465Bladder/Urethra
Cystourethroscopy
Cystourethroscopy, occurring both in the operating room and in the office, repre-
sents one of the most commonly performed procedures by urologists. A rigid or
flexible cystoscope is typically used to thoroughly examine the bladder and urethra
in both males and females. There are currently several options for simulation of
cystourethroscopy, including both bench models and virtual reality (VR) simula-
tors. The URO-Mentor™ (Simbionix Corp, Cleveland, OH, USA) can be used for
both flexible and rigid cystoscopy as well as ureteroscopy. The URO-Mentor uses a
novel, sophisticated visual engine that is able to offer high-fidelity simulation with
a number of features, including two- and three-dimensional rendering, collision
detection, texture mapping, x-ray rendering, and special effects such as blood,
smoke, and stone fragments [ 95 ]. In a study by Schout et al., the URO-Mentor sys-
tem was used in training of flexible cystoscopy by both novice and expert endosco-
pists. The study demonstrated good construct validity and found that simulation
with the URO-Mentor system resulted in large improvements in novice performance
in terms of time, trauma caused, areas inspected, and global rating scale score [ 96 ].
In another study from the same group, study participants who received training on
the URO-Mentor virtual reality system performed significantly better doing cysto-
urethroscopy on real patients than those who did not receive VR training [ 97 ].
Despite the proven benefits that high-fidelity trainers and simulators provide,
they come with significant cost, as new simulators often cost tens of thousands of
dollars. It has been questioned if low-fidelity models could allow for the same learn-
ing experience for novices. Matsumoto et al. demonstrated that a low-fidelity model
consisting of a Penrose drain representing the urethra, an inverted Styrofoam cup
representing the bladder, and drinking straws inserted into the cup as ureters was
just as effective for skill improvement in a group of 40 medical students when com-
pared to a $3,700 high-fidelity model [ 98 ]. The same authors also presented a low-
fidelity model of Styrofoam tubing, representing the urethra, leading into a bell
pepper, representing the bladder, with 18 gauge Angiocaths puncturing the bell pep-
per, representing the ureters. This model has an advantage of a very low cost and the
use of similar equipment used in the operating room, as trainees are able to practice
cystoscopy and cannulation of ureters with various types of wires.
The use of cadavers in medical education is invaluable; however, there is scant
literature available on using human cadavers in cystourethroscopy simulation. In
one study from Bowling et al., they used fresh-frozen cadavers to assess cystoscopy
skills in 29 OB/GYN residents. Various clinical scenarios were created, such as
vaginal mesh eroding into the urethra. The residents were divided into a control
group versus a study group who received training via a didactic session with bench
models. The authors found that residents who underwent didactic training had sig-
nificant decreases in scope assembly time and increases in task-specific checklists
(92.9% vs 52.5%, p < 0.001) and global rating scores (87.8% vs 57.6%, p < 0.001)
versus that of the controls [ 99 ]. Despite these benefits, cadavers are very expensive,
24 Simulation in Surgery