The traditional Halstedian model of surgical training, based on a master-apprentice system, has undergone a major transformation in recent years. Training systems dependent on case volume are no longer feasible. Learning curves are well recognised for their role in detailing the learning process. It is widely acknowledged that complications are more common and outcomes are worse earlier in the learning curve. Additionally, it has been shown that the operating room (OR) is far from an ideal learning environment especially in the early stages of the learning curve.
Simulation training offers numerous advantages over the traditional “see one, do one” model. Shifting training away from the OR allows trainees to develop the necessary psychomotor skills in a safe environment . Creating a learning environment that facilitates deliberate practice enables trainees to rehearse procedures within a structured framework . Teaching sessions can be planned around rotas rather than OR schedules, allowing more efficient and methodical training. Studies have confirmed the role of simulators in developing surgical practice . Low-fidelity models are effective in the early stages of the learning curve. Overcoming this initial phase outside of the surgical milieu allows surgeons to develop a strong surgical foundation and maintain patient safety. Further along the learning curve, high fidelity and virtual reality simulators enable more procedure specific training. Randomised studies have shown that successful simulation training translates to improved performance in the OR .
Integration of simulation training into surgical curricula has been shown to further improve its effectiveness . Fried et al.  first demonstrated the value of a specialised simulation programme with the MISTEL system. Such structured simulation training has also been shown to be effective in urological training . Accurate assessment is an important aspect of a surgical curriculum. Objective evaluation of competence is vital for ensuring that trainees reach the necessary standard before progressing. In 2003, the European Basic Laparoscopic Urological Skills examination was piloted for final year trainees. Whilst few trainees achieved the required standard, its value in the objective assessment of laparoscopic skills was demonstrated .
Numerous novel pressures and challenges are further driving changes in surgical training. Major advances such as the growth of laparoscopic and robotic surgery have been tempered by new problems. Increasing training demands on ever more limited healthcare budgets have triggered calls for efficiency. Expectations for zero-complication surgery have led to the expansion of safeguards, standardisation of practices, and ever-greater scrutiny of surgical outcomes. This has been recently highlighted by the publication of outcomes of UK surgeons . Changes to working time regulations have dramatically reduced the potential for training especially within the European Union. Combined with the growth of subspecialisation and consultant-led services, hands-on-training opportunities for trainees have fallen significantly. The traditional case volume based model of “learning-by-doing” is increasingly unable to meet these challenges. The airline industry, which has been at the vanguard of recognising the importance of on-going simulation training, offers a high standard towards which surgeons must aim .
Surgeons also need more than just technical prowess. The majority of errors arise from human or non-technical factors. Surgeons can no longer be deemed competent simply through their technical ability; communication, team-working, and decision-making skills are just as vital to performing safe surgery. Non-technical skills (NTS) further include cognitive, social, and personal resources factors. It is important to recognise that such skills are not innate but need to be learned. As with technical skills training, the aviation industry has been at the forefront of developing NTS simulation. NTS training relies on recreating specific environments. Encouraging realistic behaviours allows them to be analysed and discussed in the debriefing session. Various models have been established ranging from dedicated theatre suits to portable units. Inflatable distributed simulation units like “the Igloo” have been shown to offer low cost yet realistic environments for the development of NTS . Studies in various specialties have shown the effectiveness of NTS training. It leads not only to significant improvements in teamworking but even improved performance on laparoscopic simulators. Whether this translates to improved OR performance is yet to be proven.
Simulation training is only now starting to realise its full potential. Nevertheless, the benefits to surgical training are clear. By allowing efficient, flexible, and objectively structured training, simulation programmes have greatly aided surgeons in meeting some of the challenges of modern medicine. However there is still great potential for growth. Simulation is used only intermittently in urological training and access to simulation facilities remain sporadic. In order to fully realise the benefits of simulation, comprehensive training programmes are required. Signing off trainees on simulators before progressing to the operating room should be routine. Whilst significant progress has been made, there remains scope for further development of simulation technology in urological surgery.
Conflicts of interest
The authors have nothing to disclose.
Prokar Dasgupta and Kamran Ahmed acknowledge support from the NIHR Biomedical Research Centre, MRC Centre for Transplantation, King's Health Partners, Guy's and St. Thomas’ Charity, School of Surgery, London Deanery, Royal College of Surgeons of England, Intuitive Surgical, The Urology Foundation, Olympus, EU-FP7, Prostate Cancer UK, Technology Strategy Board, and The Vattikuti Foundation.
-  C.Q. Le, D.J. Lightner, L. VanderLei, J.W. Segura, M.T. Gettman. The current role of medical simulation in American urological residency training programs: an assessment by program directors. J Urol. 2007;177:288-291 Crossref
-  K.A. Ericsson, R.T. Krampe, C. Tesch-Römer. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363-406 Crossref
-  K. Ahmed, M. Jawad, M. Abboudi, et al. Effectiveness of procedural simulation in urology: a systematic review. J Urol. 2011;186:26-34 Crossref
-  J. Torkington, S.G. Smith, B.I. Rees, A. Darzi. Skill transfer from virtual reality to a real laparoscopic task. Surg Endosc. 2001;15:1076-1079 Crossref
-  A. Volpe, K. Ahmed, P. Dasgupta, et al. Pilot Validation Study of the European Association of Urology Robotic Training Curriculum. Eur Urol. 2015;68:292-299 Crossref
-  G.M. Fried, L.S. Feldman, M.C. Vassiliou, et al. Proving the value of simulation in laparoscopic surgery. Ann Surg. 2004;240:518-525 discussion 525–8
-  M.S. Khan, K. Ahmed, A. Gavazzi, et al. Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity. BJU Int. 2013;111:518-523
-  W.M. Brinkman, I.M. Tjiam, B.M.A. Schout, et al. Results of the European Basic Laparoscopic Urological Skills examination. Eur Urol. 2014;65:490-496
-  E. Chou, H. Abboudi, M. Shamim Khan, P. Dasgupta, K. Ahmed. Should surgical outcomes be published?. J R Soc Med. 2015;108:127-135 Crossref
-  L.S. Kao, E.J. Thomas. Navigating towards improved surgical safety using aviation-based strategies. J Surg Res. 2008;145:327-335 Crossref
-  J. Brewin, J. Tang, P. Dasgupta, et al. Full immersion simulation: validation of a distributed simulation environment for technical and non-technical skills training in Urology. BJU Int. 2015;116:156-162 Crossref
a MRC Centre for Transplantation, King's College London, United Kingdom
b Department of Urology, Guy's and St. Thomas’ NHS Foundation Trust, United Kingdom
Corresponding author. Guy's Hospital and GKT School of Medicine Urology, 1st Floor Thomas Guy House, Guy's Hospital, London Bridge, London SE1 9RT, UK. Tel. +44 207 188 6788; Fax: +44 207 1884655.
© 2015 European Association of Urology, Published by Elsevier B.V.