Keywords

16.1 Introduction

Simulation as a means of learning or rehearsing surgery has a rich history, which is as old as surgery itself. Sushruta, an ancient Indian physician—2600 years ago, widely believed to be the “Father of Surgery,” is credited with the use of fruits, vegetables, pieces of cloth/ skin/ hides, and cadaver-based experimental modules for teaching surgical skills [1,2,3]. These were the forerunners of modern low-cost simulation in which surgical residents practice tying knots, suturing on clothes, and train on animal organs.

Surgical skills, like any other motor skills, can only be acquired by repetitive practice, i.e. simulation; which consists of cognition, integration, automation, and finally, mental cognitive rehearsal of the proposed surgery [4, 5]. Simulation provides a much needed bridge between theoretical learning and real-life operating experience for a trainee and has become the foundation of modern surgical training. A recent bibliometric analysis of surgical education’s 100 most cited articles found that the majority of publications were on surgical skill acquisition by simulation and its assessment and highlighted its importance [6].

Traditionally, simulations for surgical training were practiced in an autodidactic manner in rudimentary wet labs using animal parts procured from local butcher’s shops or on cadavers. The advent of minimally invasive surgery demanded an upgrading of the science of simulations for learning new surgical skills, which had a significant learning curve due to impaired depth perception as visualization is on a two-dimensional screen, impaired tactile feedback, 2-handed choreography for dissection, non-dominant hand dexterity, accurate instrument targeting, intracorporeal suturing, different hand–eye coordination, familiarity with the fulcrum effect and, last but not least, working in a less ergonomically friendly position leading to earlier fatigability [7, 8]. Training opportunities in modern surgical skills centers were and are limited due to cost and availability [9,10,11,12]. This prompted the surgeons to unleash their ingenuity and led to the development of low-cost, easily available, and sustainable alternatives for simulation of surgical training. This was and remains very important in low- and middle-income countries.

16.2 Humble Beginning of Low-cost Simulation Systems

This revolution had humble beginnings in the form of “laparoscopy box trainers” which are made from the self-assembly of locally available/off-the-shelf/bought from online shopping portals components and even using used/discarded/expired disposable instruments (Table 16.1) [8, 13,14,15,16].

Fig. 16.1
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Abdominal wall model to simulate the Hasson open access technique [13]

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Table 16.1 Anatomy of low-cost box trainers for minimally invasive surgery
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16.3 Advantages and Qualities of Low-cost Simulation Systems

Low-cost trainers are designed basically for novice surgeons to practice generic skills required for urological surgery. A low-cost simulation system has most of the advantages of a high-fidelity system: it allows repetitive practice of skills; can be used many times by multiple users; it permits the trainee to become familiar with anatomy (to scale, tissue texture, and accurate replication of anatomy), equipment, and techniques of surgery being practiced, so the learning curve associated with real patients can be avoided as much as possible; allows learning in a low-pressure atmosphere, without undesired interference while training in dedicated teaching time rather than patient care time; it allows a range of difficulties so training can be tailored to individuals; it is easily modifiable for various procedures and allows multiple learning strategies with defined outcomes; objective assessment of trainees is possible; it allows for judging the technical skills among participants of varying expertise; it permits refresher training of skills for senior trainees; it provides a facility for feedback and can be integrated within a training curriculum; and it can be reliably reproducible and valid [14, 15, 17,18,19,20]. In addition, it is low cost, low maintenance; with easy and cheap construction so as to be accessible to trainees worldwide. Trainees can better understand the “science” of skills to be acquired if they are involved in designing such systems [21].

16.4 Low-cost Technical Skills Simulation Systems in Urology

A recent review has given an encyclopedic and scholarly evidence-based account of the current status of simulation training in urology; including models for open urology, biological and non-biological models for endo-urology, and various laparoscopic and robotic models [22]. Similarly, all low-cost simulation models in urology have been appraised by a recent comprehensive review which defined low-cost models as those costing 150 US$ or less [23]. Many low-cost simulation models in urology have been summarized in Table 16.2.

Table 16.2 Low-cost simulators in Urology (Modified from Sharma et al. [14] and Pelly et al. [23])
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As Table 16.2 shows, several low-cost models are now available for adult circumcision (Fig. 16.2), dorsal slit, and paraphimosis reduction at a cost of <$10 (Chap. 14); some of which show good face and content validity. Before the advent of low-cost models for supra-pubic catheter (SPC) insertion, it was not easy to acquire this skill, prompting junior doctors to frequently persist with urethral catheterization, with an increased risk of urethral injury [33]. Low-cost SPC models are few (<10 in number), with material costs ranging from <$2 to $60 per model. The lack of their validity and incorporation into structured curricula remain their main limitations [73]. Simple, low-cost models for training in TUR Prostate using potatoes (Fig. 16.3) or apple have been shown to be realistic with proven face, content, and construct validity [48, 46]. Similarly, low-cost diagnostic and therapeutic cystoscopy models have used porcine bladder, glass globe, round balloon, fresh frozen cadavers, and pumpkins and green peppers to simulate urinary bladder; many of which have shown improvement in trainees’ performance (Table 16.2).

Fig. 16.2
figure 2

Circumcision model, circular incision on the synthetic foreskin (a, b), dorsal slit of the foreskin and demonstration of the inner layer (c), suturing of both layers to complete the circumcision (d) [25]

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Fig. 16.3
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Use of a potato to teach basic resection skills in Hawassa Ethiopia [46]

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Fig. 16.4
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Use of Rubber balloon and tube model for Dismembered Pyeloplasty [61]

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Many low-cost simulations use porcine, chicken, and beef models; as these have inherent natural tissue properties important for the acquisition of higher surgical skills such as dissection, suturing, and use of energy sources with the same instruments that are used in clinical practice [39, 40, 47, 50, 72, 74,75,76]. The creative imagination of surgeons has led to even using the folding of the chicken skin in various shapes for various urological simulations. Many of these models have the potential for various degrees of face, content, and construct validity as teaching and learning tools in urology (Table 16.2).

Rapid and precise percutaneous renal access is a challenging step during percutaneous renal surgery [77]. Many bench, animal, and 3D printed models are available to overcome this challenge [78,79,80]. These have shown that they can improve the efficiency of training punctures in a cost-efficient manner [81]. Both animal and 3D printed models are available; animal models have been rated better than silicon models by users in one study [79]. Training on bench models for ureteroscopy allows enhanced manual dexterity as well as familiarity with the method and is recommendable before operating on patients [82, 83]. Similarly, several low-cost, high-fidelity models for pyeloplasty exhibit acceptability and content validity; and improve participant speed (Table 16.2) [64, 65].

The versatility of three-dimensional (3D) printing has a special place in simulations as it allows rapid translation of medical imaging into tangible replicas of patient-specific anatomy, which can simulate the elasticity and mechanical strength of the living organ [84,85,86]. Its potential has been used for practically all types of urological simulations and showcases its spectrum [84]. However, it is widely considered as an expansive modality for simulation. Paradoxically, it is a great boon for low-cost simulation systems as the actual cost of the models is not much if a 3D printer is already available; which is now available in many educational institutions. Including 3D printed models as low cost is analogous to the use of various expansive operating endoscopes along with imaging modalities while using various low-cost alternatives. Improvements in the science of 3D models are expected to provide even better replication of viscoelastic properties of tissues, various tissue planes and physiological tissue responses to surgical insults, along with more cost-effectiveness [87]. And finally, there is encouraging news on the front of low-cost virtual reality simulation platforms; which will be promising for resource-constrained settings [88].

16.5 Feasibility and Effectiveness of Low-cost Simulating Systems in Urology

Feasibility and effectiveness of low-cost simulating systems on the development of urological skills have been shown in many studies (Table 16.2). Both the low-fidelity, locally made, low-cost trainers and the high-fidelity simulators are equally effective means of teaching basic skills to novice learners [49, 89,90,91,92,93]. In fact, a few studies have found that for basic minimally invasive surgery training, low-fidelity models are superior to high-fidelity models; especially in resource-constrained training programs [94, 95].

16.6 Comparison of Various Simulation Systems

It is important to compare various types of simulation systems to gain a real perspective of what the low-cost alternatives actually offer (Table 16.3) [96, 97].

Table 16.3 Comparison of various simulation systems
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Table 16.3 shows that the costs shoot up when an attempt is made to upgrade a low-cost training system with high-fidelity physical reality experience, augmented with virtual assessment, explanation of tasks, appropriate feedback, and prompting. Cost is the most important determinant of access to technology and low-cost alternatives will always be needed for those who train and work in resource-constrained milieu. It must be remembered that both low-cost low-fidelity and high-cost high-fidelity systems are a continuum—two ends of the same spectrum—and not dichotomous different approaches [17]. The low-cost system is the more easily and widely available, cost-effective workhorse which can lay the foundation of basic generic surgical skills; over which the edifice of advanced skills can be then easily constructed with high-cost high-fidelity systems [14].

16.7 Low-cost Non-technical Skills Simulation

Non-technical skills (NTS), such as communication, team-work, and task coordination, are increasingly being recognized as vital to patient safety. Many simulation research studies on NTS have shown their educational benefits [98, 99]. High “psychological fidelity” can be ensured at a minimal cost to create a more realistic and acceptable scenario; and low-fidelity simulators have been shown as non-inferior to the more costly high-fidelity simulators for teaching NTS to postgraduate medical trainees [100]. This evidence has been strengthened by the successful delivery of courses for surgeons and anesthetists in Rwanda [101,102,103]. The success of these programs has led to worldwide interest in developing and teaching NTS to healthcare providers in various specialties including urology [104].

16.8 Limitations of Low-cost Simulating Systems in Urology

Surgical simulation is a “good idea whose time has come” [105]. However, except for a few randomized control trials, most published studies are observational in nature and lack rigorous science [42, 43, 49]. Moreover, most publications have not studied the cost, validity, and educational impact of their low-cost training models in terms of transferability of skills to operating theater (Table 16.2) [37, 38, 76, 106, 107]. This can be easily achieved if the surgeons designing these low-cost simulators do not stop at just designing them but take the extra small step of scientifically validating them [14]. Simulation based urological skills training has been accepted and is being used in various structured “boot-camps,” programs, and curricula across the globe [13, 108, 109]. However, greater structured integration in formal training is needed to improve resident skills and ultimately, improve the quality of patient care [110, 111]. The resource constraints of developing countries are well known; however, even developing countries seem to be lagging behind in providing necessary simulation training in urology [11]. Sensitization of trainers is also needed as it is an equally important component for the success of any simulation program. There is no doubt that there is scope of improvement in “refinement of simulation techniques leading to better fidelity, better validation, better incorporation in curriculum, and better availability across the world” [112, 113].

Key Points

  • Simulation as a means of learning or rehearsing surgery has a rich history, which is as old as surgery itself.

  • Surgical skills, like any other motor skills, can only be acquired by repetitive practice, i.e., simulation; which provides the much needed bridge between theoretical learning and real-life operating experience for a trainee and has become the foundation of modern surgical training.

  • Training opportunities in modern surgical skills centers were and are limited due to cost and availability. This has led to the development of low-cost, easily available, and sustainable alternatives for simulation of surgical training.

  • A low-cost simulation system has most of the advantages of a high-fidelity system; and in addition is low cost, low maintenance; with easy and cheap construction, so it is accessible to trainees worldwide.

  • Several low-cost biological and non-biological models are available for many open, endoscopic, laparoscopic, and robotic urological surgeries.

  • Low-fidelity locally made low-cost and high-fidelity simulators are equally effective means of teaching basic skills to novice learners.

  • Most publications on low-cost simulating systems in Urology are observational in nature and have not studied the cost, validity, and educational impact in the form of transferability of skills to operating theater. Greater structured integration in formal training and better availability across the world will improve resident skills and ultimately improve the quality of patient care.

  • There is increasing acceptance of teaching non-technical skills in various specialties including urology, with the help of low-cost low-fidelity simulators, which have been shown as non-inferior to the more costly high-fidelity simulators.