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 Eddie Shu-yin Chan
Tadashi Matsuda
Editors

Endourology Progress
Technique, Technology and Training

123
Endourology Progress
Eddie Shu-yin Chan • Tadashi Matsuda
Editors

Endourology Progress
Technique, Technology and Training
Editors
Eddie Shu-yin Chan Tadashi Matsuda
Department of Surgery Department of Urology and Andrology
The Chinese University of Hong Kong Kansai Medical University
Hong Kong Hirakata, Osaka
Japan

ISBN 978-981-13-3464-1    ISBN 978-981-13-3465-8 (eBook)

https://doi.org/10.1007/978-981-13-3465-8
Library of Congress Control Number: 2019934106

© Springer Nature Singapore Pte Ltd. 2019

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on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
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Foreword 1

Urology has the most innovative advances among the surgical specialties. Recent technology
started with shockwave lithotripsy in 1979 followed by percutaneous lithotripsy in the 1980s.
Lithotripters were installed worldwide and have revolutionized the treatment of stones from
incisions to “no scars.” The last decade has seen an accelerated technological journey includ-
ing laparoscopic instruments, robotic equipment, and endoscopes with video cameras that can
be made so small as to get retrograde access to the kidney, which was only imaginable in the
movies of the 1970s.
With these advances it is a constant learning and upgrading process for urologists to keep
pace with new techniques. Among the many endoscopes and types of lasers we have to find out
which is the most effective, appropriate, and safe for our patients. We adopt some and discard
those that are not effective. It is almost impossible for a single urologist to go into all the new
equipment. We need to attend meetings, talk to the experienced, and then adopt which is the
best for our patients bounded by the availability of resources in our health care systems.
This book is unique because it is Asian and represents the diverse cultures and the progress
made in countries with health care systems of different priorities. Illustrations are clear and
readers get to pick up the procedures step-by-step such as in robotic surgery. Tips and tricks
are helpful. Further dedicated structured training is important to ensure we are able to handle
the new technology. Further experience should be obtained by assisting the masters at work.
Eddie Chan and Tadashi Matsuda, the editors of Endourology Progress: Technique,
Technology and Training, should be congratulated for this innovative book. This book is a
comprehensive introduction for residents and trained urologists to pick up some new knowl-
edge and techniques.
It is my wish that this book will enable all urologists to offer our patients the most effective
treatment in the era of modern endourological technology.

January 2019 Man Kay Li

Mt Elizabeth Novena Hospital
Singapore
Singapore

v
Foreword 2

It is a privilege to write a Foreword for this outstanding book entitled Endourology Progress:
Technique, Technology and Training which is focused on all aspects of minimally invasive
urology. The book is unique in its East Asian origins and with over 100 contributors, all of
whom are from East Asian countries.
The opening chapter by Drs. Matsuda and Naito, which archives the history and develop-
ment of endourology in East Asia, is a wonderful chronicle of the overall impact this urologic
community has had towards progress in the field. The mission of the East Asian Society of
Endourology is articulated “to study all questions related to endourology, to stimulate interna-
tional cooperation in the field of urology and to encourage the development, evaluation and
application of all aspects of minimally invasive therapy of urological disease across the East
Asia region.” There may be no better tangible example of the success in achieving this aspira-
tion than the superb text Endourology Progress: Technique, Technology and Training.
The book is both comprehensive in its scope and current in all aspects of endourology, lapa-
roscopy, robotics, and image-guided therapies in urology. Books can often lag in a field that is
progressing as rapidly as endourology, but this comprehensive text manages to be completely
up to date. This includes detailed descriptions of leading edge interventions in areas as diverse
as pediatrics, transplantation, BPH, and MRI-guided diagnostics. The tables, illustrations, and
figures in the book are excellent and the chapters are all very well referenced. As an academic
urologist with a subspecialty interest in endourology I fully expect to be referring to this book,
both for patient care questions and for purposes related to teaching students, residents, and
fellows. Practicing urologists, trainees, and investigators with an interest in urologic technol-
ogy and innovation will all find this to be a very practical and useful text.
I have had the privilege of visiting almost all of the countries classified as being in East Asia
and in the case of some countries have visited on numerous occasions. This has often included
the experience of operating side by side with the local urologic surgeons, many of whom have
become good friends. It is my impression that many of the innovations and technical advances
in endourology and minimally invasive approaches are emanating from the major centers in
East Asian countries. In addition, I have witnessed the great value placed on training in this
world region and the chapters in Endourology Progress focused on various aspects of training
are among the best I have come across.
The editors, Drs. Eddie Chan and Tadashi Matsuda, along with all of the contributing chap-
ter authors are to be congratulated for the production of this tremendous text. Endourology
Progress: Technique, Technology and Training is an excellent contribution to existing resources
in the rapidly changing field of endourology.

John Denstedt
Division of Urology, Schulich School of Medicine and Dentistry,
Western University, London, ON, Canada

American Urological Association,

Linthicum, MD, USA

vii
Introduction

This book represents the work and development of endourology in Asia and the contribution
of East Asian Society of Endourology. The horizons of endourologic surgery are expanding.
Application of robot-assisted technique is one of the many examples of how new technologies
change the surgical practice. Urologists from Asian countries encountered a lot of challenges
due to high patient load, different diseases preference, limited access to new technologies,
diversity in languages, and surgical practice. Innovative techniques have been developed in
order to adapt the unique working environment. This book is intended to familiarize the mod-
ern urologists with the common endourology, laparoscopic and robotic urologic procedures,
and the development of technology, techniques, and training in Asian countries.
On behalf of the East Asian Society of Endourology, recognized Asian experts in the field
of endourology have contributed to share their experiences and opinions. It consisted of latest
update and advancement of surgical techniques and technology in minimally invasive surgery.
The development of endoscopic, laparoscopic, and robotic urological operations is reviewed.
A whole session dedicated to training in endourology is included. Detailed descriptions of
perioperative preparation, step-by-step surgical procedures, and tips/tricks will be emphasized
in the corresponding chapters, supplemented by photographs and illustrations. The textbook
will be divided into three specific sessions. The first session covers the important areas of
endourology training and the development of endourology in different Asian countries. In the
second session, techniques on various urologic surgeries are discussed. The third session is
dedicated to the advances of new technologies in endourology. This book is most suitable for
urology residents and young fellows who are keen to start their endourological training. It also
provides up-to-date information on current topics of endourology for practicing urologists and
experienced endourologists in Asian and other countries.
This book is contributed by more than 100 leading experts and their young fellows from
China, Japan, Korea, the Philippines, Taiwan, and Hong Kong.

ix
Contents

Part I Endourology Training

1 Introduction of East Asian Society of Endourology

and Development of Endourology in East Asia �������������������������������������������������������   3
Tadashi Matsuda and Seiji Naito
2 Training of Endourology in Asia�������������������������������������������������������������������������������   7
Kai Zhang, Tao Han, and Gang Zhu
3 Laparoscopic Training Using Cadavers ������������������������������������������������������������������� 13
Thomas Y. Hsueh
4 Simulation Training of Laparoscopy ����������������������������������������������������������������������� 19
Kazuhide Makiyama
5 Bridging the Gap Between Open Surgery and Robotics ��������������������������������������� 27
Dennis P. Serrano and Sylvia Karina L. Alip
6 Development of Robotic Urologic Surgery in Asia ������������������������������������������������� 35
Soodong D. Kim, Gyung Tak Sung, Masatoshi Eto, Katsunori Tatsugami,
Harshit Garg, Rajeev Kumar, Yinghao Sun, Bo Yang, Sheng-Tang Wu,
Allen W. Chiu, Anthony C. F. Ng, Samuel C. H. Yee, Hong Gee Sim,
and Christopher Wai Sam Cheng
7 A Nation-Wide Laparoscopic Skills Qualification:
A Thirteen-Year Experience in Japan ��������������������������������������������������������������������� 49
Tadashi Matsuda, Tomonori Habuchi, Hiroomi Kanayama, and Toshiro Terachi

Part II Endourology Techniques

8 Multiple vs. Single Access PCNL ����������������������������������������������������������������������������� 57

Michael Alfred V. Tan and Dennis G. Lusaya
9 Retrograde Intra-Renal Surgery (RIRS)����������������������������������������������������������������� 65
Deok Hyun Han
10 Radiation Exposure and Its Prevention in Endourology ��������������������������������������� 75
Takaaki Inoue and Hidefumi Kinoshita
11 TURBT: An Old Operation with New Insights ������������������������������������������������������� 81
Bryan Kwun-Chung Cheng and Jeremy Yuen-Chun Teoh
12 Robot-Assisted Radical Cystectomy: Surgical Technique ������������������������������������� 91
Cheng-kuang Yang

xi
xii Contents

13 Robot-Assisted Radical Cystectomy: Technical Tips for Totally

Intracorporeal Urinary Diversion ��������������������������������������������������������������������������� 95
Seok Ho Kang and Ji Sung Shim
14 Robot-Assisted Radical Prostatectomy: The Evolution of Technique����������������� 105
Seock Hwan Choi and Tae Gyun Kwon
15 Retzius-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy ������������� 111
K. D. Chang, C. K. Oh, and K. H. Rha
16 Robot Assisted Partial Nephrectomy: Technique and Outcomes ����������������������� 117
Nobuyuki Hinata and Masato Fujisawa
17 Minimally Invasive Ureteral Reimplantation in Children with Vesicoureteral
Reflux: History and Current Status ����������������������������������������������������������������������� 127
Nikko J. Magsanoc and Michael Chua
18 Robotic-Assisted Renal Autotransplantation: Preliminary Studies
and Future Directions����������������������������������������������������������������������������������������������� 143
Motoo Araki, Koichiro Wada, Kasumi Kawamura, Yuuki Maruyama,
Yosuke Mitsui, Takuya Sadahira, Risa Kubota, Shingo Nishimura,
Takashi Yoshioka, Yuichi Ariyoshi, Kei Fujio, Atsushi Takamoto, Morito
Sugimoto, Katsumi Sasaki, Yasuyuki Kobayashi, Shin Ebara,
Amano Hiroyuki, Masashi Inui, Masami Watanabe, Toyohiko Watanabe,
and Yasutomo Nasu
19 Robot-Assisted Laparoscopic Surgery for Upper Tract
Urothelial Carcinoma����������������������������������������������������������������������������������������������� 149
Sung Yul Park and Young Eun Yoon
20 Laparoscopic Living Donor Nephrectomy������������������������������������������������������������� 157
Jose-Vicente T. Prodigalidad and Lawrence Matthew C. Loo
21 Robotic Pyeloplasty����������������������������������������������������������������������������������������������������� 165
Ill Young Seo
22 LESS: Upper Tract, Lower Tract, and Robotic Surgery ������������������������������������� 173
Woong Kyu Han and Young Eun Yoon
23 Minimally Invasive LESS for Urachal Remnant ������������������������������������������������� 183
Fuminori Sato, Toshitaka Shin, Kenichi Hirai, Tadasuke Ando, Takeo Nomura,
Toshiro Terachi, and Hiromitsu Mimata
24 Laparoendoscopic Single-Site Pyeloplasty for Children��������������������������������������� 193
Akihiro Kawauchi, Kazuyoshi Johnin, Kenichi Kobayashi, Tetsuya Yoshida,
and Susumu Kageyama
25 ERAS Protocol in Minimal Invasive Urological Surgery ������������������������������������� 199
Ho-Yin Ngai, Chi-Man Ng, and Eddie Chan
26 Techniques and Outcomes of Taeniamyoectomyised Sigmoid Neobladder
in MIS Radical Cystectomy������������������������������������������������������������������������������������� 209
Chunxiao Liu and Abai Xu
27 Endoscopic Management of Diverticular Calculi ������������������������������������������������� 217
Xiaoshuai Gao, Jixiang Chen, Zirui Li, and Kunjie Wang

Part III Advances in Endourology Technology

28 Handbook for Ureteral Stenting����������������������������������������������������������������������������� 225

Shingo Yamamoto
Contents xiii

29 Treatment of BPH: What Is the Gold Standard? ������������������������������������������������� 233

Chunxiao Liu, Abai Xu, and Peng Xu
30 Advances in Surgery for Benign Prostatic Hyperplasia ��������������������������������������� 241
Phil Hyun Song and Yeong Uk Kim
31 Thulium: YAG Laser Resection for Benign Prostatic Enlargement��������������������� 247
Karl Marvin M. Tan, Sid C. Sergio, and Romeo Lloyd T. Romero
32 Thermal Ablation for Small Renal Masses ����������������������������������������������������������� 253
Joel Patrick A. Aldana, Jolly Jason S. Catibog, Cindy Pearl J. Sotalbo,
and Joshua Anton O. Yabut
33 Narrow-Band Imaging (NBI) ��������������������������������������������������������������������������������� 263
Seiji Naito
34 Renal Access for PCNL: The Smaller the Better?������������������������������������������������� 269
Bum Soo Kim and Hyuk Jin Cho
35 Extracorporeal Shock Wave Lithotripsy: What All Urologists
Should Know������������������������������������������������������������������������������������������������������������� 275
Timothy C. K. Ng and Anthony C. F. Ng
36 Endoscopic Management of Renal Stone: Retrograde, Antegrade,
and Combined Approaches ������������������������������������������������������������������������������������� 281
Sung Yong Cho, Woo Jin Bang, and Hyung Joon Kim
37 Navigation in Endourology, Ureteroscopy ������������������������������������������������������������� 289
Kenji Yoshida, Seiji Naito, and Tadashi Matsuda
38 Navigation in Laparoscopic and Robotic Urologic Surgery��������������������������������� 297
Fumiya Hongo and Osamu Ukimura
39 MRI-Ultrasound Fusion Prostate Biopsy��������������������������������������������������������������� 303
Wai-Kit Ma and Peter Ka-Fung Chiu
 Part I
Endourology Training
 Introduction of East Asian Society
of Endourology and Development 1
of Endourology in East Asia

Tadashi Matsuda and Seiji Naito

Abstract advances in endourology in East Asia. On November 19th,

The East Asian Society of Endourology (EASE) was estab- 2003 in Fukuoka, Japan, the leaders of endourology from
lished in 2003 to promote advances in minimally invasive Japan, Korea, China, Taiwan, and Hong Kong met and
urological surgery in East Asia, to educate young endou- decided to establish EASE as the progression of this sympo-
rologists of the member territories and to cultivate and sium. The following doctors gathered as the representatives
cement friendship among endourologists from member ter- of endourologists from each country/region:
ritories including Japan, Korea, Taiwan, China, and Hong
Kong. The Philippines subsequently became a member in • Japan: Dr. Eiji Higashihara, Kyorin University, Dr. Shiro
2007 and the annual meeting of EASE has been held in one Baba, Kitasato University, Drs. Shinichi Oshima and
of these territories on a rotational basis. This book was Yoshinari Ono, Nagoya University
planned and published as one of the activities of • Korea: Dr. Tchun Yong Lee, Hanyang University, and
EASE. Thanks to innovations in endoscopic technology and Dr. Tae-Kon Hwang, the Catholic University of Korea
surgical technique, together with the activities of the rele- • China: Dr. Li-Qun Zhou, Peking University
vant associations and societies in the EASE territories, a • Taiwan: Dr. Jun Chen, National Taiwan University
variety of endourological, laparoscopic and robotic proce- • Hong Kong: Dr. Shu-Keung Li
dures have been widely disseminated to minimize invasive-
ness and enhance effectiveness of urological treatments. The first EASE annual congress was held on November
19th, 2004 in Okayama under the presidency of Dr. Eiji
Keywords Higashihara, Kyorin University, Japan, in conjunction with
East Asia · Endourology · Laparoscopy the 18th Congress of the Japanese Society of Endourology
and ESWL.
At the Board of Directors (BOD) meeting of EASE held
on December 13th, 2007 in Hong Kong, it was decided that
1.1 I ntroduction to the East Asian Society the Philippines would join EASE and that the Annual
of Endourology (EASE) Congress of 2009 would be held in Manila.

1.1.1 History of EASE

1.1.2 Activities of EASE
The Yamanouchi International Symposium was held in con-
junction with the Japanese Society of Endourology and According to the by-laws, the mission of EASE is to study
ESWL annual congress from 2001. Here, endourologists all questions relating to endourology, to stimulate interna-
from East Asian territories gathered to discuss recent tional co-operation in the field of urology and to encourage
the development, evaluation and application of all aspects of
minimally invasive therapies of urological disease across the
T. Matsuda (*) East-Asian region.
Department of Urology and Andrology,
The annual congress of EASE has been held every year
Kansai Medical University, Osaka, Japan
e-mail: [email protected] since 2004, to enable through international co-operation in
education and research, all EASE territories to achieve the
S. Naito
Hara-Sanshin Hospital, Fukuoka, Japan highest quality of urological patient care (Table 1.1).

© Springer Nature Singapore Pte Ltd. 2019 3

E. S.-y. Chan, T. Matsuda (eds.), Endourology Progress, https://doi.org/10.1007/978-981-13-3465-8_1
4 T. Matsuda and S. Naito

Table 1.1 Annual Congress of East Asian Society of Endourology the member territories and cultivating and cementing
Year City Country/region President friendship among endourologists in the region. The activi-
1st 2004 Okayama Japan Eiji Higashihara ties of EASE have become well-known throughout the
2nd 2005 Jeju Island Korea Tae Kon Hwang global endourology community. At the 2016 BOD meeting
3rd 2006 Taipei Taiwan Jun Chen in Osaka, the BOD members agreed that EASE would con-
4th 2007 Hong Kong Hong Kong Shu-Keung Li
tinue holding annual congresses in the 2020s and pursue
5th 2008 Shanghai China Liqun Zhou
new and diverse activities such as the publishing of this
6th 2009 Manila Philippine Joel P. Aldana
7th 2010 Seoul Korea Hyeon Hoe Kim
textbook.
8th 2011 Kyoto Japan Seiji Naito
9th 2012 Taipei Taiwan Allen Chiu
10th 2013 Hefei China Yinghao Sun 1.2  evelopment of Endourology in East
D
11th 2014 Hong Kong Hong Kong Berry Fung Asia
12th 2015 Manila Philippine Joel P. Aldana
13th 2016 Osaka Japan Toshiro Terachi 1.2.1  ndourological Societies of East Asian
E
14th 2017 Hong Kong Hong Kong Eddie Chan Countries

Table 1.2 Global-scale Congress of Endourology held in EASE coun- Endourologists in East Asian countries meet at their respec-
tries/region tive national endourological society or endourological
Year Name of congress Country President branch or subgroup of their respective national urological
1989 Seventh World Congress Kyoto, Osamu Yoshida association. The year of establishment and the number of
of Endourology and Japan
members of each national endourological society are shown
SWL
1991 Third World Congress Hakone, Hiroshi Tazaki in Table 1.3. These societies and subgroups have played a
on Videourology Japan major role in the development and dissemination of mini-
1995 Seventh World Congress Taipei, Luke S. Chang mally invasive endourological procedures in each country
on Videourology Taiwan together with their respective national urological
2003 15th World Congress on Busan, Hwang Choi, Jin associations.
Videourology Korea Han Yoon,
Gyung Tak Sung
2008 26th World Congress of Shanghai, Yinghao Sun
Endourology and SWL China 1.2.2  dvancement of Endourology in
A
2011 29th World Congress of Kyoto, Tadashi Matsuda East Asia
Endourology and SWL Japan
2012 23rd World Congress on Hong Sidney KH Yip Due to the development of endourological instruments
Videourology Kong
2014 32th World Congress of Taipei, Allen Chiu
such as the Stern-McCarthy resectoscope in 1931, electro-
Endourology and SWL Taiwan hydraulic lithotripter in 1950, endoscopes equipped with
rod lens and fiber-optic light cable system around 1960,
EASE published the proceedings of the annual congress as its and ultrasonic lithotripter in 1973, a variety of endouro-
official journal named Recent Advances of Endourology from logical procedures including TURP, TUL and PCNL have
2005 to 2012. As the progression from Recent Advances of
Endourology, EASE has published this textbook of endourology,
Endourology Progress—Technique, Technology and Training. Table 1.3 Endourological societies of EASE territories
Since the establishment of EASE, the World Congress of Name of the Establishment No. of
Endourology and the World Congress of Videourology has Country society/group year members
been held in EASE territories as shown in Table 1.2 thanks to China The Endourological 1993
Branch of Chinese
the support of the other EASE members. EASE has had close Urological association
communication with the Urological Association of Asia and Hong Hong Kong 2006 252
the Asian Society of Endourology, and some EASE con- Kong Endourological Society
gresses have been held in conjunction with these bodies. Japan Japanese Society of 1987 3969
Endourology
Korea Korean Endourological 1992 750
Society
1.1.3 Future of EASE Philippine Philippine 2009 41
Endourological Society
Since its establishment in 2004, EASE has played impor- Taiwan Taiwan Urological 1978a 938a
tant roles in promoting advances in minimally invasive Association
urology in East Asia, educating young endourologists of Data on the Urological Association, not the Endourological Group
a
1 Introduction of East Asian Society of Endourology and Development of Endourology in East Asia 5

Table 1.4 Year of start of endourological procedures in EASE territories

Country TURP PCNL TUL SWL Lap. nephrectomy Lap. prostatectomy
China 1980 1985 1986 1984 1992 2000
Hong Kong 1984 1985 1996 2002
Japan 1960s 1982 1984 1984 1991 1999
Korea 1977 1984 1984 1987 1996 2002
Philippine 1969 1985 2004 1996 2001 2004
Taiwan 1984 1984 1985 1992

been developed and used around the world (Miki and

Aizawa 2009; Higashihara 2012). The year of introduction 100%
of these procedures in East Asian territories is shown in 80%
Table 1.4.
As for the endoscopic surgery for benign prostate hyper- 60%
trophy, enucleation of prostate hypertrophy was first per-
40%
formed by Hiraoka and Akimoto (1989) in Japan using a
mechanical instrument, which was the precursor of the 20%
Holnium laser or bipolar electronic enucleation of the
prostate. 0%
1965-1980a 1985 1995 2005
A flexible ureteroscope was first developed by Takayasu
and Aso in 1971 in collaboration with Olympus in Japan Conventional open surgery
PNL and/or TUL
(Takayasu et al. 1971) and the world’s first TUL was
ESWL (monotherapy or combined with PNL and/or TUL)
­performed by Pretz-Castro in 1980 using a Storz rigid ure-
teroscope (Pérez-Castro Ellendt and Martínez-Piñeiro 1982). Fig. 1.1 The transition of treatment modalities for urolithiasis in Japan
Rigid ureteroscopes were launched by Storz, Wolf and during the past 40 years according to the nation-wide surveys per-
Olympus in 1980, 1982 and 1984 respectively. Flexible ure- formed every 5–10 years since 1965 (Terai and Yoshida 2001; Yasui
et al. 2008)
teroscopes were launched by Storz in 1976 and by Olympus
in 1986. Shock wave lithotripsy (SWL), first developed by
Chaussy et al. in 1980 (Higashihara 2012; Chaussy et al. a
1982), spread rapidly in East Asian countries. The current PCNL in Korea
number of SWL machines is 911, 726, 12 and 50 in Japan, 2500 PCNL
Korea, Hong Kong and the Philippines, respectively. 2004
2000
Furthermore, in Korea and Hong Kong, the number of SWL 1614 1636
1532
procedures performed annually was more than 175,000 and 1500 1307
1,211
1300, respectively. 1026
Thanks to improvements in endoscopes or SWL machines 1000
and in surgical technique, the treatment strategy for uroli-
thiasis has dramatically shifted from open surgery to endo- 500
scopic and shock wave treatments in East Asian countries.
0
The transition of treatment modalities for urolithiasis in
Japan during the past 40 years is shown in Fig. 1.1 according b 2010 2011 2012 2013 2014 2015 2016
TUL in Korea (rigid + flexible)
to the nation-wide surveys performed every 5–10 years since 20,000 TUL
17,078
1965 (Terai and Yoshida 2001; Yasui et al. 2008). The num-
ber of PCNL and TUL in Korea are increasing as shown in 15,000
11,983 12,375
Fig. 1.2a, b, respectively. 11,132
9,712
10,000 7,884
7,102
1.2.3  evelopment of Laparoscopic Surgery
D 5,000
in East Asia
0
The first urologic laparoscopic surgery in East Asian coun-
2010 2011 2012 2013 2014 2015 2016
tries as a disease treatment was a laparoscopic varicocelec-
tomy in 1990 (Matsuda et al. 1992). The world’s first Fig. 1.2 The number of PCNL and TUL in Korea since 2010. (a)
laparoscopic adrenalectomy was performed in February of PCNL, (b) TUL
6 T. Matsuda and S. Naito

Cases Table 1.5 Introduction of surgical robot da Vinci in EASE territories

16000 Bladder/Others Varix Adrenal Country/ Year of the No. of No. of urologic
Testis Prostate/Lymph node Kidney/Ureter region first case machinesa operations in 2016
14000 China 2007 50 8000
Hong Kong 2006 10 600
12000
Korea 2006 60 5000
10000 Japan 2003 250 16,000
Philippine 2005 3 100
8000 Taiwan 2005 30 2000
At the end of 2016
a

6000

4000 Acknowledgements Drs. Yinghao Sun, Eddie Chan, Hon Ming Wong,
Koon Ho Rha, Young Eun Yoon, Joel Aldana, Takahiro Yasui, Saint
2000 Shiou-Sheng Chen, produced the data on endourology of East Asian
territories.
0
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
19 8
20 9
20 0
20 1
20 2
20 3
20 4
20 5
20 6
20 7
20 8
20 9
20 0
20 1
20 2
20 3
20 4
15
9
9
9
9
9
9
9
9
9
9
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
19

Fig. 1.3 The number of urologic laparoscopic surgeries in Japan since References
1990
Chaussy C, Schmiedt E, Jocham D, et al. First clinical experience with
extracorporeally induced destruction of kidney stones by shock
waves. J Urol. 1982;127:417–20.
Go H, Takeda M, Takahashi H, et al. Laparoscopic adrenalectomy for
1992 by Japanese doctors (Go et al. 1993). The year of intro- primary aldosteronism: a new operative method. J Laparoendosc
duction of laparoscopic nephrectomy and prostatectomy is Surg. 1993;3:455–9.
Higashihara E. Japanese contribution to endourology. Jpn J Endourol.
shown in Table 1.4. Since then, a variety of urologic laparo- 2012;25:183–201.
scopic surgeries have been introduced in these countries and Hiraoka Y, Akimoto M. Transurethral enucleation of benign prostatic
the number of surgeries in Japan is still increasing as shown hyperplasia. J Urol. 1989;142:1247–50.
in Fig. 1.3, according to the nation-wide survey of urologic Matsuda T, Horii Y, Higashi S, et al. Laparoscopic varicocelectomy: a
simple technique for clip ligation of the spermatic vessels. J Urol.
laparoscopic surgeries (The Japanese Society of Endoscopic 1992;147:636–8.
Surgery 2016). Miki M, Aizawa. The history of endourology. Jpn J Endourol ESWL.
2009;22:127–9.
Pérez-Castro Ellendt E, Martínez-Piñeiro JA. Ureteral and renal endos-
copy. A new-approach. Eur Urol. 1982;8:117–20.
1.2.4 I ntroduction of Robotic Assisted Takayasu H, Aso Y, Takagi T, et al. Clinical application of fiber-optic
Surgery in East Asia pyeloureteroscope. Urol Int. 1971;26:97–104.
Terai A, Yoshida O. Epidemiology of urolithiasis in Japan. In: Akimoto
M, Higashihara E, Orikasa S, et al., editors. Recent advances in
The surgical robot, da Vinci was first introduced to East Asia endourology, vol. 3. Tokyo: Springer; 2001. p. 23–36.
in 2003 in Japan and has since been used in East Asian coun- The Japanese Society of Endoscopic Surgery. Results of 13th nation-
tries as shown in Table 1.5. Now in 2016, the number of da wide survey of endoscopic surgery in Japan. J Jpn Soc Endosc Surg.
2016;21:772–96.
Vinci S, Si or Xi across the EASE region together with the Yasui T, Iguchi M, Suzuki S, et al. Prevalence and epidemiological
number of urological robotic operations in 2016 are shown characteristics of urolithiasis in Japan: national trends between
in Table 1.5. 1965 and 2005. Urology. 2008;71:209–12.
 Training of Endourology in Asia
2
Kai Zhang, Tao Han, and Gang Zhu

Abstract 2.1 Training Models of Endourology

For over hundred years, the training for surgeon was the
accumulation of personal experience following the model Animal and mechanical models are most commonly used for
of “see one, do one, teach one”. Even when this worked, endourology training worldwide, with the advantages of cost-
such training lacked standardization because of different effective, easy accessibility and high reliability. A large num-
cases and teachers’ experience. This is clearly suboptimal ber of models have been developed to train medical students,
from a safety viewpoint. More importantly, modern clini- residents and young urologists with limited experience in
cal ethics sits poorly with surgeons practicing new tech- transurethral resection (TUR) surgery, ureteroscopy, percuta-
niques on patients without any attempt at learning the neous nephrolithotripsy (PCNL), laparoscopy and robotic sur-
skills on simulators. Patients are also increasingly reluc- gery (Ganpule et al. 2015; Chandrasekera et al. 2006; Zhang
tant to be the “guinea pigs” for inexperienced surgeons. et al. 2008; Soria et al. 2015; Celia and Zeccolini 2011). Some
Asia has a vast territory and a large population, the devel- models could simulate the whole procedures with high fidelity
opment of endourology varies greatly among different and some could only simulate basic tasks or be used for spe-
countries and regions. Systematic training and standard- cific steps but with low cost and good reusability.
ization of technique is in pressing need in Asia, especially A model was designed with an in vitro porcine heart tis-
in developing countries. In the last couple of decades, sue model for laser prostatectomy endoscopic technique
numbers of new animal and mechanical models and simu- training in China (Zhang et al. 2009). In the evaluation study,
lators have been developed and validated. Based on the ten junior surgeons without experience of benign prostatic
currently available data, endourological training could hyperplasia (BPH) laser prostatectomy were assessed for
help surgeons to gain experience and improve skills out- ability and speed over a period of time with two technique
side the operating room in a short time. Efforts should be evaluation points: resection and vaporization. A 26F irrigat-
made to identify the best aspects of every model and pro- ing laser resectoscope was used to perform laser resection
cedure-specific simulation courses should be developed and vaporization on left ventricle chordae tendineae
and validated. Conclusive data on the training effect and (Figs. 2.1 and 2.2). Before the first and the second training
feedback on real clinical environment is also needed in stage, the trainees were trained in theory and techniques.
Asia. Feasibility, technique and both resection and vaporization
speed were analyzed. There was significant improvement in
Keywords terms of resection time, vaporization time and the total
Endourology · Training · Training model manipulation time (P < 0.01) in the second stage compared
with those of the first stage. In this model, the space of the
left ventricle in porcine heart was highly similar to the space
of prostatic urethra during the laser BPH treatment and it
was very suitable for this particular training. This model
showed that porcine heart is a simple, cheap and reproduc-
K. Zhang · G. Zhu (*) ible model for learning the basic skills of laser prostatectomy
Department of Urology, Beijing United Family Hospital,
Beijing, China
using laser before working on patients.
Pig is also widely used for laparoscopic training, mostly
T. Han
Department of Urology, Ningxia People’s Hospital,
simulating the whole procedure such as laparoscopic
Ningxia, China nephrectomy, partial nephrectomy and pyeloplasty (Chiu

© Springer Nature Singapore Pte Ltd. 2019 7

E. S.-y. Chan, T. Matsuda (eds.), Endourology Progress, https://doi.org/10.1007/978-981-13-3465-8_2
8 K. Zhang et al.

et al. 1992; Barret et al. 2001; Yang et al. 2010; Gettman attempts. For all the three trainees, the operation time showed
et al. 2002) (Fig. 2.3). The morphometric and anatomic of remarkable reduction and the quality of anastomosis improved
porcine kidney are greatly similar to human kidney (Sampaio significantly from the first to the fourth attempt, suggesting a
et al. 1998) (Fig. 2.4). favorable trend in terms of learning curve.
Early in 1993, laparoscopic nephrectomy was performed
in 15 male live pigs in Taiwan by Chiu et al. (1992). The
average operation time was 200 min. The complications
included renal vein tear in one case, mild subcutaneous
emphysema in two cases.
In India, the crop and esophagus of a chicken were used to
simulate the renal pelvis and ureter for laparoscopic pyeloplasty
training (Ramachandran et al. 2008). This model was cheap,
easily available and could provide a realistic feel to the tissue
and anatomy of human. To assess the effectiveness of this
model, three residents was chosen to complete laparoscopic
pyeloplasty for four times in a period of 1 month. The operation
time and quality of anastomosis were compared among the four

Fig. 2.3 Live porcine model for laparoscopic training

Fig. 2.1 Instruments and porcine heart model Fig. 2.4 Live porcine kidney

Fig. 2.2 Space of the left

ventricle in porcine heart
2 Training of Endourology in Asia 9

In addition to transurethral and laparoscopic procedures,

a number of models were created for training of ureteros-
copy and PCNL (Soria et al. 2015; Mishra et al. 2013; Bele
and Kelc 2016; Sinha and Krishnamoorthy 2015; Strohmaier
and Giese 2009). A biologic bench model using a porcine
kidney was reported to simulate intrarenal procedures in
China (Zhang et al. 2008). The porcine kidney was wrapped
with subcutaneous tissue and muscle in a thick skin flap. The
whole model was fixed to a wooden board with nails and the
radiologic contrast medium or normal saline could be
injected into the kidney through ureteral catheter. Stones
were placed inside the kidney through a small incision on the
renal pelvis in advance. A total of 42 urologists with limited
experience of endourology surgery attended this training,
performing percutaneous renal surgery training under ultra- Fig. 2.5 TURPSim training system
sound guidance. At the end of training, 60.6% trainees could
finish the whole procedure successfully and 85.7% trainees
regarded this model for percutaneous renal surgery training
“very helpful” or “helpful”.
In general, animal and mechanical models are easily built
and cost-effective, could provide realistic and reproducible
practice for most endourology surgery. However, the validity
varies among various models and standard evaluation system
is still lacking.

2.2 Virtual Reality Training

of Endourology

Virtual reality (AR) is defined as “Inducing targeted behav-

ior in an organism by using artificial sensory stimulation,
while the organism has little or no awareness of the interfer-
ence” (Hamacher et al. 2016). The first VR simulator
emerged in 1909 and was used for the training of aircraft
pilots (Hamacher et al. 2016). Nowadays, an increasing
number of validated VR simulators are widely used for
endourology training (Aydin et al. 2016a; Phe et al. 2017; da
Fig. 2.6 Virtual TURP surgery
Cruz et al. 2016; Noureldin et al. 2016; Tjiam et al. 2014).
In 1999, a VR simulator for transurethral resection of the
prostate (TURP) procedures was first reported (Ballaro et al. TURP simulator. It is noteworthy that all the other parame-
1999; Gomes et al. 1999). Software was developed to gener- ters, except for the global rate scale can be objectively and
ate the images of urethral and prostate with using a magnetic accurately evaluated with this VR model.
sensor input device attached to a dummy resectoscope, In accordance with rapid and wide adoption of robot-­
which could help trainees be familiar with the TURP assisted laparoscopic surgery in the last decade, robotic VR
technique. simulators emerged and were increasingly applied world-
Zhu et al. (2013) investigated the utility of VR simulators wide. At present there are five VR simulators: the Surgical
in training of TURP in China. The TURPSim system was Education Platform (SEP; SimSurgery, Oslo, Norway), the
used and 38 trainees were randomly selected to take part in Robotic Surgical System (RoSS; Simulated Surgical
the training (Figs. 2.5 and 2.6). The global rate scale, rate of Systems, San Jose, CA, USA), the dV-Trainer (Mimic,
capsule resection, amount of blood loss, external sphincter Seattle, WA, USA), the da Vinci Skills Simulator (dVSS;
injury was compared between the baseline and post-training Intuitive Surgical), and the recently introduced RobotiX
levels. It showed that all the parameters improved remark- Mentor (3D Systems, Simbionix Products, Cleveland, OH,
ably after training and most trainees were satisfied with the USA) (Moglia et al. 2016).
10 K. Zhang et al.

In Korea, the dVSS system was used to train 50 medical 2.3 Evaluation of Training Effect
school students to perform 12 exercises with the aim to
determine whether a robotic VR training enabled inexperi- The main objective of endourology training is to shorten the
enced trainees to complete a hands-on operation (Song and time needed for clinical training and provide the residents or
Ko 2016). The program was conducted in two parts. Firstly, urologists with the possibility to gain experience and improve
43 students received VR training for basic skills and skills outside the operating room. However, the role of training
advanced suture. Then a real robotic surgical system was in certification and credentialing of real surgery is still under
applied to perform urethrovesical anastomosis on a hands- investigation. There is limited data regarding whether training
on model which was created using the proximal end of rec- could affect actual performance in a hands-on setting.
tal tubes. In analysis, the console time of hands-on training In Japan, Fujimura et al. developed a mentoring system to
was significantly associated with the total time and attempt balance training new surgeons while controlling medical
of VR training, suggesting robotic VR training system quality (Fujimura et al. 2016). Novice surgeons with experi-
could help beginners to acquire and improve robotic sur- ence of radical retropubic prostatectomy and laparoscopic
gery skills. renal and adrenal surgery participated in the study (only one
In India, Mishra et al. compared the validation between a surgeon had experience of laparoscopic radical prostatec-
live porcine model and a VR simulation model for percuta- tomy). They first underwent intensive dry and animal train-
neous renal access training (Mishra et al. 2010). In this study, ing and then observed 47 cases of robot-assisted radical
a live anesthetized pig with a pre-placed ureteric catheter and prostatectomy performed by an experienced surgeon (Menon
a high-fidelity simulator (PERC Mentor, Simbionix; Lod, M, Henry Ford Hospital, Detroit, Michigan, USA). Moreover,
Israel) were used. A total of 24 urologists with experience of in the first five cases of real operation, the new surgeons were
more than 50 cases of PCNL firstly performed percutaneous supervised by a proctor who had enormous experience in
renal access with a real-time C-arm in the porcine model, laparoscopic and robot-assisted radical prostatectomy.
then operated the same procedure on the simulator. In com- In the step-by-step procedures, time limits and blood loss
parison, there was no statistical significant difference in was measured and ten checkpoints were set up during every
overall usefulness. The simulator model came with a high operation in the mentoring program. The cut-off point was
price but was safer and easier to set up than live porcine set at 70% of the time and blood loss limit. Once the time or
model. However, the live porcine model was more realistic blood loss limit was exceeded, a mentor would take over the
than the high-fidelity simulator model. operation or another new surgeon would replace the surgeon
Cai et al. reported the value of VR simulator in the skill and finished the step. In this setting, the surgical quality and
acquisition of flexible ureteroscopy (Cai et al. 2013). URO patient’s safety could be controlled to the maximum extent.
Mentor (Simbionix) VR model was used in this study. Thirty In this study, a total of 242 patients underwent robot-­
urologists took part in the study and received 1-h basic train- assisted radical prostatectomy, with the median operative
ing for the instruments and the whole procedures, then fol- time 237 min and median perioperative blood loss 300 ml.
lowed by an assessment with task of seven programs. After 88% of new surgeons could finish the whole procedure after
another 4-h practice on the simulator, the participants an average of 10.7 cases. There was no perioperative mortal-
­performed the same task. It showed that most parameters ity and no conversion to open prostatectomy. Seven patients
including total procedure time, progressing time from the (2.8%) suffered from postoperative hemorrhage and one
orifice to stone, time of stone translocation, fragmentation patient underwent emergent hemostatic surgery because of
time, laser operate proficiency scale, total laser energy, maxi- active bleeding of left epigastric artery. It is interesting to
mal size of residual stone fragments, number of trauma from note that there was no statistically difference between the
the scopes and tools and damage to the scope improved results of a mentor and those of new surgeons with a mentor
remarkably on the second assessment. This study illustrated in terms of median operative time, console time, blood loss,
that VR simulator could aid the trainees to enhance their incidence of blood transfusion and duration of catheteriza-
flexible ureteroscopy skills in a short time. tion. One must admit that the majority of studies on endou-
Generally, the high-fidelity VR simulators usually seem a rology training merely compare the results between the
very high price. However, the running cost is very low once baseline and post-training period on models or simulators.
the models are installed. It can be easily set up, only a space However, the ultimate goal of training is to improve the
and an electricity supply needed. Of the available VR simu- ­doctor’s performance on real patients. This Japanese study
lators, some have held high level of evidence and recommen- provides us some enlightenment on how to investigate the
dation, such as the UroSim and TURPsim for TUR surgery, effect of training in real clinic environment on the premise of
the URO Mentor and PERC Mentor for urolithiasis, and the ensuring medical quality and safety. Regrettably, there are
dv-Trainer for robotic surgery (Aydin et al. 2016b). too few data on this subject in Asia, even worldwide.
2 Training of Endourology in Asia 11

2.4 Training Organization in Asia Global Education Initiative Skills Courses in Endourolgy,
Laparoscopy and Robotics held in Chengdu, China, in March
There are a lot of endourology training courses supported by 2016.
local urology societies in Asian countries or Areas in the pur- In Korea, Yonsei University College of Medicine
pose of improving Asian urologist’s endoscopic skills and Department of Urology provided 1-year training program
techniques. under the guidance of a urological surgeon. During the fel-
Asian Urological Surgery Training & Education Group lowship, the fellow will be exposed to different techniques
(AUSTEG) was founded in Hong Kong, with the aim to and latest available instruments in endourologic, laparo-
enhance professional competencies to advance the standard scopic and robotic surgery.
of urological surgery in Asia through a comprehensive train- In India, ceMAST organizes courses like two-day Upper
ing platform for experience skill exchange, and hence, culti- Tract Endourology Course covering usage of semirigid ure-
vate next generations in Asia. The members are all urological teroscopes, flexible ureteroscopes, nephroscopes, etc.
experts with a high reputation from China, Japan, Korea,
Malaysia, Thailand and some other Asian countries and
regions. There are extensive curriculums including laparo-
scopic upper tract surgery, endourology and stone manage-
ment, lower tract surgery and urology nursing workshop
(Figs. 2.7 and 2.8).
East Asian Society of Endourology (EASE) regularly has
the pre-congress training program. Such as the EASE 2014
& The Sixth Hong Kong Congress of Endourology: The
Next Generation in Endourology: Training, Technique and
Technology.
Chinese Urology Association (CUA) has organized many
training courses and provided support to local training cen-
ters in China. Usually the training centers were organized by
each province and run by a local teaching hospital. There
were regular courses, which have contributed to the develop-
ment of Chinese Urology. There were also some collaborated
international courses, such as the Endourology Society Fig. 2.8 AUSTEG model training for ureteroscopy

Fig. 2.7 AUSTEG trainers

and trainees
12 K. Zhang et al.

Japanese Urological Association and Japanese Society of Chiu AW, et al. Laparoscopic nephrectomy in a porcine model. Eur
Urol. 1992;22(3):250–4.
Endourology have established a urologic laparoscopic skills da Cruz JA, et al. Does warm-up training in a virtual reality simulator
qualification system called the Endoscopic Surgical Skill improve surgical performance? A prospective randomized analysis.
Qualification (ESSQ) System in 2004 to assess the tech- J Surg Educ. 2016;73(6):974–8.
niques and skills of applicants in performing lap nephrec- Fujimura T, et al. Validation of an educational program balancing sur-
geon training and surgical quality control during robot-assisted radi-
tomy or adrenalectomy. cal prostatectomy. Int J Urol. 2016;23(2):160–6.
The Chinese University of Hong Kong (CUHK) Jockey Ganpule A, Chhabra JS, Desai M. Chicken and porcine models for train-
Club Minimally Invasive Surgery Skills Centre (MISSC) ing in laparoscopy and robotics. Curr Opin Urol. 2015;25(2):158–62.
has collaborations with the International Training Centre of Gettman MT, et al. Transvaginal laparoscopic nephrectomy:
development and feasibility in the porcine model. Urology.
Intuitive Surgical®. Intuitive Surgical® issues certifications 2002;59(3):446–50.
for all courses in robotic assisted laparoscopic surgery con- Gomes MP, et al. A computer-assisted training/monitoring system
ducted at the MISSC. CUHK MISSC runs courses covering for TURP structure and design. IEEE Trans Inf Technol Biomed.
the important clinical aspects of robotics as used in a wide 1999;3(4):242–51.
Hamacher A, et al. Application of virtual, augmented, and mixed reality
variety of specialties, including urology. A similar to urology. Int Neurourol J. 2016;20(3):172–81.
International Training Centre of Intuitive Surgical® has just Mishra S, et al. Percutaneous renal access training: content validation
recently been established in Shanghai Changhai Hospital. comparison between a live porcine and a virtual reality (VR) simu-
It is worth mentioning that, even with different organiz- lation model. BJU Int. 2010;106(11):1753–6.
Mishra S, et al. Training in percutaneous nephrolithotomy. Curr Opin
ers, all the courses combining academic lecture, model-­ Urol. 2013;23(2):147–51.
based training and practice, case discussion, providing Moglia A, et al. A systematic review of virtual reality simulators for
remarkable promotion not only on surgical skill, but also on robot-assisted surgery. Eur Urol. 2016;69(6):1065–80.
professionalism of our future medical care providers to bet- Noureldin YA, et al. Is there a place for virtual reality simulators in
assessment of competency in percutaneous renal access? World J
ter serve our patients. Urol. 2016;34(5):733–9.
Phe V, et al. Outcomes of a virtual-reality simulator-training programme
Remark Permission is obtained to show the human images on basic surgical skills in robot-assisted laparoscopic surgery. Int J
in this article according to local regulation. Med Robot. 2017;13(2) https://doi.org/10.1002/rcs.1740.
Ramachandran A, et al. A novel training model for laparoscopic pyelo-
plasty using chicken crop. J Endourol. 2008;22(4):725–8.
Sampaio FJ, Pereira-Sampaio MA, Favorito LA. The pig kidney
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 Laparoscopic Training Using Cadavers
3
Thomas Y. Hsueh

Abstract ary change of laparoscopic procedures, redefines the horizon

Surgical education is the fundamentals of medicine and of minimal invasive surgery and serves as the procedure of
warrants experience transfer from generations to genera- choice in complex urological surgical procedures. However,
tion to achieve a better disease management. Laparoscopic the evolvement of surgical training of laparoscopic proce-
procedure requires a steep learning curve compared to dures does not establish well as the development of laparo-
conventional open procedures due to two-dimensional scopic procedures. Most urologists learned laparoscopic
vision, lack of tactile sensation and limited working procedures just like the scenario about 40 years ago, as what
space. The training curriculum in laparoscopic proce- we learned from our mentors. At that time, we learned the
dures includes not only didactic lectures but also hand-on surgical procedures from our patients and from textbooks. In
surgical training lab. The application of computerized fact, the traditional training in surgery could be defined in the
simulators, tissue analogue simulators and cadavers is phrase, “see one, do one, teach one,” as what surgeons
proved to be efficient for surgical skills training in lapa- learned for many decades (Halsted 1904). However, with the
roscopy. The training in nontechnical surgical skills is awareness of patient safety, financial constraints and medical
found to have positive impact on surgical training, espe- legal issues in health care organizations, the training model
cially in interpersonal communication and team work used for many decades requires a fundamental renewal for
during emergency scenarios in the operating room. This urologists nowadays.
chapter will discuss the concept on surgical training, The advancement of computer science in the past 40 years
training curriculum design, the application of simulators and the widespread application of internet have changed
in laparoscopic training and nontechnical training in lapa- people life in all aspects of our society. The use of smart-
roscopic surgery. phone, instant online communication and online video learn-
ing provide more chances for urologists to learn new surgical
Keywords concepts. In international academic meetings, live demon-
Laparoscopy · Surgical training · Simulator stration of complex laparoscopic procedures via video
streaming technology and real time communication with
international experts deliver more opportunities for urolo-
gists in both step-by-step surgical illustrations and trouble-­
3.1 Introduction shooting scenario in learning complex laparoscopic
procedures. However, most complex laparoscopic proce-
Laparoscopic surgery was first introduced into urology in dures are associated with steeper learning curves compared
early 1990s. The advancement of technology, miniature of to conventional open procedures. The restricted vision, lack
instruments and duplication of open surgical procedures are of tactile perception, difficulty in handling endoscopic
key elements for the revolution of minimal invasive surgery instruments and limited working space are main reasons for
in the past 30 years. Robotic surgery, one of the revolution- urologists to learn laparoscopic surgery. With the growing
realization that most procedural learning curves do not
require patients for skill acquisition, the implementation of
T. Y. Hsueh (*)
Division of Urology, Department of Surgery, Taipei City Hospital training models in laparoscopic education has gained more
Renal Branch, Taipei, Taiwan and more attention in the past 20 years. Besides, the training
Department of Urology, School of Medicine, National Yang-Ming program is more important than training models (Traxer
University, Taipei, Taiwan et al. 2001). This chapter will focus on the discussion about

© Springer Nature Singapore Pte Ltd. 2019 13

E. S.-y. Chan, T. Matsuda (eds.), Endourology Progress, https://doi.org/10.1007/978-981-13-3465-8_3
14 T. Y. Hsueh

training program for laparoscopic procedures and the valid- ing the hypothesized relations. Construct validity is very
ity of training models, so as to provide a panoramic view of important in social science, psychology and language studies
current status of laparoscopic education. and are one of the important measurements for a training
curriculum of laparoscopy nowadays.

3.2 Evaluation of a Training Curriculum

3.3 Training Curriculum
Surgical education is the long-standing responsibility for
physicians as the clinical experience transferred for genera- The training curriculum using cadaveric/animal models,
tions to generations so as to treat diseases in a better way. high/low fidelity simulators and virtual reality simulators
Continuous medical education is not only important for a provide the possibility of getting knowledge-based behavior
surgeon to be competent in his specialty, but also provide a (Satava 2001). However, the course aiming to train new
chance for patients to receive better medical treatment. In laparoscopic surgical procedures should focus on both tech-
order to keep clinical competence, a well-designed training nical and non-technical skills in handing various clinical
curriculum is required in all aspects of clinical practice, scenarios. There are several issues needed to be addressed,
which would be more important in surgical field. Although such as length of the program, content of didactic courses,
the curriculum might change a lot as the alongside with the hand-on training materials and homogeneity of trainees
progression of computer science, the measuring tools remain (Vaziri 2013). It is reported that participants that are trained
constant in the past several decades. The validity test is the for more than 1 day interactive program might be more
essential part to evaluate a training curriculum and will be competent. In order to decrease the perioperative complica-
discussed in the following parts. tion rate in laparoscopic procedures, the implementation of
surgical volume after the training program is essential.
Hence, an optimal course should include not only didactic
3.2.1 Face Validity lectures and interactive simulator training program, but also
improve the performance of trainee (Kneebone 2003). The
Face validity refers to the measurement of a test in all aspects aim of the training course should focus on the decrease of
(Guion 1980; Holden 2010). It also means the transparency possible complications and increase dexterity during laparo-
and relevance to test participants. In a simple word, face scopic procedures. In 1998, a guideline from society of
validity means how a test really “looks like” as evaluated by American gastrointestinal endoscopic surgeons (SAGES)
all faculties of a training curriculum. suggested the following rules for courses design in laparo-
scopic/robotic surgery. The principles were: (1) The objec-
tives and the assessment methodology should be clearly
3.2.2 Content Validity illustrated, (2) the faculties should be qualified, (3) a funda-
mental knowledge, skills and clinical experiences should be
Content validity is also known as logical validity, which identified in participants, (4) the facilities should be ade-
refers to a measure on all aspects of the test (Lawshe 1975). quate. In 2006, Corica et al. reported the training experience
It also needs to use a designed scale to evaluate the effective- of mini-residency program for laparoscopic procedures with
ness of a test and a statistical test might be needed for further more than 2-year follow-up period. A 5-day training pro-
analysis. Content validity is most often used in academic and gram was conducted, including didactic lecture, hand-on
vocational testing and it might refer to the curriculum evalu- training in dry lab and animal models and observation of
ation in clinical education. live surgery in the operating room. The authors concluded
that 5-day mini-residency program could encourage trainees
to perform more complex laparoscopic procedures in their
3.2.3 Construct Validity daily practice. The course coordinator needs to identify the
requirement of trainees and tries to design a tailor-made
Construct validity is one of the three types of validity evi- content for all participants. The content of didactic lecture is
dence, along with the content validity and criterion validity another concern for a training course and should include
in traditional validity theory. It refers to the identification of fundamental knowledge of laparoscopic surgery, step-by-
appropriateness made on the basis of observations or mea- step laparoscopic surgical procedures and possible land-
surements for a test. In 1955, Cronbach and Meehl reported mark identification during surgery, complications of
that construct validity could be evaluated in the following laparoscopic surgery and future perspectives or current sta-
three aspects, including the articulation of a set of theoretical tus of laparoscopic surgery. For participants who have cer-
concepts and their interactions, to develop ways to measure tain level in laparoscopic procedures, the t­rouble-­shooting
the hypothetical constructs for a theory and empirically test- lecture might be more helpful so as to provide experience
3 Laparoscopic Training Using Cadavers 15

sharing scenario in the course. Finally, the satisfaction sur- Hung et al. reported another model using porcine kidney and
vey of the training course is essential for course coordina- styroform ball to mimic renal tumor requiring laparoscopic/
tors. It can provide not only the evaluation of the training robotic partial nephrectomy while face, content and construct
course, but also provide suggestions for course refinement. B validity could be demonstrated in this study. In 2013, De
To sum up, there is no perfect training curriculum, but a Win et al. reported the animal model of porcine kidney, which
training curriculum can be refined to become perfect. found to have content and construct A validity. With the
advancement in augmented reality, the computerized model
was designed. In 2015, Hung et al. reported the application of
3.4 Training Models dV-Trainer in robotic partial nephrectomy training and face,
content and construct B validity was found in this training
There were several training models focused on laparoscopic model. All four reported studies gained a level of evidence 2b.
surgical procedures. With the advancement of computer sci-
ence and virtual reality, the application of computerized model 3.4.2.2 Pyeloplasty
has gained widespread acceptance in recent years. Besides, There were two studies evaluating the application of pyelo-
there were several validated models used for radical/partial plasty model. In 2013, Jiang et al. reported the use of chicken
nephrectomy, pyeloplasty, ureteral reimplantation, and ure- crop model to simulate clinical scenario of laparoscopic
throvesical anastomosis using analogue materials. The animal pyeloplasty which demonstrated construct B validity between
model was still the most common selection to simulate clinical experts, specialists and junior residents. In 2014, Poniatowski
scenario although fresh frozen cadaveric model might provide et al. reported the pyeloplasty simulator model by using a
better experience in endoscopic dissection. The simulated low-cost, high-fidelity tissue analogue. It was reported to
training models will be discussed in the following section. have face, content and construct B validity (Poniatowski et al.
2014). Those two studies gained a level of evidence 2b.

3.4.1 Computerized Simulators 3.4.2.3 Ureteral Reimplantation

In 2013, Tunitsky et al. reported the use of hydrogel to simu-
As the development of imitative technology, application of late laparoscopic/robotic ureteral reimplantation. The model
augmented reality in real life and the widespread deployment demonstrated to have face, content and construct B validity
of high definition video system, the use of virtual reality in and gained a level of evidence 2b.
educational training has gained popularity since early 2000s
(Laguna et al. 2002). The computer-based design of a simu- 3.4.2.4 Vesicourethral Anastomosis
lator mainly focused on the reproducibility of three-­ There were several studies evaluating the training models of
dimensional environment, tissue texture and the creation of vesicourethral anastomosis. In 2006, Laguna et al. reported
force-feedback mechanisms. Besides, the possible smoke the chicken model to mimicking vesicourethral anastomosis
generation and tissue elasticity alongside the bleeding phe- and found to have construct B validity in this study with a
nomenon during endoscopic dissection and vessel ligation is level 2c evidence. In 2012, Sabbagh et al. reported the latex
another consideration to be implemented in a computer-­ UV model to simulate vesicourethral anastomosis, which
based simulator. In 2012, Matsuda et al. reported the experi- demonstrated face and predictive validity and a level 2a evi-
ence in virtual reality simulator and compared to the dence was identified. In 2014, Kang et al. reported the use of
videotape assessment from real laparoscopic procedures. tube3/dV-Trainer to simulated vesicourethral anastomosis.
They concluded that the basic skill training in virtual reality Face, content and construct B validity was found in this
simulators might demonstrate the construct and concurrent study while a level 2b evidence was identified. In 2015,
validity to evaluate preclinical laparoscopic skills. Chowriappa et al. reported the use of augmented reality to
simulate vesicourethral anastomosis in HoST/RoSS model.
Face and concurrent validity were found in this study and a
3.4.2 Analogue Training Model level 1b evidence was noted.

3.4.2.1 Partial/Radical Nephrectomy

There were several studies describing the application of train- 3.4.3 Animal Model
ing models in simulated training of partial nephrectomy. In
2010, the Procedicus MIST nephrectomy VR simulator was The use of animal to simulate real surgical scenario was a
reported to have face, content and construct B validity longstanding choice for surgical training, not only in con-
(Brewin et al. 2010). Lee et al. (2012a) reported the partial ventional open surgery, but also in laparoscopic surgical
nephrectomy model mimicking renal hilar injury, which dem- procedures (Alemozaffar et al. 2014). The most commonly
onstrated face, content and construct B validity. In 2012, used animal is porcine model while canine or calf model
16 T. Y. Hsueh

was sporadically reported. The interactive training program solution to maintain clinical competency and to learn new
can be divided to upper urinary tract and lower urinary tract. endoscopic procedures in a safe environment. In the near
The trainees will be divided into several groups and about future, laparoscopic simulation using computerized virtual
2–3 trainees per group is the usual setting. Each group will reality model, animal model and cadaveric model might
be assigned to perform 2–3 procedures in about 4 h. Partial/ serve as the step-by-step learning protocol to deliver a new
radical nephrectomy, pyeloplasty and ureteroureterostomy surgical technique from the experimental test into a practical
are the usual procedures for upper urinary tract while ure- procedure.
teroneocystostomy, enterocystoplasty and radical cystec-
tomy are usually conducted for lower urinary tract.
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