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MP14-13THE FLUORO-LESS C-ARM PERCUTANEOUS ACCESS TRAINER

Domenico Veneziano*, Minneapolis, MN; Arthur Smith, New York, NY;Troy Reihsen, Jason Speich, Robert Sweet, Minneapolis, MN

INTRODUCTION AND OBJECTIVES: Achieving proper renalaccess is one of the most challenging skill-sets for PCNL. Parallax ofthe proper calyx with c-arm is a core learning objective. Existing trainingsystems use virtual reality(VR) or fluoro-assisted biologic and syntheticmodels. VR models have limitations and are expensive and fluoroscopyis impractical and is associated with unnecessary exposure to radiation.We report the development and initial validation of a fluoro-lesspercutaneous renal access trainer.

METHODS: A mini C-arm was designed and 3D printed. Twovideocameras were mounted on the anterior and posterior portion of theC. The C was designed to tilt and rainbow. A clear flank model wascreated with a silicon material with a cast of a University of MinnesotaSimPORTAL calyceal model in it filled with fluid. The silicon model hasbeen then covered with a "blue screen" skin-like, colored material andprovided with a physical reproduction of the 10th-12th ribs. The twocameras have been connected to a computer for image processing toproduce the final on-screen image.

RESULTS: The C-arm navigation trainer has face and contentvalidity for training percutaneous access. It does so successfully withoutradiation exposure. The novel double camera system and the imageprocessing software were able to obtain visual information enough toaccomplish correctly the training tasks, without expensive additional 3dmotion tracking technologies.

CONCLUSIONS: The fluoroscopy-less C-arm navigation traineraccurately replicates the functions of a real X-ray system, without anyradiation exposure related issues, regardless the time it takes to com-plete the training sessions. The usability of a perc model, as well as ofany other specifically designed anatomical silicon models, make it a lowcost, feasible instrument for training.

Source of Funding: none

MP14-14TRENDS IN RESIDENT INVOLVEMENT IN BPH PROCEDURES

Mark Ball*, Max Kates, Hiten Patel, Brian Matlaga, Baltimore, MD

INTRODUCTION AND OBJECTIVES: Transurethral resectionof the prostate (TURP) is the historic gold standard surgical treatmentfor men suffering from symptomatic benign prostatic hyperplasia(BPH). In recent years, though, novel BPH therapies such as photo-selective vaporization of the prostate (PVP) have become increasinglyadopted. Indeed, epidemiologic evidence suggests that the utilizationof TURP is declining and laser vaporization has become the fastest

growing treatment modality. Consequently, there is concern thaturology residents are not being trained in TURP techniques to theextent they once were e an issue of particular importance given thewell described learning curve associated with TURP. We performed astudy to characterize resident participation in TURP and PVPprocedures.

METHODS: The American College of Surgeons’ National Sur-gical Quality Improvement Database (NSQIP) is a prospectively main-tained, validated database of pre-operative to 30-day postoperativesurgical outcomes that was designed to improve surgical care. Wequeried NSQIP for the years 2007-2011, using CPT codes 52601(TURP) and 52648 (PVP) to identify the study cohort. Residentinvolvement was assessed and compared, both overall and thenstratified by year as a proportion of total BPH cases.

RESULTS: A total of 6,077 BPH procedures were captured inNSQIP during the study period. Residents were involved in 1,378 pro-cedures (22.7%). TURP was performed 3,764 times, with residentsinvolved in 826 cases (21.9%). PVP was performed 2,313 times, withresidents involved in 552 (23.8%). When stratified by year, both the totalnumber of cases and the proportion of cases with resident involvementwere higher for TURP than for PVP in each year (Figure 1).Pairwisecomparison for each year were all statistically significant (p values 0.03or less).

CONCLUSIONS: TURP is more commonly performed thanPVP among institutions participating in NSQIP. With regards to surgicaltraining, residents are more likely to participate in a TURP procedurethan a PVP procedure.

Source of Funding: none

MP14-15FACE, CONTENT AND CONSTRUCT VALIDATION OF THEGREENLIGHT SIMULATOR

Kamran Ahmed*, Abdullatif Aydin, Gordon Muir,Mohammed Shamim Khan, Prokar Dasgupta, London, United Kingdom

INTRODUCTION AND OBJECTIVES: There is a limited num-ber of validated simulators available for basic urological proceduressuch as TURP and related laser therapies. This prospective study aimsto assess the feasibility, acceptability and face, content and constructvalidity of the AMS GreenLight Simulator, the first virtual reality simu-lator for GreenLight Laser Photoselective Vaporisation of the Prostate(PVP), to assess the level of transferability of the skills learnt to theoperative setting.

METHODS: This prospective, observational and comparativestudy, recruited novices (n¼25), trainees (n¼10), and expert urologists(n¼9) from various institutions in the United Kingdom and Europe.Novices, trainees and experienced surgeons performed all the subtasktraining modules once, followed by an operative case. Assistanceduring sessions wasn’t provided. The outcome measures for evaluatingconstruct validity were time to task, coagulation time, vaporization time,average sweep speed, average laser distance, blood loss, operativeerrors, and instrument cost. A quantitative survey was used to assessface and content validity, feasibility and acceptability.

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RESULTS: This study applied a stepwise process to thetraining modules and case metrics of the AMS GreenLight SIM;establishing content validity, face validity, feasibility and acceptability.Face validity revealed most experts believed that the simulator was70% realistic (7/10 on a Rating scale score). The instrumentation andvaporization function were thought to be the most realistic componentsand coagulation the least. A Leikart score for content validity revealedthe anatomy identification, sweep speed, tissue-fibre distance andcoagulation parameters to be very important concepts for the realoperative procedure. Construct validity was demonstrated in two of fivetraining modules (p¼0.043; p¼0.018) and in a considerable number ofcase metrics (p¼0.034) (Figure 1).

CONCLUSIONS: This study has demonstrated the AMSGreenLight SIM to be a valid and useful training tool for GreenLightlaser PVP. It is hoped that by using the GreenLight SIM, novice traineescan acquire skills and knowledge to a predetermined level ofproficiency.

Source of Funding: None

MP14-16INITIAL RESIDENT EXPERIENCE FROM TWO INSTITUTIONS WITHTHE GREENLIGHT LASER SIMULATOR

Bradford Stevenson*, Springfield, IL; Matthias Hofer, Chicago, IL;Tobias Kohler, Kevin McVary, Springfield, IL

INTRODUCTION AND OBJECTIVES: The use of simulatorsand skills labs has become a popular method for the rapid and safeacquisition of operative skills. The University of Minnesota’s CRESTprogram along with AMS has developed a virtual simulator for photo-selective vaporization of the prostate, the AMS GreenLight LaserSimulator. We analyzed the utilization and performance data of urologyresidents at two academic centers using the simulator. Our objectivewas to determine usage patterns, evaluate injuries as they related toresident level, determine a learning curve for novice users, and evaluatethe simulator for its potential use as part of a training curriculum.

METHODS: The simulator curriculum contained 6 modules ofcommon BPH cases and 5 training exercises. The simulator wasavailable to residents to use at their convenience. We analyzed theutilization and performance data recorded during modules based on

resident level and operative experience, as well as differences betweeninstitutions. A survey was conducted at the end of the study to evaluatethe residents’ impressions of the simulator.

RESULTS: In total, 409 cases were performed. Initial scores fornovice residents were lower than those of more experienced residents.Novice user scores approached those of experienced residents withrepeated use. Senior residents had a higher rate of adverse eventssuch as sphincter, urethral, rectal, or verumontanum injury during thesimulation cases. Stratified by module, increased adverse events wereseen during the more challenging modules such as prominent apex,trilobar coaptation, and prominent median lobe. Resident usage differedbetween institutions. Prior surgical experience with PVP differed be-tween the two institutions and correlated with initial SIM scores. Videogame experience also differed between the two institutions but did notsignificantly impact the performance on the simulator.

CONCLUSIONS: The Greenlight simulator gives PVP novicesan opportunity to become familiar with the mechanics of performing aPVP before entering the operating room. Operative experience andresident level were associated with higher initial scores, but withrepeated use novice scores approach those of experienced residents.The simulator allows identification of resident outliers and provides anobjective way for a program director to track progress and can allow fordemonstration of a minimum level of proficiency before a resident isallowed to perform a case in the operating room. Further research isneeded to validate the SIM as a training tool and to determine if usagetranslates into improved operative skills.

Source of Funding: None

MP14-17ASSESSMENT OF FACE, CONSTRUCT AND CONTENT VALIDITYOF A NOVEL VIRTUAL REALITY SIMULATOR FOR HOLMIUMLASER ENUCLEATION OF THE PROSTATE

Cameron Kuronen-Stewart*, Kamran Ahmed, Abdullatif Aydin, London,United Kingdom; Mark Cynk, Maidstone, United Kingdom; Paul Miller,Greater London, United Kingdom; Prokar Dasgupta,Muhammad Shamim Khan, Ben Challacombe, Rick Popert, London,United Kingdom

INTRODUCTION AND OBJECTIVES: Holmium laser enucle-ation of the prostate (HoLEP) is considered a difficult operation to learn.Surgical model simulators have been used in training courses as amethod to shorten the learning curve without endangering patients.Now, virtual reality (VR) simulation with its novel and varied capabilitiesmay revolutionise surgical training. However, validation is required toassess its potential.

METHODS: This prospective observational study recruited 34participants, comprising of experienced HoLEP surgeons (n¼5), con-sultants and surgical trainees experienced in endourology but notHoLEP, (HoLEP trainees n¼13), and trainees with no experience(Novices n¼16). All participants received an educational package onHoLEP, including didactic lectures on technique, instructional videosand videos of real surgeries carried out by experts. Each participantthen completed a 15-minute familiarisation exercise with the simulator.This consisted of an endourological visualization exercise followed by abasic middle lobe enucleation task. The participants then carried out afull enucleation on a 60cc prostate. Performance was assessed usingin-built simulator metrics and a quantitative questionnaire assessingface and content validity, as well as feasibility, acceptability, andeducational impact. Novice, trainee, and expert groups were comparedusing the Mann-Whitney U test.

RESULTS: Construct validity results revealed that novices(p<0.001) and trainees (p¼0.002) had significantly decreased enucle-ation efficiency (weight enucleated in grams/hour) compared to experts.Both non-expert groups also had longer procedure times intotal (p<0.001).

86% of participants agreed that simulator based assessment isessential for patient safety and 88% agreed that there was a role for avalidated VR simulator for use in HoLEP training. 97% thought that