A novel ex vivo trainer for robotic vesicourethral anastomosis

  • Kevin SheeEmail author
  • Kevin Koo
  • Xiaotian Wu
  • Fady M. Ghali
  • Ryan J. Halter
  • Elias S. Hyams
Original Article


Robotic surgical skill development is central to training in urology as well as other surgical disciplines. Vesicourethral anastomosis (VUA) in robotic prostatectomy is a challenging task for novices due to delicate tissue and difficult suturing angles. Commercially available, realistic training models are limited. Here, we describe the development and validation of a 3D-printed model of the VUA for ex vivo training using the da Vinci Surgical System. Models of the bladder and urethra were created using 3D-printing technology based on estimations of average in vivo anatomy. 10 surgical residents without prior robotics training were enrolled in the study: 5 residents received structured virtual reality (VR) training on the da Vinci Skills Simulator (“trained”), while the other 5 did not (“untrained”). 4 faculty robotic surgeons trained in robotic urologic oncology (“experts”) were also enrolled. Mean (range) completion percentage was 20% (10–30%), 54% (40–70%), and 96% (85–100%) by the untrained, trained, and expert groups, respectively. Anastomosis integrity was rated as excellent (as opposed to moderate or poor) in 40%, 60%, and 100% of untrained, trained, and expert groups, respectively. Face validity (realism) was rated as 8 of 10 on average by the expert surgeons, each of whom rated the model as a superior training tool to digital VR trainers. Content validity (usefulness) was rated as 10 of 10 by all participants. This is the first reported 3D-printed ex vivo trainer for VUA in robotic prostatectomy validated for use in robotic simulation. The addition of 3D-printed ex vivo training to existing digital simulation technologies may augment and improve robotic surgical education in the future.


Robotic surgery Surgical education Simulation Surgical skills training Prostatectomy 



This study was enabled by use of a da Vinci Skills Simulator (Intuitive, Sunnyvale, CA) provided to the authors’ institution via the “Intuitive Surgical Standalone Simulator program.”

Compliance with ethical standards

Conflict of interest

Authors Kevin Shee, Kevin Koo, Xiaotian Wu, Fady M. Ghali, Ryan J. Halter, and Elias S Hyams declare that they have no conflict of interest.

Ethical approval

Ethics committee approval was received for this study from the ethics committee of the Institutional Review Board (IRB).

Informed consent

Written informed consent was obtained from patients who participated in this study.


  1. 1.
    Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 67(1):7–30. CrossRefGoogle Scholar
  2. 2.
    Bekelman JE, Rumble RB, Chen RC, Pisansky TM, Finelli A, Feifer A, Nguyen PL, Loblaw DA, Tagawa ST, Gillessen S, Morgan TM, Liu G, Vapiwala N, Haluschak JJ, Stephenson A, Touijer K, Kungel T, Freedland SJ (2018) Clinically Localized Prostate Cancer: ASCO Clinical Practice Guideline Endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology Guideline. J Clin Oncol. Google Scholar
  3. 3.
    Hu JC, Gu X, Lipsitz SR, Barry MJ, D’Amico AV, Weinberg AC, Keating NL (2009) Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA 302(14):1557–1564. CrossRefGoogle Scholar
  4. 4.
    Trinh QD, Sammon J, Sun M, Ravi P, Ghani KR, Bianchi M, Jeong W, Shariat SF, Hansen J, Schmitges J, Jeldres C, Rogers CG, Peabody JO, Montorsi F, Menon M, Karakiewicz PI (2012) Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 61(4):679–685. CrossRefGoogle Scholar
  5. 5.
    Sooriakumaran P, Srivastava A, Shariat SF, Stricker PD, Ahlering T, Eden CG, Wiklund PN, Sanchez-Salas R, Mottrie A, Lee D, Neal DE, Ghavamian R, Nyirady P, Nilsson A, Carlsson S, Xylinas E, Loidl W, Seitz C, Schramek P, Roehrborn C, Cathelineau X, Skarecky D, Shaw G, Warren A, Delprado WJ, Haynes AM, Steyerberg E, Roobol MJ, Tewari AK (2014) A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assisted radical prostatectomy patients. Eur Urol 66(3):450–456. CrossRefGoogle Scholar
  6. 6.
    Goldenberg MG, Goldenberg L, Grantcharov TP (2017) Surgeon performance predicts early continence after robot-assisted radical prostatectomy. J Endourol 31(9):858–863. CrossRefGoogle Scholar
  7. 7.
    Tyritzis SI, Katafigiotis I, Constantinides CA (2012) All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy. J Urol 188(2):369–376. CrossRefGoogle Scholar
  8. 8.
    Zhong W, Mancuso P (2017) Utilization and surgical skill transferability of the simulator robot to the clinical robot for urology surgery. Urol Int 98(1):1–6. CrossRefGoogle Scholar
  9. 9.
    Abboudi H, Khan MS, Aboumarzouk O, Guru KA, Challacombe B, Dasgupta P, Ahmed K (2013) Current status of validation for robotic surgery simulators—a systematic review. BJU Int 111(2):194–205. CrossRefGoogle Scholar
  10. 10.
    Hung AJ, Patil MB, Zehnder P, Cai J, Ng CK, Aron M, Gill IS, Desai MM (2012) Concurrent and predictive validation of a novel robotic surgery simulator: a prospective, randomized study. J Urol 187(2):630–637. CrossRefGoogle Scholar
  11. 11.
    Chmarra MK, Dankelman J, van den Dobbelsteen JJ, Jansen FW (2008) Force feedback and basic laparoscopic skills. Surg Endosc 22(10):2140–2148. CrossRefGoogle Scholar
  12. 12.
    Williams A, McWilliam M, Ahlin J, Davidson J, Quantz MA, Butter A (2018) A simulated training model for laparoscopic pyloromyotomy: is 3D printing the way of the future? J Pediatr Surg 53(5):937–941. CrossRefGoogle Scholar
  13. 13.
    Yamada T, Osako M, Uchimuro T, Yoon R, Morikawa T, Sugimoto M, Suda H, Shimizu H (2017) Three-dimensional printing of life-like models for simulation and training of minimally invasive cardiac surgery. Innovations (Phila) 12(6):459–465. CrossRefGoogle Scholar
  14. 14.
    Barber SR, Kozin ED, Dedmon M, Lin BM, Lee K, Sinha S, Black N, Remenschneider AK, Lee DJ (2016) 3D-printed pediatric endoscopic ear surgery simulator for surgical training. Int J Pediatr Otorhinolaryngol 90:113–118. CrossRefGoogle Scholar
  15. 15.
    Cheung CL, Looi T, Lendvay TS, Drake JM, Farhat WA (2014) Use of 3-dimensional printing technology and silicone modeling in surgical simulation: development and face validation in pediatric laparoscopic pyeloplasty. J Surg Educ 71(5):762–767. CrossRefGoogle Scholar
  16. 16.
    Hickling DR, Sun TT, Wu XR (2015) Anatomy and physiology of the urinary tract: relation to host defense and microbial infection. Microbiol Spectr. Google Scholar
  17. 17.
    Seixas-Mikelus SA, Kesavadas T, Srimathveeravalli G, Chandrasekhar R, Wilding GE, Guru KA (2010) Face validation of a novel robotic surgical simulator. Urology 76(2):357–360. CrossRefGoogle Scholar
  18. 18.
    Shee K, Ghali FM, Hyams ES (2017) Practice makes perfect: correlations between prior experience in high-level athletics and robotic surgical performance do not persist after task repetition. J Surg Educ 74(4):630–637. CrossRefGoogle Scholar
  19. 19.
    Kang SG, Cho S, Kang SH, Haidar AM, Samavedi S, Palmer KJ, Patel VR, Cheon J (2014) The Tube 3 module designed for practicing vesicourethral anastomosis in a virtual reality robotic simulator: determination of face, content, and construct validity. Urology 84(2):345–350. CrossRefGoogle Scholar
  20. 20.
    Chowriappa A, Raza SJ, Fazili A, Field E, Malito C, Samarasekera D, Shi Y, Ahmed K, Wilding G, Kaouk J, Eun DD, Ghazi A, Peabody JO, Kesavadas T, Mohler JL, Guru KA (2015) Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial. BJU Int 115(2):336–345. CrossRefGoogle Scholar
  21. 21.
    Laguna MP, Arce-Alcazar A, Mochtar CA, Van Velthoven R, Peltier A, de la Rosette JJ (2006) Construct validity of the chicken model in the simulation of laparoscopic radical prostatectomy suture. J Endourol 20(1):69–73. CrossRefGoogle Scholar
  22. 22.
    Chung SD, Tai HC, Lai MK, Huang CY, Wang SM, Tsai YC, Chueh SC, Liao CH, Yu HJ (2010) Novel inanimate training model for urethrovesical anastomosis in laparoscopic radical prostatectomy. Asian J Surg 33(4):188–192. CrossRefGoogle Scholar
  23. 23.
    Ahmed K, Khan R, Mottrie A, Lovegrove C, Abaza R, Ahlawat R, Ahlering T, Ahlgren G, Artibani W, Barret E, Cathelineau X, Challacombe B, Coloby P, Khan MS, Hubert J, Michel MS, Montorsi F, Murphy D, Palou J, Patel V, Piechaud PT, Van Poppel H, Rischmann P, Sanchez-Salas R, Siemer S, Stoeckle M, Stolzenburg JU, Terrier JE, Thuroff JW, Vaessen C, Van Der Poel HG, Van Cleynenbreugel B, Volpe A, Wagner C, Wiklund P, Wilson T, Wirth M, Witt J, Dasgupta P (2015) Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts. BJU Int 116(1):93–101. CrossRefGoogle Scholar
  24. 24.
    Smith R, Patel V, Satava R (2014) Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14-society consensus template of outcomes measures and curriculum development. Int J Med Robot 10(3):379–384. CrossRefGoogle Scholar
  25. 25.
    Wilcox B, Mobbs RJ, Wu AM, Phan K (2017) Systematic review of 3D printing in spinal surgery: the current state of play. J Spine Surg 3(3):433–443. CrossRefGoogle Scholar
  26. 26.
    Li C, Yang M, Xie Y, Chen Z, Wang C, Bai Y, Zhu X, Li M (2015) Application of the polystyrene model made by 3-D printing rapid prototyping technology for operation planning in revision lumbar discectomy. J Orthop Sci 20(3):475–480. CrossRefGoogle Scholar
  27. 27.
    Izatt MT, Thorpe PL, Thompson RG, D’Urso PS, Adam CJ, Earwaker JW, Labrom RD, Askin GN (2007) The use of physical biomodelling in complex spinal surgery. Eur Spine J 16(9):1507–1518. CrossRefGoogle Scholar
  28. 28.
    Hakansson A, Rantatalo M, Hansen T, Wanhainen A (2011) Patient specific biomodel of the whole aorta—the importance of calcified plaque removal. Vasa 40(6):453–459. CrossRefGoogle Scholar
  29. 29.
    Tam MD, Laycock SD, Bell D, Chojnowski A (2012) 3-D printout of a DICOM file to aid surgical planning in a 6 year old patient with a large scapular osteochondroma complicating congenital diaphyseal aclasia. J Radiol Case Rep 6(1):31–37. Google Scholar
  30. 30.
    Oishi M, Fukuda M, Yajima N, Yoshida K, Takahashi M, Hiraishi T, Takao T, Saito A, Fujii Y (2013) Interactive presurgical simulation applying advanced 3D imaging and modeling techniques for skull base and deep tumors. J Neurosurg 119(1):94–105. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Geisel School of Medicine at DartmouthHanoverUSA
  2. 2.Section of Urology, Department of SurgeryDartmouth-Hitchcock Medical CenterLebanonUSA
  3. 3.Thayer School of Engineering at DartmouthHanoverUSA
  4. 4.One Medical Center Drive LebanonLebanonUSA

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