Alexander Beulens

62 Chapter 3 Two barbed sutures were given to the participant to complete the anastomosis between the bladder neck and the urethral stump. The suturing technique used included a running suture starting at the posterior aspect of the bladder neck. The stitches through the bladder neck were performed in an outside-in, while the stitches through the urethral stump were performed with an inside-out fashion. During the performance of the exercise the trainee received feedback by the simulator regarding the suturing direction, injuries of the structures within the pelvis and excessive force used during suturing. The exercise was finished once the anastomosis was completed. Simulator-generated guidance In one of the intervention groups (the SGG group) the guided version of the vesicourethral anastomosis exercise was used (Figure 3g). In this adapted version of the exercise the participant was provided with guidance on the place (position) and depth of the sutures. This was demonstrated by glowing orbs on the tissue. The orbs were yellow when indicating the location of the needle placement, turned green when the needle was placed correctly and turned red in case of incorrect needle placement. Proctor guided training (Proctoring) In one of the intervention groups the proctoring was provided directly by the trainer. The two involved trainers were researchers with a broad experience in simulation and training. They have been trained trough several hours of watching surgical videos and performing surgical simulation until reaching proficiency. No-guidance group In one of the intervention groups no proctoring or guidance was provided. Presentation (lecture) All participants attended a 15-minute presentation (lecture) given by the trainers. During this presentation an overview of the training, the use of the simulator and basic simulation exercises were given. A lesson on pelvic anatomy and vesicourethral anastomosis technique was carried out including a pre-recorded video performed by an expert robotic surgeon (>2100 RARPs). Furthermore, an instructional video of the simulator’s manufacturer showing the simulated vesicourethral anastomosis was included. Questionnaires During the training, the participants were asked to complete multiple questionnaires. The Baseline questionnaire included the general characteristics and surgical experience of the participants. Personal information consisted of age, gender, faculty of medical training, and hospital of employment/training. Information about surgical