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TURP simulators can be broadly divided into high-fidelity virtual reality models
versus non-virtual reality physical models—each with their own advantages and
disadvantages. Physical simulators rely upon standard TURP equipment used on
prostatic tissue surrogates, such as chicken breast, vegetable matter, or pig liver.
Trainees at the authors’ home institution use a standard TURP resectoscope with
associated electrocautery capabilities in an OR-like environment with irrigation
fluid and a standard endoscopy tower to resect portions of porcine liver. This model
is particularly useful for more inexperienced trainees who can gain experience with
assembling and using equipment likely identical to that used in the OR. The main
disadvantage of this physical surrogate models is the lack of bleeding and other
intraoperative complicating issues when resecting the tissue [ 109 ].
Another physical model, the Bristol TURP Trainer (Limbs & Things, UK), is a
disposable bench model containing a synthetic prostate within a latex bladder on a
plastic base [ 110 ] (Fig. 24.10). Trainees use a resectoscope with attached monopo-
lar or bipolar diathermy to resect the prostate model, which is complete with irriga-
tion fluid, realistic anatomy including ureteral orifices and verumontanum, and is
made of a synthetic material that can be cut with the resectoscope diathermy loop.
This is one of few physical models that has demonstrated face, content, and con-
struct validity [ 111 ]. Advantages of this model are the lifelike anatomy, as well as
the technical aspects it provides such as using actual resectoscopes, managing flu-
ids, and handling resected prostatic chips. However, similar to other physical mod-
els, the Bristol TURP Trainer does not allow for bleeding or other potential
complications of the procedure.
The first VR TURP trainer was developed in 1990 by Lardennois et al. Since its
introduction, the use of virtual reality for TURP simulation has grown significantly
[ 107 , 112 ]. Many of the earlier models were limited in utility due to their lack of
haptics, inaccurate deformation of tissues, and lack of bleeding [ 107 ]. Hemostasis
was recognized as a critical learning point by Oppenheimer et al. in successful
TURP training, so they developed simulated bleeding through the creation of a
bleeding movie texture map library [ 113 ]. This subsequently initiated the creation
of the University of Washington VR TURP trainer (UWTURP), in partnership with
Gyrus/ACMI (Reading, Berkshire, United Kingdom), which has become the most
extensively validated TURP trainer to date [ 111 , 114 ]. Created in 2000, the
UWTURP comprises a physical model of the penis and pelvis with digital recre-
ations of urothelium and resection bed being based off of digital footage from actual
TURP procedures. The simulator has the advantage of being able to track both
motion and force data, allowing for objective measures of operative errors, blood
loss, grams resected, irrigant volume, and amount of electrocautery use. Numerous
studies have validated the model; thus, the UWTURP can successfully distinguish
experts from novices. In a study by Sweet et al., no TURP experts had an operative
error on a 5 min resection task, whereas novices resected the sphincter 50% of the
time and 16% had to stop the operation because of blood loss making vision impos-
sible [ 114 ]. Simulated practice with this heavily validated model is invaluable, as
novices will learn from their mistakes in a simulated setting rather than harming
patients during the early learning curve.
W. Baas et al.