Urological training in Singapore has undergone a major overhaul over the last decade with reduced training time, expanding number of complex surgical procedures, compounded by growing expectations of an increasingly well-informed, litigious patient population. As VR simulators become increasingly popular for training, there is evidence demonstrating benefits of simulation as an adjunct to surgical training.[12–14] VR simulations offer safe environments for training and evaluation of technical skills without compromising patient safety.[15] There have been considerable technological advances in VR simulation in medical education; with respect to TURP particularly, five validated models exist: SVKTURP simulator, Bristol TURP trainer (Limbs and Things, Bristol, UK), University of Washington trainer, PelvicVisionTURP simulator and TURPsim (VirtaMed, Zurich, Switzerland).[16]
Appreciation of simulation is emulated by the development of formal simulation training programmes globally. In the UK, a national simulation-based Urology Bootcamp is compulsory.[17] The European Basic Laparoscopic Urological Skills program is validated as a laparoscopic simulation skills course and is frequently conducted in many places worldwide.[18] Advantages of simulation include opportunities to practice realistic procedures repeatedly to develop psychomotor skills and dexterity while mounting the initial learning curve in a safe, controlled environment. Automated feedback and assessment highlights each individual’s gaps in training to allow directed study, while reducing overall time commitment for faculty members.
It must be emphazised that the authors are not advocating for simulation to replace surgical training, but rather as an adjunct to training. Simulation is inadequate in honing other ‘soft skills’, including situational reaction in the operating room, teamwork with staff, communication and troubleshooting equipment.[19] These quintissential skills have to be accumulated during real-time operative experiences.
Construct validity of our TURP simulator was demonstrated as performance discrimination between experts and novices. Statistically significant differences were shown in general performance (%PR/min) and safety (TWAC). Although not statistically significant, percentage capsule resected per min was also lower in the expert group compared to novices; this can be accounted by the fact that novices did not resect enough prostate to reach the capsule for it to be significant.
The potential benefits of the TURP simulator was demonstrated in this pilot study with urological residents. Singapore’s residency programme is 6-years long; the first three years constitute junior residency with general surgical rotations, while the last three years of senior residency are spent in urology. Therefore, JR would have had limited or no prior urological operative experience compared to SR who are focused on gaining necessary competencies to be a certified specialist.
Firstly, overall performance is consistent with previously demonstrated construct validity. SR resected significantly more prostate per min compared to JR. Although the CR per min is greater in SR compared to JR, this could be confounded by the fact that JR did not resect enough prostate to reach the prostatic capsule. TWAC was also significantly longer in JR compared to SR, indicating that the SR group was safer with lower risks of causing collateral damage. (Figs. 1a-c)
Secondly, consistent improvements in all residents regardless of seniority was demonstrated. All residents resected more prostate and less capsule, and were safer in activating the tool less when not resecting in the second attempt. (Fig. 2a-c) There was a greater improvement in mean prostate resected on second attempt for JR compared to SR although this was not statistically significant. In terms of safety, there was a decrease in the mean CR in the JR group compared to the SR group. TWAC was also less in the JR group by almost 3% compared to the SR group. (Table 2) This is consistent with literature that simulation exerts the greatest benefit when a resident is uninitiated and mounting the initial learning curve.[20] Intuitively, this infers that simulation may aid trainees in acquiring basic skills, thereby surmounting the earlier, error-prone part of the learning curve in a safe manner.
We recognise that this study has limitations regarding the number of participants. However, the number of residents recruited is almost fully representative of the national residency programme at the time of writing. Another limitation is the paucity of repeated attempts to demonstrate reproducibility, retention, and translation of skills into the operative room.
These results allude to the potential benefits of TURP simulation in training and is particularly crucial in the climate of COVID-19. Elective surgeries, including TURP, have been severely curtailed as part of national containment efforts. Additionally, infection control measures require a senior doctor to perform all procedures to reduce infective exposure to staff and overall operative time. Training was severely impacted given that the traditional model of observation and practice under direct supervision of an experienced senior could not be practised. Residents were also redeployed to support other clinical services, further reducing training opportunities. Therefore, we should look to fill up such gaps with simulation-based curricula in these uncertain times.
In summary, our pilot experience in TURP simulation strengthens the evidence that the TURP simulator potentially aids in overcoming challenges expounded in the ever-changing landscape of urological training. Particularly in the COVID-19 era, where it is paramount to maintain social distancing and sound business continuity plans, learning and surgical training can continue to progress. We hope to build on this foundation and validate further research, with the aim to incorporate simulation as an adjunct into a broad-based curriculum, to develop a more robust and comprehensive training programme.