Role of Active Mentoring During Flexible Ureteroscopy Training

Introduction

T he average size of renal stones that are managed by urologists is decreasing, and there is a simultaneous increase in the size of stones that can be tackled using flexible ureteroscopy. In this background, with better availability of flexible ureteroscopes and high cost of maintenance, adequate training in flexible ureteroscopy has become important for both urology residents and practicing urologists.

It has been shown that training in flexible ureteroscopy using either virtual reality or high-fidelity nonvirtual reality models improves performance. ¹ Although active mentoring during the performance of initial procedures in surgery has been shown to decrease the learning curve, ² the same has not been studied in training models. We studied the influence of active mentoring during flexible ureteroscopy.

Materials and Methods

Model

The high-fidelity nonvirtual reality bench model used for the study was Endo-Urologie-Modell (Karl Storz^™) (Fig. 1). It consists of a mannequin of the male genitourinary tract through which standard instruments may be passed. The trainees practiced with a real flexible ureteroscope (Flex-X2, Karl Storz^™), which they will be using subsequently in their operating rooms. The trainer allows the user to simulate several endourologic techniques including visualization of the entire urinary tract, guidewire insertion, placement of stent, lithotripsy. and stone retrieval.

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FIG. 1.

The high-fidelity bench model used in the study (Endo-Urologie-Modell).

Results

There was no significant difference between the two randomized groups with respect to age, previous experience, and subspecialty interest (Table 1). There was no difference in the initial GRS between the two groups (19.1±3.8 vs 18.2±4.0, P=0.509). The GRS of both the groups improved significantly at the end of the training period (Table 2). The GRS was significantly higher in the mentor group compared with the self-trained group. The TCT was significantly lower in the mentor group compared with the self-trained group (Table 3). The Spearman ρ for the correlation between expert GRS and TCT in self-trained and actively mentored groups were −0.868 (P<0.001) and −0.932 (P<0.001), respectively. The Spearman ρ for the correlation between self-GRS and TCT in self-trained and actively mentored groups were −0.338 (P=0.205) and 0.113 (P=0.678), respectively. Thus, GRS of expert assessment in both the groups correlated with TCT while there was no correlation between GRS by self-assessment and TCT in both the groups (Fig. 2).

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FIG. 2.

Correlation between global rating scale (GRS) (expert assessment and self-assessment) and task completion times (TCTs) in the groups with and without a mentor.

Discussion

The use of flexible ureteroscopy has increased tremendously in the recent years with more patients presenting with smaller renal stones and continuous improvement in the quality of flexible ureteroscopes. Moreover, because many patients are choosing retrograde intrarenal surgery (RIRS) over percutaneous nephrolithotomy because of its less invasive nature, the indications for RIRS are expanding. There are reports of even staghorn calculi being managed with RIRS. ⁵ With this global shift toward flexible ureteroscopy in the management of renal calculi, both urology residents and practicing urologists are required to acquire and improve their skills in RIRS.

It is a well-known fact that the outcomes of surgeries improve with the number of procedures performed by the surgeon. In a study on semirigid ureteroscopy for ureteral stones, experienced endourologists who had been working as endourologic consultants for more than 3 years achieved more favorable results than general urologists who had been working as consultants in other urologic subspecialties, such as oncology, female urology, and pediatric urology. ⁶ With reducing opportunities to get hands-on training, simulator based training has an important role in developing endourology skills.

In this era of evidence-based medicine, learning basic surgical skills on the patient is no longer acceptable. There is ample evidence to show that using training models significantly improves the surgeon's skills. ^{7 –9} It has been shown that the ureteroscopy skills acquired from a simulator are transferred to the patient and that simulator training is helpful in improving clinical skills. ^{10 –12} Therefore, to improve patient outcome, reduce patient morbidity and increase the life of the costly instruments, adequate training in high-fidelity models is needed before one can perform surgery in a patient.

We conducted this study in a high-fidelity bench model (Uro-Scopic Trainer^TM). Chou and coworkers ¹ found no significant difference between two groups of inexperienced medical students trained in either a high-fidelity bench model (Uro-Scopic Trainer) or a VR simulator (URO Mentor^™). ¹ Because we are moving away from the Halsteadian way of developing surgical skills, more research into newer training models and methods of training are needed to optimize training and efficiently use resources. Although the presence of an expert throughout the training period in models may be desirable, this may be difficult in the busy schedule of a consultant urologist. Also it is not clear whether the presence of an expert is continuously needed during the training period.

In the present study, we evaluated the skills of the trainees using both Objective Structured Assessment of Technical Skills—ie, GRS and TCT. It was clear that the trainees in the actively mentored group had significantly better GRS and lower TCT than the other group. We also evaluated whether the assessment of skill acquisition by trainees themselves was accurate enough. We found correlation between TCT and GRS given by an expert but not that given by the trainees; ie, an expert is more accurate in assessing the skills of the trainee. From Figure 2, it is also evident that the variation in both GRS and TCT is low in the group with a mentor compared with the group without a mentor. This is in accordance with the goal of proper training—ie, to improve the skills and reduce interpersonal variation.

An intensive mentor-initiated approach has been shown to decrease the learning curve and maintain outcome in real-life laparoscopic surgeries. ² The same has not been studied in training models objectively, however. The presence of a mentor during the training period may significantly hasten the learning and may decrease the total time spent in the training model before acquisition of the standard skills needed to start operating on a patient, although this remains to be seen. Also, some mistakes during the training period may go unnoticed if not actively monitored and mentored during the training. This may prove costly if the same mistake is made during real-life surgery. These minor mistakes may not be picked up if only some objective criteria such as TCT are used to monitor the progress of the trainee. Therefore, we propose that active mentoring during the initial training period is useful not only to hasten learning but also to prevent mishaps later on during surgeries on the patient.

One limitation of this study is the relatively small number of participants. Another important aspect is the transferability of skills acquired in training to real-life situations. Although it is expected that actively mentored trainees will perform better intraoperatively than an unmentored group, this aspect needs to be validated in future studies.

Conclusion

An expert more accurately assesses the skill acquisition of a trainee. Active monitoring and mentoring during the training in models can lead to faster skill acquisition and reduce mistakes during performance of flexible ureteroscopy. These in turn can potentially reduce complications and improve patient outcome in the longer run, although these aspects remain to be validated.