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cannot be used repeatedly, and can be difficult to obtain in various parts of the
world.
Transurethral Resection of Bladder Tumor (TURBT)
Bladder cancer is one of the most common cancers in the world, with incidence
increasing yearly. As such, transurethral resection of bladder tumor (TURBT) is one
of the more common procedures performed by urologists [ 100 ]. There is a steep
learning curve with inexperienced endoscopists performing TURBT. New learners
are liable to inadequate inspection of the bladder, incomplete tumor resection, inad-
vertent bladder perforation, and/or increased bleeding. Additionally, patient out-
comes have proven to be tied to experience, as inexperience with TURBT has been
found to be a predictor of higher readmission rates and higher recurrence rates after
TURBT for Ta and T1 tumors [ 101 ]. Therefore, TURBT represents a profitable
target for simulation.
Currently there is one major TURBT simulator described in the literature, the
Uro-Trainer® (Karl Storz GmbH, Tuttlingen, Germany) [ 102 ]. The Uro-Trainer is a
VR simulator with both visual perception and haptic feedback, enabling users to
resect papillary bladder tumors as well as carcinoma in situ (CIS) [ 102 , 103 ]. The
Uro-Trainer is commercially available and features a customary resectoscope, two flat
screens, multiple instrumentations with varied resection loops, as well as laser instru-
ments [ 103 ]. First presented by Reich et al., the Uro-Trainer was proven as a valuable
teaching tool for both medical students and urology residents [ 104 ]. In a subsequent
study, Kruck et al. demonstrated increased area of inspection (36.8–54.3%, p < 0.05)
and improvements in resection rates (26.5% to 52.0%, p < 0.05) among novice endos-
copists [ 103 ]. The Uro-Trainer was also used in this study to teach new techniques to
experienced urologists. They found that experienced urologists gained significant
improvement in both bladder inspection (52.2% vs 62.7%, p = 0.003) and resection
rates (43.8% vs 57.1%, p = 0.002) with integrated photodynamic diagnostics (a type
of fluorescence cystoscopy) versus standard white-light cystoscopy [ 103 ].
A second TURBT simulator was recently validated in the medical literature, the
Simbla TURBT simulator (SAMED GmbH, Dresden, Germany). It is a high- fidelity
simulator that has a resectable bladder with anatomical structures and embedded
tumors within [ 105 ]. The Simbla model provides a realistic feel and scenario to
trainees by allowing the use of standard OR instruments with connected monopolar
or bipolar diathermy. It can also be connected to irrigation for continuous flow
throughout the system. In an interesting study by de Vries et al., they identified 21
procedural steps and 17 pitfalls associated with TURBT. The Simbla simulator was
found to cover 13 steps and 8 pitfalls. This simulator was found to have face, con-
tent, and construct validity [ 105 ]. Obviously, the major advantage of the Simbla
model over its VR counterparts is its ability to use real instruments and irrigation.
Intravesical Botulinum Toxin Injection (Botox)
The use of intra-detrusor injection of Botox® (botulinum toxin) for overactive blad-
der was approved in 2011 by the FDA. This provided yet another new procedure to
be learned by urologists. This procedure is done cystoscopically under local or gen-
eral anesthesia with the goal to deliver an even distribution of botulinum toxin into
W. Baas et al.