Ureterorenoscopy training on cadavers embalmed by Thiel's method: simulation or a further step towards reality? Initial report.

81 Central European Journal of Urology UROLITHIASIS ORIGINAL PAPER Ureterorenoscopy training on cadavers embalmed by Thiel’s method: simulation or a further step towards reality? Initial report Edward Mains1, Benjie Tang2, Tomasz Golabek3, Tomasz Wiatr3, Gillian Ross2, Alan Duncan2, Duncan Howie2, Iain Tait2, Piotr Chłosta3, Sławomir G. Kata1 Department of Urology, Ninewells Hospital and Medical School, Dundee, United Kingdom Cuschieri Skills Centre, University of Dundee, Dundee, United Kingdom 3 Department of Urology, Jagiellonian University, Collegium Medicum, Cracow, Poland 1 2 Citation: Mains E, Tang B, Golabek T, et al. Ureterorenoscopy training on cadavers embalmed by Thiel’s method: simulation or a further step towards reality? Initial report. Cent European J Urol. 2017; 70: 81-87. Article history Submitted: Sept. 11, 2016 Accepted: Dec. 15, 2016 Published online: March 14, 2017 Corresponding author Edward Mains Ninewells Hospital and Medical School Department of Urology Ninewells Avenue DD1 9SY Dundee, UK phone: +44 781 050 4856 Introduction The technique of ureterorenoscopy has a significant learning curve. Cadavers embalmed by the Thiel method have been successfully used for simulation training in a number of surgical specialties. Here we present our experience of the first use of Thiel cadavers in a formal ureteroscopy training course. Material and methods The inaugural ‘Masterclass in Flexible Ureterorenoscopy’ was run with participants performing ureterorenoscopy on three Thiel cadavers under expert supervision. A qualitative questionnaire was delivered to the participants and faculty. Assessed domains were tissue characteristics of the cadaveric urinary tract, anatomical features and procedural aspects. A five-point Likert score was used to assess responses. Data regarding participant experience in endourology were also collected. Results 8 questionnaires were collected. All participants completed cadaveric ureterorenoscopy. Threequarters reported the overall quality of tissue in the cadaveric bladder, ureters and pelvicalyceal system as high or excellent.Half reported the cadaveric bladder as being softer than in a live patient, whilst five out of eight thought that the cadaveric ureter was softer and more prone to trauma. Seven out of eight were satisfied with the overall quality of the cadaveric model. The quality of vision and irrigation in the upper urinary tracts was reported as high. Conclusions Thiel cadavers have been shown to have excellent tissue characteristics, as well as being durable and reusable. We have described the first use of Thiel cadavers in a designated ureterorenoscopy course, with high levels of delegate satisfaction. Further work is required to develop the role of Thiel cadavers as part of an integrated, modular urology training. Key Words: ureteroscopy ‹› cadavers ‹› Thiel embalming ‹› simulation ‹› training INTRODUCTION Appropriate training in diagnostic and therapeutic ureterorenoscopy is essential, as the procedure requires a high degree of dexterity and endoscopic skills, as well as a comprehensive understanding of upper urinary tract anatomy. It has been recognised that complication rates should be low in the hands of experienced endoscopists, but that significant risks, including ureteric injury, remain associated with the procedure [1]. Cent European J Urol. 2017; 70: 81-87 The implementation of novel technologies and techniques, the increasing demands of service provision, coupled with a reduced exposure to practical anatomy in undergraduate education lends further impetus to efforts to improve the efficiency of training and reduce the learning curve [2, 3]. These factors have promoted the development of procedure- specific training models for use in urological training, with a range of computer-based and animal model simulators described [4]. The first ureterorenoscopy doi: 10.5173/ceju.2017.913 82 Central European Journal of Urology simulators incorporated x-ray imaging, detailed anatomy of upper urinary tract in order to mimic a sensation of interaction with tissue [6]. It has been demonstrated that the outcomes are superior for simulators with a higher fidelity i.e. the ability to produce a more ‘life-like’ training environment. Training on cadavers may complement the lack of other simulators in providing sensation and feeling of real interaction. Cadaveric models have been described as the ‘gold-standard’ in technical skill development, with the potential to provide the training substrate and haptic feedback which is lacking in other simulators [7, 8]. Thiel’s method on embalming has been previously described [3]. Thiel cadavers have been used in a formal laparoscopic nephrectomy training course accredited by the British Association of Urological Surgeons, with participants reporting very high correlation between the cadaveric experience and the live procedures [3]. Moreover, a human cadaver embalmed by Thiel's method was described as a training model for cystoscopy and transurethral resection of the prostate, as well as other, nonurological procedures [8, 9, 10]. Application of this method allows for preservation of the color, consistency and transparency of cadaveric tissues, offering excellent disinfection whilst minimising exposure to embalming chemicals [11–14]. In this study, we aimed to assess the potential role of Thiel cadavers in skill acquisition for ureterorenoscopy. Figure 1. Cadaveric ureteric orifice following several ureteroscopies, with guidewire in place. MATERIAL AND METHODS A two-day masterclass in flexible ureteroscopy was run at our center. Six urologists in training participated in the course, with three endourology Consultants as faculty. Three male cadavers prepared by Thiel’s method, were available. Thiel fixation involves a water-based solution of glycol and various salts to achieve long-term cadaveric preservation whilst retaining tissue elasticity and compliance. The embalming procedure consists of vascular perfusion followed by submersion of the cadaver in embalming fluid for a period of at least 3 months. The embalming solution consists of boric acid and various salts for fixation and disinfection, low levels of 4-chloro-3-methylenphenol for mould prevention, ethylene glycol for preservation of tissue plasticity, low concentrations of formalin (0.8% in the submersion fluid) and alcohol and morpholine for preservation of tissue consistency and colour. The cadavers are preserved long-term and can be used and re-used for multiple procedures [11–14]. Cadavers were placed in the lithotomy position. Saline irrigation was run, with pressure bags providing Figure 2. Cadaveric ureter with guidewire in place. an irrigant pressure of 100 mmHg. Bilateral semirigid and flexible ureteroscopy had been performed by an expert (high volume ureteroscopist) on each cadaver prior to the course to ensure technical suitability. All ureters could be entered and the pelvicalyceal system w (...truncated)