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Construction, Validation and Application of a Virtual Reality Simulator for the Training of Transurethral Resection of the Prostate
Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Urology in Östergötland.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The fundamental of surgical training is the traditional apprenticeship method introduced by William Halsted which has been used for the last 100 years. It is based on learning in the operating room (OR) where the resident is guided by an experienced surgeon and gradually and methodically exposed to surgery. The continuous development of surgical methods together with the growing awareness of medical errors and ethical considerations have made the Halsted method outdated and there is an obvious need to be able to learn the skills of surgery without risking patient safety. New methods such as laparoscopy and endoscopy demand specific skills and abilities that may not be met by everyone. At the same time, the physical limitations of these new methods have made it possible to construct virtual reality (VR) simulators to practise and learn the skills necessary.

This study is about the construction and evaluation of a VR-simulator for the training of transurethral resection of the prostate (TURP). It also concerns the specific abilities needed to become a good surgeon.

A simulator for training TURP was developed after a face validity study where 17 experienced urologists gave their opinion of the specific content necessary for the training of this procedure. After a content validity study by nine experienced urologists and application of necessary improvements, a group of 11 medical students and nine experienced urologists performed a construct validity test where the urologists showed significantly higher levels of both skill and effectiveness compared to the inexperienced students when performing a simulated TURP procedure. The students showed a positive learning curve, but did not reach the levels of the urologists. The results of the experienced urologists were used as the minimal criterion level when 24 urology residents practised the procedure. Training took place while on a course on benign enlargement of the prostate and its treatment options, with emphasis on the “gold standard” treatment – TURP. During the course they performed three guided and video-taped TURP-procedures each on selected patients. Between two of the procedures they performed criterion-based training in the simulator. This VR-to-OR study showed improvement in operative skills with the same patient outcome as in the normal clinical situation. It also showed that simulator training improved their skills even more. During their time on the course their personality traits (TCI) and cognitive abilities (Rey complex figure and recognition trial, tower of London, WAIS-III) were tested. The results showed that a better learning curve in the OR was associated with a better simulator learning curve and a good visuospatial memory. The associated personality traits were high levels of goal directedness, impulse control, responsibility, anticipation of harmful events and a balanced attachment style.

In conclusion, we have demonstrated that it was technically possible to construct a useful simulator for the training of TURP (PelvicVision®) which may now be considered clinically validated for this purpose. Novice training and performance in the simulator improves the learning curve and predicts the resident’s performance in the OR. The results support the implementation of validated simulation technology in a criterion-based training curriculum for residents. Furthermore, the results showed preliminary data on personality traits and visuospatial abilities that are important for learning a complex surgical procedure.

Place, publisher, year, edition, pages
Linköping University Electronic Press, 2010. , 86 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1167
Keyword [en]
Surgical education, simulation, transurethral resection of prostate, psychometric tests, personality, validation, virtual reality, proficiency based training, objective assessment
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-54466ISBN: 978-91-7393-444-2 (print)OAI: oai:DiVA.org:liu-54466DiVA: diva2:304118
Public defence
2010-04-30, Berzeliussalen, Hälsouniversitetet, Campus Valla, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2010-03-17 Created: 2010-03-17 Last updated: 2015-11-19Bibliographically approved
List of papers
1. Use of a virtual reality, real-time, simulation model for the training of urologists in transurethral resection of the prostate
Open this publication in new window or tab >>Use of a virtual reality, real-time, simulation model for the training of urologists in transurethral resection of the prostate
2005 (English)In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 39, no 4, 313-320 p.Article in journal (Refereed) Published
Abstract [en]

Objective. There is a growing need to develop surgical skills outside the operating theatre. In this study we describe the development of a virtual reality training system for practising transurethral resection of the prostate (TURP). Material and methods. A face validity study was performed using a questionnaire sent to 28 experienced urologists to find out the ideal characteristics of a simulated TURP. Based on the comments a simulator was constructed and a content validity study was then performed in which nine experienced urologists tested the simulator and answered a second questionnaire. After corrections to the simulator, a basic construct validity test was performed. Results. We have developed a computer-based simulator based on the requirements listed by 17 urologists. It consists of a modified resectoscope connected to a haptic device and supported by a frame. The software provides a virtual view of the prostatic lumen and resectoscope tip, a haptic rendering that generates force feedback and a simulation module that computes the information from the haptic device, resectoscope fluid tap and handle and the foot pedals. The software also simulates bleeding, absorption of irrigation fluid and pressure gradients. Variables are measured and presented in a result file after each "operation". Nine experienced urologists performed a content validity study and changes were made accordingly. A basic construct validity test performed by seven inexperienced students showed a significant improvement in performance after they each performed six simulated procedures. Conclusion. We have developed a simulator that may be used to practise TURP and which meets most of the demands raised in a face validity study. A basic construct validity test showed improved performance after repeated practice in the simulated environment.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-30805 (URN)10.1080/00365590510031246 (DOI)16432 (Local ID)16432 (Archive number)16432 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13
2. Construct validity of a full procedure, virtual reality, real-time, simulation model for training in transurethral resection of the prostate.
Open this publication in new window or tab >>Construct validity of a full procedure, virtual reality, real-time, simulation model for training in transurethral resection of the prostate.
2010 (English)In: Journal of endourology / Endourological Society, ISSN 1557-900X, Vol. 24, no 1, 109-15 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To examine the content and construct validity of a full procedure transurethral prostate resection simulation model (PelvicVision). MATERIALS AND METHODS: The full procedure simulator consisted of a modified resectoscope connected to a robotic arm with haptic feedback, foot pedals, and a standard desktop computer. The simulation calculated the flow of irrigation fluid, the amount of bleeding, the corresponding blood fog, the resectoscope movements, resection volumes, use of current, and blood loss. Eleven medical students and nine clinically experienced urologists filled in questionnaires regarding previous experiences, performance evaluation, and their opinion of the usefulness of the simulator after performing six (students) and three (urologists) full procedures with different levels of difficulty. Their performance was evaluated using a checklist. RESULTS: The urologists finished the procedures in half the time as the students with the same resection volume and blood loss but with fewer serious perforations of the prostatic capsule and/or sphincter area and less irrigation fluid uptake. The resectoscope tip movement was longer and the irrigation fluid uptake per resected volume was about 5 times higher for the students. The students showed a positive learning curve in most variables. CONCLUSION: There is proof of construct validity and good content validation for this full procedure simulator for training in transurethral resection of the prostate. The simulator could be used in the early training of urology residents without risk of negative outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53081 (URN)10.1089/end.2009.0114 (DOI)19961333 (PubMedID)
Available from: 2010-01-15 Created: 2010-01-15 Last updated: 2010-03-17
3. Impact of Virtual Reality-Simulated Training on Urology Residents Performance of Transurethral Resection of the Prostate
Open this publication in new window or tab >>Impact of Virtual Reality-Simulated Training on Urology Residents Performance of Transurethral Resection of the Prostate
2010 (English)In: Journal of endourology, ISSN 0892-7790, E-ISSN 1557-900X, Vol. 24, no 9, 1521-5128 p.Article in journal (Refereed) Published
Abstract [en]

Background: There are today a number of VR-simulators for practicing the TURP procedure, but few data on the effect of training on surgical performance.

Objective: To test if practicing the TURP procedure in a VR-simulator increases the skills and dexterity of urology residents when performing the procedure on patients. Design, setting and participants Twenty-four urology residents attended a five-day course on diagnosis and treatment of benign prostatic enlargement. Each of the residents did three video-recorded TURP procedures on patients.

Intervention: Between two of the procedures the residents underwent criterion-based practice in a TURP simulator (PelvicVision).

Measurements: The TURP procedure was peroperatively evaluated using objective structured assessment of technical skills (OSATS). The video-recordings of the procedures were analyzed on a minute to minute basis regarding the main action during that minute, if that action was successful, and errors.

Results and Limitations: The participating residents rated patient safety as high, they believed they learned most from the real operations, and they gained knowledge about both the procedure and the instrumentation used. The mean practice time in the simulator was 198 minutes before reaching the criterion level. Comparison of the first and last TURP procedures showed an increase in autonomous operation time and in successful actions and a decrease in hemostasis time without increased blood loss. The proportion of residents believed able to perform a simple TURP procedure increased from 10% to about 75%. OSATSscores and self-evaluations were significantly improved. The scores increased significantly more with than without simulator practice. The patient follow-up showed no increased risks or poorer results regarding micturition.

Conclusions: Practice in a simulator based environment improves the skills and dexterity of urology residents when performing the procedure on patients, without increased risks or poorer results for the patients.

Place, publisher, year, edition, pages
Mary Ann Liebert, Inc., 2010
Keyword
Prostate, transurethral resection of prostate, computer simulation, education, medical, task performance and analysis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54462 (URN)10.1089/end.2009.0667 (DOI)000281864700026 ()
Available from: 2010-03-17 Created: 2010-03-17 Last updated: 2017-12-12
4. Simulator performance, psychometrics and personality testing guiding the choice of clinical discipline
Open this publication in new window or tab >>Simulator performance, psychometrics and personality testing guiding the choice of clinical discipline
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The complexity of surgical training has increased and surgery put high demands on personal abilities that cannot be met by all even after training. Selection of personnel is critical to many professions, including surgery, but the selection procedure of surgical apprenticeship is not well developed. It would be of value to get an early assessment of important personal features like the ability to learn complex procedures. Further, individuals learn in different ways and the personality may influence this ability. Other important aspects are visuospatial abilities, working memory and executive functioning. These variables are measured in the present study by: learning curves in a TURP VR-simulator, scores from the personality test TCI-R, Rey complex figure and recognition trial, Tower of London (dx) and tests from WAISIII.

Twenty-four residents in urology performed three real TUR-P procedures and their performances were analyzed with OSATS and video-recordings. The learning curves from the OR were compared with the results from the simulation practice, personality tests and psychometrics using multiple linear regression. The findings from personality and psychometric data were also compared with the general population to see if there are any indications of a “surgical personality”. The urology residents in this sample have a welldeveloped character (effective, mature, reliable, goal-oriented, empathetic, tolerant, supportive, cooperative) and with high reward dependence (tender-hearted, dedicated, sociable) together with better executive planning abilities and better verbal working memory than normal.

The connections between the operation learning curves and the variables above indicate that a better learning score is associated with a good learning score in a simulated environment, goal-directedness, a high level of impulse control, anticipation of harmful events and responsibility, a balanced attachment style and a good visual spatial memory.

Keyword
Surgical training, simulator, transurethral resection of prostate, psychometric tests, personality
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54464 (URN)
Available from: 2010-03-17 Created: 2010-03-17 Last updated: 2010-03-17Bibliographically approved

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