4 41Open Surgery
Despite more minimally invasive surgical approaches at the urologists disposal
today, open surgery remains the backbone of urological surgery. Because of the
growing number of surgeries being done in a minimally invasive manner, trainees
have had less exposure to open surgery. Therefore, simulation in open surgery is one
way of gaining open experience without putting patients at risk. Currently available
simulators for open surgery are comprised of bench models, cadavers, and animal
models.
Human cadavers likely represent the best option for open surgery simulation, but
cadavers are expensive and often not readily available. In a large study comprised of
81 urology residents and 27 urology faculty members, Ahmed et al. recently put
forth a simulation program in which participants performed a number of procedures
on fresh-frozen cadavers [ 4 ]. These procedures included circumcision, vasectomy,
orchiopexy, hydrocele repair, radical orchiectomy, open cystotomy, management of
bladder perforation, transureteroureterostomy, Boari flap, psoas hitch, open surgical
packing of the pelvis, and nephrectomy [ 4 , 5 ]. Questionnaires of the participants
indicated that the cadaveric simulations had face validity (mean score 3/5) and all
procedures scored ≥3 out of 5 in terms of usefulness for learning anatomy and
improving surgical skills (content validity). Interestingly, participants rated human
cadaveric simulation to be the best form of training, followed by live animal simula-
tion, animal tissue models, bench models, and virtual reality.
Because cadaver simulations are simply “surgeries” performed the same way as
they would be in living patients, these will not be discussed individually. Described
below are the few currently validated non-cadaveric models of open surgery.
Bladder
Suprapubic Tube Placement
Suprapubic tube (SPT) placement is a rather common procedure performed by urol-
ogists, but trainees often have to “learn on their feet” as this is a procedure often
done alone and sporadically in an emergent setting. Because of this, trainees often
have difficulty acquiring the skill and confidence to perform the procedure and
many times elect to attempt difficult urethral catheter placement, which may put a
patient at increased harm. To bolster the skills necessary for SPT placement, there
are currently three validated bench models that can be used by trainees for proce-
dural simulation.
The first SPT model called the “UroEmerge™ Suprapubic Catheter Model” was
described by Shergill et al. in 2008 [ 6 ]. The authors created the model by injecting
a 3 liter bag of irrigation fluid with 10 cc of povidone-iodine, giving the fluid a urine
color, and tying the bag with two tourniquets to simulate a full bladder (Fig. 24.2).
This “bladder” was then placed within a plastic trainer housing and covered with a
commercially available abdominal open and closure pad which simulates abdomi-
nal skin, subcutaneous fat, and rectus sheath (Limbs & Things, UK) (Fig. 24.3).
24 Simulation in Surgery