451on the body, allowing generous autonomy on deciding one’s surgical approach.
Once trocar placement has been decided, users can use a number of instruments
including forceps, Maryland dissectors, scissors, hook device, clips, laparoscopic
stapling devices, and entrapment bags. A foot pedal allows for the use of simu-
lated electrocautery, and a scope handled by an assistant can be changed between
0°, 30°, and 45° lens. The simulator also includes haptics, giving tactile feedback.
Realistic bleeding is also included with the simulator, with the degree of bleeding
depending upon the injury and type of vessel involved. Surgeons have the option
of achieving hemostasis with gauze, forceps, or clips. In a follow-up study by
Makiyama et al., face and content validity of the simulator was demonstrated in
13 preoperative simulations (7 nephrectomies, 4 partial nephrectomies, and 2
pyeloplasties) carried out by three surgeons [ 50 ]. On a 1–5-point Likert scale, the
surgeons rated anatomical integrity to be 3.4 ± 1.1 (face validity), utility of the
simulations to be 4.2 ± 1.1 (content validity), and confidence during subsequent
surgery to be 4.1 ± 1.1.
Pyeloplasty
There are five procedures currently identified by the American Urological
Association’s (AUA) Laparoscopic, Robotic, and New Surgical Technology
(LRNST) Committee for which simulation would be beneficial [ 51 ]. One of those
procedures is laparoscopic pyeloplasty (LPP). LPP is done most often for uretero-
pelvic junction (UPJ) obstruction. This is a technically challenging procedure when
done laparoscopically because it requires excision of the UPJ obstruction, spatula-
tion of the renal pelvis and proximal ureter, and suturing of the anastomosis—all
which must be accomplished intracorporeally. Without surprise, the learning curve
for laparoscopic pyeloplasty can be steep for beginners [ 52 ].
Currently, the simulation options available for laparoscopic pyeloplasty include
bench and animal models. The Simulation PeriOperative Resource for Training
and Learning (SimPORTAL) from the University of Minnesota is responsible for
the creation of a number of surgical simulation models. One model is a high-
fidelity physical renal pelvis/ureter tissue analog bench model that allows for
simulation of laparoscopic pyeloplasty. Using organosilicate-based materials,
Poniatowski et al. created the pyeloplasty simulation model by 3D printing a
patient-specific mold [ 51 ]. The renal pelvis is approximately 6 cm in the superior-
inferior direction and 3 cm in the anterior-posterior direction, with an attached
18 cm ureter with 0.8 cm diameter. The UPJ obstruction has an outer diameter of
0.5 cm with an inner diameter of 0.2 cm. The model can then be placed in a stan-
dard laparoscopic box trainer, and the procedure can be performed. Additionally,
the creators of this model integrated lines going down the length of the model that
can only be seen under UV light. These lines allow for Black Light Assessment of
Surgical Technique (BLAST™) to be done after the exercise, specifically looking
for alignment of the UV-sensitive lines, indicating proper alignment of the UPJ
anastomosis. Poniatowski et al. demonstrated face, content, and construct validity
of the pyeloplasty model in a study of 31 attending clinical urologists. Face valid-
ity was demonstrated with a questionnaire given to participants after using the
24 Simulation in Surgery