Original Paper
Urologia Internationalis
Received: November 14, 2014 Accepted after revision: January 9, 2015 Published online: February 26, 2015
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
Novel Transparent Urinary Tract Simulator Improves Teaching of Urological Operation Skills at a Single Institution Xiao Zhong Pingxian Wang Jiayu Feng Wengang Hu Chibing Huang Department of Urology, Second Affiliated Hospital, Third Military Medical University, Chongqing, PR China
Abstract Objective: This randomized controlled study compared a novel transparent urinary tract simulator with the traditional opaque urinary tract simulator as an aid for efficiently teaching urological surgical procedures. Methods: Senior medical students were tested on their understanding of urological theory before and after lectures concerning urinary system disease. The students received operative training using the transparent urinary tract simulator (experimental group, n = 80) or the J3311 opaque plastic urinary tract simulator (control, n = 80), specifically in catheterization and retrograde double-J stent implantation. The operative training was followed by a skills test and student satisfaction survey. Results: The test scores for theory were similar between the two groups, before and after training. Students in the experimental group performed significantly better than those in the control group on the procedural skills test, and also had significantly better self-directed learning skills, analytical skills, and greater motivation to learn. Conclusion: During the initial step of training, the novel transparent urinary tract simulator significantly improved the efficiency of teaching urological procedural skills compared with the traditional opaque device. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0042–1138/15/0951–00380$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
The teaching of urological surgery skills is essential in medical school, as with other surgical specialties [1]. It is worth noting that allowing an unprepared and inexperienced student to attempt an invasive procedure, such as catheterization, greatly increases the risk of infection and harm to the patient [2]. In addition, patients undergoing catheterization and retrograde double-J stent implantation are often unwilling to allow students to perform the procedure [3]. In most countries, the curriculum relies on multimedia-assisted lectures, which allow teaching the course content in a relatively short amount of time [4]. To demonstrate the basic techniques used in urinary surgery, instructors apply computer and multimedia technologies, after which students are given the opportunity to observe and learn these skills using an opaque plastic urinary tract model. Unfortunately, the visual representation that these models provide is not adequate. Students report that they have a poor understanding of the purpose of the procedures and how the surgical instruments should be applied [5]. To solve these problems, we developed a transparent urinary tract simulator. The simulator is designed to aid both teaching theory and the demonstration of procedural skills, at a low cost. In this study, we explored the advantages of the transparent urinary tract simulator as a teaching aid, and we provide a theoretical basis for its further application. The Chibing Huang, MD, PhD Department of Urology, Second Affiliated Hospital, Third Military Medical University Chongqing 400037 (PR China) E-Mail chibinghuang2008 @ outlook.com
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Key Words Medical education · Urinary tract simulator · Medical simulator · Catheterization · Ureteroscope · Cystoscopy
Color version available online
a
b
e
c
d
f
Fig. 1. Transparent urinary tract simula-
viability and advantages of the simulator for teaching urological procedural skills was tested relative to that of a traditional opaque model.
Materials and Methods Simulator Design and Construction For the design of the simulator, the urinary anatomy parameters developed by Tortora and Grabowski [6] were used. Other factors such as applicability and durability were also considered. To design the simulator in three dimensions, we used UGNX 7.0 software (Siemens PLM Software, Munich, Germany), Mastercam 9.1 software (CNC Software, Tolland, Mass., USA), and a KR-H6 computerized numerical control machine (Jing Yi, Shenzhen, China). The wall of the simulator consists of an outer and an inner layer. The outer layer is made of polymethyl methacrylate to maintain the shape of the urinary tract. The main ingredient of the inner layer is acrylonitrile butadiene styrene, which simulates the swelling characteristics of the urinary tract. Both materials are produced by Fu Sheng Yuan (Dongguan, China). Two types of transparent urinary tract simulators were constructed to mimic the urinary tracts of men (fig. 1a) and women (fig. 1b), respectively. These can be used to demonstrate catheterization (fig. 1c) and retrograde double-J stent implantation (fig. 1d). Randomized Controlled Trial Designed to Evaluate the Transparent Simulator Study Design This was a randomized controlled study, which compared the teaching efficiency of the transparent urinary tract simulator to that of the traditional opaque plastic simulator. The local ethics committee approved the study. One hundred and sixty seniors from the Third Military Medical University were randomly and equally divided into an experimental
A New Transparent Urological Simulator
group and a control group. Students in the experimental group were taught using the newly designed transparent urinary tract simulator, while the students in the control group were taught using the J3311 opaque plastic urinary tract simulator (Le Yu Model Plant, Jiangsu, China). Before the lectures, a test paper was administered to evaluate the students’ comprehension of urinary system diseases. The score on this test was considered the baseline theory score. Instruction Using the Urinary Tract Simulators For the convenience of the instructors, each group was further stratified randomly into four subgroups (20 students each). All the instructors were well trained and presented their lessons in accordance with the same protocol. All students attended a preliminary lecture, were given the rules of the class, and were allocated to the instructors. The lectures regarding urinary system obstruction were delivered over the course of 2 days. Theory was taught between 08.00 and 12.00 h, and the procedural skills were taught between 15.00 and 18.30 h (fig. 1e). The lectures included PowerPoint slides and instructive videos that presented urinary obstruction in detail, including pathogenesis, clinical manifestations, diagnosis, and treatment, with an emphasis on how to alleviate obstructions. In the afternoon, each group watched videos for 20 min that featured the use of rigid cystoscopies (R. Wolf Medical Instruments, Knittlingen, Germany), catheters (Braun Medical Instruments, Shanghai, China), and double-J stents (Zhong Kang Shun Medical Equipment, Jinan, China). The instructors themselves then demonstrated catheterization (fig. 1c) and retrograde double-J stent implantation (fig. 1d). There were no differences in the teaching times among the eight subgroups. At 15.40 h, all groups were separated into different rooms to practice catheterization or retrograde double-J stent implantation for the next 170 min, 85 min for each procedure. The only difference between the experimental and control groups was the urinary tract simulators used to perform the exercise. Relevant resource materials, including textbooks, clinical photos, and videos were available to every participant.
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
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tors and demonstrations of urological operations: male transparent urology simulator (a), female transparent urology simulator (b), urinary catheterization (c), retrograde double-J stent implantation (d), opaque simulators (e), and procedural skills test (f).
Table 1. Results of the theory, procedural skills, and student satisfaction evaluations
Experimental
Control
p
Number of students passing the theory test Postcourse theory test scores
76 77.4±4.5
75 76.7±3.6
0.40 0.54
Number of students passing the procedural skills test Postcourse procedural skills test scores
76 36.2±3.1
74 31.8±2.8
0.39 0.04
4.1±0.4 3.7±0.7 3.8±0.3 3.7±0.4 3.2±0.5
4.0±0.5 3.7±0.6 3.0±0.4 2.7±0.3 2.9±0.4
0.71 0.87 0.04 0.03 0.56
4.0±0.5 3.8±0.6 3.5±0.4 3.4±0.5 3.6±0.6
4.1±0.4 3.9±0.5 2.9±0.3 2.3±0.6 2.1±0.5
0.71 0.79 0.04 0.03 0.03
3.8±0.5 3.7±0.6 3.7±0.4 3.7±0.6 3.8±0.4
2.6±0.4 2.5±0.5 2.5±0.3 2.5±0.5 2.5±0.6
0.04 0.04 0.04 0.04 0.04
Procedural skills scores Urinary catheterization Sterilization Inspecting instrument and lubrication Holding the instrument correctly Catheterization technique Fixing the urine tube Retrograde ureteral catheterization Sterilization Inspecting instrument and lubrication Holding the instrument correctly Cystoscopy Implantation of double-J stent Student satisfaction survey Learning style was effective at developing my self-directed learning skills Learning style was effective at sharping my analytical skills Learning style inspired my interest to learn Simulator was well designed Overall, I was satisfied with the quality of the course
40
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
Student Satisfaction Survey A questionnaire was modified from a previous study [8] to assess the students’ opinion of the usefulness of the transparent simulator in developing their procedural skills and their attitude toward the teaching method. The questionnaire consisted of 5 Likert questions that ranged from 1 (strongly disagree) to 5 (strongly agree; table 1). The questionnaire was completed anonymously by the students immediately after the completion of the course. Statistical Analyses An independent-samples Student’s t test was used to compare the mean test scores between the two groups, and a paired-samples Student’s t test was applied to compare the pre- and postcourse test scores. Student satisfaction was evaluated using a Mann-Whitney test. SPSS 16.0 software was used for the statistical analyses, and p < 0.05 was considered statistically significant.
Results
Participants There were 80 students in the experimental group (45 men, 35 women, aged 21.8 ± 2.2 years) and 80 in the control group (40 men, 40 women, aged 22.1 ± 2.0 years). The differences in gender ratio (p = 0.78) and ages (p = 0.76) between the two groups were not significant. Zhong/Wang/Feng/Hu/Huang
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Student Assessment After all the lectures were finished, the students were required to complete tests of theory and procedural skills on the following day between 08.00 and 17.30 h. The theory test, which covered the basic knowledge of urinary obstruction and clinical applications, had a maximum possible score of 100 points and had to be completed within 2 h. Standard score sheets were completed by two graders from the urology department (1 attending doctor and 1 associate professor), who were blinded to the identity of the students. The students were then apportioned randomly to four examination rooms and participated in the procedural skills test independently. The test included stations for catheterization and retrograde double-J stent implantation, in which 4 Yorkshire pigs were used [7]. The performance of each student was scored between 10 and 50 points, with each procedure scored between 5 and 25 points. Five key scoring items were utilized to evaluate the students’ performance: (1) sterilization (minus 1 point for a mistake), (2) instrument inspection and lubrication, (3) holding the instrument in the correct position (minus 1 point for a mistake), (4) catheterization or cystoscopy technique, and (5) urine tube fixation or retrograde double-J stent implantation (fig. 1f). Given that the main aim of the study was to evaluate the efficiency of teaching procedural skills using the transparent urology tract simulator, the primary study outcome was the scores obtained from the procedural skills test. There were 8 graders for the procedural skills test (7 attending doctors and 1 associate professor), allocated into four test rooms randomly, who were blinded to the students’ group identity.
n
Co
so ari mp
b
ri
e Exp
t
n me
n
Co
so ari mp
c
e rse urs ou co e stc r o P P
Fig. 2. Comparison of test scores: Prelecture theory test scores of the two groups (a), postlecture theory test scores of the two groups (b), pre- and postlecture theory test scores of the experimental
Student Assessments There was no significant difference in the baseline theory test scores between the experimental (71.5 ± 3.1) and control (72.5 ± 3.2) groups (p = 0.68; fig. 2a). For the postcourse theory test, 76 students in the experimental group and 75 students in the control group passed the examination (p = 0.40; table 1). The postcourse theory scores of the students in the experimental group (77.4 ± 4.5) were not significantly higher than those of the students in the control group (76.7 ± 3.6; p = 0.54; table 1; fig. 2b). Furthermore, the differences between the pre- and postcourse theory test scores in the experimental group (71.5 ± 3.1 and 77.4 ± 4.5, respectively; p = 0.03; fig. 2c) were similar to those of the control group (72.5 ± 3.2 and 76.7 ± 3.6; p = 0.04; fig. 2d). In the procedural skills test, the mean score of the experimental group was significantly higher than that of the control group (36.2 ± 3.1 and 31.8 ± 2.8, respectively; p = 0.04; fig. 2e; table 1). Student Satisfaction Survey Compared with the students in the control group, those in the experimental group reported that their training in procedural skills (with the simulator) was significantly more effective at developing their self-directed learning skills (3.8 ± 0.5 compared with 2.6 ± 0.4; p = 0.04), analytical skills (3.7 ± 0.6 compared with 2.5 ± 0.5; p = 0.04), and inspiring them to learn (3.7 ± 0.4 compared with 2.5 ± 0.3; p = 0.04). More students in the experimental group reported that the simulator used in their training was well designed (3.7 ± 0.6 compared with 2.5 ± 0.5; p = 0.04). In addition, the transparent simulator earned more satisfaction than the opaque simulator in study satisfaction (3.8 ± 0.4 compared with 2.5 ± 0.6; p = 0.04; table 1). A New Transparent Urological Simulator
d
100 90 80 70 60 50 40 30 20 10 0
50
*
e rse urs ou co e stc r o P P
*
40 Test scores
* Test scores
100 90 80 70 60 50 40 30 20 10 0
30 20 10 0
e
t
en
rim
e Exp
n
so
ri pa om
C
group (c), pre- and post-lecture theory test scores of the control group (d), and procedural skills test scores of the two groups (e). Data are presented as means ± SD, * p < 0.05.
Discussion
To improve the teaching and demonstration of the basic techniques of urinary surgery to medical students, we designed and developed a transparent urinary tract simulator. The viability and advantages of the simulator for teaching procedural skills were evaluated in our medical school through a randomized controlled study that compared the transparent urinary tract simulator to the traditional opaque plastic simulator. The results of the students’ procedural skills test and satisfaction survey showed that the transparent urinary tract simulator was much more effective than the opaque urinary tract simulator in helping students achieve a good command of urinary catheterization and retrograde double-J stent implantation, and was more highly rated by the students. In medical education, simulation-based preclinical teaching has emerged as an effective way to quickly improve students’ operative technique. Various simulation-based teaching methods and simulators have been used in several areas [9, 10], including the opaque plastic model [11], a computer-based teaching network [12], and simulated operating rooms [13]. These approaches improve students’ and residents’ surgical skills [14] and self-confidence, as well as increase patient satisfaction [15]. With the development of technology, high-fidelity simulators such as the Uro-Scopic Trainer and the ureteroscopy bench model from Limbs and Things have been utilized and are highly rated for the training of urology residents [16, 17]. However, these models are costly [18] and many medical universities, including ours, are unable to afford them for undergraduate education, and therefore continue to use ordinary opaque plastic simulators. However, the opaque plastic simUrol Int 2015;95:38–43 DOI: 10.1159/000375129
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ri
e Exp
t
n me
100 90 80 70 60 50 40 30 20 10 0
Test scores
Test scores
Test scores
a
100 90 80 70 60 50 40 30 20 10 0
42
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
catheterization, cystoscopy, microscopic examination of the ureter, and retrograde double-J stent implantation. The use of this model will greatly reduce the cost of purchasing different simulators and the area needed to store them. Although the results of the present study are encouraging, it has several limitations that need to be considered. First, the study was not a double-blind trial, which might have permitted some bias in the results. Secondly, the trial was only conducted at a single institution, and the results would be more convincing if conducted at more institutions. Thirdly, the transparent simulator has great potential for improvement since at present it is not able to simulate the clinical scenario by transforming to an opaque simulator easily.
Conclusion
In conclusion, during the initial stages of teaching urinary procedural skills to medical students, the novel transparent urinary tract simulator was significantly better than the opaque simulator, and the students who used it rated their training more highly. The low cost and multifunctionality of the transparent urinary tract simulator adds to its value as a tool for teaching urological procedural skills.
Acknowledgements All the students participating in the study deserve our praise and thanks.
Disclosure Statement All authors declare that there are no competing financial interests.
References
1 Buscarini M, Stein JP: Training the urologic oncologist of the future: where are the challenges? Urol Oncol 2009;27:193–198. 2 Wu EH, Elnicki DM, Alper EJ, Bost JE, Corbett EC Jr, Fagan MJ, Mechaber AJ, Ogden PE, Sebastian JL, Torre DM: Procedural and interpretive skills of medical students: experiences and attitudes of fourth-year students. Acad Med 2008;83:S63–S67. 3 Yang RL, Reinke CE, Mittal MK, Kean CR, Diaz E, Fishman NO, Morris JB, Kelz RR: The surgery clerkship: an opportunity for preclinical credentialing in urinary catheterization. Am J Surg 2012;204:535–539.
Zhong/Wang/Feng/Hu/Huang
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ulator fails to provide a visual representation of the procedures internally, and some students are not able to form a clear idea of how the instruments work in the urinary tract. A previous study showed that both the transparent and opaque models reduced the number of errors, needle passes, and time per attempt in ultrasound-guided regional anesthesia simulation training. However, students using the transparent model required significantly less time to complete the training than did students using the opaque one [19]. Inspired by this, we constructed a novel low-cost transparent urinary tract simulator to overcome the defects of the opaque urinary tract simulator. In the present study, the two student groups scored similarly on the theory test, but the procedural skills test scores of those trained with the transparent urinary tract model were significantly higher than those who used the opaque model. Thus, the transparent simulator did well in improving the students’ procedural skills. With regard to the five score items, we found that students using the transparent model scored significantly higher at holding the instrument correctly (for both urinary and retrograde ureteral catheterization), urinary catheterization and cystoscopic examination technique (urinary and retrograde ureteral catheterization, respectively), and implantation of the double-J stent during retrograde ureteral catheterization. Students of the two groups performed similarly only with regard to sterilization, inspecting the instrument, and lubrication. The students in the experimental group clearly had a deeper understanding of the procedures and the reasons that the key points of each were crucial to success. It is reasonable to believe that the experimental group’s better scores were due to the outside view provided by the transparent model. The ability to visualize the internal anatomy of the urinary tract facilitated the students’ comprehension, and thereby reduced the difficulty of training the stages of the procedures. The training of medical students using the transparent model is a step-by-step forward process. During the initial steps, the model allows clear demonstration of the urological procedures and is accepted more easily by the student. Subsequently, the transparent model can be covered by a drape, therefore increasing the difficulty and simulating the clinical scenario. Of course, the live porcine model remains superior to nonbiological materials in the training of endourological skills for the more realistic haptic feedback it provides [20]. It is worth noting that most of the simulators sold commercially are useful for training only one procedure. However, the transparent urinary tract simulator can be used to demonstrate the anatomy of the urinary tract,
A New Transparent Urological Simulator
10 Bradley P: The history of simulation in medical education and possible future directions. Med Educ 2006;40:254–262. 11 White MA, Dehaan AP, Stephens DD, Maes AA, Maatman TJ: Validation of a high fidelity adult ureteroscopy and renoscopy simulator. J Urol 2010;183:673–677. 12 Riley JB, Austin JW, Holt DW, Searles BE, Darling EM: Internet-based virtual classroom and educational management software enhance students’ didactic and clinical experiences in perfusion education programs. J Extra Corpor Technol 2004; 36: 235–239. 13 Lee JY, Mucksavage P, Canales C, McDougall EM, Lin S: High fidelity simulation based team training in urology: a preliminary interdisciplinary study of technical and nontechnical skills in laparoscopic complications management. J Urol 2012;187:1385–1391. 14 Papatsoris AG, Shaikh T, Patel D, Bourdoumis A, Bach C, Buchholz N, Masood J, Junaid I: Use of a virtual reality simulator to improve percutaneous renal access skills: a prospective study in urology trainees. Urol Int 2012; 89: 185–190.
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
15 Brim NM, Venkatan SK, Gordon JA, Alexander EK: Long-term educational impact of a simulator curriculum on medical student education in an internal medicine clerkship. Simul Healthc 2010;5:75–81. 16 Matsumoto ED: Low-fidelity ureteroscopy models. J Endourol 2007;21:248–251. 17 Matsumoto ED, Pace KT, D’A Honey RJ : Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills. Int J Urol 2006;13:896–901. 18 Varkey P, Murad MH, Braun C, Grall KJ, Saoji V: A review of cost-effectiveness, cost-containment and economics curricula in graduate medical education. J Eval Clin Pract 2010; 16:1055–1062. 19 Liu Y, Glass NL, Glover CD, Power RW, Watcha MF: Comparison of the development of performance skills in ultrasound-guided regional anesthesia simulations with different phantom models. Simul Healthc 2013;8:368–375. 20 Tunc L, Resorlu B, Unsal A, Oguz U, Diri A, Gozen AS, Bedir S, Ozgok Y: In vivo porcine model for practicing retrograde intrarenal surgery. Urol Int 2014;92:64–67.
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4 Leser R, Baca A, Uhlig J: Effectiveness of multimedia-supported education in practical sports courses. J Sports Sci Med 2011;10:184– 192. 5 Brehmer M, Tolley D: Validation of a bench model for endoscopic surgery in the upper urinary tract. Eur Urol 2002;42:175–179; discussion 180. 6 Tortora GJ, Grabowski SR: Principles of Anatomy and Physiology, ed 9. New York, John Wiley and Sons, 2000. 7 Chew BH, Lange D: In vivo evaluation of the third generation biodegradable stent: a novel approach to avoiding the forgotten stent syndrome. J Urol 2013, Epub ahead of print. 8 Li J, Li QL, Chen ML, Xie HF, Li YP, Chen X: Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from china. Med Teach 2013;35:e963–e970. 9 Fonseca AL, Evans LV, Gusberg RJ: Open surgical simulation in residency training: a review of its status and a case for its incorporation. J Surg Educ 2013;70:129–137.
Urologia Internationalis
Received: November 14, 2014 Accepted after revision: January 9, 2015 Published online: February 26, 2015
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
Novel Transparent Urinary Tract Simulator Improves Teaching of Urological Operation Skills at a Single Institution Xiao Zhong Pingxian Wang Jiayu Feng Wengang Hu Chibing Huang Department of Urology, Second Affiliated Hospital, Third Military Medical University, Chongqing, PR China
Abstract Objective: This randomized controlled study compared a novel transparent urinary tract simulator with the traditional opaque urinary tract simulator as an aid for efficiently teaching urological surgical procedures. Methods: Senior medical students were tested on their understanding of urological theory before and after lectures concerning urinary system disease. The students received operative training using the transparent urinary tract simulator (experimental group, n = 80) or the J3311 opaque plastic urinary tract simulator (control, n = 80), specifically in catheterization and retrograde double-J stent implantation. The operative training was followed by a skills test and student satisfaction survey. Results: The test scores for theory were similar between the two groups, before and after training. Students in the experimental group performed significantly better than those in the control group on the procedural skills test, and also had significantly better self-directed learning skills, analytical skills, and greater motivation to learn. Conclusion: During the initial step of training, the novel transparent urinary tract simulator significantly improved the efficiency of teaching urological procedural skills compared with the traditional opaque device. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0042–1138/15/0951–00380$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
The teaching of urological surgery skills is essential in medical school, as with other surgical specialties [1]. It is worth noting that allowing an unprepared and inexperienced student to attempt an invasive procedure, such as catheterization, greatly increases the risk of infection and harm to the patient [2]. In addition, patients undergoing catheterization and retrograde double-J stent implantation are often unwilling to allow students to perform the procedure [3]. In most countries, the curriculum relies on multimedia-assisted lectures, which allow teaching the course content in a relatively short amount of time [4]. To demonstrate the basic techniques used in urinary surgery, instructors apply computer and multimedia technologies, after which students are given the opportunity to observe and learn these skills using an opaque plastic urinary tract model. Unfortunately, the visual representation that these models provide is not adequate. Students report that they have a poor understanding of the purpose of the procedures and how the surgical instruments should be applied [5]. To solve these problems, we developed a transparent urinary tract simulator. The simulator is designed to aid both teaching theory and the demonstration of procedural skills, at a low cost. In this study, we explored the advantages of the transparent urinary tract simulator as a teaching aid, and we provide a theoretical basis for its further application. The Chibing Huang, MD, PhD Department of Urology, Second Affiliated Hospital, Third Military Medical University Chongqing 400037 (PR China) E-Mail chibinghuang2008 @ outlook.com
Downloaded by: Kungliga Tekniska Hogskolan 198.143.54.65 - 1/28/2016 10:25:12 AM
Key Words Medical education · Urinary tract simulator · Medical simulator · Catheterization · Ureteroscope · Cystoscopy
Color version available online
a
b
e
c
d
f
Fig. 1. Transparent urinary tract simula-
viability and advantages of the simulator for teaching urological procedural skills was tested relative to that of a traditional opaque model.
Materials and Methods Simulator Design and Construction For the design of the simulator, the urinary anatomy parameters developed by Tortora and Grabowski [6] were used. Other factors such as applicability and durability were also considered. To design the simulator in three dimensions, we used UGNX 7.0 software (Siemens PLM Software, Munich, Germany), Mastercam 9.1 software (CNC Software, Tolland, Mass., USA), and a KR-H6 computerized numerical control machine (Jing Yi, Shenzhen, China). The wall of the simulator consists of an outer and an inner layer. The outer layer is made of polymethyl methacrylate to maintain the shape of the urinary tract. The main ingredient of the inner layer is acrylonitrile butadiene styrene, which simulates the swelling characteristics of the urinary tract. Both materials are produced by Fu Sheng Yuan (Dongguan, China). Two types of transparent urinary tract simulators were constructed to mimic the urinary tracts of men (fig. 1a) and women (fig. 1b), respectively. These can be used to demonstrate catheterization (fig. 1c) and retrograde double-J stent implantation (fig. 1d). Randomized Controlled Trial Designed to Evaluate the Transparent Simulator Study Design This was a randomized controlled study, which compared the teaching efficiency of the transparent urinary tract simulator to that of the traditional opaque plastic simulator. The local ethics committee approved the study. One hundred and sixty seniors from the Third Military Medical University were randomly and equally divided into an experimental
A New Transparent Urological Simulator
group and a control group. Students in the experimental group were taught using the newly designed transparent urinary tract simulator, while the students in the control group were taught using the J3311 opaque plastic urinary tract simulator (Le Yu Model Plant, Jiangsu, China). Before the lectures, a test paper was administered to evaluate the students’ comprehension of urinary system diseases. The score on this test was considered the baseline theory score. Instruction Using the Urinary Tract Simulators For the convenience of the instructors, each group was further stratified randomly into four subgroups (20 students each). All the instructors were well trained and presented their lessons in accordance with the same protocol. All students attended a preliminary lecture, were given the rules of the class, and were allocated to the instructors. The lectures regarding urinary system obstruction were delivered over the course of 2 days. Theory was taught between 08.00 and 12.00 h, and the procedural skills were taught between 15.00 and 18.30 h (fig. 1e). The lectures included PowerPoint slides and instructive videos that presented urinary obstruction in detail, including pathogenesis, clinical manifestations, diagnosis, and treatment, with an emphasis on how to alleviate obstructions. In the afternoon, each group watched videos for 20 min that featured the use of rigid cystoscopies (R. Wolf Medical Instruments, Knittlingen, Germany), catheters (Braun Medical Instruments, Shanghai, China), and double-J stents (Zhong Kang Shun Medical Equipment, Jinan, China). The instructors themselves then demonstrated catheterization (fig. 1c) and retrograde double-J stent implantation (fig. 1d). There were no differences in the teaching times among the eight subgroups. At 15.40 h, all groups were separated into different rooms to practice catheterization or retrograde double-J stent implantation for the next 170 min, 85 min for each procedure. The only difference between the experimental and control groups was the urinary tract simulators used to perform the exercise. Relevant resource materials, including textbooks, clinical photos, and videos were available to every participant.
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
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tors and demonstrations of urological operations: male transparent urology simulator (a), female transparent urology simulator (b), urinary catheterization (c), retrograde double-J stent implantation (d), opaque simulators (e), and procedural skills test (f).
Table 1. Results of the theory, procedural skills, and student satisfaction evaluations
Experimental
Control
p
Number of students passing the theory test Postcourse theory test scores
76 77.4±4.5
75 76.7±3.6
0.40 0.54
Number of students passing the procedural skills test Postcourse procedural skills test scores
76 36.2±3.1
74 31.8±2.8
0.39 0.04
4.1±0.4 3.7±0.7 3.8±0.3 3.7±0.4 3.2±0.5
4.0±0.5 3.7±0.6 3.0±0.4 2.7±0.3 2.9±0.4
0.71 0.87 0.04 0.03 0.56
4.0±0.5 3.8±0.6 3.5±0.4 3.4±0.5 3.6±0.6
4.1±0.4 3.9±0.5 2.9±0.3 2.3±0.6 2.1±0.5
0.71 0.79 0.04 0.03 0.03
3.8±0.5 3.7±0.6 3.7±0.4 3.7±0.6 3.8±0.4
2.6±0.4 2.5±0.5 2.5±0.3 2.5±0.5 2.5±0.6
0.04 0.04 0.04 0.04 0.04
Procedural skills scores Urinary catheterization Sterilization Inspecting instrument and lubrication Holding the instrument correctly Catheterization technique Fixing the urine tube Retrograde ureteral catheterization Sterilization Inspecting instrument and lubrication Holding the instrument correctly Cystoscopy Implantation of double-J stent Student satisfaction survey Learning style was effective at developing my self-directed learning skills Learning style was effective at sharping my analytical skills Learning style inspired my interest to learn Simulator was well designed Overall, I was satisfied with the quality of the course
40
Urol Int 2015;95:38–43 DOI: 10.1159/000375129
Student Satisfaction Survey A questionnaire was modified from a previous study [8] to assess the students’ opinion of the usefulness of the transparent simulator in developing their procedural skills and their attitude toward the teaching method. The questionnaire consisted of 5 Likert questions that ranged from 1 (strongly disagree) to 5 (strongly agree; table 1). The questionnaire was completed anonymously by the students immediately after the completion of the course. Statistical Analyses An independent-samples Student’s t test was used to compare the mean test scores between the two groups, and a paired-samples Student’s t test was applied to compare the pre- and postcourse test scores. Student satisfaction was evaluated using a Mann-Whitney test. SPSS 16.0 software was used for the statistical analyses, and p < 0.05 was considered statistically significant.
Results
Participants There were 80 students in the experimental group (45 men, 35 women, aged 21.8 ± 2.2 years) and 80 in the control group (40 men, 40 women, aged 22.1 ± 2.0 years). The differences in gender ratio (p = 0.78) and ages (p = 0.76) between the two groups were not significant. Zhong/Wang/Feng/Hu/Huang
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Student Assessment After all the lectures were finished, the students were required to complete tests of theory and procedural skills on the following day between 08.00 and 17.30 h. The theory test, which covered the basic knowledge of urinary obstruction and clinical applications, had a maximum possible score of 100 points and had to be completed within 2 h. Standard score sheets were completed by two graders from the urology department (1 attending doctor and 1 associate professor), who were blinded to the identity of the students. The students were then apportioned randomly to four examination rooms and participated in the procedural skills test independently. The test included stations for catheterization and retrograde double-J stent implantation, in which 4 Yorkshire pigs were used [7]. The performance of each student was scored between 10 and 50 points, with each procedure scored between 5 and 25 points. Five key scoring items were utilized to evaluate the students’ performance: (1) sterilization (minus 1 point for a mistake), (2) instrument inspection and lubrication, (3) holding the instrument in the correct position (minus 1 point for a mistake), (4) catheterization or cystoscopy technique, and (5) urine tube fixation or retrograde double-J stent implantation (fig. 1f). Given that the main aim of the study was to evaluate the efficiency of teaching procedural skills using the transparent urology tract simulator, the primary study outcome was the scores obtained from the procedural skills test. There were 8 graders for the procedural skills test (7 attending doctors and 1 associate professor), allocated into four test rooms randomly, who were blinded to the students’ group identity.
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Fig. 2. Comparison of test scores: Prelecture theory test scores of the two groups (a), postlecture theory test scores of the two groups (b), pre- and postlecture theory test scores of the experimental
Student Assessments There was no significant difference in the baseline theory test scores between the experimental (71.5 ± 3.1) and control (72.5 ± 3.2) groups (p = 0.68; fig. 2a). For the postcourse theory test, 76 students in the experimental group and 75 students in the control group passed the examination (p = 0.40; table 1). The postcourse theory scores of the students in the experimental group (77.4 ± 4.5) were not significantly higher than those of the students in the control group (76.7 ± 3.6; p = 0.54; table 1; fig. 2b). Furthermore, the differences between the pre- and postcourse theory test scores in the experimental group (71.5 ± 3.1 and 77.4 ± 4.5, respectively; p = 0.03; fig. 2c) were similar to those of the control group (72.5 ± 3.2 and 76.7 ± 3.6; p = 0.04; fig. 2d). In the procedural skills test, the mean score of the experimental group was significantly higher than that of the control group (36.2 ± 3.1 and 31.8 ± 2.8, respectively; p = 0.04; fig. 2e; table 1). Student Satisfaction Survey Compared with the students in the control group, those in the experimental group reported that their training in procedural skills (with the simulator) was significantly more effective at developing their self-directed learning skills (3.8 ± 0.5 compared with 2.6 ± 0.4; p = 0.04), analytical skills (3.7 ± 0.6 compared with 2.5 ± 0.5; p = 0.04), and inspiring them to learn (3.7 ± 0.4 compared with 2.5 ± 0.3; p = 0.04). More students in the experimental group reported that the simulator used in their training was well designed (3.7 ± 0.6 compared with 2.5 ± 0.5; p = 0.04). In addition, the transparent simulator earned more satisfaction than the opaque simulator in study satisfaction (3.8 ± 0.4 compared with 2.5 ± 0.6; p = 0.04; table 1). A New Transparent Urological Simulator
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group (c), pre- and post-lecture theory test scores of the control group (d), and procedural skills test scores of the two groups (e). Data are presented as means ± SD, * p < 0.05.
Discussion
To improve the teaching and demonstration of the basic techniques of urinary surgery to medical students, we designed and developed a transparent urinary tract simulator. The viability and advantages of the simulator for teaching procedural skills were evaluated in our medical school through a randomized controlled study that compared the transparent urinary tract simulator to the traditional opaque plastic simulator. The results of the students’ procedural skills test and satisfaction survey showed that the transparent urinary tract simulator was much more effective than the opaque urinary tract simulator in helping students achieve a good command of urinary catheterization and retrograde double-J stent implantation, and was more highly rated by the students. In medical education, simulation-based preclinical teaching has emerged as an effective way to quickly improve students’ operative technique. Various simulation-based teaching methods and simulators have been used in several areas [9, 10], including the opaque plastic model [11], a computer-based teaching network [12], and simulated operating rooms [13]. These approaches improve students’ and residents’ surgical skills [14] and self-confidence, as well as increase patient satisfaction [15]. With the development of technology, high-fidelity simulators such as the Uro-Scopic Trainer and the ureteroscopy bench model from Limbs and Things have been utilized and are highly rated for the training of urology residents [16, 17]. However, these models are costly [18] and many medical universities, including ours, are unable to afford them for undergraduate education, and therefore continue to use ordinary opaque plastic simulators. However, the opaque plastic simUrol Int 2015;95:38–43 DOI: 10.1159/000375129
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Urol Int 2015;95:38–43 DOI: 10.1159/000375129
catheterization, cystoscopy, microscopic examination of the ureter, and retrograde double-J stent implantation. The use of this model will greatly reduce the cost of purchasing different simulators and the area needed to store them. Although the results of the present study are encouraging, it has several limitations that need to be considered. First, the study was not a double-blind trial, which might have permitted some bias in the results. Secondly, the trial was only conducted at a single institution, and the results would be more convincing if conducted at more institutions. Thirdly, the transparent simulator has great potential for improvement since at present it is not able to simulate the clinical scenario by transforming to an opaque simulator easily.
Conclusion
In conclusion, during the initial stages of teaching urinary procedural skills to medical students, the novel transparent urinary tract simulator was significantly better than the opaque simulator, and the students who used it rated their training more highly. The low cost and multifunctionality of the transparent urinary tract simulator adds to its value as a tool for teaching urological procedural skills.
Acknowledgements All the students participating in the study deserve our praise and thanks.
Disclosure Statement All authors declare that there are no competing financial interests.
References
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ulator fails to provide a visual representation of the procedures internally, and some students are not able to form a clear idea of how the instruments work in the urinary tract. A previous study showed that both the transparent and opaque models reduced the number of errors, needle passes, and time per attempt in ultrasound-guided regional anesthesia simulation training. However, students using the transparent model required significantly less time to complete the training than did students using the opaque one [19]. Inspired by this, we constructed a novel low-cost transparent urinary tract simulator to overcome the defects of the opaque urinary tract simulator. In the present study, the two student groups scored similarly on the theory test, but the procedural skills test scores of those trained with the transparent urinary tract model were significantly higher than those who used the opaque model. Thus, the transparent simulator did well in improving the students’ procedural skills. With regard to the five score items, we found that students using the transparent model scored significantly higher at holding the instrument correctly (for both urinary and retrograde ureteral catheterization), urinary catheterization and cystoscopic examination technique (urinary and retrograde ureteral catheterization, respectively), and implantation of the double-J stent during retrograde ureteral catheterization. Students of the two groups performed similarly only with regard to sterilization, inspecting the instrument, and lubrication. The students in the experimental group clearly had a deeper understanding of the procedures and the reasons that the key points of each were crucial to success. It is reasonable to believe that the experimental group’s better scores were due to the outside view provided by the transparent model. The ability to visualize the internal anatomy of the urinary tract facilitated the students’ comprehension, and thereby reduced the difficulty of training the stages of the procedures. The training of medical students using the transparent model is a step-by-step forward process. During the initial steps, the model allows clear demonstration of the urological procedures and is accepted more easily by the student. Subsequently, the transparent model can be covered by a drape, therefore increasing the difficulty and simulating the clinical scenario. Of course, the live porcine model remains superior to nonbiological materials in the training of endourological skills for the more realistic haptic feedback it provides [20]. It is worth noting that most of the simulators sold commercially are useful for training only one procedure. However, the transparent urinary tract simulator can be used to demonstrate the anatomy of the urinary tract,
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