EndoWorld

Making treatment risk free Virtual reality transurethral surgical training

URO 26-1-E/02-2005

Making treatment risk freeVirtual reality transurethral surgical training

Today, the simulation of complex endo-scopic procedures by means of ‘virtualreality (VR)’, as part of training and furthertraining, is seen as a very worthwhile goalin urology. Even on less realistic models,several groups were able to conclusivelyprove that such an approach is of benefitto trainee physicians [1–3].

The virtual TUR simulator fromKARL STORZ enables numerous realistictasks to be carried out, and thus facilitatesfocused individual training. The skillsacquired, for example in personal operat-ing techniques, are continuously improvedand optimized.

Thanks to the range of variable and flexiblesoftware training modules, training can beprovided in anatomy, as well as in thebasics of diagnostic and therapeuticmeasures in endourologic interventions.

In particular, the difficult hand-eye coordi-nation, which is needed for the inspectionof the lower urinary tract and for perform-ing therapeutic interventions, can, with thevirtual training module, be practised andsystematically improved so that itbecomes, to a large extent, routine, and ahigh level of skill is developed – withoutendangering patients.

The system enables a percentage evalua-tion of those parts of the bladder surfacewhich have been specifically examined;the distal distance and guidance of theendoscope in relation to the surface formpart of the evaluation criteria.

To create the feeling of a ‘realistic’ inter-vention, a variety of telescopes with differ-ent angles of view are available (Fig. 2).Furthermore, the external appearance ofall the instruments, as well as the functionsof an endoscopic camera, such as focus- Fig. 1

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ing, have been integrated into the systemto optimize the instrument-related learningeffect (Fig. 3).

The unique ‘Patient creation module’ simu-lates the morphology, the position, the sizeand the number of tumors randomly, as ‘innature’.

In this way, unique ‘virtual patients’ arecreated. This greatly increases the successof training, as each case is different.Therefore, the trainee physician must con-tinuously adapt to new situations (Fig 5).

The integrated ‘session manager’ providesa choice of micropapillary tumors, flat carcinomas in situ, as well as a ‘mixedsession’ offering a complete range ofmacropathologic conditions. This gives thetrainee physician an unlimited choice ofnew, realistic operating room situations.

To provide training on therapeutic measures, there is a choice between HFresection and coagulation with various HFresection loops, as well as laser applica-tion (Fig. 6).

There is even a beep sound integrated intothis system to check that the unit is acti-vated, such as real units have.Hemorrhages that occur during tumorresection must be controlled properly bythe trainee physician by means of contactcoagulation, which, like the laser, is trig-gered by a pedal.

If hemorrhaging is overlooked or coagula-tion is not performed properly, vision deteriorates due to the red coloration ofthe irrigation liquid. To improve the situa-tion, the trainee has to perform ‘virtualrinsing’. Hemorrhages and any loss ofblood are realistically visualized.

This system allows you to experience HFresection on simulated tissue in a remark-ably realistic manner. KARL STORZ has achieved this by meansof the patented Force Feedback System[4.5) integrated into the resectoscope.Here, the forces resulting from contactwith the bladder wall or resection are simulated and conveyed realistically to theuser via the instrument.

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Fig. 6

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The anatomically flexible bladder walllooks just like the real thing and thereforecontributes to the realistic overall impres-sion. The bladder content can be easilysimulated at different levels.

The PDD procedure (photodynamic diagnostics) which has been additionallyintegrated into the ‘Indications module’means training now compromises this newapplication procedure (Fig. 4) - allowingthis procedure, which is extremely efficientfor tumor recognition, to be trained.

New medical indications can be integratedinto the ‘Indications module’ at any time.Therefore, from a medical perspective, thesystem is always ‘up to date’.

As well as the percentage evaluation, display of the surface of the bladder whichhas been inspected, and evaluation of suc-cessful tumor resections, the loss of bloodin real time is also transmitted to the‘Statistics module’.

The latest results and data are displayedon a second monitor next to the custom-ary endoscopic monitor, to check howsuccessful learning has been. This data istransferred cumulatively to the ‘Statisticsmodule’ and can be output for each individual user.

Furthermore, the additional monitor showsthe morphology of the bladder and thetumors, as well as the current position ofthe endoscope with working element introduced via the instrument port on virtu-al slice images. With this representation,even beginners can assess the depth ofthe instrument position, something which,using the endoscopic image, would onlybe possible for a very experienced physi-cian.

Simulation of the, in comparison, consider-ably more complex transurethral resectionof the prostate (TURP) is also available asan additional option, for the purposes oftraining and further training.

Fundamental findings that are the basis forthe implementation of this simulator wereaquired from a project (MISSIMU) spon-sored by the EU. The realistic virtual imag-ing of the TUR simulator was implemented

and evaluated in close cooperation withthe Department of Urology ( Prof. Dr. Dr.h.c. Alfons Hofstetter and Dr. Margarita Noll)and the Laser Research Laboratory atGrosshadern University Hospital in Munich.

Prof. Dr. med. Christian Stief, University Hospital Grosshadern, Munich

Senior physician Dr. med. Oliver Reich,University Hospital Grosshadern, Munich

Bibliography

1 MANYAK MJ, SANTANGELO K, HAHN J ET AL:Virtual reality surgical simulation for lowerurinary tract endoscopy and procedures.J Endourol, 16(3):185, 2002

2 SHAH J, MACKY S, VALE J ET AL:Simulation in urology – a role for virtualreality ? BJU International, 88:661, 2001

3 HOZNEK A, KATZ R, GETTMAN M ET AL:Laparoscopic and robotic surgical train-ing in urology. Curr Urol Rep, 4(2):130, 2003

4 IRION, KM, BÖHM, R ET AL:Simulatorvorrichtung mit zumindest zweiBewegungsfreiheitsgraden für dieVerwendung bei einem realen InstrumentDeutsche Patentschrift von KARL STORZGmbH & Co. KG, 03.11.2000

5 IRION, KM, BÖHM, R ET AL:Simulatorvorrichtung mit zumindest zweiBewegungsfreiheitsgraden für einInstrumentEP-Patentschrift von KARL STORZGmbH & Co. KG, 03.11.2000

6 NOLL, MARGARITA:Konzeption und Evaluation einesEndoskopie-Simulators für die Urologie.Dissertation, LMU München:Medizinische Fakultät (2003)

57 1000 01 URO Trainer Set, hardware including controller set withGerman-language operating system, including camera head;not including software or resectoscope

57 1000 01U URO Trainer Set, hardware including controller set withEnglish-language operating system, including camera head;not including software or resectoscope

6 7

57 0270 50 D Resectoscope, active, for use with URO Trainer Set 57 1000 01/57 1000 01U

57 0270 50 E Resectoscope, passive, for use with URO Trainer Set 57 1000 01/57 1000 01U

57 0900 01-01URO Trainer Software ‘Bladder’, German and English

57 090002-01 URO Trainer Software ‘Bladder and Prostate’,German and English

57 0900 03-01CD Update ‘Bladder and Prostate’, German and English

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