Another concern is that our study only measured outcomeson the simulator, while not assessing the ability of simulatortraining to improve clinical operative performance. The find-ings that urology residents performed better on the simulatorwith increasing years of training and that the performance ofthe trained medical students was inferior to that of moreexperienced residents indirectly validate the ability of thesimulator to faithfully represent the clinical experience. Nev-ertheless, the ultimate question of whether the skills learnedon the VU simulator are transferable to the operating roommust be addressed. While there are obvious limitations toassessing medical students in the operating room, we arecurrently in the process of validating the simulator using ahuman cadaver model.

CONCLUSIONS

Novice medical students tested on a virtual ureteroscopysimulator significantly improved task completion time andoperative skills with training. Moreover, the performance ofthe students on the simulator after training was statisticallysimilar to that of residents who had completed nearly 1 yearof urology training. This pilot study suggests that VU skillstraining may help first year residents overcome the initialclinical ureteroscopy learning curve, although further clini-cal validation is required.

REFERENCES

1. Scott, D. J., Bergen, P. C., Rege, R. V., Laycock, R., Tesfay, S. T.,Valentine, R. J. et al: Laparoscopic training on bench models:better and more cost effective than operating room experience?J Am Coll Surg, 191: 272, 2000

2. Bridges, M. and Diamond, D. L.: The financial impact of teachingsurgical residents in the operating room. Am J Surg, 177: 28,1999

3. Daniels, G. F., Jr., Garnett, J. E. and Carter, M. F.: Uretero-scopic results and complications: experience with 130 cases.J Urol, 139: 710, 1988

4. Rowan, A. N.: Is justification of animal research necessary?JAMA, 269: 1113, 1993

5. Anastakis, D. J., Regehr, G., Reznick, R. K., Cusimano, M.,Murnaghan, J., Brown, M. et al: Assessment of technical skillstransfer from the bench training model to the human model.Am J Surg, 177: 167, 1999

6. Rolfe, J. M. and Staples, K. J.: Flight Simulation. Cambridge,United Kingdom: Cambridge University Press, p. 232, 1986

7. Issenberg, S. B., McGaghie, W. C., Hart, I. R., Mayer, J. W.,Felner, J. M., Petrusa, E. R. et al: Simulation technology forhealth care professional skills training and assessment.JAMA, 282: 861, 1999

8. Colt, H. G., Crawford, S. W. and Galbraith, O., 3rd: Virtualreality bronchoscopy simulation: a revolution in proceduraltraining. Chest, 120: 1333, 2001

9. Derossis, A. M., Bothwell, J., Sigman, H. H. and Fried, G. M.:The effect of practice on performance in a laparoscopic simu-lator. Surg Endosc, 12: 1117, 1998

10. Wilhelm, D. M., Ogan, K., Roehrborn, C. G., Cadeddu, J. A. andPearle, M. S.: Assessment of basic endoscopic performanceusing a virtual reality simulator. J Am Coll Surg, 195: 675,2002

11. Kuo, R. L., Delvecchio, F. C. and Preminger, G. M.: Virtualreality: current urologic applications and future developments.J Endourol, 15: 117, 2001

12. Eubanks, T. R., Horgan, S., Resnick, B., Pellegrini, C. andSinanan, M.: Laparoscopic drills do not improve objectivelymeasured motor skills in surgery residents. Proceedings ofSociety of American Gastrointestinal Endoscopic Surgeons an-nual meeting, Seattle, Washington, April 1998

13. Rosser, J. C., Jr., Rosser, L. E. and Savalgi, R. S.: Objectiveevaluation of a laparoscopic surgical skill program for resi-dents and senior surgeons. Arch Surg, 133: 657, 1998

14. Derossis, A. M., Fried, G. M., Abrahamowicz, M., Sigman, H. H.,Barkun, J. S. and Meakins, J. L.: Development of a model fortraining and evaluation of laparoscopic skills. Am J Surg, 175:482, 1998

15. Martin, J. A., Regehr, G., Reznick, R., MacRae, H., Murnaghan,J., Hutchison, C. et al: Objective structured assessment oftechnical skill (OSATS) for surgical residents. Br J Surg, 84:273, 1997

16. Reznick, R., Regehr, G., MacRae, H., Martin, J. and McCulloch,W.: Testing technical skill via an innovative “bench station”examination. Am J Surg, 173: 226, 1997

17. Macmillan, A. I. and Cuschieri, A.: Assessment of innate abilityand skills for endoscopic manipulations by the AdvancedDundee Endoscopic Psychomotor Tester: predictive and con-current validity. Am J Surg, 177: 274, 1999

EDITORIAL COMMENT

As a medical student 20 years ago I recall a surgery intern saying“Monkeys can be trained to perform surgery.” Are we there yet? Theauthors trained medical students to perform virtual ureteroscopycomparably to junior urology residents. This finding implies thatother novice ureteroscopists (beginning junior residents or olderpracticing urologists with no prior ureteroscopy experience) mightacquire ureteroscopy skills using VU.1 The incremental improve-ment decreased as training level increased, implying that educa-tional benefits of VU training are greatest for (and perhaps limitedto) ureteroscopy novices.

However, the study end point was VU performance. The authorsdid not show content validity (does VU testing actually assess clin-ical ureteroscopy skills?) or criterion validity (does VU predict per-formance on clinical ureteroscopy?). Criterion validity is necessary ifVU is used for resident applicant screening. Thus, all we know is thatnovice ureteroscopists can be trained to play an expensive ureteros-copy video game and play it as well as junior urology residents. Weneed a study in which junior residents are randomized to VU versusno VU training and then assess clinical ureteroscopy skills, withattending observers blinded to VU training status.

So what is the role for VU? I believe that VU will flatten thelearning curve for novice ureteroscopists. Furthermore, virtual sim-ulators are already being tested for other skills.2 It seems likely thaturology trainees will have increased opportunities to learn throughvirtual surgery simulators. It may not be far-fetched that we cansoon train monkeys to perform ureteroscopy.

Joel M. H. TeichmanDivision of UrologySt. Paul’s HospitalVancouver, BC, Canada

1. Watterson, J. D., Beiko, D. T., Kuan, J. K. and Denstedt, J. D.: Arandomized, prospective blinded study validating the acquisi-tion of ureteroscopy skills using a computer based virtualreality endourological simulator. J Urol, 168: 1928, 2002

2. Beiko, D. T., Watterson, J. D., Knudsen, B. E., Bennett, J. D.,Pace, K. T., Honey, R. J. D’a. et al: PERC mentor: a newcomputer-based virtual reality simulator for percutaneous re-nal access. J Urol, suppl., 169: 473, abstract 1775, 2003

REPLY BY AUTHORS

We wholeheartedly agree that VU simulators need to be validatedin the clinical setting. Before training programs line up to purchasethem and VU training becomes pervasive in our educational curric-ulum, it is imperative that content and criterion validity be demon-strated. Otherwise, these simulators are simply glorified videogames.

VIRTUAL URETEROSCOPY SIMULATOR 323