URO Mentor Validation Studies

Percutaneous renal access simulators.

Stern J, Zeltser IS, Pearle MS.

Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.

J Endourol. 2007 Mar;21(3):270-3.

Percutaneous renal access is an integral step in percutaneous renal drainage and percutaneous nephrolithotomy. Urologists are increasingly obtaining access themselves, as this eliminates reliance on a second "surgeon" and increases flexibility with respect to procedure timing and the location of the access tract. Surprisingly few models have been developed to train urologists in percutaneous renal access. Harvested porcine kidney/ureter units mounted so they can be viewed radiographically and accessed by needle puncture through material simulating the human flank have been incorporated into two models. The PERC Mentor (Simbionix; Lod, Israel) is a virtual-reality simulator developed specifically for training in percutaneous renal puncture. Hands-on intraoperative training continues to be the primary method for learning percutaneous renal access. However, bench model and simulator-based education offer a useful adjunct.

Analysis of a Computer Based Simulator as an Educational Tool for Cystoscopy: Subjective and Objective Results.

Gettman MT, Le CQ, Rangel LJ, Slezak JM, Bergstralh EJ, Krambeck AE.
Departments of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota.

J Urol. 2007 Nov 12

PURPOSE: Resident education in cystoscopy has traditionally relied on clinical instruction. However, simulators are now available outside the clinical setting. We evaluated a simulator for flexible and rigid cystoscopy. MATERIALS AND METHODS: We evaluated 30 novice and 27 expert cystoscopists on a computer based cystoscopic simulator (UroMentor, Simbionix, Lod, Israel). All subjects performed 5 trials of 3 basic cystoscopic tasks. The objective measurement was procedure time, and subjective measures were assessment of the simulator and individual tasks by the cystoscopist. Repeated measures analyses were performed using mixed effects regression models. RESULTS: There was a significant difference in median age between novice and expert cystoscopists at 46 (range 25 to 63) and 35 (range 28 to 68) years old, respectively (p = 0.014). Experts completed simulations significantly faster than novices in all trials. For the first trial median times (novice vs expert) were 300 vs 68 seconds (p <0.001) for guide wire placement, 650 vs 179 seconds (p <0.001) for bladder examination and 119 vs 71 seconds (p <0.001) for bladder lesion fulguration. At the fifth trial median times (novice vs expert) were 57 vs 31 seconds (p = 0.001) for guide wire placement, 164 vs 67 seconds (p <0.001) for bladder examination and 55 vs 40 seconds (p = 0.007) for bladder lesion fulguration. Subjective task evaluations were lower in novice subjects but improved after training. Subjective simulator evaluations were more favorable in novice subjects. CONCLUSIONS: Objectively, expert and novice performance of cystoscopic tasks can be distinguished with the UroMentor. Subjective assessments suggest ongoing refinement of the simulator as a learning tool for cystoscopic skills training.

Virtual reality ureteroscopy simulator as a valid tool for assessing endourological skills.
Matsumoto ED, Pace KT, D'A Honey RJ.
Division of Urology, McMaster University, Hamilton, Ontario, Canada.
Int J Urol. 2006 Jul;13(7):896-901.

The following abstract was published and presented as part of the poster session at the European Association for Endoscopic Surgery (EAES) Meeting, September 13 - 16, 2006 in Berlin, Germany.
The poster won a price for best poster presentation in the education category.

Determination of Construct Validity of the URO Mentor, a Virtual Reality Simulator for Endourological Procedures
Schout, BMA, Dolmans Valerie, De Beer NAM, Hendrikx AJM
Catharina Hospital Eindhoven, Eindhoven, The Netherlands

Introduction: Residents learn operative skills by an apprentice-type of training. Due to ethical concerns this type of training is no longer acceptable. Nowadays skills labs are arising with different type of training models. Selection of models is mostly based on their costs and looks. Proper validation studies are necessary to use models in an evidence-based manner. This study determines the construct validity of the URO Mentor, a virtual reality simulator for endourological procedures. Construct validity answers the question: “Can the simulator distinguish between novices and experts?”.
Methods: Ten interns (novices) and 21 urologists (experts) performed a cystoscopy task with biopsy taking and coagulation of the biopsy site on the URO Mentor. Novices performed this task 5 times, experts once. Afterwards they filled in a questionnaire.
Results: Experts are significantly faster (Wilcoxon, p<0.0005) and cause less traumata (p=0.015) during the first task when compared to novices. Data show a decrease in total performance time over runs, which is significant for all tasks compared with the first one (p=0.0010). The number of traumata is significantly smaller during the fourth and fifth tasks, compared to the first task (p=0.023).
Conclusion: This pilot study shows the URO Mentor can distinguish between novices and experts and proves there is a significant improvement in total time and number of traumata after training, thus demonstrating construct validity. Further study is needed to distinguish between true task learning and the effect of learning how to use the URO Mentor.

The following abstract was published and presented as part of the poster session at the European Association for Endoscopic Surgery (EAES) Meeting, September 13 - 16, 2006 in Berlin, Germany.

The Virtual Reality Simulator the URO Mentor is a Realistic and Valid Training Model: Determination of Face Validity
Dolmans VEMG, Schout Barbara , De Beer NAM, Hendrikx  AJM
Catharina Hospital Eindhoven, Eindhoven, The Netherlands

Introduction. At the moment more and more training models become available for training in urology. In order to know whether such models improve learning curves of residents and contribute to the educational program, these models need to be validated. We are performing a validation study on the URO Mentor, a virtual reality simulator which simulates endourologic procedures. Face validity is one aspect of the validation process. It addresses the question: “To what degree does the URO Mentor resemble reality as judged by a specific (target) population?”.
Aim. To determine face validity of the URO Mentor virtual reality simulator in order to investigate realism and usefulness of this educational tool. Methods. We questioned 70 urologists and residents after they performed a urethrocystoscopic task (bladder inspection, biopsy and coagulation) or a ureterorenoscopic task (stone manipulation of a distal ureter stone). We also investigated possible questionnaire bias related to performance on the URO Mentor.
Results. The overall appraisal was 7.2 in a scale of 1 to 10 (1 is poor, 10 is good). A regression analysis showed that this judgment is independent of age, experience or task performance (p>0.05). Of all interviewees, 86% considered working with the URO Mentor as realistic. Usefulness was judged from average to very useful by 89% of the urologists and residents. On average, over 73% would consider purchasing a URO Mentor if financial means were available, but subjects who caused more traumata during the task were less likely to answer positively to this question.
Conclusion. According to our study, the URO Mentor is a realistic and useful training model for educational purposes.

Validation of computer-based training in ureterorenoscopy. 
Knoll T, Trojan L, Haecker A, Alken P, Michel MS.
Department of Urology, University Hospital Mannheim, Germany.
BJU Int. 2005 Jun;95(9):1276-9.

OBJECTIVES: To evaluate the outcome of training both urological novices and experts, using the recently developed UroMentor (Simbionix Ltd, Israel) trainer, that provides a realistic simulation of rigid and flexible ureterorenoscopy (URS). SUBJECTS AND METHODS: Twenty experienced urologists (total number of previous flexible URSs 21-153) were monitored during simulated flexible URS for treating a lower calyceal stone, and the outcome was correlated with individual experience. A score was compiled based on the variables recorded, including total operation time, stone contact time, complications such as bleeding or perforation, and treatment success. A further five urological residents with no endourological experience were trained on the UroMentor in rigid URS for ureteric stone treatment. Their acquired clinical skills were subsequently compared to those of five urological residents who received no simulator training. RESULTS: All 20 experienced urologists disintegrated the stone on the simulator, and the score achieved was related to their personal experience; there was a significant difference in performance in those with < 40 and > 80 previous flexible URSs. For the five urological residents with no endourological experience, simulator training improved their skills, and comparison with urological residents who had received no simulator training showed advantages for the trained residents. After being trained on the simulator, the group performed better in the first four URSs on patients. CONCLUSIONS: Individual experience correlates with individual performance on the simulator. Simulator training was helpful in improving clinical skills. Although the distribution of computer-based simulators is limited by high prices, virtual reality-based training has the potential to become an important tool for clinical education.

Virtual ureteroscopy predicts ureteroscopic proficiency of medical students on a cadaver.
Ogan K, Jacomides L, Shulman MJ, Roehrborn CG, Cadeddu JA, Pearle MS.
Department of Urology, University of Texas Southwestern Medical Center, Dallas, 75390, USA.
J Urol. 2004 Aug;172(2):667-71.

PURPOSE: Training on a virtual reality (VR) simulator has been shown to improve the performance of VR endoscopic tasks by novice endoscopists. However, to our knowledge the translation of VR skills into clinical endoscopic proficiency has not been demonstrated. We established criterion validity for a VR ureteroscopy simulator by evaluating VR trained subjects in a cadaver model. MATERIALS AND METHODS: A total of 32 participants, including 16 medical students and 16 urology residents, were evaluated at baseline on a VR ureteroscopy simulator (Uromentor, Simbionix, Lod, Israel), performing simple diagnostic ureteroscopy. The students then underwent 5 hours of supervised training on the simulator. Two weeks later all participants were reevaluated (VR2) on the simulator when repeating the initial task. Each participant was then assessed on the performance of a similar diagnostic ureteroscopy in a male cadaver. RESULTS: In medical students VR2 and cadaver performances correlated closely for several measured parameters (total time for task completion and overall global ratings score). In contrast, there was little correlation between the 2 performances in residents. Indeed, performance on the cadaver correlated more closely with the training level than VR2 scores. Despite VR training medical students were unable to perform cadaver ureteroscopy comparably to residents. CONCLUSIONS: For novice endoscopists performance on the simulator after training predicted operative (cadaver) performance and, thus, it may be useful for the education and assessment of physicians in training. However, VR training is unable to override the impact of clinical training, although it may help shorten the learning curve early in training.

Use of a Virtual Reality Simulator for Ueteroscopy Training
Jacomides L, Ogan K, Cadeddu JA, Pearle MS.
Department of Urology, The University of Texas Southwestern Medical Center , Dallas, 75390, USA .
J Urol. 2004 Jan;171(1):320-3; discussion 323.

PURPOSE: Virtual reality surgical simulators may shorten operative time and reduce the potential for iatrogenic injury by providing training outside the operating room. We hypothesized that training on a virtual ureteroscopy (VU) simulator would allow novice endoscopists to overcome the initial learning curve before entering the operating room. MATERIALS AND METHODS: We evaluated 16 medical students on their ability to perform specific ureteroscopic tasks on a VU simulator. The students trained on the simulator for a total of 5 hours over multiple sessions using different training modules and then were retested on the initial module. Likewise, 16 urology residents with varying degrees of endoscopic experience were assessed on the same test module twice, without additional simulator training. RESULTS: The students improved task completion time from 17.4 to 8.7 minutes (p <0.05), while the residents performed the task in 7.6 minutes at baseline and 6.7 minutes at the second trial. Stratification of residents by years of urology training revealed that the mean completion time for the students after training did not differ statistically from that of first year residents who had performed a median of 14 clinical ureteroscopies. Furthermore, the subjective performance scores of the students were comparable to those of the first year residents. CONCLUSIONS: Novice medical students trained on a VU simulator improved task completion time by 50% after training, and performed comparably to residents who had completed nearly 1 year of urology training. VR training may allow beginning urology residents to shorten the initial learning curve associated with ureteroscopy training, although this hypothesis requires further validation.

Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator
Wilhelm DM, Ogan K, Roehrborn CG, Cadeddu JA, Pearle MS.
Department of Urology and The Southwestern Center for Minimally Invasive Surgery, The University of Texas Southwestern Medical Center at Dallas, 75390-9110, USA.
J Urol. 2003 Aug;170(2 Pt 1):692.

BACKGROUND: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. STUDY DESIGN: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). RESULTS: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p < 0.001), and evaluator assessment (p < 0.001). Comparing the posttest results of the control and trained arms, we found significantly better posttest scores in the trained group for the following parameters: ability to perform the task (p = 0.035), overall performance (p = 0.004), and total evaluator score (p < or = 0.001). CONCLUSIONS: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.

Validation of a Flexible Cystoscopy Course
Shah J, Montgomery B, Langley S, Darzi A.
Academic Surgical Unit, Imperial College School of Medicine, St. Mary's Hospital, London, UK.
BJU Int. 2002 Dec;90(9):833-5

OBJECTIVE: To examine the instructional effectiveness of a course for nurses wishing to learn flexible cystoscopy, using a virtual reality flexible cystoscopy simulator to measure the outcome. SUBJECTS AND METHODS: Fourteen urology nurse practitioners with no previous experience of cystoscopy were taught the basic techniques of flexible cystoscopy. They then had supervised group instruction during which they practised flexible cystoscopy on an inanimate latex model, and were taught how to handle the cystoscope, followed by unsupervised practice, including use of the virtual reality (VR) simulator (URO Mentor, Simbionix, Israel). They then undertook a cystoscopy task on the simulator; within the bladder there were 10 flags (numbered 1-10) at key positions. By visualizing and photographing each of the flags the subject would have visualized the entire bladder mucosa. The number of flags seen was thus used as a measure of how much of the bladder mucosa was examined. The VR simulator also measured the total procedure time. After a day of training the subjects were reassessed and the changes in performance evaluated. Subjects were also asked their opinion of the use of VR for flexible cystoscopy. RESULTS: The median (range) time to complete the procedure before the course was 3.33 (2-5.5) min and the number of flags seen 7 (6-9). After the course, the median time decreased to 2.85 (1.5-4.42) min and the number of flags seen increased to 8 (6-9). The change in time was significant (P = 0.03) but the difference in the number of flags was not (P = 0.12). All 14 subjects enjoyed the use of VR for learning flexible cystoscopy; they all reported that they were more confident in handling a flexible cystoscope and in undertaking flexible cystoscopy. CONCLUSION: The virtual reality simulator was an effecctive tool for teaching flexible cystoscopy.

The URO Mentor : Development and Evaluation of a New Computer-Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological procedures
Michel MS, Knoll T, Kohrmann KU, Alken P.
Department of Urology, University Hospital Mannheim , Germany.
BJU Int. 2002 Feb;89(3):174-7.

OBJECTIVE: To overcome the current disadvantages of traditional training methods for ureterorenoscopy and percutaneous nephrolitholapaxy, using the URO Mentor (Simbionix, Tel Aviv, Israel ) computer-assisted simulator. METHODS: The URO Mentor device for training and quality control in ureterorenoscopy was developed using virtual reality, multimedia technology and intelligent tutoring systems. The central software system features a proprietary visualization engine (the SVE) which allows real-time simulation by offering a high-level object-orientated application program interface (written in C++) available for use with either Microsoft, DirectX 7 or OpenGL as platforms. The SVE includes general procedures to allow two- (2D) and three-dimensional (3D) rendering, collision detection, collision correction, 3D morphing, 2D image manipulation, texture mapping, 'bump' mapping, video texture, X-ray rendering, special effects (blood, smoke, stone fragments and more) and reflections. RESULTS: The system allows a complete training session on a wide range of procedures by offering different types of cases and virtual patients, and features a full representation of the endourological procedures under direct vision and by using interactive fluoroscopy with a contrast agent. The supported tools include: baskets, graspers, intracorporal lithotripters, guidewires, catheters, stents, biopsy and dilatation devices. The endourological procedures that can be performed are lithotripsy, tumour resection, treatment of strictures and obstructions, stent placement and biopsies. CONCLUSION: The URO Mentor introduces a new generation of mannequin equipped with a special haptic device, providing trainees with an unparalleled life-like sensation while training for diagnostic and therapeutic endourological procedures. By bringing key advances into urological simulation (e.g. with the real-time X-ray renderer) and by integrating in a single system both high-quality simulation and learning tools, the URO Mentor provides new perspectives for computer-based urological training systems and methods.

Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator
Wilhelm, D.M., Ogan, K., Roehrborn, C.G., Cadeddu, J.A. and Pearle,M.S.
J.Am.Coll.Surg., 195:675-681, 2002.

The article shows that students trained on a VR simulator, the URO MENTOR™, demonstrated statistically significant improvement on repeat testing while a control group showed no improvement. The authors claim that endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the OR.

A Randomized, Prospective Blinded Study Validating the Acquisition of Ureteroscopy Skills Using a Computer Based Virtual Reality Endourological Simulator
James D. Watterson, Darren T. Beiko, James K Kuan and John D. Denstedt
The Journal of Urology, November 2002; Vol, 168, 1928-1932.

The article shows that the use of the URO MENTOR™ resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. In addition, correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the uroteroscopy simulator for the assessment of uroteroscopy skills.

The following abstracts on topics involving the URO Mentor™ simulator were published and presented at the 20th World Congress on Endourology and SWL, 18th Basic Research Symposium, September 19-22, 2002 in Genoa, Italy.
The articles were presented as part of the poster session and were also selected for presentation in the plenary session of "Highlights of Basic Research Symposium". The full abstracts are available in the Journal of Endourology Abstracts, volume 16, Supplement1, September 2002:

P16-27 Laparoscopic & Endourologic Simulators for Training
Steiner, Charles, Inderbir S. Gill, Ran Cohen, Inbal Mazor.
The abstract discusses a study designed to investigate the efficacy of an endourologic simulator and a laparoscopic surgical simulator as part of a formal training course. Residents were divided into 2 groups after being initially scored on basic endourologic and laparoscopic skills in the inanimate trainer and an acute porcine model. One group then underwent 8 hours of training on each of the two simulators and the second group received more classic training involving observation and training on the inanimate trainer. Preliminary results indicate significantly superior technical skill acquisition for the group trained on the simulators.

P3-3 The URO Mentor Virtual Reality (VR) Ureteroscopy Simulator as a Valid Tool for Assessing Endourological Skills
Pace, Kenneth, Edward D. Matsumoto, Solieman Bilgasem, and R. John Honey.
The abstract discusses a study conducted to validate performance on the URO MENTOR with previously developed assessment tools and to compare it to performance on a high fidelity ureteroscopy bench model. Performances of senior and junior residents were scored and compared, leading to the conclusions that simulator performance is comparable to a validated high fidelity ureteroscopy bench model and that the simulator is a useful tool in assessing resident endourological skills.

P3-4 Acquisition of Ureteroscopy Skills Using a Computer-Based Virtual Reality Endourological Simulator: Validation of the URO Mentor Simulator
Watterson, James D., Beiko, Darren T. Kuan, James K. Denstedt, John D. The abstract discusses a study conducted using the URO MENTOR simulator to evaluate and validate its use in the acquisition of basic ureteroscopic skills. 20 novices were assessed in the study, which demonstrated the utility of a virtual reality ureteroscopy simulator in endourological training. The study concluded that use of the simulator leads to rapid acquisition of ureteroscopic skills in trainees with no prior surgical training and that the simulator is a valid tool for assessment of ureteroscopic skills.

P3-5 Comparison of Residents and Inexperienced Medical Students on an Endoscopic Virtual Reality Simulator
Jacomides, Luicas, Kenneth Ogan, Jeffrey A. Cadeddu, and Margaret S. Pearle.
The study examined first and second year medical students as well as urology residents with varied experience. A portion of the medical students who were given training on the virtual ureteroscopy simulator were found to improve their task completion time by 50% after training, and in fact to better the time of first year residents with some actual ureteroscopy experience.

P3-6 Assessment of Basic Elements of Human Performance Predicts Ureteroscopics Skills in the Virtual Environment
Jeffery A. Cadeddu, David Wilhelm, MD Kenneth Ogan, MD Margaret S.l Pearle, MD George V. Kondraske, Ph.D.
In this study the URO MENTOR simulator was used as a means for measurement of ureteroscopic skills. The study was designed to assess the impact of basic elements of human performance (BEP) on endoscopic performance. Measurements of BEP were compared to ureteroscopy and laser lithotripsy in the URO MENTOR, and were found predictive of VR ureteroscopic performance.

The following abstracts on topics involving the URO Mentor™ simulator were published and presented at the AUA exhibition in Orlando, Florida, May 26 - 29, 2002. The full abstracts are available in the Proceedings of the AUA Exhibition:

Abstract ID 101952: State-of-the-art Endourological Training Using Computer-Based Virtual Reality Simulation.
James D Watterson, Darren T Beiko, James K Kuan, John D Denstedt.
The abstract , which has been accepted for publication by the Journal of Urology, discusses a study designed to evaluate the use of a computer-based ureteroscopy simulator (URO Mentor™) in the acquisition of basic ureteroscopic skills. Twenty novice trainees were divided randomly into 2 groups and then tested for skill level. Subsequent to the first testing one group received mentored training on the simulator, the second group did not. Both groups were statistically analyzed, and the conclusions reached were that use of the simulator resulted in the rapid acquisition of basic ureteroscopy skills and proved the effectiveness of the simulator as an instructional tool.

Abstract ID 100693: Assessment of Basic Endoscopic Performance Using a Virtual Reality Simulator.
David M Wilhelm, Kenneth Ogan, Jeffery A Cadeddu, Margaret S Pearle, Dallas, TX; Stephen Y Nakada, Sean P hedican, Madison, WI.
The abstract, which has been submitted to the Journal of American Surgery, discusses a study designed to evaluate the effect of supervised training using a state of the art virtual reality genitourinary endoscopy simulator on performance of basic endoscopic skills in novice endoscopists. Evaluation of 20 medical students performing a simulator case was compared with their subsequent performance after half of them received training on the simulator. Results suggest that students trained on the virtual reality simulator demonstrated statistically significant improvement on repeat testing while the control group showed no improvement. The authors summarized that endourologic training using the simulator facilitates performance of basic endourologic tasks and may translate into better performance in the operating room.

Abstract ID 104606: The URO Mentor: A New Computer Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological Procedures
Maurice S Michel, Thomas Knoll, Kai U Kuhrmann, Peter Alken.
The abstract describes the URO Mentor™ simulator with details on the software employed, and a description of features and benefits. The authors believe that the URO Mentor opens new perspectives for computer based urological training systems and methods.

The same findings were published lately in BJU international:

M. S. Michel, T. Knoll, K. U. Kohrmann and P. Alken, Department of Urology, University Hospital Mannheim, Germany. The URO Mentor: Development and Evaluation of a New Computer-Based Interactive Training System for Virtual Life-Like Simulation of Diagnostic and Therapeutic Endourological Procedures. British Journal of Urology International (2002), 89, 174-177.
This article provides a thorough description and evaluation of the URO Mentor simulator with particular emphasis on the features and benefits of training with the simulator. Among the benefits enumerated in the article are: a reduction in complications, reduction in procedure times, shorter training periods and the continuous monitoring of competence.

The URO Mentor: Continuous Development and Evaluation of an Intelligent Computer Based Training System for Ureterorenoscopy
and PNL
Presented as a Poster at the EUA exhibition on May, 2001,
Geneva, Switzerland
Michel M.S., Knoll T., Frede T., Kohrmann K.U. and Alken P.
Department of Urology, University Hospital, Mannheim, Germany,
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URO Mentor Publications

Interactive Multimedia Training
Maurice Stephan Michel Knoll, Kai Uwe Koehrmann, Peter Alken.
Deutsches Arzteblatt/PraxisComputer 4/2002.

Translation to English
Original Article in German

Training in Endourology - The Role of Simulators
J.M.C.H. de la Rosette MD Ph.D., European Urology Today, June 2001
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