462
nature. As such, simulation-based training has been developed for this procedure.
There is currently one validated ureteral reimplantation model described in the litera-
ture. This model consists of a plastic box which has a simulated bladder and ureter
held in place by alligator clips (Fig. 24.9). The bladder and ureters are made of a com-
mercially available hydrogel material (LifeLike BioTissue, Canada). The simulated
bladder was created with a 12 × 15 cm rectangular piece of the hydrogel. The simu-
lated ureter was created with hydrogel as well with a 0.5 mm wall thickness, 6 mm in
diameter, and 15 cm in length. A 1 cm incision was made in the “bladder,” and a 6F
ureteral stent was passed through the ureter, and the anastomosis was then performed
using a standard robot. Tunitsky et al. studied this model with 21 participants divided
into “procedure experts” (>10 robotically assisted ureteral reimplant procedures per-
formed), “robot experts” (fellowship- trained gynecologic surgeons with experience in
a number of robot procedures), and “trainees” (fourth-year urology residents as well
as urology and urogynecology fellows) [ 83 ]. After completing the simulation, all of
the experts “agreed” or “strongly agreed” that the model was realistic and useful
(face validity). Using a Global Operative Assessment of Laparoscopic Skills (GOALS)
scale, the authors demonstrated construct validity by showing that procedure experts
score significantly higher than both robotic experts and trainees (p = 0.02 and
p = 0.004, respectively), and robotic experts performed significantly better than the
trainees (p = 0.05). The authors have suggested that the model can be reused about ten
times with an approximate cost of $22 (excluding stent and suture cost).
Prostate
Robot-Assisted Laparoscopic Radical Prostatectomy
The radical prostatectomy represents one surgery that has seen significant changes
since the introduction of robot-assisted surgery. Because of the robot’s ability for
vision magnification and the use of small, long instruments which work well deep
within the pelvis, there has been a dramatic shift in prostatectomies being done
primarily open to now most being done with robotic assistance (RALRP) [ 84 ].
There have been multiple studies which have shown a rather steep learning curve for
RALRP, with some suggesting that 250 cases may be necessary to gain proficiency
at RALRP [ 85 ]. Increased experience with RALRP has been shown to result in
fewer anastomotic strictures and a lower rate of cancer recurrence [ 86 , 87 ]. As such,
simulation training for RALRP has been developed to supplement the often inade-
quate RALRP exposure experienced during residency.
Alemozaffar et al. first described a unique simulation for RALRP in which a
female porcine genitourinary tract tissue is fashioned into a male pelvic genitouri-
nary model which can be used to simulate RALRP [ 88 ]. The authors started by
making a plaster replica of the male pelvis with a fitted rubber pad to simulate the
urogenital diaphragm. They then harvested the vagina, bladder, and ureters from a
female pig. Through a number of steps, the porcine vagina was fashioned into a
rectum and prostatic pedicle with the introitus becoming the prostate gland. The
fallopian tubes were used to create seminal vesicles and the dorsal venous complex
(DVC). Ureters were used to represent the neurovascular bundles running along the
W. Baas et al.