Multi-institutional validation of a Perfused Robot-Assisted Partial Nephrectomy Procedural Simulation platform utilizing clinically relevant objective metrics of simulators (CROMS).

BACKGROUND Robot-assisted partial nephrectomy (RAPN) is becoming the standard treatment for small renal masses. However, the availability of realistic validated, non-biohazardous procedural platform for training are lacking. OBJECTIVE The multi-institutional validation of a high-fidelity, perfused, inanimate, simulation platform for RAPN utilizing incorporated clinically relevant objective metrics of simulation (CROMS) applying modern validity standards. MATERIALS AND METHODS Utilizing a combination of 3D printing and hydrogel casting a RAPN model was developed from a patient's C.T. scan with a 4.2 cm, upper-pole renal tumor (RENAL nephrometry score 7x). 3D-printed casts designed from the patient's imaging were utilized to fabricate and register hydrogel (Polyvinyl alcohol) components of the kidney including vascular and pelvicalyceal systems. Following mechanical and anatomical verification of the kidney phantom, it was surrounded by other relevant hydrogel organs and placed in a laparoscopic trainer. 27 novice and 16 expert urologists categorized according to caseload, from 5 academic institutions completed the simulation. RESULTS Clinically-Relevant Objective Metrics of Simulators (CROMS), operative complications, and objective performance ratings [Global Evaluative Assessment of Robotic Skills (GEARS)] were compared between groups using Wilcoxon rank-sum ( continuous variables) and parametric chi-squared (categorical variables) tests. Pearson and Point- Biserial correlation coefficients corelated GEARS scores to each CROMS. Post-simulation questionnaires subjectively supplemented realism ratings and training effectiveness. RESULTS Expert ratings demonstrated model's superiority to other procedural simulations in replicating procedural steps, bleeding, tissue texture, and appearance. Significant difference between groups was demonstrated in CROMS [console time (p<0.001), warm ischemia time (p<0.001), estimated blood loss (p<0.001)] and GEARS (p<0.001). Six major intraoperative complications occurred only in novice simulations. GEARS scores highly correlated with the CROMS. CONCLUSIONS This perfused, procedural model offers an unprecedented realistic simulation platform which incorporates objective, clinically relevant, and procedure-specific performance metrics.