471recent technology of targeted therapies for prostate cancer and the necessity for
more accurate sampling of the prostate to avoid areas of untreated cancer.
It was at the University of Western Ontario where Chalasani et al. developed the
first prostate biopsy simulator [ 131 ]. Simulator images come from a TRUS image
bank that was created by collecting 3D TRUS images from 50 patients at the time
of live biopsy. These images were incorporated into a mock pelvis which allowed
for multiple simulated biopsies to be done with either a standard endfire or sidefire
TRUS probe. Consisting of a rectangular box made using polyoxymethylene plas-
tic, the mock pelvis is complete with dense elastic foam imbedded within to simu-
late the rectal wall as well as a tight elastic port of entry representative of the anus.
The box can be manipulated such that simulated biopsies can be performed in either
the left lateral decubitus or lithotomy positions. An embedded magnetic sensor
tracks movement of the probe, and biopsies are fired with a foot pedal. Chalasani
et al. demonstrated face, content, and construct validity in a small study involving
26 physicians; however, they did not reach statistical significance—likely because
of the small sample size.
Recently, second prostate biopsy simulator has been created by Fiard et al. [ 132 ].
The simulator (unnamed, Grenoble University Hospital, Grenoble, France) is a lap-
top computer attached to a Phantom Omni haptic device and a stylus representing
the ultrasound probe. Moving the stylus allows the user to explore the virtual pros-
tate. Prostate images were obtained from human biopsy procedures. The software is
also equipped with an evaluation system that evaluates users on their ability to accu-
rately sample 12 sectors of the prostate. Fiard et al. demonstrated face and content
validity in their small study 21 participants, consisting of 7 experts and 14 novices.
The median rating of realism was remarkable, being rated 9/10 by novices and
8.2/10 by experts. However, construct validity did not reach statistical significance
due to the small sample size, despite a 12% difference in scoring between novices
and experts.
Kidney/Ureter
Ureteroscopy
Ureteroscopy (URS) incorporates an extensive range of multiple instruments
used for a number of purposes. Some of the indications for URS include the
management of upper tract urolithiasis, ureteral strictures, ureteropelvic junction
(UPJ) obstruction, ureterocele incision/excision, upper tract biopsies, and abla-
tion/excision of upper tract tumors. URS is accomplished with the use of either a
semirigid or flexible ureteroscopes, of which there are many choices depending
upon the manufacturer and the indication. With the ever-increasing incidence of
urolithiasis in the United States, the incorporation of URS in the urologists’
repertoire has also increased, especially since URS is a first-line treatment in
stones <2 cm [ 133 , 134 ].
There is not an established outcome currently for expertise of URS, but several
studies on the learning curve for URS have used varying endpoints to estimate
24 Simulation in Surgery