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array:24 [ "pii" => "S217357861400105X" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2014.06.003" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "639" "copyright" => "AEU" "copyrightAnyo" => "2014" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Urol Esp. 2014;38:451-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 532 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 412 "PDF" => 108 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210480614000643" "issn" => "02104806" "doi" => "10.1016/j.acuro.2014.02.013" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "639" "copyright" => "AEU" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Urol Esp. 2014;38:451-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 643 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 484 "PDF" => 147 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo Original</span>" "titulo" => "Simulador de realidad virtual para el entrenamiento en vaporización fotoselectiva de la próstata con láser de diodo 980<span class="elsevierStyleHsp" style=""></span>nm y curva de aprendizaje de la técnica" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "451" "paginaFinal" => "458" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Virtual reality simulator for training on photoselective vaporization of the prostate with 980<span class="elsevierStyleHsp" style=""></span>nm diode laser and learning curve of the technique" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1946 "Ancho" => 1950 "Tamanyo" => 396055 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La reconstrucción tridimensional obtenida permite calcular el porcentaje de ablación de tejido prostático, comparando volumen antes y después del procedimiento.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.C. Angulo, I. Arance, A. García-Tello, M.M. Las Heras, G. Andrés, H. Gimbernat, F. Lista, F. Ramón de Fata" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Angulo" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 3 => array:2 [ "nombre" => "M.M." "apellidos" => "Las Heras" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 5 => array:2 [ "nombre" => "H." "apellidos" => "Gimbernat" ] 6 => array:2 [ "nombre" => "F." "apellidos" => "Lista" ] 7 => array:2 [ "nombre" => "F." "apellidos" => "Ramón de Fata" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217357861400105X" "doi" => "10.1016/j.acuroe.2014.06.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357861400105X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480614000643?idApp=UINPBA00004N" "url" => "/02104806/0000003800000007/v1_201408240357/S0210480614000643/v1_201408240357/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173578614000924" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2014.05.006" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "644" "copyright" => "AEU" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2014;38:459-64" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 431 "formatos" => array:3 [ "EPUB" => 9 "HTML" => 299 "PDF" => 123 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Angiogenesis inhibition impairs testicular morphology in experimental left varicocele rat model" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "459" "paginaFinal" => "464" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La inhibición de la angiogénesis deteriora la morfología testicular en modelo de rata con varicocele izquierdo experimental" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 698 "Ancho" => 930 "Tamanyo" => 244470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Increase in microvessel density in ELV group (indicated by arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Gökhan-Köse, Ş.R. Erdem, Ç.L. Peşkircioğlu, B. Çaylak" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Gökhan-Köse" ] 1 => array:2 [ "nombre" => "Ş.R." "apellidos" => "Erdem" ] 2 => array:2 [ "nombre" => "Ç.L." "apellidos" => "Peşkircioğlu" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Çaylak" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480614000692" "doi" => "10.1016/j.acuro.2013.12.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480614000692?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578614000924?idApp=UINPBA00004N" "url" => "/21735786/0000003800000007/v1_201408240422/S2173578614000924/v1_201408240422/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173578614000535" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2014.03.010" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "617" "copyright" => "AEU" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2014;38:445-50" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 510 "formatos" => array:3 [ "EPUB" => 13 "HTML" => 374 "PDF" => 123 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Complications associated with laparoscopic adrenalectomy: Description and standardized assessment" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "445" "paginaFinal" => "450" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Descripción y evaluación estandarizada de complicaciones asociadas a adrenalectomía laparoscópica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O.A. 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Angulo, I. Arance, A. García-Tello, M.M. Las Heras, G. Andrés, H. Gimbernat, F. Lista, F. Ramón de Fata" "autores" => array:8 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Angulo" "email" => array:1 [ 0 => "javier.angulo@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 3 => array:2 [ "nombre" => "M.M." "apellidos" => "Las Heras" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 5 => array:2 [ "nombre" => "H." "apellidos" => "Gimbernat" ] 6 => array:2 [ "nombre" => "F." "apellidos" => "Lista" ] 7 => array:2 [ "nombre" => "F." "apellidos" => "Ramón de Fata" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Simulador de realidad virtual para el entrenamiento en vaporización fotoselectiva de la próstata con láser de diodo 980<span class="elsevierStyleHsp" style=""></span>nm y curva de aprendizaje de la técnica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1578 "Ancho" => 2201 "Tamanyo" => 156074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Results obtained in the first phase of the study comparing groups of experience: test of spatial orientation, overall score obtained, percentage on the efficacy score, and percentage on the security score.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The virtual reality simulation is a new model for improving surgical skills in various fields of surgery and medical education. It is an essential tool not only in learning of skills but also in the objective structured clinical assessment (OSCE) of students of medical sciences and training specialists.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Moreover, the use of advanced simulators makes it possible to train skills in different settings and record real-time operations for the objective evaluation of the trainees. There are specific simulators for various techniques of urological and endoscopic and laparoscopic surgery. Possibly the best studied model is transurethral resection of the prostate (TURP).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> This technique remains the standard surgical treatment for lower urinary tract symptoms associated with benign prostatic hypertrophy (BPH), although the training of residents and specialists in training in this task is not always easy. The wide spread of medical treatments, generally combined medical therapy, and of alternative treatments has lead to a decrease in the number of these processes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is in this environment of less invasive treatments where simulation makes more sense, since high-level effectiveness and safety results are required. The use of appropriate virtual reality platforms means an increase in opportunities to learn quickly and effectively. However, it is essential that a simulator not only recreates a situation but it is also able to measure what it is supposed to be measured. It is therefore needed to carry out external validation thereof by means of reliability studies.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The assessment of discriminant validity is the easiest way to perform this type of studies. It consists in analyzing the performance of tasks by means of metric elements of primary competition. Such studies have been conducted to evaluate the model of virtual reality in training of TUPR,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9,10</span></a> but it is less developed for new, less invasive technologies, such as enucleation and/or prostate vaporization.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this study, the usefulness of a virtual reality simulator for training of the technique of photoselective vaporization of the prostate with diode laser is investigated. Discriminative validity is evaluated to determine factors associated with competences in a population of specialists in urology, resident physicians in training and medical undergraduate students. On the other hand, in a second step a descriptive analysis of the learning curve of this technique is raised, and the factors that affect and modify the pattern of learning are evaluated.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Virtual reality simulator</span><p id="par0020" class="elsevierStylePara elsevierViewall">Myo Sim Simulator (VirTaMed AG, Zürich, Switzerland) offering personalized training for prostate vaporization with Twister fiber (Biolitec AG, Jena, Germany) in contact mode. This simulator consists of an electric cystoscope transformed with 23<span class="elsevierStyleHsp" style=""></span>Ch gauge and continuous irrigation, foot pedal, portable computer terminal with monitor and feedback system (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Very accurately, the simulator recreates the endoscopic anatomy and morphology of the urethra, prostate, and bladder. Virtual cystoscope manipulation produces simulated movements of the lens and the endoscopic environment, very reliable to reality. It also recreates the Twister fiber and its movement using spins thereof through the working channel of the cystoscope with one hand (the left one for right-handed usually) while the other hand holds the cystoscope lens (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The software of the simulator offers a variety of scenarios composed of 12 virtual patients with different levels of difficulty, from the small middle lobe to hypertrophy of both lateral lobes and the middle lobe of growing character.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">This equipment offers training for prostate vaporization with 980-nm Twister fiber with quartz head shape, and it therefore works in contact mode.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Because of its morphological characteristics, it has been specially designed for high-risk patients, with the intention of simplifying and improving the old procedure of prostate ablation with side-fire fibers and reducing the adverse effects generated by the tissue sloughing. This fiber design, especially in its larger size format, also helps reduce the procedure time and improve the rate of tissue ablation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The simulator occasionally presents challenging situations, such as cases of difficult access and with heavy bleeding that even hinder visibility.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery is automatically recorded in real time and the analysis software performs a complete report per case showing a mixed score based on elements of efficacy and safety. It also provides a three-dimensional reconstruction of the final result in terms of percentage of ablation of prostate tissue (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The final efficacy report reflects the overall score on the total score (190 points) and per field: amount of vaporized prostate (40 points), amount of unexposed capsule (40 points), procedure time (40 points), laser active time (40 points), ablation rate (10 points), tissue contact when active (10 points), energy used (10 points). The elements that define the security on the total (80 points) were to avoid: sphincter hits (10 points), verumontanum hits (10 points), excavation at the bladder neck (10 points), ureteral orifices hits (10 points), blood loss<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml (10 points), active laser into the urethra<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>s (10 points), active laser near the lens<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>s (10 points), and visualization of ureteral orifices (10 points).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study consisted of two phases. First it was established whether there were differences between the overall and detailed score per elements between different groups of subjects with different and recognized level of professional experience to practice prostate vaporization with diode laser (Twister fiber). Secondly, the magnitude of the learning curve for this procedure was evaluated. We defined as treatment optimization and achieving the objectives set, the maintained obtaining of a median score >90% on the possible total. We also studied the factors affecting the learning curve. The entire study lasted a total of 60<span class="elsevierStyleHsp" style=""></span>h of simulation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Prior to beginning training for all the examined patients, we defined some objectives, consisting in: (a) identifying the anatomical margins and getting a 3D mental picture of the endoscopic anatomy of the prostate; (b) observing the pathological deformation that benign prostatic hypertrophy causes in different scenarios of morphology and prostate volume and urethral occlusion; (c) safely managing the laser fiber and the lens, separating from anatomical elements that should not be damaged (bladder wall, ureteral orifices, urethral sphincter); (d) correctly understanding the differences between vaporization and enucleation, as a case study showing the technique of prostatic ablation by contact laser vaporization; (e) coagulating bleeding sources in the event that they happen; and (f) carrying out safe examination at the end of the procedure. It is emphasized that the most efficient procedure is the one that increases as much as possible the contact time to achieve maximum effectiveness with the least possible amount of energy administered, so improving the safety of the procedure as well.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the first phase of the study, a total of 18 subjects were evaluated as surgeons. The group was made up of six students from the School of Biomedical Sciences, six Resident Medical Interns (RMI) of urology and six Specialist Urology Department Physicians (SDP) with >5 years work experience. They all performed 55-ml prostate ablation on two occasions, and we compared the score obtained in the second one for the different groups in overall terms of efficiency (190 points) and safety (80 points), with the intention of demonstrating the construct validity when differentiating the experience of the surgeons. In this same group we applied a psychometric test of spatial orientation ability, based on the identification of an object projected on different orientation. The test consisted of six items and it was conducted in 5<span class="elsevierStyleHsp" style=""></span>min (score between 0 and 6) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In the second phase, six of the initiated surgeons (three 3rd–5th year RMI and three SPD) sequentially repeated 15 prostate ablations (55 and 70<span class="elsevierStyleHsp" style=""></span>cc glands, in successive series of five procedures per session). The results obtained in the total score (combines efficacy and safety) were tabulated and the evolution of these results was compared to define the improvement of the parameters obtained in the form of learning curve. Finally we analyzed whether differences in the experience of the surgeons, the spatial orientation skills, and the kind of sequence performed modified that evolution.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The results of the test of spatial orientation are analyzed descriptively and the median and interquartile ranges thereof are defined. The comparison of scores obtained per groups of individuals with the simulator is carried out using the Tukey test, comparing groups 2 by 2. When it is desired to establish whether there are differences between groups comprehensively, we apply the analysis of variance (ANOVA) or Kruskal–Wallis as non-parametric test.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In order to set the learning curve, the median overall score is analyzed for each ordinal assessment (first, second, third-procedure patients, etc.) and it is defined what the number of observation is from which the median reaches 90% of the overall score. Then it is analyzed whether there is deviation in this pattern per groups of experience (RMI vs. SPD), way of performing the sequence (growing repetitive vs. random) and per groups of results in the spatial orientation test (low vs. on median value).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The median value of the test of spatial orientation for the 16 subjects was 2.5 (1–6). When comparing the medians of the groups, differences were detected (SPD 3 [1–6], RMI 2.67 [2–4] and students 2.5 [2–4]) were detected, but without reaching statistical significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.9) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The overall rating of efficacy and safety obtained with the simulator was in line with the level of experience (SPD 224.5 [195–240], RMI 175 [160–203] and students 156 [117–171]; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005). However, when performing pairwise comparison, significant differences between SPD and students are detected (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004), but they do not reach statistical significance between SPD and RMI (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.12) or between RMI and students (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.2) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to the effectiveness of the procedure we detected overall differences (SPD 149.5 [125–160], RMI 100 [90–142] and students 90.5 [58–102]; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0036) and differences in the comparison between SPD and students (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0026) and between RMI and students (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.08). Analyzing in detail the different indicators, the ablation rate (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01), the procedure time (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03), and the amount of unexposed capsule (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03) differ, but no differences are detected in the amount of resected prostate (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.5), time of laser activity (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.2), percentage of tissue contact when the laser is active (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.4), or the energy used (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.1). No differences were observed between groups in the safety score either (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.5) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><p id="par0075" class="elsevierStylePara elsevierViewall">With regard to the learning curve in the second phase of the study, a median percentage is obtained on the total score >90% in the third procedure for 55<span class="elsevierStyleHsp" style=""></span>ml prostates, and in the fourth one for 70<span class="elsevierStyleHsp" style=""></span>ml prostates (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). Since all the subjects had completed the first exercise before, representing two additional cases of prostate ablation with a volume of 55<span class="elsevierStyleHsp" style=""></span>ml, we can say that the learning curve is overcome to achieve optimal results after performing four cases in prostates of 55<span class="elsevierStyleHsp" style=""></span>ml and 10 cases for 70-ml glands (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">This evolution in skill acquisition does not change depending on previous experience if the time in which an efficiency >90% is obtained, differentiating RMI vs. SPD (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.6); but it does in relation to the order of repetition if ascending progressive sequence (first cases of 55<span class="elsevierStyleHsp" style=""></span>ml and then 70<span class="elsevierStyleHsp" style=""></span>ml) is distinguished vs. randomized scheme (alternating volumes casually) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007). This fact reveals that the best way to conduct a training is repetition in increasing order of complexity. On the other hand, the surgeons who do not reach the median value in the spatial orientation test fail to exceed the 90% percentage score despite the repetition of the procedure.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The standard treatment of BPH is TURP for glands small to moderate and open prostatectomy for greater prostates.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, laser techniques have increased in popularity in this indication since their introduction in the 1990s.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> They make it possible to obtain a surgical field with virtually no bleeding, leading to excellent visibility and producing fewer complications, shorter hospital stay, and shorter probe time than the TURP.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> These facts also involve large reduction in the costs of healthcare of these patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Different laser treatment systems used for BPH also produce different effects on the tissue: coagulation, vaporization, resection, or enucleation through an incision.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Possibly the most used prostatic ablation methods are photoselective vaporization ablation and enucleation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The former tends to be performed in smaller prostates, while the latter is reserved for major glands. Nevertheless, the experience gained and improved instruments make it possible to practice vaporization in larger prostates as well, and it is in these cases where the high-intensity diode laser (alone or in combination with TURP) has better indication,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> especially in patients on anticoagulant therapy or with increased risk of bleeding.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The application of diode laser for BPH has evolved over time. Early studies showed excellent bleeding control, but a high retreatment and complications rate in the form of vaporization, possibly due to deep coagulation.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,21</span></a> However, there are no comparative studies with other vaporization modalities such as KTP laser. Also, mimicking prostate enucleation with Holmium laser (HoLEP), we successfully described the technique of diode laser enucleation of the prostate (DiLEP).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Currently the technique of high-power 980-nm diode laser ablation with side-firing fiber has gradually evolved into a new application with contact laser fiber with quartz head-also known as Twister, improving its resistance to degradation and the tissue ablation rate.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> This recent technology has demonstrated a high therapeutic power and good long-term safety.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,23,24</span></a> Comparative studies with TURP and other types of lasers are required, but photoselective vaporization with diode laser currently represents an excellent therapeutic element for symptomatic BPH, especially in the increasingly common group of patients taking antiplatelet medication.</p><p id="par0095" class="elsevierStylePara elsevierViewall">This paper conducts external validation of the personalized virtual reality simulator for photoselective vaporization of the prostate with 980-nm diode laser and Twister fiber. Despite the limited number of surgeons evaluated, a correlation between the tested efficacy parameters and the different experience groups is shown. This simulation model has therefore discriminative validity, and it is a good tool for training in skills and as an OSCE tool for doctors and residents in training. Repeating the procedure allows for rapid learning to better face surgery. Surgeons with spatial orientation skills do better than those in whom this ability is less developed or exercised. For professionals involved (experts or specialists in training), there are no major differences in the acquisition of learning according to the previous level of experience, which shows that it is a simple technique. The sequential repetition of the procedure in increasing levels of difficulty promotes learning. The main problems of simulation models, such as the one that we evaluate in this paper, reside in their limited availability and the high cost of developing them.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres364419" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec344023" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres364420" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec344024" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Virtual reality simulator" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Study design" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack90754" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-14" "fechaAceptado" => "2014-02-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec344023" "palabras" => array:5 [ 0 => "Diode laser" 1 => "Prostate vaporization" 2 => "Computer simulation" 3 => "Medical education" 4 => "Objective structured clinical evaluation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec344024" "palabras" => array:5 [ 0 => "Láser de diodo" 1 => "Vaporización prostática" 2 => "Simulación por ordenador" 3 => "Educación médica" 4 => "Evaluación clínica objetiva estructurada" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The utility of a virtual reality simulator for training of the photoselective vaporization of the prostate with diode laser was studied.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two experiments were performed with a simulator (VirtaMed AG, Zürich, Switzerland) with software for specific training in prostate vaporization in contact mode with Twister fiber (Biolitec AG, Jena, German). Eighteen surgeons performed ablation of the prostate (55<span class="elsevierStyleHsp" style=""></span>cc) twice and compared the score obtained (190 points efficacy and 80 safety) in the second one of them by experience groups (medical students, residents, specialists). They also performed a spatial orientation test with scores of 0–6. After, six of these surgeons repeated 15 ablations of the prostate (55 and 70<span class="elsevierStyleHsp" style=""></span>ml). Improvement of the parameters obtained was evaluated to define the learning curve and how experience, spatial orientation skills and type of sequences performed affects them.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Global efficacy and safety score were different according to the grade of experience (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.005). When compared by pairs, specialist-student differences were detected (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004), but not specialist-resident (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.12) or resident-student (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.2). Regarding efficacy of the procedure, specialist-student (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0026) and resident-student (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.08) differences were detected. The different partial indicators in terms of efficacy were rate of ablation (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01), procedure time (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03) and amount of unexposed capsule (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03). Differences were not observed between groups in safety (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.5). Regarding the learning curve, percentage median on the total score exceeded 90% after performing four procedures for prostates of 55<span class="elsevierStyleHsp" style=""></span>ml and 10 procedures for prostate glands of 70<span class="elsevierStyleHsp" style=""></span>ml. This course was not modified by previous experience (resident-specialist; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.6). However, it was modified according to the repetition sequence (progressive-random; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.007). Surgeons whose spatial orientation was less than the median of the group (value 2.5) did not surpass 90% of the score in spite of repetition of the procedure.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Simulation for ablation of the prostate with contact diode laser is a good learning model with discriminative validity, as it correlates the metric results with levels of experience and skills. The sequential repetition of the procedure on growing levels of difficulty favors learning.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se investiga la utilidad de un simulador de realidad virtual para el entrenamiento de la vaporización fotoselectiva de la próstata con láser de diodo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se han practicado 2 experimentos con un simulador (VirtaMed AG, Zürich, Suiza) con software para entrenamiento específico en vaporización prostática modo de contacto con fibra Twister (Biolitec AG, Jena, Alemania). Dieciocho cirujanos realizaron ablación prostática (55<span class="elsevierStyleHsp" style=""></span>cc) por duplicado y se comparó la puntuación obtenida (190 puntos eficacia y 80 seguridad) en la segunda de ellas por grupos de experiencia (alumnos médicos, residentes, especialistas). También realizaron prueba de orientación espacial con puntuaciones de 0 a 6. Posteriormente 6 de estos cirujanos repitieron 15 ablaciones prostáticas (55 y 70<span class="elsevierStyleHsp" style=""></span>ml). Se evalúa la mejora de los parámetros obtenidos para definir la curva de aprendizaje y cómo influye la experiencia, las habilidades de orientación espacial y el tipo de secuencia realizada.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La puntuación global de eficacia y seguridad fue diferente según el grado de experiencia (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,005). Al comparar por pares se detectaron diferencias especialista-alumno (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,004), pero no especialista-residente (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,12) o residente-alumno (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,2). Con respecto a la eficacia del procedimiento se detectan diferencias especialista-alumno (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0026) y residente-alumno (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,08). Los indicadores parciales diferentes en términos de eficacia fueron tasa de ablación (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,01), tiempo de procedimiento (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,03) y cantidad de cápsula no expuesta (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,03). No se observaron diferencias entre grupos en seguridad (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,5). Con respecto a la curva de aprendizaje la mediana del porcentaje sobre la puntuación total superó el 90% tras realizar 4 procedimientos para próstatas de 55 <span class="elsevierStyleHsp" style=""></span>ml y 10 para glándulas de 70<span class="elsevierStyleHsp" style=""></span>ml. Esta evolución no se modificó por experiencia previa (residente-especialista; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,6), pero sí según la secuencia de repetición (progresiva-aleatoria; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,007). Los cirujanos con orientación espacial inferior a la mediana del grupo (valor 2,5) no superaron el 90% de puntuación a pesar de la repetición del procedimiento.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La simulación para la ablación prostática con láser de diodo de contacto es un buen modelo de aprendizaje con validez discriminativa, al correlacionar resultados métricos con niveles de experiencia y habilidades. La repetición secuencial del procedimiento en niveles crecientes de dificultad favorece el aprendizaje.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Angulo JC, Arance I, García-Tello A, Las Heras MM, Andrés G, Gimbernat H, et al. Simulador de realidad virtual para el entrenamiento en vaporización fotoselectiva de la próstata con láser de diodo 980<span class="elsevierStyleHsp" style=""></span>nm y curva de aprendizaje de la técnica. Actas Urol Esp. 2014;38:451–458.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1215 "Ancho" => 1344 "Tamanyo" => 218523 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Simulator for prostate vaporization with diode laser in contact mode: (A) electric cystoscope transformed with 23<span class="elsevierStyleHsp" style=""></span>Ch gauge and continuous irrigation, (B) foot pedal, and (C) laptop computer with monitor and feedback system.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1196 "Ancho" => 1345 "Tamanyo" => 315741 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Working procedure with the simulator that recreates photoselective vaporization of the prostate.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1340 "Ancho" => 1344 "Tamanyo" => 248353 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The three-dimensional reconstruction obtained makes it possible to calculate the percentage of ablation of prostate tissue, comparing volume before and after the procedure.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2685 "Ancho" => 2169 "Tamanyo" => 540124 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Psychometric test of spatial orientation capacity based on the identification of an object projected in a different orientation (score 1–6).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1578 "Ancho" => 2201 "Tamanyo" => 156074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Results obtained in the first phase of the study comparing groups of experience: test of spatial orientation, overall score obtained, percentage on the efficacy score, and percentage on the security score.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2260 "Ancho" => 1584 "Tamanyo" => 132183 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Evolution of the results obtained (percentage on overall score) in the second phase of the study expressed as a percentage on total score in prostates of 55 and 70<span class="elsevierStyleHsp" style=""></span>ml, five cases each.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Objective structured assessment of technical skill (OSATS) for surgical residents" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. 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To Pedro Saornil (Comercial Médico Quirúrgica, SA) and Oliver Bangert (Biolitec AG) for their methodological help in acquiring the virtual reality simulator.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003800000007/v1_201408240422/S217357861400105X/v1_201408240422/en/main.assets" "Apartado" => array:4 [ "identificador" => "6274" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003800000007/v1_201408240422/S217357861400105X/v1_201408240422/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357861400105X?idApp=UINPBA00004N" ]
