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Surgical Simulation in Urology: Where Are We Now?

By: Andrew Rabley, MD and Robert Sweet, MD, FACS | Posted on: 01 Sep 2022

The roots of surgical simulation stretch back in time to ancient India, where texts from around 500 CE mention the use of models to practice surgical skills, and has certainly stood the test of time, as simulation remains a stalwart in today’s surgical learning environment.1 Urology has long been a field that champions the use of simulation, evidenced by the fact that simulation has touched most urological procedures occurring today in some way, shape, or form.1 Many current practices within urology have come about due to the advent of innovative technologies. The July 2022 issue of The Journal of Urology® highlights this technical prowess within our field. Cacciamani et al note in their editorial, “Robotic Urologic Oncologic Surgery: Ever-Widening Horizons” that “as a field, urology has long been fertile ground for thoughtful innovation and recent technologies.”2 In response to these innovations, surgical simulation within urology has followed suit, with new platforms and methodologies paving the way for today’s learners to further enhance both their technical and nontechnical skills as well as redefining the impact simulation can have on patient care and surgical outcomes.

3D printing has taken the field of surgical simulation, especially within urology, by storm. A review by Smith et al in 2019 found that 3D printing technologies had been applied to simulation activities involving a wide variety of urological surgical procedures including percutaneous nephrolithotomy (PCNL), robotic-assisted partial nephrectomy, renal transplantation, laparoscopic pyeloplasty, prostate brachytherapy, transurethral resection of bladder tumors, and urethrovesical anastomosis.3 Patient-specific 3D printing is now pushing the envelope and changing our understanding of surgical simulation as it applies to preoperative training. Ghazi et al have shown success in creating anatomically accurate patient-specific 3D-printed models for simulation training for both PCNL and robotic-assisted partial nephrectomy.4 They have also shown that pre-surgical rehearsal using patient-specific models prior to PCNL can have a positive impact on patient outcome metrics such as reduced complications and need for additional procedures.5 Importantly, these models, along with other simulators and simulation platforms for multiple urological procedures shown in the Table, have validity evidence supporting their efficacy.1,5

Table. Urological procedures with validated simulation platforms

Cystoscopy PCNL
Ureteroscopy Radical nephrectomy (laparoscopic, robotic)
Transurethral resection of bladder tumor Partial nephrectomy (laparoscopic, robotic)
Transurethral resection of the prostate Pyeloplasty
Photoselective vaporization of the prostate Prostatectomy (robotic)
Holmium laser enucleation of the prostate Urethrovesical anastomosis (laparoscopic, robotic)
Transrectal ultrasound-guided biopsy of the prostate Sacrocolpopexy
Suprapubic tube placement Vasovasostomy

The use of virtual, or augmented, reality, both as a modality for simulation training as well as a tool for improving surgical procedures, has also risen in popularity as of late. Roberts et al performed a systematic review investigating the application of augmented reality in urology and found 60 studies reporting the use of augmented reality technology for a wide variety of urological interventions such as prostate, renal, penile, ureteral, and adrenal surgery.6 These modern technologies, in combination with the rise of advanced imaging, are changing the way we care for our patients, both through the impact on simulation training and the impact on actual surgical procedures.

“Artificial intelligence and machine learning may not come to mind when we think about simulation in the traditional sense, but we would argue that they, in their own respects, are an advanced form of simulation.”

Artificial intelligence and machine learning may not come to mind when we think about simulation in the traditional sense, but we would argue that they, in their own respects, are an advanced form of simulation. The complex computer modeling represented under the umbrella of artificial intelligence or machine learning works to simulate outcomes and provide predictions for future events or results based on clinical variables. So, while it may not be simulation in the educational or training sense of the word, it is still a type of simulation. The June 2022 issue of AUANews presented an article by Rickard and Lorenzo titled, “What Machine Learning Offers in Elucidating Vesicoureteral Reflux,” which showed the clear relevance of this topic.7 The field of artificial intelligence and machine learning is poised to have an impact, whether it is thought of as a means of simulation or not.

“As surgical technologies have advanced, simulation tools have mimicked that trajectory.”

As surgical technologies have advanced, simulation tools have mimicked that trajectory. Urology as a field has certainly embraced this progressive mentality, as evidenced by the recent advancements in urological surgical simulation discussed here. A clear future direction of surgical simulation is integration of the artificial intelligence and “smart” technologies directly into our simulators. A prime example of this is MoHSES™ (Modular Healthcare Simulation and Education System), which is an open-source simulation platform in development at CREST (Center for Research in Education Simulation Technology) at the University of Washington and partner institutions.8 MoHSES combines a state-of-the-art modular manikin with BioGears®, an open-source, lumped parameter, full-body human physiology engine. This allows for a complete simulation experience, from diagnosis based on physical exam or physiological findings demonstrated by the manikin to interventions done directly to the manikin that then initiate the expected physiological or clinical response to treatment.8,9

The future of surgical simulation as a field, especially within urology, is bright. The potential is limitless, especially if we can continue to collaborate with one another, sharing ideas and technologies to develop better simulation platforms. The American College of Surgeons Accredited Education Institutes has recognized the opportunity for impact and, as such, has created a consortium of 100 accredited simulation centers worldwide as well as 19 accredited surgical simulation fellowship programs across the country.10 These fellowship programs focus on training the next generation of surgeons and surgical trainees in the art of simulation-based education and surgical simulation development. Importantly, these programs aren’t just for general surgeons. The accredited fellowship programs at the University of Washington and the University of Minnesota have trained multiple domestic and international urologists and urology trainees during their existence, and their work has resulted in multiple novel urological simulation platforms and unique simulation curricula. With these and numerous other continued efforts to advance the field, we are confident that simulation will continue to have a positive impact not only on trainees, but on patients as well.

  1. Stefanidis D. Comprehensive Healthcare Simulation: Surgery and Surgical Subspecialties. Comprehensive Healthcare Simulation.
  2. Cacciamani G, Desai M, Siemens DR, Gill IS. Robotic urologic oncologic surgery: ever-widening horizons. J Urol. 2022;208(1):8-9.
  3. Smith B, Dasgupta P. 3D printing technology and its role in urological training. World J Urol. 2020;38(10):2385-2391.
  4. Melnyk R, Oppenheimer D, Ghazi AE. How specific are patient-specific simulations? Analyzing the accuracy of 3D-printing and modeling to create patient-specific rehearsals for complex urological procedures. World J Urol. 2022;40(3):621-626.
  5. Ghazi A, Melnyk R, Farooq S, et al. Validity of a patient-specific percutaneous nephrolithotomy (PCNL) simulated surgical rehearsal platform: impact on patient and surgical outcomes. World J Urol. 2022;40(3):627-637.
  6. Roberts S, Desai A, Checcucci E, et al. Augmented reality” applications in urology: a systematic review. Minerva Urol Nephrol. 2022; doi: 10.23736/S2724-6051.22.04726-7.
  7. Rickard M, Lorenzo A. What machine learning offers in elucidating vesicoureteral reflux. AUA News 2022 June; 27(6):5-7.
  8. MoHSES™, The Advanced Modular Manikin™. 2015;
  9. Applied Research Associates, Inc. BioGears®. 2018;
  10. American College of Surgeons. AEI-Accredited Fellowship Programs. 2022;