training tools, there is a need for more validity studies. Further attempts to investigate translational outcomes to the operating theater when using these simulators is particularly warranted. More training tools incorporating full-immersion simulation and nontechnical skills training are recommended., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Difficult surgical procedures may result in a higher mental workload, leading to increased fatigue and subsequent errors. This study was aimed to investigate the effect of repeated simulation training in ureterorenoscopy in a high-fidelity setting on the performance and mental workload of novice operators., Methods: Medical students voluntarily participated in the present simulation study. After a didactic and video-based lecture, they underwent simulation training involving a renal stone case, including a rigid cystoscope component (task 1, performing a WHO checklist, assembling a scope, and insertion of a guide-wire and an access sheath after examining the bladder) and a flexible ureterorenoscope component (task 2, retrieving a stone located in the upper calyx using a basket after inspecting the upper, middle, and lower calyx). Training was performed in a mock operating theater. Technical skills were assessed by one author (an experienced urologist) onsite using an Objective Structured Assessment of Technical Skills (OSATS) score at each training session. The mental workload was subjectively evaluated by the National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire after each training session., Results: Seventeen students completed a minimum of 6 training sessions (male: female = 10: 7, median age of 22) over a median of 21 days (range, 10-32). In both tasks 1 and 2, the OSATS score improved over the 6 sessions with evidence of plateauing (MANOVA model, task 1: p < 0.0001, task 2: p < 0.0001). In contrast, the NASA-TLX score persistently decreased without plateauing (task 1: p = 0.0005, task 2: p = 0.0028)., Conclusions: Under repeated simulation training in ureterorenoscopy in a high-fidelity setting, participants showed a continual decrease of the mental workload, while the improvement of technical skills reached a plateau over the 6 sessions. Our study showed the important benefit of simulation training to reduce the mental workload by repeated scenario training before actual clinical practice.

Context: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important., Objective: To provide guidance on an optimised "train-the-trainer" (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training., Evidence Acquisition: The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement., Evidence Synthesis: There was 100% consensus that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90., Conclusions: Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation., Patient Summary: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised "train-the trainer" curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts' knowledge of surgical training., (Copyright © 2019 European Association of Urology. All rights reserved.)

Background: 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., Objective: This systematic review aims to identify current methods used to teach nontechnical skills and how these methods are assessed to determine their validity, evidence, and role in training., Methods: MEDLINE and Embase databases were searched for English language articles between 2000 and 2017 for nontechnical surgical skills training. Original research articles were included if they described non-technical surgical skills training modalities and their assessment. Results were assessed for the level of evidence and each modality was awarded a level of recommendation, using a modified educational Oxford Centre for Evidence-Based Medicine classification, as adapted by the European Association of Endoscopic Surgery., Results: A total of 19 studies were identified pertaining to high fidelity simulation (n = 8), low fidelity simulation (n = 6), didactic teaching (n = 2) and crisis resource management (n = 3). Of the included studies 1 was classified Level 1b, 1 level 2b, 7 level 2b, 2 level 2c, and 8 level 3., Conclusion: With the importance of nontechnical skills being increasingly recognized, it is essential for surgeons to receive adequate training in nontechnical skills. Therefore the most valuable teaching modalities such as high and low fidelity simulation needs to be implemented into surgical training curricula., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effectiveness of motor imagery (MI) for technical skill and non-technical skill (NTS) training in minimally invasive surgery (MIS)., Subjects and Methods: A single-blind, parallel-group randomised controlled trial was conducted at the Vattikuti Institute of Robotic Surgery, King's College London. Novice surgeons were recruited by open invitation in 2015. After basic robotic skills training, participants underwent simple randomisation to either MI training or standard training. All participants completed a robotic urethrovesical anastomosis task within a simulated operating room. In addition to the technical task, participants were required to manage three scripted NTS scenarios. Assessment was performed by five blinded expert surgeons and a NTS expert using validated tools for evaluating technical skills [Global Evaluative Assessment of Robotic Skills (GEARS)] and NTS [Non-Technical Skills for Surgeons (NOTSS)]. Quality of MI was assessed using a revised Movement Imagery Questionnaire (MIQ)., Results: In all, 33 participants underwent MI training and 29 underwent standard training. Interrater reliability was high, Krippendorff's α = 0.85. After MI training, the mean (sd) GEARS score was significantly higher than after standard training, at 13.1 (3.25) vs 11.4 (2.97) (P = 0.03). There was no difference in mean NOTSS scores, at 25.8 vs 26.4 (P = 0.77). MI training was successful with significantly higher imagery scores than standard training (mean MIQ score 5.1 vs 4.5, P = 0.04)., Conclusions: Motor imagery is an effective training tool for improving technical skill in MIS even in novice participants. No beneficial effect for NTS was found., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Background: With the increased use of simulation for surgical training, there is a need for objective forms of assessment to evaluate trainees. The Global Evaluative Assessment of Robotic Skills (GEARS) is widely used for assessing skills in robotic surgery, but there are no recognised checklist scoring systems. This study aimed to develop a checklist for suturing in robotic surgery., Methods: A suturing checklist for needle driving and knot tying was constructed following evaluation of participants performing urethrovesical anastomoses. Key procedural steps were identified from expert videos, while assessing novice videos allowed identification of common technical errors. 22 novice and 13 expert videos were marked on needle driving, while 18 novices and 10 experts were assessed on knot tying. Validation of the finalised checklist was performed with the assessment of 39 separate novices by an expert surgeon and compared to GEARS scoring., Results: The internal consistency of the preliminary checklist was high (Cronbach's alpha = 0.870 for needle driving items; 0.736 for knot tying items), and after removal of poorly correlating items, the final checklist contained 23 steps. Both the needle driving and knot tying categories discriminated between novices and experts, p < 0.005. While the GEARS score demonstrated construct validity for needle driving, it could not significantly differentiate between novices and experts for knot tying, p = 0.286. The needle driving category significantly correlated with the corresponding GEARS scores (r s  = 0.613, p < 0.005), but the correlation for knot tying was insignificant (r s  = 0.296, p = 0.127). The pilot data indicates the checklist significantly correlated with the GEARS score (p < 0.005)., Conclusion: This study reports the development of a valid assessment tool for suturing in robotic surgery. Given that checklists are simple to use, there is significant scope for this checklist to be used in surgical training.

Background and Aims: Procedures for urolithiasis are a core part of the development for the urologist in training. Understanding the learning curve of the procedures is important, allowing for planning in the training and assessment of trainees. The aim of this study was to systematically review the literature pertaining to learning curves in urolithiasis surgery., Materials and Methods: The review was registered on the PROSPERO database and conducted in keeping with the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Embase, MEDLINE, and PsycINFO were systematically searched from inception to January 2018, with a reference review conducted. All empirical studies on learning curves in urolithiasis surgery were included irrespective of procedure. Articles describing pediatric surgery, nontechnical skills in surgery, or those not written in English were excluded., Results: Of 390 articles identified from screening, a final 18 studies were included. Fourteen studies identified the learning curve in percutaneous nephrolithotomy. These studies identified a learning curve of between 30 and 60 cases for both operative time (OT) and complication rates. Four articles focused on flexible ureteroscopy (FURS); the learning curve for FURS has been outlined as 60 cases for OT and 56 cases for fragmentation efficacy., Conclusions: The complexities of determining learning curves are extensive; studies use different parameters to measure outcomes and observe skill acquisition rates of surgeons with differing prior experience. Evidence in this article can guide trainee urologists with regard to the expected rate of progress. Multi-operator multicenter research utilizing standard outcome measures should be conducted to establish definitive learning curves.

Objective: To perform the first validation of a full procedural virtual reality robotic training module and analysis of novice surgeon's learning curves., Design: Participants completed the bladder neck dissection task and urethrovesical anastomosis task (UVA) as part of the prostatectomy module. Surgeons completed feedback questionnaires assessing the realism, content, acceptability and feasibility of the module. Novice surgeons completed a 5.5-hour training programme using both tasks., Setting: King's College London, London., Participants: 13 novice, 24 intermediate and 8 expert surgeons completed the validation study., Results: Realism was scored highly for BDN (mean 3.4/5) and UVA (3.74/5), as was importance of BDN (4.32/5) and UVA (4.6/5) for training. It was rated as a feasible (3.95/5) and acceptable (4/5) tool for training. Experts performed significantly better than novice group in 6 metrics in the UVA including time (p = 0.0005), distance by camera (p = 0.0010) and instrument collisions (p = 0.0033), as well as task-specific metrics such as number of unnecessary needle piercing points (p = 0.0463). In novice surgeons, a significant improvement in performance after training was seen in many metrics for both tasks. For bladder neck dissection task, this included time (p < 0.0001), instrument collisions (p = 0.0013) and total time instruments are out of view (p = 0.0251). For UVA, this included time (p = 0.0135), instrument collisions (p = 0.0066) and task-specific metrics such as injury to the urethra (p = 0.0032) and bladder (p = 0.0189)., Conclusions: Surgeons found this full procedural VR training module to be a realistic, feasible and acceptable component for a robotic surgical training programme. Construct validity was proven between expert and novice surgeons. Novice surgeons have shown a significant learning curve over 5.5 hours of training, suggesting this module could be used in a surgical curriculum for acquisition of technical skills. Further implementation of this module into the curriculum and continued analysis would be beneficial to gauge how it can be fully utilised., (Copyright © 2017. Published by Elsevier Inc.)

Background: To establish objective benchmarks at the level of a competent robotic surgeon across different exercises and metrics for the RobotiX Mentor virtual reality (VR) simulator suitable for use within a robotic surgical training curriculum., Methods: This retrospective observational study analysed results from multiple data sources, all of which used the RobotiX Mentor VR simulator. 123 participants with varying experience from novice to expert completed the exercises. Competency was established as the 25th centile of the mean advanced intermediate score. Three basic skill exercises and two advanced skill exercises were used., Setting: King's College London., Participants: 84 Novice, 26 beginner intermediates, 9 advanced intermediates and 4 experts were used in this retrospective observational study., Results: Objective benchmarks derived from the 25th centile of the mean scores of the advanced intermediates provided suitably challenging yet also achievable targets for training surgeons. The disparity in scores was greatest for the advanced exercises. Novice surgeons are able to achieve the benchmarks across all exercises in the majority of metrics., Conclusion: We have successfully created this proof-of-concept study, which requires validation in a larger cohort. Objective benchmarks obtained from the 25th centile of the mean scores of advanced intermediates provide clinically relevant benchmarks at the standard of a competent robotic surgeon that are challenging yet also attainable. That can be used within a VR training curriculum allowing participants to track and monitor their progress in a structured and progressional manner through five exercises. Providing clearly defined targets, ensuring that a universal training standard has been achieved across training surgeons., Competing Interests: Competing interests: NR acknowledges financial support from the Vattikuti Foundation. PH acknowledges financial support from the Royal College of Surgeons of England in the form of an Intercalated BSc research award. KA and PD acknowledge financial support from the National Institute for Health Research (NIHR) Biomedical Research Centre-based Guy’s and St Thomas’s NHS Foundation trust. PD also acknowledges the support of the Medical Research Council Centre for Transplantation, London Deanery, London School of Surgery, Guy’s and St. Thomas’ Charity, European Union, Vattikuti Foundation and Olympus., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The aim of this study was to determine the correlation of visual-spatial ability with progression along the learning curve for robotic surgical skills training., Methods: A total of 21 novice participants were recruited. All participants completed a training program consisting of 5 training sessions of 30 minutes of virtual reality (VR) simulation and 30 minutes of dry laboratory training. The VR simulation part was the subject of the present study. During VR simulation training, participants performed the basic skill exercises of Camera Targeting 1, Pick and Place, and Peg Board 1 followed by advanced skill exercises of Suture Sponge 1 and Thread the Rings. The visual-spatial ability was assessed using a mental rotation test (MRT). Pearson correlation coefficients were used to assess the relationship between the MRT score and simulator score for the aforementioned 5 tasks. Student t test was used to compare the simulator score between high- and low-MRT score groups., Results: A median MRT score of 26/40 (range: 13-38) was observed. Approximately 19 participants completed the full curriculum but 2 did not complete "Thread the Rings" during the study period. A significant correlation was observed between the MRT score and simulator score only in "Suture Sponge 1" over the first 3 attempts (first: r = 0.584, p = 0.0054; second: r = 0.443, p = 0.0443; third: r = 0.4458, p = 0.0428). After the third attempt, this significant correlation was lost. Comparison of the score for "Suture Sponge 1" between the high-MRT and low-MRT scoring participants divided by a median MRT score of 26 also showed a significant difference in the score until the third trial., Conclusion: Our observations suggest that the spatial cognitive ability influences the initial learning of robotic suturing skills. Further studies are necessary to verify the usefulness of an individual's spatial ability to tailor the surgical training program., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Non-technical skills (NTS) are being increasingly recognised as vital for safe surgical practice. Numerous NTS rating systems have been developed to support effective training and assessment. Yet despite the additional challenges posed by robotic surgery, no NTS rating systems have been developed for this unique surgical environment. This study reports the development and validation of the first NTS behavioural rating system for robotic surgery., Methods: A comprehensive index of all relevant NTS behaviours in robotic surgery was developed through observation of robotic theatre and interviews with robotic surgeons. Using a Delphi methodology, a panel of 16 expert surgeons was consulted to identify behaviours important to NTS assessment. These behaviours were organised into an appropriate assessment template. Experts were consulted on the feasibility, applicability and educational impact of ICARS. An observational trial was used to validate ICARS. 73 novice, intermediate and expert robotic surgeons completed a urethrovesical anastomosis within a simulated operating room. NTS were tested using four scripted scenarios of increasing difficulty. Performances were video recorded. Robotic and NTS experts assessed the videos post hoc using ICARS and the standard behavioural rating system, NOn-Technical Skills for Surgeons (NOTSS)., Results: 28 key non-technical behaviours were identified by the expert panel. The finalised behavioural rating system was organised into four principle domains and seven categories. Expert opinion strongly supported its implementation. ICARS was found to be equivalent to NOTSS on Bland-Altman analysis and accurately differentiated between novice, intermediate and expert participants, p = 0.01. Moderate agreement was found between raters, Krippendorff's alpha = 0.4. The internal structure of ICARS was shown to be consistent and reliable (median Cronbach alpha = 0.92, range 0.85-0.94)., Conclusion: ICARS is the first NTS behavioural rating system developed for robotic surgery. Initial validation has shown it to be an effective and reliable tool. Implementation of ICARS will supported structured training and assessment of NTS within the robotic surgical curriculum.

Background: There is a need for new approaches to surgical training in order to cope with the increasing time pressures, ethical constraints, and legal limitations being placed on trainees. One of the most interesting of these new approaches is "cognitive training" or the use of psychological processes to enhance performance of skilled behaviour. Its ability to effectively improve motor skills in sport has raised the question as to whether it could also be used to improve surgical performance. The aim of this review is to provide an overview of the current evidence on the use of cognitive training within surgery, and evaluate the potential role it can play in surgical education., Methods: Scientific database searches were conducted to identify studies that investigated the use of cognitive training in surgery. The key studies were selected and grouped according to the type of cognitive training they examined., Results: Available research demonstrated that cognitive training interventions resulted in greater performance benefits when compared to control training. In particular, cognitive training was found to improve surgical motor skills, as well as a number of non-technical outcomes. Unfortunately, key limitations restricting the generalizability of these findings include small sample size and conceptual issues arising from differing definitions of the term 'cognitive training'., Conclusions: When used appropriately, cognitive training can be a highly effective supplementary training tool in the development of technical skills in surgery. Although further studies are needed to refine our understanding, cognitive training should certainly play an important role in future surgical education., (Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Objective: Development of nontechnical skills for surgeons has been recognized as an important factor in surgical care. Training tools for this specific domain are being created and validated to maximize the surgeon's nontechnical ability. This systematic review aims to outline, address, and recommend these training tools., Design: A full and comprehensive literature search, using a systematic format, was performed on ScienceDirect and PubMed, with data extraction occurring in line with specified inclusion criteria., Setting: Systematic review was performed fully at King's College London., Results: A total of 84 heterogeneous articles were used in this review. Further, 23 training tools including scoring systems, training programs, and mixtures of the two for a range of specialities were identified in the literature. Most can be applied to surgery overall, although some tools target specific specialities (such as neurosurgery). Interrater reliability, construct, content, and face validation statuses were variable according to the specific tool in question., Conclusions: Study results pertaining to nontechnical skill training tools have thus far been universally positive, but further studies are required for those more recently developed and less extensively used tools. Recommendations can be made for individual training tools based on their level of validation and for their target audience. Based on the number of studies performed and their status of validity, NOTSS and Oxford NOTECHS II can be considered the gold standard for individual- and team-based nontechnical skills training, respectively, especially when used in conjunction with a training program., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To develop benchmark scores of competency for use within a competency based virtual reality (VR) robotic training curriculum., Subjects and Methods: This longitudinal, observational study analysed results from nine European Association of Urology hands-on-training courses in VR simulation. In all, 223 participants ranging from novice to expert robotic surgeons completed 1565 exercises. Competency was set at 75% of the mean expert score. Benchmark scores for all general performance metrics generated by the simulator were calculated. Assessment exercises were selected by expert consensus and through learning-curve analysis. Three basic skill and two advanced skill exercises were identified., Results: Benchmark scores based on expert performance offered viable targets for novice and intermediate trainees in robotic surgery. Novice participants met the competency standards for most basic skill exercises; however, advanced exercises were significantly more challenging. Intermediate participants performed better across the seven metrics but still did not achieve the benchmark standard in the more difficult exercises., Conclusion: Benchmark scores derived from expert performances offer relevant and challenging scores for trainees to achieve during VR simulation training. Objective feedback allows both participants and trainers to monitor educational progress and ensures that training remains effective. Furthermore, the well-defined goals set through benchmarking offer clear targets for trainees and enable training to move to a more efficient competency based curriculum., (© 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.)

Objective: Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor., Design: This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves., Setting and Participants: We included 15 urology fellows from UK, Europe, and Australia., Results: A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps. Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p = 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt. We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level > median case number of first attempt > most frequently undertaken in surgical training., Conclusions: An evidence-based modular training pathway has been developed that facilitates a safe introduction to RARP for novice surgeons., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: 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., Design: PubMed, ERIC, and Google Scholar databases were searched for articles that described otolaryngology simulators or training models between 1980 and April 2016. Any validation studies for simulators were also retrieved. Titles and abstracts were screened for relevance using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Level of evidence (LoE) and Level of recommendation (LoR) was awarded to each study and model, respectively., Results: A total of 70 studies were identified describing 64 simulators. Out of these, at least 54 simulators had 1 validation study. Simulators for the ear and temporal bone surgery were the most common (n = 32), followed by laryngeal and throat (n = 20) and endoscopic sinus surgery (n = 12). Face validity was evaluated by 29 studies, 20 attempted to show construct, 20 assessed content, 20 transfer, and only 2 assessed concurrent validity. Of the validation assessments, 2 were classified as Level 1b, 10 Level 2a, and 48 Level 2b. No simulators received the highest LoR, but 8 simulators received a LoR of 2., Conclusions: Despite the lack of evidence in outcome studies and limited number of high-validity otolaryngology simulators, the role of simulation continues to grow across surgical specialties Hence, it is imperative that the simulators are of high validity and construct for trainees to practice and rehearse surgical skills to develop confidence., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

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.

Objectives: To describe the progress being made in training for minimally invasive surgery (MIS) in urology., Methods: A group of experts in the field provided input to agree on recommendations for MIS training. A literature search was carried out to identify studies on MIS training, both in general and specifically for urological procedures., Results: The literature search showed the rapidly developing options for e-learning, box and virtual training, and suggested that box training is a relatively cheap and effective means of improving laparoscopic skills. Development of non-technical skills is an integral part of surgical skills training and should be included in training curricula. The application of modular training in surgical procedures showed more rapid skills acquisition. Training curricula for MIS in urology are being developed in both the USA and Europe., Conclusion: Training in MIS has shifted from 'see-one-do-one-teach-one' to a structured learning, from e-learning to skills laboratory and modular training settings., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Background and Purpose: The advances in both video games and minimally invasive surgery have allowed many to consider the potential positive relationship between the two. This review aims to evaluate outcomes of studies that investigated the correlation between video game skills and performance in laparoscopic surgery., Methods: A systematic search was conducted on PubMed/Medline and EMBASE databases for the MeSH terms and keywords including "video games and laparoscopy," "computer games and laparoscopy," "Xbox and laparoscopy," "Nintendo Wii and laparoscopy," and "PlayStation and laparoscopy." Cohort, case reports, letters, editorials, bulletins, and reviews were excluded. Studies in English, with task performance as primary outcome, were included. The search period for this review was 1950 to December 2014., Results: There were 57 abstracts identified: 4 of these were found to be duplicates; 32 were found to be nonrelevant to the research question. Overall, 21 full texts were assessed; 15 were excluded according to the Medical Education Research Study Quality Instrument quality assessment criteria. The five studies included in this review were randomized controlled trials. Playing video games was found to reduce error in two studies (P 0.002 and P 0.045). For the same studies, however, several other metrics assessed were not significantly different between the control and intervention group. One study showed a decrease in the time for the group that played video games (P 0.037) for one of two laparoscopic tasks performed. In the same study, however, when the groups were reversed (initial control group became intervention and vice versa), a difference was not demonstrated (P for peg transfer 1 - 0.465, P for cobra robe - 0.185). Finally, two further studies found no statistical difference between the game playing group and the control group's performance., Conclusion: There is a very limited amount of evidence to support that the use of video games enhances surgical simulation performance.

Objective: 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., Design: A prospective analysis of data acquired from a comparative study of simulation vs nonsimulation training was conducted. Half of the participants underwent training of technical and nontechnical skills within ureteroscopy, with the remaining half undergoing no training. All were assessed within a full immersion environment against both technical (time to completion, Objective Structured Assessment of Technical Skills, and task-specific checklist scores) and nontechnical parameters (Nontechnical Skills for Surgeons [NOTSS] rating scale). The data of whole and individual cohorts were analyzed using Pearson correlation coefficient., Setting: The trial took place within the Simulation and Interactive Learning Centre at Guy's Hospital, London, UK., Participants: In total, 32 novice participants with no prior practical ureteroscopy experience were included within the data analysis., Results: A correlation was found within all outcome measures analyzed. For the whole cohort, a strong negative correlation was found between time to completion and NOTSS scores (r = -0.75, p < 0.001), with strong positive correlations identified when NOTSS scores were compared with Objective Structured Assessment of Technical Skills (r = 0.89, p < 0.001) and task-specific checklist scores (r = 0.91, p < 0.001). Similar results were observed when each cohort was analyzed separately. Finally, all individual nontechnical skill components demonstrated a strong correlation with all technical skill parameters, regardless of training., Conclusions: A strong correlation between technical and nontechnical performance exists, which was demonstrated to be irrespective of training received. This may suggest an inherent link between skill sets. Furthermore, all nontechnical skill sets are important in technical performance. This supports the notion that both of these skills should be trained and assessed together within 1 curriculum., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the face, content and construct validity of the distributed simulation (DS) environment for technical and non-technical skills training in endourology. To evaluate the educational impact of DS for urology training., Subjects and Methods: DS offers a portable, low-cost simulated operating room environment that can be set up in any open space. A prospective mixed methods design using established validation methodology was conducted in this simulated environment with 10 experienced and 10 trainee urologists. All participants performed a simulated prostate resection in the DS environment. Outcome measures included surveys to evaluate the DS, as well as comparative analyses of experienced and trainee urologist's performance using real-time and 'blinded' video analysis and validated performance metrics. Non-parametric statistical methods were used to compare differences between groups., Results: The DS environment demonstrated face, content and construct validity for both non-technical and technical skills. Kirkpatrick level 1 evidence for the educational impact of the DS environment was shown. Further studies are needed to evaluate the effect of simulated operating room training on real operating room performance., Conclusions: This study has shown the validity of the DS environment for non-technical, as well as technical skills training. DS-based simulation appears to be a valuable addition to traditional classroom-based simulation training., (© 2014 The Authors BJU International © 2014 BJU International Published by John Wiley & Sons Ltd.)

Objective: To validate robot-assisted surgery skills acquisition using an augmented reality (AR)-based module for urethrovesical anastomosis (UVA)., Methods: Participants at three institutions were randomised to a Hands-on Surgical Training (HoST) technology group or a control group. The HoST group was given procedure-based training for UVA within the haptic-enabled AR-based HoST environment. The control group did not receive any training. After completing the task, the control group was offered to cross over to the HoST group (cross-over group). A questionnaire administered after HoST determined the feasibility and acceptability of the technology. Performance of UVA using an inanimate model on the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was assessed using a UVA evaluation score and a Global Evaluative Assessment of Robotic Skills (GEARS) score. Participants completed the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire for cognitive assessment, as outcome measures. A Wilcoxon rank-sum test was used to compare outcomes among the groups (HoST group vs control group and control group vs cross-over group)., Results: A total of 52 individuals participated in the study. UVA evaluation scores showed significant differences in needle driving (3.0 vs 2.3; P = 0.042), needle positioning (3.0 vs 2.4; P = 0.033) and suture placement (3.4 vs 2.6; P = 0.014) in the HoST vs the control group. The HoST group obtained significantly higher scores (14.4 vs 11.9; P 0.012) on the GEARS. The NASA TLX indicated lower temporal demand and effort in the HoST group (5.9 vs 9.3; P = 0.001 and 5.8 vs 11.9; P = 0.035, respectively). In all, 70% of participants found that HoST was similar to the real surgical procedure, and 75% believed that HoST could improve confidence for carrying out the real intervention., Conclusion: Training in UVA in an AR environment improves technical skill acquisition with minimal cognitive demand., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: 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., Design: The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases., Results: In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study., Conclusions: Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Validation studies are an important part of simulator evaluation and are considered necessary to establish the effectiveness of simulation-based training. The widely used Bristol transurethral resection of prostate (TURP) simulator has not been formally validated., Objectives: Evaluation of the face, content, and construct validities of the Bristol TURP simulator as an endourology training tool., Design: Using established validation methodology, face, content, and construct validities were evaluated. Face and content validities were assessed using a structured quantitative survey. Construct validity was assessed by comparing the performance of experts and novices using a validated performance scale and resection efficiency., Participants and Setting: Overall, 8 novice urologists and 8 expert urologists participated in the study. The study was conducted in a dedicated surgical simulation training facility., Results: All 16 participants felt the model was a good training tool and should be used as an essential part of urology training (face validity). Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.38-3.57/5); however, the model does not simulate bleeding. Experts significantly outperformed novices (p < 0.001) across all measures of performance, therefore establishing construct validity., Conclusions: The Bristol TURP simulator shows face, content, and construct validities, although some aspects of the simulator were not very realistic (e.g., bleeding). This study provides evidence for the continuing use of this simulator in endourology training., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe how learning curves are measured and what procedural variables are used to establish a 'learning curve' (LC). To assess whether LCs are a valuable measure of competency., Patients and Methods: A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases., Results: Variables should be fully defined and when possible, patient-specific variables should be used. Trainee's prior experience and level of supervision should be quantified; the case mix and complexity should ideally be constant. Logistic regression may be used to control for confounding variables. Ideally, a learning plateau should reach a predefined/expert-derived competency level, which should be fully defined. When the group splitting method is used, smaller cohorts should be used in order to narrow the range of the LC. Simulation technology and competence-based objective assessments may be used in training and assessment in LC studies., Conclusions: Measuring the surgical LC has potential benefits for patient safety and surgical education. However, standardisation in the methods and variables used to measure LCs is required. Confounding variables, such as participant's prior experience, case mix, difficulty of procedures and level of supervision, should be controlled. Competency and expert performance should be fully defined., (© 2013 The Authors. BJU International © 2013 BJU International.)

Background: Continuing medical education and objective performance assessment remain the key components of recertification. Objective skills assessment in routine practice remains challenging due to extensive variations in case selection and treatments. This study explores expert opinions regarding objective skills assessment for specialists within the framework of recertification., Methods: We used a qualitative, semi-structured interview-based approach to obtain information and suggestions about key issues and recommendations relating to specialists' skills assessment. Twenty-two face-to-face interviews were conducted. Interviews were transcribed and analysed by two reviewers., Results: The information from the interviews was categorized under the headings of: (1) the components of specialist-level skills, (2) the methods for assessing specialist skills, (3) the types of tools and procedures used during observational assessment, (4) the unsuccessful specialists, and (5) the selection and training of assessors for specialist assessment., Conclusions: Outcome-based assessment of performance followed by observation of practice, were recommended as effective modes of evaluation of performance., (Copyright © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Aim: Access to facilities that allow trainees to develop their laparoscopic skills is very limited in the hospital environment and courses can be very expensive. We set out to build an inexpensive yet effective trainer to allow laparoscopic skill acquisition in the home or classroom environment based on using a tablet as a replacement for the laparoscopic stack and camera., Methods: The cavity in which to train was made from a cardboard box; we left the sides and back open to allow for natural light to fill the cavity. An iPad 2 (Apple Inc.) was placed over the box to act as our camera and monitor. We provided 10 experienced laparoscopic surgeons with the task of passing a suture needle through 3 hoops; then they filled in a questionnaire to assess Face (training capacity) and Content (performance) validity., Results: On a 5-point Likert scale, the tablet-based laparoscopic trainer scored a mean 4.2 for training capacity (hand eye coordination, development, and maintenance of lap skills) and for performance (graphics, video, and lighting quality) it scored a mean 4.1., Conclusions: The iPad 2-based laparoscopic trainer was successfully validated for training. It allows students and trainees to practice at their own pace and for inexpensive training on the go. Future "app-"based skills are planned., (Copyright © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Context: Non-technical skills are important behavioural aspects that a urologist must be fully competent at to minimise harm to patients. The majority of surgical errors are now known to be due to errors in judgment and decision making as opposed to the technical aspects of the craft., Evidence Acquisition: The authors reviewed the published literature regarding decision-making theory and in practice related to urology as well as the current tools available to assess decision-making skills. Limitations include limited number of studies, and the available studies are of low quality., Evidence Synthesis: Decision making is the psychological process of choosing between alternative courses of action. In the surgical environment, this can often be a complex balance of benefit and risk within a variable time frame and dynamic setting. In recent years, the emphasis of new surgical curriculums has shifted towards non-technical surgical skills; however, the assessment tools in place are far from objective, reliable and valid. Surgical simulators and video-assisted questionnaires are useful methods for appraisal of trainees., Conclusion: Well-designed, robust and validated tools need to be implemented in training and assessment of decision-making skills in urology. Patient safety can only be ensured when safe and effective decisions are made.

What's known on the subject? and What does the study add? Inanimate trainers and simulators have been shown to facilitate the skill acquisition of urologists. However, there are significant challenges to integrating standalone simulation programmes into mainstream urology curricula. This study provides a framework to overcome these challenges and discusses the advantages of centralised urology simulation centres and their potential to serve as key adjuncts in the certification and validation process of urologists. Fixed performance-based outcomes of inanimate trainers and simulators have been praised as useful adjuncts in urology for reducing the learning curve associated with the acquisition of new technical and non-technical skills without compromising patient safety. Simulators are becoming an integral part of the urology training curriculum and their effectiveness is totally dependent on the structure of the programme implemented. The present paper discusses the fundamental concepts of centralized urology centres and their potential to serve as key adjuncts in the certification and validation process of urologists. In summary, proficiency-based curricula with well structured endpoints and objective tools for validating proficiency are critical in developing a simulation programme in urology. We concludes that more educational research into the outcomes of integrated urology curricula followed by trainee/trainer opinion surveys will help address some of these criteria., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Background: Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment., Methods: Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included., Results: Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse., Conclusions: There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level., (Copyright © 2011. Published by Elsevier Inc.)

The aim of revalidation (or maintenance of certification) is to reassure patients, the general public, employers and other healthcare professionals that an individual is fit to practice. It may lead to a reduction in near misses or adverse events. The process of revalidation entails a commitment to the provision of lifelong learning and assessment of clinical practice that ultimately ensure patient safety. Lifelong learning addresses knowledge and skills, whereas assessment of clinical practice ensures quality of care. Various learning and assessment tools are available in clinical practice; however, the tools for revalidation are not validated at specialist level. Further research is needed to develop and implement evidence-based structured programmes of revalidation that consider the holistic needs of modern urologists., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Urology is becoming increasingly reliant on inter-disciplinary collaboration. As a result of this interaction and developments in technology, the existing system of training, certification and recertification needs revision. The skill-set required of urologists has become multidimensional. As the field of urology continues to evolve, the recognition of the need for objective and efficient certification for trainees and a recertification program for specialists has increased. Training programs need to provide a curriculum focused on knowledge, communication, cognitive and technical skills, with the inclusion of simulation-based training. For specialists, the benefits of teaching through mentorship should be evaluated, and outcome-based assessment of patient morbidity and mortality needs to be further developed and validated.

Assessment of medical specialists was introduced to ensure patient safety and to maintain professional knowledge. Cardiovascular specialist assessment is challenging, as the ongoing development of new technologies is associated with increased requirements for up-to-date training and acquisition of new skills. The cardiovascular specialties include cardiology, vascular interventional radiology, cardiac surgery and vascular surgery. Assessment within these disciplines involves evaluation of knowledge in addition to technical and nontechnical skills, a process that is termed recertification or maintenance of certification. Increasingly, there is a demand for professional accountability through recertification because of concerns about professional negligence and increased awareness of medical errors. In this article we describe the process of recertification in different geographical regions and discuss the role of current tools used to recertify cardiovascular specialists and, in particular, how their use can contribute to the requirements of patient care.

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 U tests. 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. [ABSTRACT FROM AUTHOR]

Objective: To assess and quantify the surgical learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon.Methods: A retrospective analysis of 253 consecutive cases performed by the same surgeon from 2006 to 2013 was conducted. Primary outcomes included enucleation ratio and morcellation efficiencies and complication rates. Three-month postoperative prostate-specific antigen values were used as secondary measures. Cases were divided into cohorts of 20 cases to assess changes in means analyzed through Analysis of Variance (ANOVA) tests. Scatter plots of cases with a best-fit line were drawn to analyze the learning curve.Results: The mean age of patients across the cases was 69.21 years with an average transrectal ultrasound prostate volume of 95.84 cc. Enucleation ratio efficiency was significantly different between cohorts (P = .02) plateau after 50-60 cases conducted. Similarly, a significant difference is shown for morcellation efficiency (P = .01) with stabilization in performance after 60 cases. Complication rates decreased through the caseload but did not show a statistical difference (P = .62) or plateauing on the graph. Finally, no difference between 3-month postoperative prostate-specific antigen values was seen (P = .083); however, a learning curve of 50 cases was observed graphically.Conclusion: Within our single-surgeon cohort, we experienced a learning curve of 40-60 cases for the HoLEP procedure. Large variability in performance late into the caseload demonstrates the technical difficulty of HoLEP. Owing to this, adjuncts to training such as simulation-based training may be of use for the new surgeon to shorten the initial phase of learning. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the face, content, and construct validity of a novel virtual reality simulator for holmium laser enucleation of the prostate (HoLEP) and to assess its feasibility and acceptability as a training model.Methods: This prospective observational study recruited 53 participants, comprising of 3 groups: HoLEP experts (n = 11), intermediates (n = 24), and novices (n = 18). All participants received an educational package and a 15-minute familiarization exercise with the simulator. All participants then carried out a full enucleation on an identical 60 cm(3) virtual prostate. Performance was assessed using in-built simulator metrics, and a questionnaire was distributed assessing face and content validity, as well as feasibility, and acceptability. Novice, intermediate, and expert groups were compared using the Mann-Whitney U test.Results: Construct validity data revealed significant differences in enucleation efficiency (grams enucleated per hour) when comparing experts to intermediates (P = .003), experts to novices (P <.001), and intermediates to novices (P = .001). Face validity was rated by experts as acceptable, with a mean score of 5.6 out of 10 when asked to rate the overall realism. Content validity questions showed that 85% of participants agreed that simulator-based assessment is essential for patient safety and 87% agreed that there was a role for a validated virtual reality simulator for use in HoLEP training.Conclusion: This study established face, content, and construct validity for this novel virtual reality HoLEP simulator. The majority of participants also thought that it is a feasible and acceptable model for HoLEP training. [ABSTRACT FROM AUTHOR]