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Background: Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. This systematic review aimed to examine the literature relating to the learning curves of major urological robotic and laparoscopic procedures., Methods: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic literature search strategy was employed across PubMed, EMBASE, and the Cochrane Library from inception to December 2021, alongside a search of the grey literature. Two independent reviewers completed the article screening and data extraction stages using the Newcastle-Ottawa Scale as a quality assessment tool. The review was reported in accordance with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) guidelines., Results: Of 3702 records identified, 97 eligible studies were included for narrative synthesis. Learning curves are mapped using an array of measurements including operative time (OT), estimated blood loss, complication rates as well as procedure-specific outcomes, with OT being the most commonly used metric by eligible studies. The learning curve for OT was identified as 10-250 cases for robot-assisted laparoscopic prostatectomy and 40-250 for laparoscopic radical prostatectomy. The robot-assisted partial nephrectomy learning curve for warm ischaemia time is 4-150 cases. No high-quality studies evaluating the learning curve for laparoscopic radical cystectomy and for robotic and laparoscopic retroperitoneal lymph node dissection were identified., Conclusion: There was considerable variation in the definitions of outcome measures and performance thresholds, with poor reporting of potential confounders. Future studies should use multiple surgeons and large sample sizes of cases to identify the currently undefined learning curves for robotic and laparoscopic urological procedures., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Aim: The aim of this study is to validate a totally non biologic training model that combines the use of ultrasound and X ray to train Urologists and Residents in Urology in PerCutaneous NephroLithotripsy (PCNL)., Methods: The training pathway was divided into three modules: Module 1, related to the acquisition of basic UltraSound (US) skill on the kidney; Module 2, consisting of correct Nephrostomy placement; and Module 3, in which a complete PCNL was performed on the model. Trainees practiced on the model first on Module 1, than in 2 and in 3. The pathway was repeated at least three times. Afterward, they rated the performance of the model and the improvement gained using a global rating score questionnaire., Results: A total of 150 Urologists took part in this study. Questionnaire outcomes on this training model showed a mean 4.21 (range 1-5) of positive outcome overall. Individual constructive validity showed statistical significance between the first and the last time that trainees practiced on the PCNL model among the three different modules. Statistical significance was also found between residents, fellows and experts scores. Trainees increased their skills during the training modules., Conclusion: This PCNL training model allows for the acquisition of technical knowledge and skills as US basic skill, Nephrostomy placement and entire PCNL procedure. Its structured use could allow a better and safer training pathway to increase the skill in performing a PCNL.

It has been demonstrated that publication of individual surgeons' outcomes has improved patient safety and choice. Taking into consideration the lack of negative impact on patient selection and surgical training, it is difficult to argue that surgeons' outcomes should not be openly available in urology., (Copyright © 2021. Published by Elsevier B.V.)

Background: Basic simulation training in endourology was established with the endoscopic stone treatment step 1 (EST-s1), which is now recognized worldwide for training and examination. Following on from EST-s1, the endoscopic stone treatment step 2 (EST-s2) was started by the European Association of Urology (EAU) sections. Objective: We describe the methodology used in the development of EST-s2 assessment curriculum. Materials and Methods: The "full-life cycle curriculum development" template was followed for curriculum development, focusing on intermediate training of EST protocol with complex endourologic tasks. A cognitive task analysis (CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EAU Urolithiasis Section experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in European Urology Residents Education Programme 2019 and in phase five the protocol was finalized with full tutor instruction sheet. Results: The EST-s2/A curriculum development took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees, respectively. Although the experts agreed that EST-s2/A protocol was well structured (96%), covered the complex endourologic maneuvers (92%), and was useful to optimize and improve hands-on-training (HoT) sessions (92%), the overall evaluation was scored 4.25/5 by trainees. Conclusion: We describe the development methodology for intermediate EST curriculum, which also provides a roadmap on developing other HoT protocols in future. Patients Summary: In this report we described the development of the novel intermediate training curriculum for EST, called EST-s2, which took 3 years of collaborative work inside the EAU. This article is aimed to strengthen the standards in curriculum development and clearly describe the background of this new EAU official endourology protocol.

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.

Introduction and Objectives: Standardization of hands-on training (HoT) has profoundly impacted the educational field in the last decade. To provide quality training sessions on a global scale, the European School of Urology Training group developed a teaching guide for tutors in 2015. Our study aims to understand whether this guide alone can provide information enough to match the performance improvement guaranteed by an expert tutor., Material and Methods: 4 randomized groups of participants underwent HoT sessions with different teaching modalities: an expert surgeon (group 1), an expert E-BLUS tutor (group 2), E-BLUS guide alone (group 3), no tutor (group 4). Groups 1 and 2 were respectively provided with two different tutors to avoid biases related to personal tutor ability. Along the training session, each participant could perform five trials on two E-BLUS tasks: Peg transfer and Knot tying. During trials 1 and 5, completion time and number of errors were recorded for analysis with Pi-score algorithm. The average per-group Pi-scores were then compared to measure different performance improvement results., Results: 60 participants from Italy were enrolled and randomized into four groups of 15. Pi-scores recorded on Peg transfer task were 24,6 (group 1), 26,4 (group 2), 42,2 (group 3), 11,7 (group 4). Pi-scores recorded on Knot tying task were 33,2 (group 1), 31,3 (group 2), 37,5 (group 3), 18,6 (group 4)., Conclusion: Compared to a human tutor, standardized teaching with the EBLUS guide may produce similar performance improvement. This evidence opens doors to automated teaching and to several novelties in hands-on training.

Objectives: To develop a wet laboratory training model for learning core laparoscopic surgical skills and evaluating learners' competency level outside the operating room., Methods: Participants completed three tasks (task 1: tissue dissection around the aorta; task 2: tissue dissection and division of the renal artery; task 3: renal parenchymal closure). Each performance was video recorded and subsequently evaluated by two experts, according to the Global Operative Assessment of Laparoscopic Skills and task-specific metrics that we developed (Assessment Sheet of Laparoscopic Skills in Wet Lab score). Mean scores were used for analyses. The subjective mental workload was also assessed (NASA Task Load Index)., Results: The 54 participants included 32 urologists, eight young trainees and 14 medical students. A total of 13 participants were categorized as experts (≥50 laparoscopic surgeries), eight as intermediates (10-49) and 33 as novices (0-9). There were significant differences in the Global Operative Assessment of Laparoscopic Skills and Assessment Sheet of Laparoscopic Skills in Wet Lab scores among the three groups in all three tasks. Higher NASA Task Load Index scores were observed in novices, and there were significant differences in tasks 1 (Kruskal-Wallis test, P = 0.0004) and 2 (P = 0.0002), and marginal differences in task 3 (P = 0.0745) among the three groups., Conclusions: Our training model has good construct validity, and differences in the NASA Task Load Index score reflect previous laparoscopic surgical experiences. Our findings show the ability to assess both laparoscopic surgical skills and mental workloads, which could help educators comprehend trainees' level outside the operating room. Given the decreasing opportunity to carry out pure laparoscopic surgeries because of the dissemination of robotic surgery, especially in urology, our model can offer practical training opportunities., (© 2020 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association.)

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.)

Purpose: With non-technical skills (NTS) deficits being recognised as a major cause for error in surgery, there is an increasing interest in their training and evaluation. A growing number of training courses are emerging and some NTS curricula have also been created. Many different training methods are described in the literature but there is still uncertainty with regards to their optimum combination within a curriculum., Methods: A literature review of the electronic database Medline was performed. All articles published before December 2018 were screened by abstract and included if deemed relevant by the author. The included articles' reference lists were also screened for further relevant studies., Results: Simulation training is accepted as the most effective way to train NTS. Within simulation training, it is shown that the 'igloo' full immersion/distributed simulation environment is appropriate for teaching NTS in urological scenarios where a designated operating room or space is not available. The use of multiple settings, for example wards and clinics as well as the operating room, is advantageous, as is training in an interprofessional team. Classroom teaching also plays a role in NTS training as an adjunct to simulation, with evidence that it improves some parameters of NTS. All levels, including qualified surgeons, benefit from NTS training; however, adaptation to both trainee level and specialty is important. Although less time consuming, training juniors and seniors together mainly benefits juniors, and training NTS at the same time as technical skills detracts from the quality of teaching. Debriefing is an important part of training and should be well structured; there are many debriefing models in existence, allowing for choice of method based on examiner preference and participant demographic. Furthermore, examiners should be well briefed in their task and trained in NTS assessment., Conclusion: To move forward, studies should combine tried and tested learning techniques into a curriculum covering all training levels, which should then be validated and followed up long term to ensure a positive impact on patient safety.

Objectives: To develop and validate the Urethroplasty Training and Assessment Tool (UTAT) using Healthcare Failure Mode and Effect Analysis (HFMEA) for training and assessment of urology trainees learning this urethral reconstruction technique, as urethroplasty is the 'gold standard' treatment for long and recurrent urethral strictures and with a variety of techniques and a lack of standardised reconstructive curricula, there is a need for procedure-specific training tools to improve surgeon training and patient safety., Materials and Methods: This international observational study was performed over an 11-month period. The HFMEA was used to identify and evaluate hazardous stages of urethroplasty to develop the UTAT. Hazard scores were calculated for the included steps of urethroplasty. Content validation was performed by 12 expert surgeons and multidisciplinary teams from international tertiary centres., Results: The HFMEA process resulted in an internationally validated UTAT. Hazard scores ≥4 and single point weaknesses were included to implement actions and outcome measures. Content validation was achieved by circulating the process map, hazard analysis table, and developed tools. Changes were implemented based on the feedback received from expert surgeons. The content validated dorsal onlay buccal mucosa graft bulbar UTAT contained five phases, 10 processes and 23 sub-processes., Conclusions: The modular UTAT offers a comprehensive validated training tool developed via a detailed HFMEA protocol. This may be utilised to standardise the training and assessment of urology trainees., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

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.

Background: Simulation-based training offers an acceptable adjunct to the traditional mentor-apprentice model in helping trainees to traverse the early stages of the learning curve for ureteroscopy and percutaneous renal surgery. In addition, nontechnical skills are increasingly important in preventing adverse events in the operating room, and simulation-based training can be used for training in such skills. Incorporation of simulation into formalised, standardised, and validated curricula offers an applicable method for training residents., Objective: To develop a curriculum for urolithiasis procedures incorporating technical and nontechnical skills training for implementation across Europe., Design, Setting, and Participants: An international panel of experts from EULIS, EUREP, ESU and ESUT was consulted in five stages. The study incorporated a mix of qualitative and quantitative data for collection and analysis. Responses were drawn out in (1) an opinion survey and (2) a curriculum development survey, which were discussed in (3) a focus group meeting. Group responses from this meeting were analysed for themes, which were discussed at (4) a focus group meeting, where consensus was reached among the group. Data analysis and integration at this stage were used to draft the curriculum., Results and Limitations: All group meetings were transcribed from the focus group discussion. Eight themes were generated, into which all data were categorised. These were: need for a training curriculum; curriculum objectives; curriculum structure; curriculum content; teaching platforms and tools; assessment and certification; validation and implementation; and global integration of the curriculum. A curriculum, including recommended simulators for use, was subsequently proposed., Conclusions: We propose a comprehensive curriculum for training in urolithiasis. Additional planning is required for full validation and implementation before it can be used to train residents., Patient Summary: Stone disease accounts for a major proportion of surgical interventions worldwide. We describe a consensus guideline for effective training of stone surgeons., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Surgeons training in the twenty-first century are subject to a myriad of pressures, as has always been the case within surgical training. These include reduced hours available for training and increased threat of litigation against their operating practice. The Halstedian approach of "see one, do one, teach one" has been replaced within surgical training and simulation has become established to enable urology trainees to develop technical and non-technical skills away from the operating room. With the primary focus as patient safety and increasing operating skill, "simulation training" encompasses several modalities. These include wet-lab cadaveric and animal models, dry lab, high fidelity, low-fidelity and virtual reality (VR). These can be used to practice generic surgical skills, such as laparoscopic suturing or knot tying on a robotic console. Beyond this there is potential for simulation training courses and full-immersion simulation to address non-technical skills and team aspects within the operating room. To incorporate simulators into training, models must be carefully designed and evaluated according to certain considerations, ensuring that they address parameters such as face, content and construct validity. This review aimed to provide an overview of simulation platforms available within endourology, considering ureterorenoscopy and percutaneous nephrolithotomy and the status of their validation.

Background: Our aim was to understand the specific factors which influence medical students' choice to train in urology, in order to attract the best and the brightest into the specialty during a challenging time for surgical training in the United Kingdom, Methods: A cross-sectional web-based survey was generated to evaluate: 1) perceptions of urology; 2) attitudes about urology as a career; 3) exposure to urology at medical school; and 4) proficiency in common urological procedures. The survey was sent to all 33 medical schools in the UK and advertised to all medical students., Results: The survey received 488 responses were received from 14 medical schools; 59.8% of respondents did not consider a career in urology. Factors affecting a career choice in urology included: 1) year of study; 2) male gender; 3) favorable perceptions of urology; 4) favorable attitudes about urology as a career; 5) more hours of urology teaching in preclinical years; 6) attendance at urology theatre sessions; 7) confidence in performing urological procedures; and 8) more attempts at male catheterization. The commonest reason for not considering urology was inadequate exposure to urology. Students in Year 3 were more likely to consider urology than final-year students, due to multifactorial reasons., Conclusions: Year of study is a novel factor affecting students' consideration of urology as a career. This paper clearly shows that early and sustained exposure to urology positively correlated with considering a career in urology. Urologists must be more active in promoting the specialty to medical students.

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.

Purpose: Increased awareness of patient safety, advances in surgical technology and reduced working times have led to the adoption of simulation enhanced training. However, the simulators available need to be scientifically evaluated before integration into curricula. We identify the currently available training models for urological surgery, their status of validation and the evidence behind each model., Materials and Methods: MEDLINE®, Embase® and the Cochrane Library databases were searched for English language articles published between 1990 and 2015 describing urological simulators and/or validation studies of these models. All studies were assessed for level of evidence, and each model was subsequently awarded a level of recommendation using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education by the European Association of Endoscopic Surgeons., Results: A total of 91 validation studies were identified pertaining to training models in endourology (63), laparoscopic surgery (17), robot-assisted surgery (8) and open urological surgery (6), with a total of 55 models. Of the included studies 6 were classified Level 1b, 9 Level 2a, 39 Level 2b and 19 Level 2c. Of all the training models the URO Mentor™ was the only one to receive a level of recommendation of 1., Conclusions: UroSimulation is a growing field and increasing numbers of models are being produced. However, there are still too few validation studies with a high level of evidence demonstrating the transferability of skills. Nevertheless, efforts should be made to use the currently available models in curriculum based training programs., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

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.)

Objectives: To assess face, content, and construct validity of the RobotiX Mentor virtual reality simulator, to assess its acceptability as a robotic surgery training tool and feasibility of its use, and to develop a supplementary training curriculum., Subjects and Methods: This prospective, observational, and comparative study recruited novice (n = 20), intermediate (n = 15), and expert (n = 11) robotic surgeons as participants from institutions across the United Kingdom and at the 30th European Association of Urology Annual Meeting. Each participant completed nine surgical tasks across two modules on the simulator, followed by a questionnaire to evaluate subjective realism (face validity), task importance (content validity), feasibility, and acceptability. Outcome measures of novice, intermediate, and expert groups were compared using Mann-Whitney U-tests to assess construct validity., Results: Construct validity was demonstrated in a total of 17/25 performance evaluation metrics (p < 0.001). Experts performed better than intermediates with regard to time taken to complete the first (p = 0.002) and second (p = 0.043) module, number of instrument collisions (p = 0.040), path length (p =  .049), number of cuts >2 mm deep (p = 0.033), average distance from suture target (p = 0.015), and number of suture breakages (p = 0.038). Participants determined both the simulator console and psychomotor tasks as highly realistic (mean: 3.7/5) and important for surgical training (4.5/5), with system pedals (4.2/5) and knot tying task (4.6/5) scoring highest, respectively. The simulator was also rated as an acceptable (4.3/5) tool for training and its use highly feasible (4.3/5)., Conclusion: Construct, face, and content validity was established for the RobotiX Mentor, and feasibility and acceptability of incorporation into surgical training were ascertained. The RobotiX Mentor shows potential as a valuable tool for training and assessment of trainees in robotic skills. Investigation of concurrent and predictive validity is necessary to complete validation, and evaluation of learning curves would provide insight into its value for training.

The objectives of this review were to identify and evaluate the efficacy of mentorship programmes for minimally invasive procedures in urology and give recommendations on how to improve mentorship. A systematic literature search of the PubMed/Medline databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In all, 21 articles were included in the review and divided into four categories: fellowships, mini-fellowships, mentored skills courses and novel mentorship programmes. Various structures of mentorship programme were identified and in general, mentorship programmes were found to be feasible, having content validity and educational impact. Perioperative data showed equally good outcomes when comparing trainees and specialists. Mentorship programmes are effective and represent one of the best current methods of training in urology. However, participation in such programmes is not widespread. The structure of mentorship programmes is highly variable, with no clearly defined 'best approach' for postgraduate training. This review offers recommendations as to how this 'best approach' can be established., (© 2014 The Authors. BJU International © 2014 BJU International Published by John Wiley & Sons Ltd.)

Objective: To evaluate the urology human cadaver training program developed by the British Association of Urological Surgeons., Design: This prospective, observational comparative study recruited urology residents, with different levels of experience, in 2 sessions of a 3-day modular cadaveric operative urology training. Participants performed various procedures on fresh-frozen cadaveric specimens, as per module, supervised by certified urological surgeons. At the conclusion of each module, all residents and faculty were invited to complete an evaluation survey., Setting: The training days were hosted by the British Association of Urological Surgeons at the University of Manchester Surgical Skills and Simulation Centre., Participants: A total of 81 urology residents were recruited, with a maximum of 14 participants attending each module, over 2 sessions. We allocated 2 participants to each cadaver with access to all necessary equipment and guidance., Results: A total of 102 evaluation surveys were received from the trainees and faculty; a response rate of 94%. All procedures scored a mean of 3 on 5 for face validity, which is higher than the acceptability range. Regarding content validity, participants and faculty rated all aspects ≥3 on 5. Respondents held a positive view of the cadaver sessions and believed them to be useful for learning anatomy and steps of an operation (mean = 4.54) and as a confidence booster for performing a procedure (mean = 4.33). Furthermore, it was thought that the training program significantly improved skills (mean = 4.11), gave transferrable skills for the operating room (mean = 4.21), and was feasible to be incorporated into training programs (mean = 4.29). Human cadaveric simulation was rated as the best mode of simulation-based training for all the procedures in the curriculum., Conclusions: This study on cadaveric simulation training demonstrated face and content validities. It also showed feasibility, acceptability, a high value for educational influence and cost-effectiveness for cadaveric simulation. A simulation-based training pathway has been proposed for effective procedural training in urology., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented., Materials and Methods: An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points., Results: In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions., Conclusion: This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

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: 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.)

Objective: To evaluate the experience and views regarding live surgical broadcasts (LSB) among European urologists attending the European Association of Urology Robotic Urology Society (ERUS) congress in September 2012., Materials and Methods: An anonymous survey was distributed via email inviting the participants of the ERUS congress with experience of LSB to share their opinions about LSB. The outcomes measured included; personal experience of LSB, levels of anxiety faced and the perceived surgical quality. The impact of factors, such as communication/team-working, travel fatigue and lack of specific equipment were also evaluated., Results: In all, 106 surgeons responded with 98 (92.5%) reporting personal experience of LSB; 6.5% respondents noted 'significant anxiety' increasing to 19.4% when performing surgery away from home (P < 0.001). Surgical quality was perceived as 'slightly worse' and 'significantly worse' by 16.1% and 2.2%, which deteriorated further to 23.9% and 3.3% respectively in a 'foreign' environment (P = 0.005). In all, 10.9% of surgeons 'always' brought their own surgical team compared with 37% relying on their host institution; 2.4% raised significant concerns with their team and 18.8% encountered significantly more technical difficulties. Lack of specific equipment (10.3%), language difficulties (6.2%) and jet lag (7.3%) were other significant factors reported. In all, 75% of surgeons perceived the audience wanted a slick demonstration; however, 52.2% and 42.4% respectively also reported the audience wished the surgeon to struggle or manage a complication during a LSB., Conclusions: A small proportion of surgeons had significantly heightened anxiety levels and lower perceived performance during LSB, which in a 'foreign' environment seemed to affect a greater proportion of surgeons. Various factors appear to impact surgical performance raising concerns about the appropriateness of unregulated LSB as a teaching method. To mitigate these concerns, surgeons' performing live surgery feel that the operation needs to be well planned using appropriate equipment; with many considering bringing their own team or operating from home on a video link., (© 2013 The Authors. BJU International © 2013 BJU International.)

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.)

Background: The transforming field of urological surgery continues to demand development of novel training devices and curricula for its trainees. Contemporary trainees have to balance workplace demands while overcoming the cognitive barriers of acquiring skills in rapidly multiplying and advancing surgical techniques. This article provides a brief review of the process involved in developing a surgical curriculum and the current status of real and simulation-based curricula in the 4 subgroups of urological surgical practice: open, laparoscopic, endoscopic, and robotic., Methods: An informal literature review was conducted to provide a snapshot into the variety of simulation training tools available for technical and nontechnical urological surgical skills within all subgroups of urological surgery using the following keywords: "urology, surgery, training, curriculum, validation, non-technical skills, technical skills, LESS, robotic, laparoscopy, animal models." Validated training tools explored in research were tabulated and summarized., Results and Conclusions: A total of 20 studies exploring validated training tools were identified. Huge variation was noticed in the types of validity sought by researchers and suboptimal incorporation of these tools into curricula was noted across the subgroups of urological surgery. The following key recommendations emerge from the review: adoption of simulation-based curricula in training; better integration of dedicated training time in simulated environments within a trainee's working hours; better incentivization for educators and assessors to improvise, research, and deliver teaching using the technologies available; and continued emphasis on developing nontechnical skills in tandem with technical operative skills., (© 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.)

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.)

Simulation, if appropriately integrated into surgical training, may provide a time efficient, cost effective and safe method of training. The use of simulation in urology training is supported by a growing evidence base for its use, leading many authors to call for it to be integrated into the curriculum. There is growing evidence for the utilisation of part task (technical skills) simulators to shorten the learning curve in an environment that does not compromise patient safety. There is also evidence that non-technical skills affect patient outcomes in the operating room and that high fidelity team based simulation training can improve non-technical skills and surgical team performance. This evidence has strengthened the argument of surgical educators who feel that simulation should be formally incorporated into the urology training curriculum to develop both technical and non-technical skills with the aim of optimising performance and patient safety., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: To identify and assess potential hazards in robot-assisted urological surgery. To develop a comprehensive checklist to be used in operating theatres with robotic technology., Methods: Healthcare Failure Mode and Effects Analysis (HFMEA), a risk assessment tool, was used in a urology operating theatre with innovative robotic technology in a UK teaching hospital between June and December 2011. A 15-member multidisciplinary team identified 'failure modes' through process mapping and flow diagrams. Potential hazards were rated according to severity and frequency and scored using a 'hazard score matrix'. All hazards scoring ≥8 were considered for 'decision tree' analysis, which produced a list of hazards to be included in a surgical safety checklist., Results: Process mapping highlighted three main phases: the anaesthesia phase, the operating phase and the postoperative handover to recovery phase. A total of 51 failure modes were identified, 61% of which had a hazard score ≥8. A total of 22 hazards were finalised via decision tree analysis and were included in the checklist. The focus was on hazards specific to robotic urological procedures such as patient positioning (hazard score 12), port placement (hazard score 9) and robot docking/de-docking (hazard score 12)., Conclusions: HFMEA identified hazards in an operating theatre with innovative robotic technologies which has led to the development of a surgical safety checklist. Further work will involve validation and implementation of the checklist., (© 2013 BJU International.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants - South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres)., Objectives: To establish the feasibility and acceptability of a centralized, simulation-based training-programme. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills., Materials and Methods: For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales., Results: In total 33, three specialist registrars of different grades and five urological nurses participated in the present study. Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized. A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills., Conclusions: A centralized simulation programme that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety., (© 2012 BJU International.)

Background: The Productive Operating Theatre (TPOT) is a theatre improvement programme designed by the UK National Health Service. The aim of this study was to evaluate the implementation of TPOT in urology operating theatres and identify obstacles to running an ideal operating list., Method: TPOT was introduced in two urology operating theatres in September 2010. A multidisciplinary team identified and audited obstacles to the running of an ideal operating list. A brief/debrief system was introduced and patient satisfaction was recorded via a structured questionnaire. The primary outcome measure was the effect of TPOT on start and overrun times., Results: Start times: 39-41% increase in operating lists starting on time from September 2010 to June 2011, involving 1,365 cases. Overrun times: Declined by 832 min between March 2010 and March 2011. The cost of monthly overrun decreased from September 2010 to June 2011 by GBP 510-3,030. Patient experience: A high degree of satisfaction regarding level of care (77%), staff hygiene (71%) and information provided (72%), while negative comments regarding staff shortages and environment/facilities were recorded., Conclusions: TPOT has helped identify key obstacles and shown improvements in efficiency measures such as start/overrun times., (Copyright © 2013 S. Karger AG, Basel.)

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? Provision of high-quality care necessitates the identification and measurement of relevant quality indicators. Urological surgery currently does not have a validated quality-of-care framework to guide surgical quality improvement. This article aims to delineate quality of care processes, current status of quality indicators for major urological cancers as well as recommend a provisional framework for evaluation of quality for urological procedures. Growing demands for patient safety, lower cost and quality of care have resulted in several initiatives of quality measurement across urological surgery. Although candidate indicators have been proposed in various procedures, the field still lacks a valid quality framework. Better understanding of the interplay between patient selection, surgical expertise, preoperative-, intraoperative, postoperative processes and outcomes is needed. Consensus needs to be achieved in which validated structural, process and outcomes measures to employ, how this data should be collected, which agencies to share this data with and how to use this data to effect change in health policy. Compliance with quality framework needs to be continuously audited with its outcomes frequently benchmarked against international standards. Pursuit of quality improvement schemes require significant investment and need to be weighed against current budgetary constraints., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

What's known on the subject? and What does the study add? Dedicated training hours for surgeons are falling as the complexity of techniques and patient expectations are increasing. Urologists therefore need to train in more sophisticated and effective ways. This article looks at past and current urological training and suggests emerging and innovative ways to teach the next generation of urologists. Since 2004 the estimated available training time, for all doctors, has dropped from 30, 000 h to ≈ 8, 000h. By decreasing the initial stages of the learning curve, medical simulation has the potential to compensate for the reduced time available to train urologists. The current urological training pathway consists of 2 years of foundation year training, 2 years of core surgical training, followed by 5 years of specialty training. Training time pressures and the expansion of treatment techniques have led to a trend towards increased sub-specialization in urology. To optimize patient care, training programmes must evolve, taking into account several key issues and in accordance with advances in urological care., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

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.)

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.)

Purpose: We analyzed studies validating the effectiveness and deficiencies of simulation for training and assessment in urology. We documented simulation types (synthetic, virtual reality and animal models), participant experience level and tasks performed. The feasibility, validity, cost-effectiveness, reliability and educational impact of the simulators were also evaluated., Materials and Methods: The MEDLINE®, EMBASE™ and PsycINFO® databases were systematically searched until September 2010. References from retrieved articles were reviewed to broaden the search., Results: The study included case reports, case series and empirical studies of training and assessment in urology using procedural simulation. The model name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on face, content and construct validity. Most studies suitably addressed content, construct and face validation as well as the feasibility, educational impact and cost-effectiveness of simulation models. Synthetic, animal and virtual reality models were demonstrated to be effective training and assessment tools for junior trainees. Few investigators looked at the transferability of skills from simulation to real patients., Conclusions: Current simulation models are valid and reliable for the initial phase of training and assessment. For advanced and specialist level skill acquisition animal models can be used but availability is limited due to supply shortages and ethical restrictions. More research is needed to validate simulated environments for senior trainees and specialists., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

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.