Figure 1. “Teabags” training module.

Figure 2. Video of an expert robotic surgeon completing the vesicourethral anastomosis module.

Figure 3. Scorecard for self-assessment on the “Teabags” module.

Figure 4. QR code.

Gamification, using principles of game design like competition and rewards, has been shown to be an effective way of enhancing resident training in various specialities.^1-4 This has been particularly true in surgical fields, where skill acquisition is paramount and trainees often identify themselves as competitive and comfortable working in teams.

When we piloted gamified robotic surgical simulation training (sim) at Columbia University Irving Medical Center in 2020, using the Intuitive Surgical da Vinci Skills Simulator (also known as “the backpack”), we saw a significant increase in time residents spent on sim exercises and found that most residents reported increased confidence in their surgical skills, autonomy in the operating room, and anticipated future sim training.⁵ Our preliminary experience showed us that gamification can provide a framework for sim practice that is instructive, motivating, and fun for residents. Understanding that there is no substitute for live surgery, we gained confidence that time spent training effectively with sim could improve performance and training gains in the operating room.

Exciting developments in sim are pushing the field forward across multiple fronts. Recent advances include high-fidelity hydrogel models with imbedded force sensors⁶ and automated performance metrics.⁷ We believe that centers with accessible da Vinci Xi robots that are unable to obtain these new technologies can still do sim effectively using cheap and easily attainable supplies. Furthermore, we believe there is still work to be done to engage trainees in sim and build consensus on what amount and type of sim training benefits urology trainees most. Gamification enables us to incentivize goal-directed training, instructing the resident who is already juggling clinical duties, board study, and research activities on what surgical skills to practice and what level of competency to aim for.

This year, we built a sim curriculum of our own and began testing the merits of gamification more rigorously. In the first half of the academic year, mid- and senior-level residents (PGY-3s, -4s, and -5s in a 6-year program) completed a dry lab curriculum designed to develop key technical skills including efficiency, precise cutting, tissue handling, retraction and third arm use, dissection, needle control, knot tying, and 3D problem solving. Our aim was to supplement existing virtual reality training platforms with models made from supplies that anyone can find in a supply closet or grocery store. Our first training block included 3 “skill modules,” each of which was designed to target at least 1 key technical skill. For example, a module designed to train needle control, knot tying, and appropriate use of tension involves sewing together 2 boggy teabags without displacing or tearing them (Figure 1). The block ended with 1 “anatomic module,” which, rather than focusing on developing a discrete skill, is meant to simulate a challenging step of a commonly performed robotic surgery. We used materials such as a Foley catheter, dish sponge, and paper cup to build a simulated vesicourethral anastomosis (Figure 2). Residents were provided videos demonstrating how to build each module so they could practice on their own.

In the second half of the year, this curriculum was gamified by making it a team competition. All residents were assigned to teams with attending coaches. At the start of each month, we sent out a scoring rubric and a narrated video of an expert robotic surgeon completing the module of the month, so residents came to each session knowing exactly what they needed to do to score well. In addition to the traditional surgeon’s-eye view, we also nested a synced video of the surgeon’s hands as a “picture-in-picture” in the corner (Figure 2). We believe that this will allow trainees to develop proper technique more readily, with appropriate attention to disciplined hand and arm positioning. We also sent out online scorecards, by which residents could score their own performance on each module. In the teabag module, for example, a competitor loses points if the teabag is dragged out of place, if the suture line does not sit exactly at the margin between the tea pouch and its circumferential collar, or if the suture was pulled too hard and tears a hole in the teabag (Figure 3). Team scores were totaled at the end of each month to determine the winner of the round, and the team with the best win-loss record was crowned as champions. We have been prospectively testing the validity of these modules, with attending urologists grading each module’s ability to simulate important surgical maneuvers, while scores from surgeons at each level, from attendings down to junior residents, are compared for each module.

In the coming year, we plan to share our curriculum and best practices on an open access website and hope to allow users to keep track of their scores, host competitions within and across institutions, and share their own experiences and ideas for sim. By providing a virtual platform dedicated to gamifying sim that is accessible to all training programs, our objective is to increase interactivity and fun, and foster the exchange of ideas that will help us build consensus on the optimal use of robotic sim in urology training.

This endeavor, which we have named GAMERS (GU Alliance for Maximizing Education From Robotic Simulation), is funded entirely by a grant from the Society of Academic Urologists.

We invite all those interested in learning more about our modules and gamified curriculum, as well as future opportunities for collaboration, to register via the QR code below (Figure 4).

Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.

Ethics Statement: This study received institutional review board approval (IRB No. AAAT2309).