Surgical training has transitioned from traditional apprenticeship models, emphasizing observation, to more inclusive, skill-focused, hands-on training methods. The necessity for this change arose from recognizing the shortcomings of traditional surgical training methods. Simulation and hands-on training are integral components of residency programs worldwide, especially in urology, due to the increasing prominence of minimally invasive and robotic surgery.

Given the evolving worldwide scenario of subspecialization of urology, there is an inclination of trainees and members to opt for subspecialization early in their careers. Training opportunities vary among different centers, resulting in some residents being underexposed to specific procedures and subspecialties. The rising number of residents entering the urology stream annually, coupled with regional variations in caseload, further adds to the likelihood of missed exposure and limited hands-on experience.

The Indian School of Urology (ISU), which is an academic wing of the Urological Society of India (USI) for education and skill learning, conducts different hands-on training workshops and courses periodically for the benefit of trainees and members. Tailored training on different modules accommodates individual learning curves and imparts knowledge, building confidence before assisting or performing these surgeries.¹

ISU has positioned itself to bridge the gap in hands-on experience among trainee members. ISU meticulously designs its annual calendar of hands-on training, tailoring sessions for specific procedures using cadavers, porcine models, tissue models like chicken crop, and synthetic models. These sessions are aimed at enhancing skill acquisition and knowledge among residents and members. These workshops utilize biological models and cadavers to provide participants with an experience closely resembling operating on human patients.

Fresh cadaver-based modules (Figure 1) impart training of radical cystectomy, lymph node templates dissection, bowel resection and anastomosis (hand-sewn and stapler aided), and creation of orthotopic pouches, continent pouches, and bowel conduits. Skill learning for renal transplantation is also gained from cadaveric modules with training modules on laparoscopic donor nephrectomy, open explantation of kidneys, and implantation with vascular (using both external iliac artery/internal iliac artery and external iliac vein) and ureterovesical anastomosis. Participants rate this as highly realistic, closely resembling live surgery and thus enabling them to acquire necessary skills. Penile prosthesis (malleable and inflatable) and artificial urethral sphincter are procedures performed in university teaching and corporate hospitals as implants are costly and necessitate experience and skills to reduce complications.

A focused workshop on these cadaver models with eligibility of participants with committed interest in these surgeries gets enthusiastic response.

The hands-on workshop in advanced laparoscopic procedures on cadaveric prostatectomy models with training in different types of prostatectomy (nerve sparing and otherwise) with different planes of prostate dissection (extrafascial, interfascial and intrafascial) offers well-discernible anatomical features, making them ideal for members with active interest and practice in uro-oncology or those seeking expertise in minimally invasive urology. Similarly, urethroplasty techniques (transecting and nontransecting) and mid-urethral tapes for stress incontinence on cadaver models expose the trainees to scenarios resembling live surgeries. Coupled with expert guidance of training faculty and masterly scripted modules, these hands-on cadaver workshops offer an ideal opportunity for skill development and proficiency building. However, the limitations of cadaveric training include availability of fresh cadavers, procurement, and higher costs involved.² Due to these factors, hands-on training on human cadaveric models is held in selected centers equipped with infrastructure facilities that closely simulate a live surgical operating room environment, facilitating cadaver procurement for training purposes. All participants are provided with preworkshop online learning materials outlining the modules’ content, teaching materials, and pre- and posttraining assessment forms. Robust script of these modules with quality teaching from faculty of eminence makes skill learning prodigious and easy to reproduce.

Animal models and animal tissue models, such as porcine (Figure 2) or chicken models, have been extensively used for simulating laparoscopic procedures in surgical training.³ ISU conducts hands-on training on real-time laparoscopic procedures such as transperitoneal nephrectomy and partial nephrectomy using porcine models. Renal anatomy closely resembles humans, and the experience gained on laparoscopic pig models galvanizes laparoscopy skills in these procedures. Porcine models offer the advantage of handling real tissues that respond and bleed, unlike box lap and pelvic trainers.

Hands-on training of laparoscopic pyeloplasty on chicken crop (Figure 3) provides experience of laparoscopic suturing skills closely resembling human renal pelvic-ureteric anastomosis. Initial suturing on bench models followed by exercises on chicken crop enhances laparoscopic pyeloplasty suturing skills. Recording of the exercise followed by an assessment with feedback from expert faculty gives participants an insight to cover the lacunae. Bench hands-on training in microvascular procedures (Figure 4) like atrioventricular fistula microanastomosis with 8-0 polypropylene suture forms part of the hands-on training in these workshops.

ISU also offers hands-on training in advanced endourology procedures on prostate such as holmium laser enucleation of the prostate (Figure 5) and transurethral resection of the prostate on artificial prostate models. Skill learning of stone procedures like percutaneous nephrolithotomy module emphasizes puncture (fluoroscopic and without fluoroscopy), tract dilatation, and fragmentation on Bego stones and removal. Retrograde intrarenal surgery module is also available with navigation of flexible ureteroscopy, and laser stone pulverization with tips from expert faculty is facilitated for all residents.

Emerging simulation modalities, such as advancements in 3D modeling and virtual reality training, are transforming urologic education. The increased availability and reduced costs of 3D printers have led to widespread adoption of 3D-printed models for training purposes. Examples include models for percutaneous nephrolithotomy, partial nephrectomy, laparoscopic pyeloplasty, and robotic surgical simulation. It is anticipated that high-fidelity synthetic models will eventually replace animal and cadaveric models in the future.⁴ It will be exciting to delve into these once affordable by ISU.

Residents and members who have participated in urology hands-on workshops have demonstrated improvements in knowledge, comfort with instruments, and overall confidence.

Hands-on training by participants under supervision of faculty offers objective assessment to evaluate trainee performance, enabling continuous monitoring of progress and feedback provision. High-stakes tests ascertain the level of competency attained by candidates or their success in completing the course.⁵ These assessment techniques enable trainees to systematically develop competency in a variety of surgical skills over time. ISU utilizes objective performance assessment by experts to document the skill and performance of trainees. As time progresses, hands-on training holds the potential to become a standard component of the curriculum and credentialing process for trainee urologists and members.

Being a vast country with more than 500 residents joining per year, ISU holds these programs in dedicated centers throughout the calendar year. In addition, it targets the meetings for hands-on training of different modules, where high attendance of residents in training is expected. Accordingly, ISU holds courses at the annual conference of USI, annual conferences of various regional zones, and other meetings of its sections. At the annual conference held in February 2024, 12 hands-on courses with participation of 225 members were conducted. The Urological Medical Education and Training Program (UROMET) is a consolidated hands-on training workshop program of 6 courses that has been running now for more than 7 years and has trained more than 1000 trainees and members. The ISU, with the help of its faculty, holds a “Train the Trainers” course to expand its pool of mentors and teaching faculty.

ISU remains committed to impart education and skill learning to its trainees and members of USI, aiming to ensure consistent learning in both knowledge and skills for all. Holding these courses across different geographic zones and dedicated centers throughout the country provides skill learning and enhancement among its residents members, offers opportunity of learning in areas and procedures in which they are not exposed or least exposed, and gives members a platform to hone their proficiency in advanced laparoscopy, transplantation, microsurgical, and advanced endourologic procedures.