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Eddie Shu-yin Chan
Tadashi Matsuda
Editors
Endourology Progress
Technique, Technology and Training
123
Eddie Shu-yin Chan • Tadashi Matsuda
Editors
Technique, Technology and Training
Editors
Eddie Shu-yin Chan Tadashi Matsuda
Department of Surgery Department of Urology and Andrology
The Chinese University of Hong Kong Kansai Medical University
Hong Kong Hirakata, Osaka
Japan
ISBN 978-981-13-3464-1 ISBN 978-981-13-3465-8 (eBook)

https://doi.org/10.1007/978-981-13-3465-8
Library of Congress Control Number: 2019934106
© Springer Nature Singapore Pte Ltd. 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore
Foreword 1
Urology has the most innovative advances among the surgical specialties. Recent technology
started with shockwave lithotripsy in 1979 followed by percutaneous lithotripsy in the 1980s.
Lithotripters were installed worldwide and have revolutionized the treatment of stones from
incisions to “no scars.” The last decade has seen an accelerated technological journey includ-
ing laparoscopic instruments, robotic equipment, and endoscopes with video cameras that can
be made so small as to get retrograde access to the kidney, which was only imaginable in the
movies of the 1970s.
With these advances it is a constant learning and upgrading process for urologists to keep
pace with new techniques. Among the many endoscopes and types of lasers we have to find out
which is the most effective, appropriate, and safe for our patients. We adopt some and discard
those that are not effective. It is almost impossible for a single urologist to go into all the new
equipment. We need to attend meetings, talk to the experienced, and then adopt which is the
best for our patients bounded by the availability of resources in our health care systems.
This book is unique because it is Asian and represents the diverse cultures and the progress
made in countries with health care systems of different priorities. Illustrations are clear and
readers get to pick up the procedures step-by-step such as in robotic surgery. Tips and tricks
are helpful. Further dedicated structured training is important to ensure we are able to handle
the new technology. Further experience should be obtained by assisting the masters at work.
Eddie Chan and Tadashi Matsuda, the editors of Endourology Progress: Technique,
Technology and Training, should be congratulated for this innovative book. This book is a
comprehensive introduction for residents and trained urologists to pick up some new knowl-
edge and techniques.
It is my wish that this book will enable all urologists to offer our patients the most effective
treatment in the era of modern endourological technology.
January 2019 Man Kay Li

Mt Elizabeth Novena Hospital
Singapore
Singapore
v
Foreword 2
It is a privilege to write a Foreword for this outstanding book entitled Endourology Progress:
Technique, Technology and Training which is focused on all aspects of minimally invasive
urology. The book is unique in its East Asian origins and with over 100 contributors, all of
whom are from East Asian countries.
The opening chapter by Drs. Matsuda and Naito, which archives the history and develop-
ment of endourology in East Asia, is a wonderful chronicle of the overall impact this urologic
community has had towards progress in the field. The mission of the East Asian Society of
Endourology is articulated “to study all questions related to endourology, to stimulate interna-
tional cooperation in the field of urology and to encourage the development, evaluation and
application of all aspects of minimally invasive therapy of urological disease across the East
Asia region.” There may be no better tangible example of the success in achieving this aspira-
tion than the superb text Endourology Progress: Technique, Technology and Training.
The book is both comprehensive in its scope and current in all aspects of endourology, lapa-
roscopy, robotics, and image-guided therapies in urology. Books can often lag in a field that is
progressing as rapidly as endourology, but this comprehensive text manages to be completely
up to date. This includes detailed descriptions of leading edge interventions in areas as diverse
as pediatrics, transplantation, BPH, and MRI-guided diagnostics. The tables, illustrations, and
figures in the book are excellent and the chapters are all very well referenced. As an academic
urologist with a subspecialty interest in endourology I fully expect to be referring to this book,
both for patient care questions and for purposes related to teaching students, residents, and
fellows. Practicing urologists, trainees, and investigators with an interest in urologic technol-
ogy and innovation will all find this to be a very practical and useful text.
I have had the privilege of visiting almost all of the countries classified as being in East Asia
and in the case of some countries have visited on numerous occasions. This has often included
the experience of operating side by side with the local urologic surgeons, many of whom have
become good friends. It is my impression that many of the innovations and technical advances
in endourology and minimally invasive approaches are emanating from the major centers in
East Asian countries. In addition, I have witnessed the great value placed on training in this
world region and the chapters in Endourology Progress focused on various aspects of training
are among the best I have come across.
The editors, Drs. Eddie Chan and Tadashi Matsuda, along with all of the contributing chap-
ter authors are to be congratulated for the production of this tremendous text. Endourology
Progress: Technique, Technology and Training is an excellent contribution to existing resources
in the rapidly changing field of endourology.
John Denstedt
Division of Urology, Schulich School of Medicine and Dentistry,
Western University, London, ON, Canada
American Urological Association,

Linthicum, MD, USA
vii
Introduction
This book represents the work and development of endourology in Asia and the contribution
of East Asian Society of Endourology. The horizons of endourologic surgery are expanding.
Application of robot-assisted technique is one of the many examples of how new technologies
change the surgical practice. Urologists from Asian countries encountered a lot of challenges
due to high patient load, different diseases preference, limited access to new technologies,
diversity in languages, and surgical practice. Innovative techniques have been developed in
order to adapt the unique working environment. This book is intended to familiarize the mod-
ern urologists with the common endourology, laparoscopic and robotic urologic procedures,
and the development of technology, techniques, and training in Asian countries.
On behalf of the East Asian Society of Endourology, recognized Asian experts in the field
of endourology have contributed to share their experiences and opinions. It consisted of latest
update and advancement of surgical techniques and technology in minimally invasive surgery.
The development of endoscopic, laparoscopic, and robotic urological operations is reviewed.
A whole session dedicated to training in endourology is included. Detailed descriptions of
perioperative preparation, step-by-step surgical procedures, and tips/tricks will be emphasized
in the corresponding chapters, supplemented by photographs and illustrations. The textbook
will be divided into three specific sessions. The first session covers the important areas of
endourology training and the development of endourology in different Asian countries. In the
second session, techniques on various urologic surgeries are discussed. The third session is
dedicated to the advances of new technologies in endourology. This book is most suitable for
urology residents and young fellows who are keen to start their endourological training. It also
provides up-to-date information on current topics of endourology for practicing urologists and
experienced endourologists in Asian and other countries.
This book is contributed by more than 100 leading experts and their young fellows from
China, Japan, Korea, the Philippines, Taiwan, and Hong Kong.
ix
Contents
Part I Endourology Training
1 Introduction of East Asian Society of Endourology

and Development of Endourology in East Asia �� 3
Tadashi Matsuda and Seiji Naito
2 Training of Endourology in Asia�� 7
Kai Zhang, Tao Han, and Gang Zhu
3 Laparoscopic Training Using Cadavers �� 13
Thomas Y. Hsueh
4 Simulation Training of Laparoscopy �� 19
Kazuhide Makiyama
5 Bridging the Gap Between Open Surgery and Robotics �� 27
Dennis P. Serrano and Sylvia Karina L. Alip
6 Development of Robotic Urologic Surgery in Asia �� 35
Soodong D. Kim, Gyung Tak Sung, Masatoshi Eto, Katsunori Tatsugami,
Harshit Garg, Rajeev Kumar, Yinghao Sun, Bo Yang, Sheng-Tang Wu,
Allen W. Chiu, Anthony C. F. Ng, Samuel C. H. Yee, Hong Gee Sim,
and Christopher Wai Sam Cheng
7 A Nation-Wide Laparoscopic Skills Qualification:
A Thirteen-Year Experience in Japan �� 49
Tadashi Matsuda, Tomonori Habuchi, Hiroomi Kanayama, and Toshiro Terachi
Part II Endourology Techniques
8 Multiple vs. Single Access PCNL �� 57

Michael Alfred V. Tan and Dennis G. Lusaya
9 Retrograde Intra-Renal Surgery (RIRS)�� 65
Deok Hyun Han
10 Radiation Exposure and Its Prevention in Endourology �� 75
Takaaki Inoue and Hidefumi Kinoshita
11 TURBT: An Old Operation with New Insights �� 81
Bryan Kwun-Chung Cheng and Jeremy Yuen-Chun Teoh
12 Robot-Assisted Radical Cystectomy: Surgical Technique �� 91
Cheng-kuang Yang
xi
xii Contents
13 Robot-Assisted Radical Cystectomy: Technical Tips for Totally

Intracorporeal Urinary Diversion �� 95
Seok Ho Kang and Ji Sung Shim
14 Robot-Assisted Radical Prostatectomy: The Evolution of Technique�� 105
Seock Hwan Choi and Tae Gyun Kwon
15 Retzius-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy �� 111
K. D. Chang, C. K. Oh, and K. H. Rha
16 Robot Assisted Partial Nephrectomy: Technique and Outcomes �� 117
Nobuyuki Hinata and Masato Fujisawa
17 Minimally Invasive Ureteral Reimplantation in Children with Vesicoureteral
Reflux: History and Current Status �� 127
Nikko J. Magsanoc and Michael Chua
18 Robotic-Assisted Renal Autotransplantation: Preliminary Studies
and Future Directions�� 143
Motoo Araki, Koichiro Wada, Kasumi Kawamura, Yuuki Maruyama,
Yosuke Mitsui, Takuya Sadahira, Risa Kubota, Shingo Nishimura,
Takashi Yoshioka, Yuichi Ariyoshi, Kei Fujio, Atsushi Takamoto, Morito
Sugimoto, Katsumi Sasaki, Yasuyuki Kobayashi, Shin Ebara,
Amano Hiroyuki, Masashi Inui, Masami Watanabe, Toyohiko Watanabe,
and Yasutomo Nasu
19 Robot-Assisted Laparoscopic Surgery for Upper Tract
Urothelial Carcinoma�� 149
Sung Yul Park and Young Eun Yoon
20 Laparoscopic Living Donor Nephrectomy�� 157
Jose-Vicente T. Prodigalidad and Lawrence Matthew C. Loo
21 Robotic Pyeloplasty�� 165
Ill Young Seo
22 LESS: Upper Tract, Lower Tract, and Robotic Surgery �� 173
Woong Kyu Han and Young Eun Yoon
23 Minimally Invasive LESS for Urachal Remnant �� 183
Fuminori Sato, Toshitaka Shin, Kenichi Hirai, Tadasuke Ando, Takeo Nomura,
Toshiro Terachi, and Hiromitsu Mimata
24 Laparoendoscopic Single-Site Pyeloplasty for Children�� 193
Akihiro Kawauchi, Kazuyoshi Johnin, Kenichi Kobayashi, Tetsuya Yoshida,
and Susumu Kageyama
25 ERAS Protocol in Minimal Invasive Urological Surgery �� 199
Ho-Yin Ngai, Chi-Man Ng, and Eddie Chan
26 Techniques and Outcomes of Taeniamyoectomyised Sigmoid Neobladder
in MIS Radical Cystectomy�� 209
Chunxiao Liu and Abai Xu
27 Endoscopic Management of Diverticular Calculi �� 217
Xiaoshuai Gao, Jixiang Chen, Zirui Li, and Kunjie Wang
Part III Advances in Endourology Technology
28 Handbook for Ureteral Stenting�� 225

Shingo Yamamoto
Contents xiii
29 Treatment of BPH: What Is the Gold Standard? �� 233

Chunxiao Liu, Abai Xu, and Peng Xu
30 Advances in Surgery for Benign Prostatic Hyperplasia �� 241
Phil Hyun Song and Yeong Uk Kim
31 Thulium: YAG Laser Resection for Benign Prostatic Enlargement�� 247
Karl Marvin M. Tan, Sid C. Sergio, and Romeo Lloyd T. Romero
32 Thermal Ablation for Small Renal Masses �� 253
Joel Patrick A. Aldana, Jolly Jason S. Catibog, Cindy Pearl J. Sotalbo,
and Joshua Anton O. Yabut
33 Narrow-Band Imaging (NBI) �� 263
Seiji Naito
34 Renal Access for PCNL: The Smaller the Better?�� 269
Bum Soo Kim and Hyuk Jin Cho
35 Extracorporeal Shock Wave Lithotripsy: What All Urologists
Should Know�� 275
Timothy C. K. Ng and Anthony C. F. Ng
36 Endoscopic Management of Renal Stone: Retrograde, Antegrade,
and Combined Approaches �� 281
Sung Yong Cho, Woo Jin Bang, and Hyung Joon Kim
37 Navigation in Endourology, Ureteroscopy �� 289
Kenji Yoshida, Seiji Naito, and Tadashi Matsuda
38 Navigation in Laparoscopic and Robotic Urologic Surgery�� 297
Fumiya Hongo and Osamu Ukimura
39 MRI-Ultrasound Fusion Prostate Biopsy�� 303
Wai-Kit Ma and Peter Ka-Fung Chiu
Part I
Endourology Training
Introduction of East Asian Society
of Endourology and Development 1
of Endourology in East Asia
Tadashi Matsuda and Seiji Naito
Abstract advances in endourology in East Asia. On November 19th,

The East Asian Society of Endourology (EASE) was estab- 2003 in Fukuoka, Japan, the leaders of endourology from
lished in 2003 to promote advances in minimally invasive Japan, Korea, China, Taiwan, and Hong Kong met and
urological surgery in East Asia, to educate young endou- decided to establish EASE as the progression of this sympo-
rologists of the member territories and to cultivate and sium. The following doctors gathered as the representatives
cement friendship among endourologists from member ter- of endourologists from each country/region:
ritories including Japan, Korea, Taiwan, China, and Hong
Kong. The Philippines subsequently became a member in • Japan: Dr. Eiji Higashihara, Kyorin University, Dr. Shiro
2007 and the annual meeting of EASE has been held in one Baba, Kitasato University, Drs. Shinichi Oshima and
of these territories on a rotational basis. This book was Yoshinari Ono, Nagoya University
planned and published as one of the activities of • Korea: Dr. Tchun Yong Lee, Hanyang University, and
EASE. Thanks to innovations in endoscopic technology and Dr. Tae-Kon Hwang, the Catholic University of Korea
surgical technique, together with the activities of the rele- • China: Dr. Li-Qun Zhou, Peking University
vant associations and societies in the EASE territories, a • Taiwan: Dr. Jun Chen, National Taiwan University
variety of endourological, laparoscopic and robotic proce- • Hong Kong: Dr. Shu-Keung Li
dures have been widely disseminated to minimize invasive-
ness and enhance effectiveness of urological treatments. The first EASE annual congress was held on November
19th, 2004 in Okayama under the presidency of Dr. Eiji
Keywords Higashihara, Kyorin University, Japan, in conjunction with
East Asia · Endourology · Laparoscopy the 18th Congress of the Japanese Society of Endourology
and ESWL.
At the Board of Directors (BOD) meeting of EASE held
on December 13th, 2007 in Hong Kong, it was decided that
1.1 I ntroduction to the East Asian Society the Philippines would join EASE and that the Annual
of Endourology (EASE) Congress of 2009 would be held in Manila.
1.1.1 History of EASE

1.1.2 Activities of EASE
The Yamanouchi International Symposium was held in con-
junction with the Japanese Society of Endourology and According to the by-laws, the mission of EASE is to study
ESWL annual congress from 2001. Here, endourologists all questions relating to endourology, to stimulate interna-
from East Asian territories gathered to discuss recent tional co-operation in the field of urology and to encourage
the development, evaluation and application of all aspects of
minimally invasive therapies of urological disease across the
T. Matsuda (*) East-Asian region.
Department of Urology and Andrology,
The annual congress of EASE has been held every year
Kansai Medical University, Osaka, Japan
e-mail: matsudat@takii.kmu.ac.jp since 2004, to enable through international co-operation in
education and research, all EASE territories to achieve the
S. Naito
Hara-Sanshin Hospital, Fukuoka, Japan highest quality of urological patient care (Table 1.1).
© Springer Nature Singapore Pte Ltd. 2019 3

E. S.-y. Chan, T. Matsuda (eds.), Endourology Progress, https://doi.org/10.1007/978-981-13-3465-8_1
4 T. Matsuda and S. Naito
Table 1.1 Annual Congress of East Asian Society of Endourology the member territories and cultivating and cementing
Year City Country/region President friendship among endourologists in the region. The activi-
1st 2004 Okayama Japan Eiji Higashihara ties of EASE have become well-known throughout the
2nd 2005 Jeju Island Korea Tae Kon Hwang global endourology community. At the 2016 BOD meeting
3rd 2006 Taipei Taiwan Jun Chen in Osaka, the BOD members agreed that EASE would con-
4th 2007 Hong Kong Hong Kong Shu-Keung Li
tinue holding annual congresses in the 2020s and pursue
5th 2008 Shanghai China Liqun Zhou
new and diverse activities such as the publishing of this
6th 2009 Manila Philippine Joel P. Aldana
7th 2010 Seoul Korea Hyeon Hoe Kim
textbook.
8th 2011 Kyoto Japan Seiji Naito
9th 2012 Taipei Taiwan Allen Chiu
10th 2013 Hefei China Yinghao Sun 1.2 evelopment of Endourology in East
D
11th 2014 Hong Kong Hong Kong Berry Fung Asia
12th 2015 Manila Philippine Joel P. Aldana
13th 2016 Osaka Japan Toshiro Terachi 1.2.1 ndourological Societies of East Asian
E
14th 2017 Hong Kong Hong Kong Eddie Chan Countries
Table 1.2 Global-scale Congress of Endourology held in EASE coun- Endourologists in East Asian countries meet at their respec-
tries/region tive national endourological society or endourological
Year Name of congress Country President branch or subgroup of their respective national urological
1989 Seventh World Congress Kyoto, Osamu Yoshida association. The year of establishment and the number of
of Endourology and Japan
members of each national endourological society are shown
SWL
1991 Third World Congress Hakone, Hiroshi Tazaki in Table 1.3. These societies and subgroups have played a
on Videourology Japan major role in the development and dissemination of mini-
1995 Seventh World Congress Taipei, Luke S. Chang mally invasive endourological procedures in each country
on Videourology Taiwan together with their respective national urological
2003 15th World Congress on Busan, Hwang Choi, Jin associations.
Videourology Korea Han Yoon,
Gyung Tak Sung
2008 26th World Congress of Shanghai, Yinghao Sun
Endourology and SWL China 1.2.2 dvancement of Endourology in
A
2011 29th World Congress of Kyoto, Tadashi Matsuda East Asia
Endourology and SWL Japan
2012 23rd World Congress on Hong Sidney KH Yip Due to the development of endourological instruments
Videourology Kong
2014 32th World Congress of Taipei, Allen Chiu
such as the Stern-McCarthy resectoscope in 1931, electro-
Endourology and SWL Taiwan hydraulic lithotripter in 1950, endoscopes equipped with
rod lens and fiber-optic light cable system around 1960,
EASE published the proceedings of the annual congress as its and ultrasonic lithotripter in 1973, a variety of endouro-
official journal named Recent Advances of Endourology from logical procedures including TURP, TUL and PCNL have
2005 to 2012. As the progression from Recent Advances of
Endourology, EASE has published this textbook of endourology,
Endourology Progress—Technique, Technology and Training. Table 1.3 Endourological societies of EASE territories
Since the establishment of EASE, the World Congress of Name of the Establishment No. of
Endourology and the World Congress of Videourology has Country society/group year members
been held in EASE territories as shown in Table 1.2 thanks to China The Endourological 1993
Branch of Chinese
the support of the other EASE members. EASE has had close Urological association
communication with the Urological Association of Asia and Hong Hong Kong 2006 252
the Asian Society of Endourology, and some EASE con- Kong Endourological Society
gresses have been held in conjunction with these bodies. Japan Japanese Society of 1987 3969
Endourology
Korea Korean Endourological 1992 750
Society
1.1.3 Future of EASE Philippine Philippine 2009 41
Endourological Society
Since its establishment in 2004, EASE has played impor- Taiwan Taiwan Urological 1978a 938a
tant roles in promoting advances in minimally invasive Association
urology in East Asia, educating young endourologists of Data on the Urological Association, not the Endourological Group
a
1 Introduction of East Asian Society of Endourology and Development of Endourology in East Asia 5
Table 1.4 Year of start of endourological procedures in EASE territories

Country TURP PCNL TUL SWL Lap. nephrectomy Lap. prostatectomy
China 1980 1985 1986 1984 1992 2000
Hong Kong 1984 1985 1996 2002
Japan 1960s 1982 1984 1984 1991 1999
Korea 1977 1984 1984 1987 1996 2002
Philippine 1969 1985 2004 1996 2001 2004
Taiwan 1984 1984 1985 1992
been developed and used around the world (Miki and

Aizawa 2009; Higashihara 2012). The year of introduction 100%
of these procedures in East Asian territories is shown in 80%
Table 1.4.
As for the endoscopic surgery for benign prostate hyper- 60%
trophy, enucleation of prostate hypertrophy was first per-
40%
formed by Hiraoka and Akimoto (1989) in Japan using a
mechanical instrument, which was the precursor of the 20%
Holnium laser or bipolar electronic enucleation of the
prostate. 0%
1965-1980a 1985 1995 2005
A flexible ureteroscope was first developed by Takayasu
and Aso in 1971 in collaboration with Olympus in Japan Conventional open surgery
PNL and/or TUL
(Takayasu et al. 1971) and the world’s first TUL was
ESWL (monotherapy or combined with PNL and/or TUL)
performed by Pretz-Castro in 1980 using a Storz rigid ure-
teroscope (Pérez-Castro Ellendt and Martínez-Piñeiro 1982). Fig. 1.1 The transition of treatment modalities for urolithiasis in Japan
Rigid ureteroscopes were launched by Storz, Wolf and during the past 40 years according to the nation-wide surveys per-
Olympus in 1980, 1982 and 1984 respectively. Flexible ure- formed every 5–10 years since 1965 (Terai and Yoshida 2001; Yasui
et al. 2008)
teroscopes were launched by Storz in 1976 and by Olympus
in 1986. Shock wave lithotripsy (SWL), first developed by
Chaussy et al. in 1980 (Higashihara 2012; Chaussy et al. a
1982), spread rapidly in East Asian countries. The current PCNL in Korea
number of SWL machines is 911, 726, 12 and 50 in Japan, 2500 PCNL
Korea, Hong Kong and the Philippines, respectively. 2004
2000
Furthermore, in Korea and Hong Kong, the number of SWL 1614 1636
1532
procedures performed annually was more than 175,000 and 1500 1307
1,211
1300, respectively. 1026
Thanks to improvements in endoscopes or SWL machines 1000
and in surgical technique, the treatment strategy for uroli-
thiasis has dramatically shifted from open surgery to endo- 500
scopic and shock wave treatments in East Asian countries.
0
The transition of treatment modalities for urolithiasis in
Japan during the past 40 years is shown in Fig. 1.1 according b 2010 2011 2012 2013 2014 2015 2016
TUL in Korea (rigid + flexible)
to the nation-wide surveys performed every 5–10 years since 20,000 TUL
17,078
1965 (Terai and Yoshida 2001; Yasui et al. 2008). The num-
ber of PCNL and TUL in Korea are increasing as shown in 15,000
11,983 12,375
Fig. 1.2a, b, respectively. 11,132
9,712
10,000 7,884
7,102
1.2.3 evelopment of Laparoscopic Surgery
D 5,000
in East Asia
0
The first urologic laparoscopic surgery in East Asian coun-
2010 2011 2012 2013 2014 2015 2016
tries as a disease treatment was a laparoscopic varicocelec-
tomy in 1990 (Matsuda et al. 1992). The world’s first Fig. 1.2 The number of PCNL and TUL in Korea since 2010. (a)
laparoscopic adrenalectomy was performed in February of PCNL, (b) TUL
6 T. Matsuda and S. Naito
Cases Table 1.5 Introduction of surgical robot da Vinci in EASE territories

16000 Bladder/Others Varix Adrenal Country/ Year of the No. of No. of urologic
Testis Prostate/Lymph node Kidney/Ureter region first case machinesa operations in 2016
14000 China 2007 50 8000
Hong Kong 2006 10 600
12000
Korea 2006 60 5000
10000 Japan 2003 250 16,000
Philippine 2005 3 100
8000 Taiwan 2005 30 2000
At the end of 2016
a
6000
4000 Acknowledgements Drs. Yinghao Sun, Eddie Chan, Hon Ming Wong,
Koon Ho Rha, Young Eun Yoon, Joel Aldana, Takahiro Yasui, Saint
2000 Shiou-Sheng Chen, produced the data on endourology of East Asian
territories.
0
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
19 8
20 9
20 0
20 1
20 2
20 3
20 4
20 5
20 6
20 7
20 8
20 9
20 0
20 1
20 2
20 3
20 4
15
9
9
9
9
9
9
9
9
9
9
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
19
Fig. 1.3 The number of urologic laparoscopic surgeries in Japan since References
1990
Chaussy C, Schmiedt E, Jocham D, et al. First clinical experience with
extracorporeally induced destruction of kidney stones by shock
waves. J Urol. 1982;127:417–20.
Go H, Takeda M, Takahashi H, et al. Laparoscopic adrenalectomy for
1992 by Japanese doctors (Go et al. 1993). The year of intro- primary aldosteronism: a new operative method. J Laparoendosc
duction of laparoscopic nephrectomy and prostatectomy is Surg. 1993;3:455–9.
Higashihara E. Japanese contribution to endourology. Jpn J Endourol.
shown in Table 1.4. Since then, a variety of urologic laparo- 2012;25:183–201.
scopic surgeries have been introduced in these countries and Hiraoka Y, Akimoto M. Transurethral enucleation of benign prostatic
the number of surgeries in Japan is still increasing as shown hyperplasia. J Urol. 1989;142:1247–50.
in Fig. 1.3, according to the nation-wide survey of urologic Matsuda T, Horii Y, Higashi S, et al. Laparoscopic varicocelectomy: a
simple technique for clip ligation of the spermatic vessels. J Urol.
laparoscopic surgeries (The Japanese Society of Endoscopic 1992;147:636–8.
Surgery 2016). Miki M, Aizawa. The history of endourology. Jpn J Endourol ESWL.
2009;22:127–9.
Pérez-Castro Ellendt E, Martínez-Piñeiro JA. Ureteral and renal endos-
copy. A new-approach. Eur Urol. 1982;8:117–20.
1.2.4 I ntroduction of Robotic Assisted Takayasu H, Aso Y, Takagi T, et al. Clinical application of fiber-optic
Surgery in East Asia pyeloureteroscope. Urol Int. 1971;26:97–104.
Terai A, Yoshida O. Epidemiology of urolithiasis in Japan. In: Akimoto
M, Higashihara E, Orikasa S, et al., editors. Recent advances in
The surgical robot, da Vinci was first introduced to East Asia endourology, vol. 3. Tokyo: Springer; 2001. p. 23–36.
in 2003 in Japan and has since been used in East Asian coun- The Japanese Society of Endoscopic Surgery. Results of 13th nation-
tries as shown in Table 1.5. Now in 2016, the number of da wide survey of endoscopic surgery in Japan. J Jpn Soc Endosc Surg.
2016;21:772–96.
Vinci S, Si or Xi across the EASE region together with the Yasui T, Iguchi M, Suzuki S, et al. Prevalence and epidemiological
number of urological robotic operations in 2016 are shown characteristics of urolithiasis in Japan: national trends between
in Table 1.5. 1965 and 2005. Urology. 2008;71:209–12.
Training of Endourology in Asia
2
Kai Zhang, Tao Han, and Gang Zhu
Abstract 2.1 Training Models of Endourology

For over hundred years, the training for surgeon was the
accumulation of personal experience following the model Animal and mechanical models are most commonly used for
of “see one, do one, teach one”. Even when this worked, endourology training worldwide, with the advantages of cost-
such training lacked standardization because of different effective, easy accessibility and high reliability. A large num-
cases and teachers’ experience. This is clearly suboptimal ber of models have been developed to train medical students,
from a safety viewpoint. More importantly, modern clini- residents and young urologists with limited experience in
cal ethics sits poorly with surgeons practicing new tech- transurethral resection (TUR) surgery, ureteroscopy, percuta-
niques on patients without any attempt at learning the neous nephrolithotripsy (PCNL), laparoscopy and robotic sur-
skills on simulators. Patients are also increasingly reluc- gery (Ganpule et al. 2015; Chandrasekera et al. 2006; Zhang
tant to be the “guinea pigs” for inexperienced surgeons. et al. 2008; Soria et al. 2015; Celia and Zeccolini 2011). Some
Asia has a vast territory and a large population, the devel- models could simulate the whole procedures with high fidelity
opment of endourology varies greatly among different and some could only simulate basic tasks or be used for spe-
countries and regions. Systematic training and standard- cific steps but with low cost and good reusability.
ization of technique is in pressing need in Asia, especially A model was designed with an in vitro porcine heart tis-
in developing countries. In the last couple of decades, sue model for laser prostatectomy endoscopic technique
numbers of new animal and mechanical models and simu- training in China (Zhang et al. 2009). In the evaluation study,
lators have been developed and validated. Based on the ten junior surgeons without experience of benign prostatic
currently available data, endourological training could hyperplasia (BPH) laser prostatectomy were assessed for
help surgeons to gain experience and improve skills out- ability and speed over a period of time with two technique
side the operating room in a short time. Efforts should be evaluation points: resection and vaporization. A 26F irrigat-
made to identify the best aspects of every model and pro- ing laser resectoscope was used to perform laser resection
cedure-specific simulation courses should be developed and vaporization on left ventricle chordae tendineae
and validated. Conclusive data on the training effect and (Figs. 2.1 and 2.2). Before the first and the second training
feedback on real clinical environment is also needed in stage, the trainees were trained in theory and techniques.
Asia. Feasibility, technique and both resection and vaporization
speed were analyzed. There was significant improvement in
Keywords terms of resection time, vaporization time and the total
Endourology · Training · Training model manipulation time (P < 0.01) in the second stage compared
with those of the first stage. In this model, the space of the
left ventricle in porcine heart was highly similar to the space
of prostatic urethra during the laser BPH treatment and it
was very suitable for this particular training. This model
showed that porcine heart is a simple, cheap and reproduc-
K. Zhang · G. Zhu (*) ible model for learning the basic skills of laser prostatectomy
Department of Urology, Beijing United Family Hospital,
Beijing, China
using laser before working on patients.
Pig is also widely used for laparoscopic training, mostly
T. Han
Department of Urology, Ningxia People’s Hospital,
simulating the whole procedure such as laparoscopic
Ningxia, China nephrectomy, partial nephrectomy and pyeloplasty (Chiu

8 K. Zhang et al.
et al. 1992; Barret et al. 2001; Yang et al. 2010; Gettman attempts. For all the three trainees, the operation time showed
et al. 2002) (Fig. 2.3). The morphometric and anatomic of remarkable reduction and the quality of anastomosis improved
porcine kidney are greatly similar to human kidney (Sampaio significantly from the first to the fourth attempt, suggesting a
et al. 1998) (Fig. 2.4). favorable trend in terms of learning curve.
Early in 1993, laparoscopic nephrectomy was performed
in 15 male live pigs in Taiwan by Chiu et al. (1992). The
average operation time was 200 min. The complications
included renal vein tear in one case, mild subcutaneous
emphysema in two cases.
In India, the crop and esophagus of a chicken were used to
simulate the renal pelvis and ureter for laparoscopic pyeloplasty
training (Ramachandran et al. 2008). This model was cheap,
easily available and could provide a realistic feel to the tissue
and anatomy of human. To assess the effectiveness of this
model, three residents was chosen to complete laparoscopic
pyeloplasty for four times in a period of 1 month. The operation
time and quality of anastomosis were compared among the four
Fig. 2.3 Live porcine model for laparoscopic training
Fig. 2.1 Instruments and porcine heart model Fig. 2.4 Live porcine kidney
Fig. 2.2 Space of the left

ventricle in porcine heart
2 Training of Endourology in Asia 9
In addition to transurethral and laparoscopic procedures,

a number of models were created for training of ureteros-
copy and PCNL (Soria et al. 2015; Mishra et al. 2013; Bele
and Kelc 2016; Sinha and Krishnamoorthy 2015; Strohmaier
and Giese 2009). A biologic bench model using a porcine
kidney was reported to simulate intrarenal procedures in
China (Zhang et al. 2008). The porcine kidney was wrapped
with subcutaneous tissue and muscle in a thick skin flap. The
whole model was fixed to a wooden board with nails and the
radiologic contrast medium or normal saline could be
injected into the kidney through ureteral catheter. Stones
were placed inside the kidney through a small incision on the
renal pelvis in advance. A total of 42 urologists with limited
experience of endourology surgery attended this training,
performing percutaneous renal surgery training under ultra- Fig. 2.5 TURPSim training system
sound guidance. At the end of training, 60.6% trainees could
finish the whole procedure successfully and 85.7% trainees
regarded this model for percutaneous renal surgery training
“very helpful” or “helpful”.
In general, animal and mechanical models are easily built
and cost-effective, could provide realistic and reproducible
practice for most endourology surgery. However, the validity
varies among various models and standard evaluation system
is still lacking.
2.2 Virtual Reality Training

of Endourology
Virtual reality (AR) is defined as “Inducing targeted behav-

ior in an organism by using artificial sensory stimulation,
while the organism has little or no awareness of the interfer-
ence” (Hamacher et al. 2016). The first VR simulator
emerged in 1909 and was used for the training of aircraft
pilots (Hamacher et al. 2016). Nowadays, an increasing
number of validated VR simulators are widely used for
endourology training (Aydin et al. 2016a; Phe et al. 2017; da
Fig. 2.6 Virtual TURP surgery
Cruz et al. 2016; Noureldin et al. 2016; Tjiam et al. 2014).
In 1999, a VR simulator for transurethral resection of the
prostate (TURP) procedures was first reported (Ballaro et al. TURP simulator. It is noteworthy that all the other parame-
1999; Gomes et al. 1999). Software was developed to gener- ters, except for the global rate scale can be objectively and
ate the images of urethral and prostate with using a magnetic accurately evaluated with this VR model.
sensor input device attached to a dummy resectoscope, In accordance with rapid and wide adoption of robot-
which could help trainees be familiar with the TURP assisted laparoscopic surgery in the last decade, robotic VR
technique. simulators emerged and were increasingly applied world-
Zhu et al. (2013) investigated the utility of VR simulators wide. At present there are five VR simulators: the Surgical
in training of TURP in China. The TURPSim system was Education Platform (SEP; SimSurgery, Oslo, Norway), the
used and 38 trainees were randomly selected to take part in Robotic Surgical System (RoSS; Simulated Surgical
the training (Figs. 2.5 and 2.6). The global rate scale, rate of Systems, San Jose, CA, USA), the dV-Trainer (Mimic,
capsule resection, amount of blood loss, external sphincter Seattle, WA, USA), the da Vinci Skills Simulator (dVSS;
injury was compared between the baseline and post-training Intuitive Surgical), and the recently introduced RobotiX
levels. It showed that all the parameters improved remark- Mentor (3D Systems, Simbionix Products, Cleveland, OH,
ably after training and most trainees were satisfied with the USA) (Moglia et al. 2016).
10 K. Zhang et al.
In Korea, the dVSS system was used to train 50 medical 2.3 Evaluation of Training Effect
school students to perform 12 exercises with the aim to
determine whether a robotic VR training enabled inexperi- The main objective of endourology training is to shorten the
enced trainees to complete a hands-on operation (Song and time needed for clinical training and provide the residents or
Ko 2016). The program was conducted in two parts. Firstly, urologists with the possibility to gain experience and improve
43 students received VR training for basic skills and skills outside the operating room. However, the role of training
advanced suture. Then a real robotic surgical system was in certification and credentialing of real surgery is still under
applied to perform urethrovesical anastomosis on a hands- investigation. There is limited data regarding whether training
on model which was created using the proximal end of rec- could affect actual performance in a hands-on setting.
tal tubes. In analysis, the console time of hands-on training In Japan, Fujimura et al. developed a mentoring system to
was significantly associated with the total time and attempt balance training new surgeons while controlling medical
of VR training, suggesting robotic VR training system quality (Fujimura et al. 2016). Novice surgeons with experi-
could help beginners to acquire and improve robotic sur- ence of radical retropubic prostatectomy and laparoscopic
gery skills. renal and adrenal surgery participated in the study (only one
In India, Mishra et al. compared the validation between a surgeon had experience of laparoscopic radical prostatec-
live porcine model and a VR simulation model for percuta- tomy). They first underwent intensive dry and animal train-
neous renal access training (Mishra et al. 2010). In this study, ing and then observed 47 cases of robot-assisted radical
a live anesthetized pig with a pre-placed ureteric catheter and prostatectomy performed by an experienced surgeon (Menon
a high-fidelity simulator (PERC Mentor, Simbionix; Lod, M, Henry Ford Hospital, Detroit, Michigan, USA). Moreover,
Israel) were used. A total of 24 urologists with experience of in the first five cases of real operation, the new surgeons were
more than 50 cases of PCNL firstly performed percutaneous supervised by a proctor who had enormous experience in
renal access with a real-time C-arm in the porcine model, laparoscopic and robot-assisted radical prostatectomy.
then operated the same procedure on the simulator. In com- In the step-by-step procedures, time limits and blood loss
parison, there was no statistical significant difference in was measured and ten checkpoints were set up during every
overall usefulness. The simulator model came with a high operation in the mentoring program. The cut-off point was
price but was safer and easier to set up than live porcine set at 70% of the time and blood loss limit. Once the time or
model. However, the live porcine model was more realistic blood loss limit was exceeded, a mentor would take over the
than the high-fidelity simulator model. operation or another new surgeon would replace the surgeon
Cai et al. reported the value of VR simulator in the skill and finished the step. In this setting, the surgical quality and
acquisition of flexible ureteroscopy (Cai et al. 2013). URO patient’s safety could be controlled to the maximum extent.
Mentor (Simbionix) VR model was used in this study. Thirty In this study, a total of 242 patients underwent robot-
urologists took part in the study and received 1-h basic train- assisted radical prostatectomy, with the median operative
ing for the instruments and the whole procedures, then fol- time 237 min and median perioperative blood loss 300 ml.
lowed by an assessment with task of seven programs. After 88% of new surgeons could finish the whole procedure after
another 4-h practice on the simulator, the participants an average of 10.7 cases. There was no perioperative mortal-
performed the same task. It showed that most parameters ity and no conversion to open prostatectomy. Seven patients
including total procedure time, progressing time from the (2.8%) suffered from postoperative hemorrhage and one
orifice to stone, time of stone translocation, fragmentation patient underwent emergent hemostatic surgery because of
time, laser operate proficiency scale, total laser energy, maxi- active bleeding of left epigastric artery. It is interesting to
mal size of residual stone fragments, number of trauma from note that there was no statistically difference between the
the scopes and tools and damage to the scope improved results of a mentor and those of new surgeons with a mentor
remarkably on the second assessment. This study illustrated in terms of median operative time, console time, blood loss,
that VR simulator could aid the trainees to enhance their incidence of blood transfusion and duration of catheteriza-
flexible ureteroscopy skills in a short time. tion. One must admit that the majority of studies on endou-
Generally, the high-fidelity VR simulators usually seem a rology training merely compare the results between the
very high price. However, the running cost is very low once baseline and post-training period on models or simulators.
the models are installed. It can be easily set up, only a space However, the ultimate goal of training is to improve the
and an electricity supply needed. Of the available VR simu- doctor’s performance on real patients. This Japanese study
lators, some have held high level of evidence and recommen- provides us some enlightenment on how to investigate the
dation, such as the UroSim and TURPsim for TUR surgery, effect of training in real clinic environment on the premise of
the URO Mentor and PERC Mentor for urolithiasis, and the ensuring medical quality and safety. Regrettably, there are
dv-Trainer for robotic surgery (Aydin et al. 2016b). too few data on this subject in Asia, even worldwide.
2 Training of Endourology in Asia 11
2.4 Training Organization in Asia Global Education Initiative Skills Courses in Endourolgy,
Laparoscopy and Robotics held in Chengdu, China, in March
There are a lot of endourology training courses supported by 2016.
local urology societies in Asian countries or Areas in the pur- In Korea, Yonsei University College of Medicine
pose of improving Asian urologist’s endoscopic skills and Department of Urology provided 1-year training program
techniques. under the guidance of a urological surgeon. During the fel-
Asian Urological Surgery Training & Education Group lowship, the fellow will be exposed to different techniques
(AUSTEG) was founded in Hong Kong, with the aim to and latest available instruments in endourologic, laparo-
enhance professional competencies to advance the standard scopic and robotic surgery.
of urological surgery in Asia through a comprehensive train- In India, ceMAST organizes courses like two-day Upper
ing platform for experience skill exchange, and hence, culti- Tract Endourology Course covering usage of semirigid ure-
vate next generations in Asia. The members are all urological teroscopes, flexible ureteroscopes, nephroscopes, etc.
experts with a high reputation from China, Japan, Korea,
Malaysia, Thailand and some other Asian countries and
regions. There are extensive curriculums including laparo-
scopic upper tract surgery, endourology and stone manage-
ment, lower tract surgery and urology nursing workshop
(Figs. 2.7 and 2.8).
East Asian Society of Endourology (EASE) regularly has
the pre-congress training program. Such as the EASE 2014
& The Sixth Hong Kong Congress of Endourology: The
Next Generation in Endourology: Training, Technique and
Technology.
Chinese Urology Association (CUA) has organized many
training courses and provided support to local training cen-
ters in China. Usually the training centers were organized by
each province and run by a local teaching hospital. There
were regular courses, which have contributed to the develop-
ment of Chinese Urology. There were also some collaborated
international courses, such as the Endourology Society Fig. 2.8 AUSTEG model training for ureteroscopy
Fig. 2.7 AUSTEG trainers

and trainees
12 K. Zhang et al.
Japanese Urological Association and Japanese Society of Chiu AW, et al. Laparoscopic nephrectomy in a porcine model. Eur
Urol. 1992;22(3):250–4.
Endourology have established a urologic laparoscopic skills da Cruz JA, et al. Does warm-up training in a virtual reality simulator
qualification system called the Endoscopic Surgical Skill improve surgical performance? A prospective randomized analysis.
Qualification (ESSQ) System in 2004 to assess the tech- J Surg Educ. 2016;73(6):974–8.
niques and skills of applicants in performing lap nephrec- Fujimura T, et al. Validation of an educational program balancing sur-
geon training and surgical quality control during robot-assisted radi-
tomy or adrenalectomy. cal prostatectomy. Int J Urol. 2016;23(2):160–6.
The Chinese University of Hong Kong (CUHK) Jockey Ganpule A, Chhabra JS, Desai M. Chicken and porcine models for train-
Club Minimally Invasive Surgery Skills Centre (MISSC) ing in laparoscopy and robotics. Curr Opin Urol. 2015;25(2):158–62.
has collaborations with the International Training Centre of Gettman MT, et al. Transvaginal laparoscopic nephrectomy:
development and feasibility in the porcine model. Urology.
Intuitive Surgical®. Intuitive Surgical® issues certifications 2002;59(3):446–50.
for all courses in robotic assisted laparoscopic surgery con- Gomes MP, et al. A computer-assisted training/monitoring system
ducted at the MISSC. CUHK MISSC runs courses covering for TURP structure and design. IEEE Trans Inf Technol Biomed.
the important clinical aspects of robotics as used in a wide 1999;3(4):242–51.
Hamacher A, et al. Application of virtual, augmented, and mixed reality
variety of specialties, including urology. A similar to urology. Int Neurourol J. 2016;20(3):172–81.
International Training Centre of Intuitive Surgical® has just Mishra S, et al. Percutaneous renal access training: content validation
recently been established in Shanghai Changhai Hospital. comparison between a live porcine and a virtual reality (VR) simu-
It is worth mentioning that, even with different organiz- lation model. BJU Int. 2010;106(11):1753–6.
Mishra S, et al. Training in percutaneous nephrolithotomy. Curr Opin
ers, all the courses combining academic lecture, model- Urol. 2013;23(2):147–51.
based training and practice, case discussion, providing Moglia A, et al. A systematic review of virtual reality simulators for
remarkable promotion not only on surgical skill, but also on robot-assisted surgery. Eur Urol. 2016;69(6):1065–80.
professionalism of our future medical care providers to bet- Noureldin YA, et al. Is there a place for virtual reality simulators in
assessment of competency in percutaneous renal access? World J
ter serve our patients. Urol. 2016;34(5):733–9.
Phe V, et al. Outcomes of a virtual-reality simulator-training programme
Remark Permission is obtained to show the human images on basic surgical skills in robot-assisted laparoscopic surgery. Int J
in this article according to local regulation. Med Robot. 2017;13(2) https://doi.org/10.1002/rcs.1740.
Ramachandran A, et al. A novel training model for laparoscopic pyelo-
plasty using chicken crop. J Endourol. 2008;22(4):725–8.
Sampaio FJ, Pereira-Sampaio MA, Favorito LA. The pig kidney
as an endourologic model: anatomic contribution. J Endourol.
1998;12(1):45–50.
References Sinha M, Krishnamoorthy V. Use of a vegetable model as a training tool
for PCNL puncture. Indian J Urol. 2015;31(2):156–9.
Aydin A, et al. Simulation-based training and assessment in urological Song PH, Ko YH. The surgical skill of a novice trainee manifests in
surgery. Nat Rev Urol. 2016a;13(9):503–19. time-consuming exercises of a virtual simulator rather than a quick-
Aydin A, et al. Current status of simulation and training models in finishing counterpart: a concurrent validity study using an urethro-
urological surgery: a systematic review. J Urol. 2016b;196(2): vesical anastomosis model. J Surg Educ. 2016;73(1):166–72.
312–20. Soria F, et al. Development and validation of a novel skills training model
Ballaro A, et al. A computer generated interactive transurethral pros- for retrograde intrarenal surgery. J Endourol. 2015;29(11):1276–81.
tatic resection simulator. J Urol. 1999;162(5):1633–5. Strohmaier WL, Giese A. Improved ex vivo training model for percuta-
Barret E, et al. Laparoscopic partial nephrectomy in the pig: compari- neous renal surgery. Urol Res. 2009;37(2):107–10.
son of three hemostasis techniques. J Endourol. 2001;15(3):307–12. Tjiam IM, et al. Evaluation of the educational value of a virtual reality
Bele U, Kelc R. Upper and lower urinary tract endoscopy training on TURP simulator according to a curriculum-based approach. Simul
Thiel-embalmed cadavers. Urology. 2016;93:27–32. Healthc. 2014;9(5):288–94.
Cai JL, et al. Proficiency of virtual reality simulator training in flex- Yang B, et al. A novel training model for retroperitoneal laparoscopic
ible retrograde ureteroscopy renal stone management. Chin Med J. dismembered pyeloplasty. J Endourol. 2010;24(8):1345–9.
2013;126(20):3940–3. Zhang Y, et al. Novel biologic model for percutaneous renal surgery
Celia A, Zeccolini G. Ex vivo models for training in endourology: learning and training in the laboratory. Urology. 2008;72(3):513–6.
construction of the model and simulation of training procedures. Zhang K, Zhu G, Wan B, Wang JY. Application of porcine heart as
Urologia. 2011;78(Suppl 18):16–20. animal tissue model for 2 micron continuous wave laser endoscopic
Chandrasekera SK, et al. Basic laparoscopic surgical training: exami- technique training. Chin J Urol. 2009;30(9):627–9.
nation of a low-cost alternative. Eur Urol. 2006;50(6):1285–90. Zhu H, et al. Virtual reality simulator for training urologists on transure-
1290–1 thral prostatectomy. Chin Med J. 2013;126(7):1220–3.
Laparoscopic Training Using Cadavers
3
Thomas Y. Hsueh
Abstract ary change of laparoscopic procedures, redefines the horizon

Surgical education is the fundamentals of medicine and of minimal invasive surgery and serves as the procedure of
warrants experience transfer from generations to genera- choice in complex urological surgical procedures. However,
tion to achieve a better disease management. Laparoscopic the evolvement of surgical training of laparoscopic proce-
procedure requires a steep learning curve compared to dures does not establish well as the development of laparo-
conventional open procedures due to two-dimensional scopic procedures. Most urologists learned laparoscopic
vision, lack of tactile sensation and limited working procedures just like the scenario about 40 years ago, as what
space. The training curriculum in laparoscopic proce- we learned from our mentors. At that time, we learned the
dures includes not only didactic lectures but also hand-on surgical procedures from our patients and from textbooks. In
surgical training lab. The application of computerized fact, the traditional training in surgery could be defined in the
simulators, tissue analogue simulators and cadavers is phrase, “see one, do one, teach one,” as what surgeons
proved to be efficient for surgical skills training in lapa- learned for many decades (Halsted 1904). However, with the
roscopy. The training in nontechnical surgical skills is awareness of patient safety, financial constraints and medical
found to have positive impact on surgical training, espe- legal issues in health care organizations, the training model
cially in interpersonal communication and team work used for many decades requires a fundamental renewal for
during emergency scenarios in the operating room. This urologists nowadays.
chapter will discuss the concept on surgical training, The advancement of computer science in the past 40 years
training curriculum design, the application of simulators and the widespread application of internet have changed
in laparoscopic training and nontechnical training in lapa- people life in all aspects of our society. The use of smart-
roscopic surgery. phone, instant online communication and online video learn-
ing provide more chances for urologists to learn new surgical
Keywords concepts. In international academic meetings, live demon-
Laparoscopy · Surgical training · Simulator stration of complex laparoscopic procedures via video
streaming technology and real time communication with
international experts deliver more opportunities for urolo-
gists in both step-by-step surgical illustrations and trouble-
3.1 Introduction shooting scenario in learning complex laparoscopic
procedures. However, most complex laparoscopic proce-
Laparoscopic surgery was first introduced into urology in dures are associated with steeper learning curves compared
early 1990s. The advancement of technology, miniature of to conventional open procedures. The restricted vision, lack
instruments and duplication of open surgical procedures are of tactile perception, difficulty in handling endoscopic
key elements for the revolution of minimal invasive surgery instruments and limited working space are main reasons for
in the past 30 years. Robotic surgery, one of the revolution- urologists to learn laparoscopic surgery. With the growing
realization that most procedural learning curves do not
require patients for skill acquisition, the implementation of
T. Y. Hsueh (*)
Division of Urology, Department of Surgery, Taipei City Hospital training models in laparoscopic education has gained more
Renal Branch, Taipei, Taiwan and more attention in the past 20 years. Besides, the training
Department of Urology, School of Medicine, National Yang-Ming program is more important than training models (Traxer
University, Taipei, Taiwan et al. 2001). This chapter will focus on the discussion about

14 T. Y. Hsueh
training program for laparoscopic procedures and the valid- ing the hypothesized relations. Construct validity is very
ity of training models, so as to provide a panoramic view of important in social science, psychology and language studies
current status of laparoscopic education. and are one of the important measurements for a training
curriculum of laparoscopy nowadays.
3.2 Evaluation of a Training Curriculum

3.3 Training Curriculum
Surgical education is the long-standing responsibility for
physicians as the clinical experience transferred for genera- The training curriculum using cadaveric/animal models,
tions to generations so as to treat diseases in a better way. high/low fidelity simulators and virtual reality simulators
Continuous medical education is not only important for a provide the possibility of getting knowledge-based behavior
surgeon to be competent in his specialty, but also provide a (Satava 2001). However, the course aiming to train new
chance for patients to receive better medical treatment. In laparoscopic surgical procedures should focus on both tech-
order to keep clinical competence, a well-designed training nical and non-technical skills in handing various clinical
curriculum is required in all aspects of clinical practice, scenarios. There are several issues needed to be addressed,
which would be more important in surgical field. Although such as length of the program, content of didactic courses,
the curriculum might change a lot as the alongside with the hand-on training materials and homogeneity of trainees
progression of computer science, the measuring tools remain (Vaziri 2013). It is reported that participants that are trained
constant in the past several decades. The validity test is the for more than 1 day interactive program might be more
essential part to evaluate a training curriculum and will be competent. In order to decrease the perioperative complica-
discussed in the following parts. tion rate in laparoscopic procedures, the implementation of
surgical volume after the training program is essential.
Hence, an optimal course should include not only didactic
3.2.1 Face Validity lectures and interactive simulator training program, but also
improve the performance of trainee (Kneebone 2003). The
Face validity refers to the measurement of a test in all aspects aim of the training course should focus on the decrease of
(Guion 1980; Holden 2010). It also means the transparency possible complications and increase dexterity during laparo-
and relevance to test participants. In a simple word, face scopic procedures. In 1998, a guideline from society of
validity means how a test really “looks like” as evaluated by American gastrointestinal endoscopic surgeons (SAGES)
all faculties of a training curriculum. suggested the following rules for courses design in laparo-
scopic/robotic surgery. The principles were: (1) The objec-
tives and the assessment methodology should be clearly
3.2.2 Content Validity illustrated, (2) the faculties should be qualified, (3) a funda-
mental knowledge, skills and clinical experiences should be
Content validity is also known as logical validity, which identified in participants, (4) the facilities should be ade-
refers to a measure on all aspects of the test (Lawshe 1975). quate. In 2006, Corica et al. reported the training experience
It also needs to use a designed scale to evaluate the effective- of mini-residency program for laparoscopic procedures with
ness of a test and a statistical test might be needed for further more than 2-year follow-up period. A 5-day training pro-
analysis. Content validity is most often used in academic and gram was conducted, including didactic lecture, hand-on
vocational testing and it might refer to the curriculum evalu- training in dry lab and animal models and observation of
ation in clinical education. live surgery in the operating room. The authors concluded
that 5-day mini-residency program could encourage trainees
to perform more complex laparoscopic procedures in their
3.2.3 Construct Validity daily practice. The course coordinator needs to identify the
requirement of trainees and tries to design a tailor-made
Construct validity is one of the three types of validity evi- content for all participants. The content of didactic lecture is
dence, along with the content validity and criterion validity another concern for a training course and should include
in traditional validity theory. It refers to the identification of fundamental knowledge of laparoscopic surgery, step-by-
appropriateness made on the basis of observations or mea- step laparoscopic surgical procedures and possible land-
surements for a test. In 1955, Cronbach and Meehl reported mark identification during surgery, complications of
that construct validity could be evaluated in the following laparoscopic surgery and future perspectives or current sta-
three aspects, including the articulation of a set of theoretical tus of laparoscopic surgery. For participants who have cer-
concepts and their interactions, to develop ways to measure tain level in laparoscopic procedures, the trouble-shooting
the hypothetical constructs for a theory and empirically test- lecture might be more helpful so as to provide experience
3 Laparoscopic Training Using Cadavers 15
sharing scenario in the course. Finally, the satisfaction sur- Hung et al. reported another model using porcine kidney and
vey of the training course is essential for course coordina- styroform ball to mimic renal tumor requiring laparoscopic/
tors. It can provide not only the evaluation of the training robotic partial nephrectomy while face, content and construct
course, but also provide suggestions for course refinement. B validity could be demonstrated in this study. In 2013, De
To sum up, there is no perfect training curriculum, but a Win et al. reported the animal model of porcine kidney, which
training curriculum can be refined to become perfect. found to have content and construct A validity. With the
advancement in augmented reality, the computerized model
was designed. In 2015, Hung et al. reported the application of
3.4 Training Models dV-Trainer in robotic partial nephrectomy training and face,
content and construct B validity was found in this training
There were several training models focused on laparoscopic model. All four reported studies gained a level of evidence 2b.
surgical procedures. With the advancement of computer sci-
ence and virtual reality, the application of computerized model 3.4.2.2 Pyeloplasty
has gained widespread acceptance in recent years. Besides, There were two studies evaluating the application of pyelo-
there were several validated models used for radical/partial plasty model. In 2013, Jiang et al. reported the use of chicken
nephrectomy, pyeloplasty, ureteral reimplantation, and ure- crop model to simulate clinical scenario of laparoscopic
throvesical anastomosis using analogue materials. The animal pyeloplasty which demonstrated construct B validity between
model was still the most common selection to simulate clinical experts, specialists and junior residents. In 2014, Poniatowski
scenario although fresh frozen cadaveric model might provide et al. reported the pyeloplasty simulator model by using a
better experience in endoscopic dissection. The simulated low-cost, high-fidelity tissue analogue. It was reported to
training models will be discussed in the following section. have face, content and construct B validity (Poniatowski et al.
2014). Those two studies gained a level of evidence 2b.
3.4.1 Computerized Simulators 3.4.2.3 Ureteral Reimplantation

In 2013, Tunitsky et al. reported the use of hydrogel to simu-
As the development of imitative technology, application of late laparoscopic/robotic ureteral reimplantation. The model
augmented reality in real life and the widespread deployment demonstrated to have face, content and construct B validity
of high definition video system, the use of virtual reality in and gained a level of evidence 2b.
educational training has gained popularity since early 2000s
(Laguna et al. 2002). The computer-based design of a simu- 3.4.2.4 Vesicourethral Anastomosis
lator mainly focused on the reproducibility of three- There were several studies evaluating the training models of
dimensional environment, tissue texture and the creation of vesicourethral anastomosis. In 2006, Laguna et al. reported
force-feedback mechanisms. Besides, the possible smoke the chicken model to mimicking vesicourethral anastomosis
generation and tissue elasticity alongside the bleeding phe- and found to have construct B validity in this study with a
nomenon during endoscopic dissection and vessel ligation is level 2c evidence. In 2012, Sabbagh et al. reported the latex
another consideration to be implemented in a computer- UV model to simulate vesicourethral anastomosis, which
based simulator. In 2012, Matsuda et al. reported the experi- demonstrated face and predictive validity and a level 2a evi-
ence in virtual reality simulator and compared to the dence was identified. In 2014, Kang et al. reported the use of
videotape assessment from real laparoscopic procedures. tube3/dV-Trainer to simulated vesicourethral anastomosis.
They concluded that the basic skill training in virtual reality Face, content and construct B validity was found in this
simulators might demonstrate the construct and concurrent study while a level 2b evidence was identified. In 2015,
validity to evaluate preclinical laparoscopic skills. Chowriappa et al. reported the use of augmented reality to
simulate vesicourethral anastomosis in HoST/RoSS model.
Face and concurrent validity were found in this study and a
3.4.2 Analogue Training Model level 1b evidence was noted.
3.4.2.1 Partial/Radical Nephrectomy

There were several studies describing the application of train- 3.4.3 Animal Model
ing models in simulated training of partial nephrectomy. In
2010, the Procedicus MIST nephrectomy VR simulator was The use of animal to simulate real surgical scenario was a
reported to have face, content and construct B validity longstanding choice for surgical training, not only in con-
(Brewin et al. 2010). Lee et al. (2012a) reported the partial ventional open surgery, but also in laparoscopic surgical
nephrectomy model mimicking renal hilar injury, which dem- procedures (Alemozaffar et al. 2014). The most commonly
onstrated face, content and construct B validity. In 2012, used animal is porcine model while canine or calf model
16 T. Y. Hsueh
was sporadically reported. The interactive training program solution to maintain clinical competency and to learn new
can be divided to upper urinary tract and lower urinary tract. endoscopic procedures in a safe environment. In the near
The trainees will be divided into several groups and about future, laparoscopic simulation using computerized virtual
2–3 trainees per group is the usual setting. Each group will reality model, animal model and cadaveric model might
be assigned to perform 2–3 procedures in about 4 h. Partial/ serve as the step-by-step learning protocol to deliver a new
radical nephrectomy, pyeloplasty and ureteroureterostomy surgical technique from the experimental test into a practical
are the usual procedures for upper urinary tract while ure- procedure.
teroneocystostomy, enterocystoplasty and radical cystec-
tomy are usually conducted for lower urinary tract.
References
3.4.4 Cadaveric Model Alemozaffar M, Narayanan R, Percy A, et al. Validation of a novel,

tissue-based simulator for robot-assisted radical prostatectomy. J
Endourol. 2014;28:995–1000.
The use of cadaveric model for surgical training may provide Brewin J, Nedas T, Challacombe B, et al. Face, content and construct
an ideal environment to realize real human anatomy and to validation of the first virtual reality laparoscopic nephrectomy simu-
simulate manipulations in laparoscopic surgery. It also serves lator. BJU Int. 2010;106:850–4.
Chowriappa A, Raza SJ, Fazili A, et al. Augmented-reality-based
as the transition to evaluate the surgical competence of train- skills training for robot-assisted urethrovesical anastomo-
ees from simulation-based training model to real laparo- sis: a multi- institutional randomised controlled trial. BJU Int.
scopic surgeries. In 2008, Giger et al. reported the experience 2015;115:336–45.
using Thiel cadavers in laparoscopic training. They reported Corica FA, Boker JR, Chou DS, et al. Short-term impact of a lapa-
rosocpic “mini-residency” experience on postgraduate urologists’
a high satisfaction scores were identified for the course and practice patterns. J Am Coll Surg. 2006;203:692–8.
all participants were willing to recommend the course to Cronbach LJ, Meehl PE. Construct validity in psychological tests.
their colleagues. In 2012, Sharma and Horgan reported the Psychol Bull. 1955;52:281–302.
comparison between fresh frozen cadavers and high-fidelity De Win G, Van Bruwaene S, Allen C, et al. Design and implementa-
tion of a proficiency-based, structured endoscopy course for medi-
simulators for laparoscopic training. They found that fresh cal students applying for a surgical specialty. Adv Med Educ Pract.
frozen cadaver was perceived as a better tool for laparoscopic 2013;4:103–15.
training. In 2016, Imakuma et al. reported the application of Giger U, Fresard I, Hafliger A, et al. Laparoscopic training on Thiel
fresh frozen cadavers for laparoscopic training without pneu- human cadavers: a model to teach advanced laparoscopic proce-
dures. Surg Endosc. 2008;22:901–6.
moperitoneum. They concluded that the use of fresh frozen Guion RM. On trinitarian doctrines of validity. Prof Psychol.
cadavers could provide a promising model for laparoscopic 1980;11:385–98.
training. However, the use of cadavers might raise several Halsted SW. The training of the surgeon. Bull John Hopkins Hosp.
ethic and financial issues which limit the widespread use of 1904;15:267–75.
Holden RB. Face validity. In: Weiner IB, Craighead WE, editors. The
cadaveric model. Corsini encyclopedia of psychology. 4th ed. NJ: Wiley; 2010.
p. 637–8.
Hung AJ, Ng CK, Patil MB, et al. Validation of a novel robotic-
3.4.5 Non-technical Skill Training assisted partial nephrectomy surgical training model. BJU Int.
2012;110:870–4.
Hung AJ, Shah SH, Dalag L, et al. Development and validation of
The nontechnical skill training was first reported in England, a novel robotic procedure specific simulation platform: partial
which refers to the evaluation of situation awareness, com- nephrectomy. J Urol. 2015;194:520–6.
munication, teamwork and decision making and leadership. Imakuma ES, Ussami EY, Meyer A. Laparoscopic training model using
fresh human cadavers without the establishment of pneumoperito-
Lee et al. (2012b) reported the experience in high-fidelity neum. J Minim Access Surg. 2016;12:190–3.
simulation-based training for laparoscopic complication Jiang C, Liu M, Chen J, et al. Construct validity of the chicken crop
management. They concluded that the nontechnical training model in the simulation of laparoscopic pyeloplasty. J Endourol.
might improve the interdisciplinary communication skills. 2013;27:1032–6.
Kang SG, Cho S, Kang SH, et al. The Tube 3 module designed for
practicing vesicourethral anastomosis in a virtual reality robotic
simulator: determination of face, content, and construct validity.
3.5 Conclusion Urology. 2014;84:345–50.
Kneebone R. Simulation in surgical training: educational issues and
practical implications. Med Educ. 2003;27:267–77.
With the advancement of optic technology, energy-based Laguna MP, Hatzinger M, Rassweiler J. Simulators and endourological
endoscopic equipment and computer science, the implemen- training. Curr Opin Urol. 2002;12:209–15.
tation of laparoscopic surgeries into surgeon’s daily practice Laguna MP, Arce-Alcazar A, Mochtar CA, et al. Construct validity of
is essential nowadays. The introduction of laparoscopic the chicken model in the simulation of laparoscopic radical prosta-
tectomy suture. J Endourol. 2006;20:69–73.
training into continuous medical education could provide a
3 Laparoscopic Training Using Cadavers 17
Lawshe CH. A quantitative approach to content validity. Pers Psychol. a prospective, single-blind, randomized, controlled study. J Urol.
1975;28:563–75. 2012;187:1861–6.
Lee JY, Mucksavage P, McDougall EM. Simulating laparoscopic renal SAGES. Guidelines for granting of privileges for laparoscopic and/or
hilar vessel injuries: preliminary evaluation of a novel surgical train- thoracoscopic general surgery. Society of American Gastrointestinal
ing model for residents. J Endourol. 2012a;26:393–7. Endoscopic Surgeons (SAGES). Surg Endosc. 1998;12:379–80.
Lee JY, Mucksavage P, Canales C, et al. High fidelity simulation based Satava RM. Surgical education and surgical simulation. World J Surg.
team training in urology: a preliminary interdisciplinary study on 2001;25:1484–9.
technical and nontechnical skills in laparoscopic complications Sharma M, Horgan A. Comparison of fresh-frozen cadaver and high-
management. J Urol. 2012b;187:1385–91. fidelity virtual reality simulators as methods of laparoscopic train-
Matsuda T, McDougall EM, Ono Y, et al. Positive correlation between ing. World J Surg. 2012;36:1732–7.
motion analysis data on the LapMentor virtual reality surgical simu- Traxer O, Gettman MT, Napper CA, et al. The impact of intensive lap-
lator and the results from videotape assessment of real laparoscopic aroscopic skills training on the operative performance of urology
surgeries. J Endourol. 2012;26:1506–11. residents. J Urol. 2001;166:1658–61.
Poniatowski LH, Wolf JS Jr, Nakada SY, et al. Validity and acceptabil- Tunitsky E, Murphy A, Barber MD, et al. Development and validation
ity of a high-fidelity physical simulation model for training of lapa- of a ureteral anastomosis simulation model for surgical training.
roscopic pyeloplasty. J Endourol. 2014;28:393–8. Female Pelvic Med Reconstr Surg. 2013;19:346–51.
Sabbagh R, Chatterjee S, Chawla A, et al. Transfer of laparoscopic Vaziri M. Laparoscopic surgical education. J Minim Invasive Surg Sci.
radical prostatectomy skills from bench model to animal model: 2013;2:1–2.
Simulation Training of Laparoscopy
4
Kazuhide Makiyama
Abstract 4.1 Introduction

Simulators are often used as educational tools for training
surgeons in laparoscopic procedures. Some surgical sim- Surgical techniques have advanced in the past three decades.
ulators have been proven to shorten clinical learning In the urological field, the majority of major surgical proce-
curves, and it was demonstrated that techniques learnt by dures that were performed using open methods have been
using a simulator can be brought into the operation room. replaced by laparoscopic and robotic techniques. Now, in
Laparoscopic surgical simulators can be classified into high-volume centers, open surgery is only conducted in lim-
box and virtual reality type. Box-type simulators are ited and complicated cases, for example, those involving
cheaper and have a superior array of surgical tools. By bulky tumors or tumors affecting the major vessels, etc. When
using box trainers, trainees are able to use and become open surgery is performed by a trainee surgeon, a trainer will
familiar with real surgical tools. Box trainers are perfectly be in front of the trainee, both the trainer and trainee share the
suited for learning suturing and knot tying. Virtual reality operative field and the trainer can freely manipulate and con-
simulators are generally more expensive than box train- trol the operation easily. On the other hand, in laparoscopic
ers. The main advantage of virtual reality simulators is surgery the surgeon is basically alone, and scopists and assis-
that every movement of the forceps is recordable in vir- tants are supposed to concentrate on their own roles. When
tual space. Thus, the recorded data can be analyzed, and trainers want to manipulate and control such surgery, they
trainees’ skills can be assessed objectively. Patient- have to remove the trainee from the surgeon’s position. So, it
specific simulators represent a new technological is more difficult to teach surgery to trainees without sacrific-
advancement. They provide patient-specific training, in ing surgical “smoothness” in laparoscopic procedures. Thus,
which patients’ three-dimensional imaging data are used laparoscopic procedures are considered to be difficult to learn
to create virtual reality simulations. and teach. For this reason, trainees have to be well educated
It is necessary to evaluate the usefulness and adequacy outside of the operative room before they perform laparo-
of laparoscopic simulators. There are several ways to vali- scopic surgery for the first time. In addition, surgeons are sup-
date laparoscopic simulators, including both subjective posed to acquire most of the knowledge and skills required
and objective methods. Subjective simulator evaluations for a particular surgical procedure by themselves. Training
assess face and content validity, whereas quantitative outside of the operation room can shift the learning curve
evaluations examine construct, concurrent, and predictive from inside to outside of the operation room and minimize the
validity. clinical learning curve. Simulations offer the opportunity for
surgeons to improve their technical skills in a structured, low-
Keywords pressure environment outside of the operation room without
Simulator · Laparoscopy · Training putting patient safety at risk (Gava 2004).
Surgical simulators are one of the tools used for training
outside of the operation room. The need for surgical simula-
tors has increased with the rise of surgical technology and so
the market for them has expanded. Some surgical simulators
have been proven to shorten clinical learning curves. In fact,
K. Makiyama (*) it was demonstrated that techniques obtained from s imulators
Department of Urology, Yokohama City University Graduate
can be brought into the operation room. In this chapter, we
School of Medicine, Yokohama, Kanagawa, Japan
e-mail: makiya@yokohama-cu.ac.jp review laparoscopic surgical simulators.

20 K. Makiyama
4.2 he Use of Simulators Laparoscopic

T created by VR technology to train surgeons in surgical pro-
Surgery Training cedures and hand-eye coordination. VR-type simulators are
task trainers. Mission rehearsal simulators are mainly used to
Training for laparoscopic surgery requires the trainee to determine the risks of surgery in advance via preoperative
acquire both knowledge and skills. At present, knowledge can surgical training with a patient-specific model and to improve
be obtained from academic conferences, academic websites, the surgeon’s skills to minimize risks during the actual oper-
textbooks, and videos. On the other hand, skill training is per- ation. Patient-specific simulators are mission rehearsal simu-
formed using simulators, animals, or cadavers. Although train- lators. In general, the technical difficulty and cost of a system
ing using animals or cadavers is useful, it is expensive, and increase from classifications (1) to (3).
trainees have few chances to participate in such training.
Conversely, simulator training can be performed repeatedly
from day to day and is useful for skill acquisition. In the past 4.4 Box-Type Simulators (Box Trainer)
two decades, the laparoscopic simulator market has expanded.
As simulators are not affected by ethical or hygiene issues, it Box trainers are superior to other types of simulator in terms
is expected that the need for surgical simulators will increase. of their cost and surgical tools. Box trainers are relatively
By using laparoscopic surgical simulators, surgeons can train cheap. In box trainers, trainees are able to use and become
for laparoscopic surgery outside of the operating room. If sim- familiar with real surgical tools. Box trainers are perfectly
ulators are appropriately incorporated into surgical training, suited to basic training, e.g., learning suturing and knot
they are considered to be a time-saving, cost-effective, and tying. Although some VR simulators have suturing and knot-
safe method of training (Le et al. 2007). In addition, some sur- tying applications, box trainers seem to be the best type of
geons and urologists recognize simulators as important tools simulator for training that requires fine manipulation and
for laparoscopic surgical training (Le et al. 2007; Korndorffer tactile sensation, especially for knot tying. Repeated training
Jr et al. 2006; Fried et al. 1999), and several randomized trials with a trainer could provide maximal benefits for trainees in
have reported that the use of virtual reality (VR) surgical simu- terms of allowing them to acquire adequate suturing and
lators can improve performance in the operating room knot-tying skills. Through such repetitive training, trainees
(Aggarwal et al. 2007; Grantcharov et al. 2004; Haque and obtain hand-eye coordination (Fig. 4.1).
Srinivasan 2006; Palter and Grantcharov 2014). Although box trainers are commercially available from a lot
In the United States, FLS (Fundamentals of Laparoscopic of companies, they can be “scratch built”(Aslam et al. 2016),
Surgery) certification is required for American Board of which can be a cost-effective way of acquiring laparoscopic
Surgery Certification. The FLS process consists of hands-on
manual skill practice and training via a box-type simulator. It
was reported that undergoing FLS laparoscopic surgery
training to proficiency levels can improve trainee perfor-
mance (Sroka et al. 2010).
4.3 Classification of Laparoscopic

Surgical Simulators
Table 4.1 shows a surgical simulator classification. As indi-

cated in the table, part-task trainers are designed to train sur-
geons in the handling of tools during surgery. Box trainers
are part-task trainers. Task trainers use virtual human bodies Fig. 4.1 Training using a box trainer
Table 4.1 Classification of laparoscopic surgical simulators

Surgical Basic Patient-specific
Classification Typical example Applications tools training Procedure-specific training training
(1) Part-task Box trainers Mechanical Real Possible Possible with a good Impossible
trainers model
(2) Task trainers Common VR simulators Virtual Virtual Possible Possible Impossible
reality
(3) Mission Patient-specific Virtual Virtual Possible Possible Possible
rehearsal simulators reality
4 Simulation Training of Laparoscopy 21
skills. Low-cost alternatives are needed to allow trainees to neys, stomach, lungs, liver, colon, and blood vessels, etc. By
practice and develop their laparoscopic skills outside of the using such three-dimensional organ models in a box trainer,
workplace (Li and George 2017). A portable bookbinder- trainees can participate in more realistic training involving
sized box trainer that is used in combination with a smartphone real surgical tools. Figure 4.3 shows examples of three-
has been developed (http://www.g-mark.org/award/ dimensional kidney models that are used for partial nephrec-
describe/42712), and a box trainer that incorporates an iPad has tomy training. They can be cut and sutured freely. These
been reported to be effective (Ruparel et al. 2014). As described three-dimensional organ models can be used to reduce and
above, trainees can create homemade box trainers by them- replace animal training. In addition, they might bridge the
selves, which can be beneficial in terms of cost and space. gap between real surgery and VR simulators.
Another important issue for box trainers is image quality. Another recently developed technology is the suture eval-
Recently, in response to surgeons’ requests, it has become uation system (https://www.kyotokagaku.com/products/
possible to obtain high-quality laparoscopic images. However, detail01/m57.html). This system includes a personal com-
many box trainers still only produce low-quality images. puter, a camera, a suturing unit, and a suture pad with pres-
Thus, it will be necessary to improve the image quality of box sure sensors. It can evaluate a surgeon’s skill, the procedure
trainers in order to facilitate high-quality training. Achurra time, the force placed on a particular tissue, suture tension,
et al. (2017) reported that box trainer image quality is an stitch spacing, and stich equidistance (Ieiri et al. 2013).
important issue. Although this product seems to be a bit expensive, an increase
You can place any material in a box trainer and freely in demand might reduce the price, and it has the advantage of
practice whatever skills you want. Traditionally, chicken allowing objective assessments to be carried out.
meat and mandarin oranges are used for dissection training.
Bimanual coordination skill can be obtained by trimming
chicken skin from poultry or finding and dissecting nerves or
blood vessels from poultry. In addition, trainees peel skin
from mandarin oranges using laparoscopic forceps. During
such skin-peeling training, rough dissection will cause the ADA DVC
orange to rupture, leading to the release of juice. Therefore, Bladder
trainees try to carefully dissect such oranges so that they do Urethra
not release the juice. Sponge and rubber goods of moderate
size and hardness can be used for suturing training. Thus,
appropriate training can be conducted using everyday items. PDA RUM
It is important to have an aim during training. Training for
Denonvillier
certain procedures or situations can also be conducted using
ordinary goods. For example, Fig. 4.2 shows a vesicourethral
anastomosis model composed of sponge, chicken, and rub-
ber tubing. The sponge mimics the pelvic floor, anterior rec-
tal wall, and deep dorsal complex; the chicken represents the
bladder; and the rubber tube mimics the urethra. Fig. 4.2 A vesicourethral anastomosis model. In this model, chicken
meat, sponge, and rubber tubing are used to mimic the bladder,
Recently, with the rise of three-dimensional printers and Denonvilliers’ fascia, deep dorsal vein complex (DVC), anterior detru-
advances in material engineering, three-dimensional training sor apron (ADA), posterior detrusor apron (PDA), rectourethral muscle
models have been developed, including models of the kid- (RUM), and urethra
Fig. 4.3 Examples of

three-dimensional kidney
models used for practicing
partial nephrectomy
Another random document with
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He raised his stick. It was a thick, heavy stick of acacia wood, hard as
iron: had he brought it down on Yubra's head he would have killed him. But
God saved them both. Their eyes met and it was as though Maïta had
looked at Khnum.
He slowly lowered the stick without touching Yubra's head, staggered

and fell into his chair, burying his face in his hands. He was motionless for
a few minutes, then he uncovered his face and said, without looking at
Yubra:
"Away with you! Begone! You are not a slave to me any more. Untie his
hands and let him go, no one is to interfere with him. I have pardoned him."
"Perhaps I was wrong," said Dio to Pentaur, as she walked with him
across the garden to Tuta's boat in the canal. "Perhaps you Egyptians can
rebel after all...."
"You judge by Yubra?" Pentaur asked.
"Yes. Have you many such?"
"Yes, we have."
"Well, then, there is sure to be rebellion. How strange it is, Taur: you
and I have just been disputing whether the Son had come already or is to
come, and here is the same thing over again..."
"It is the same thing everywhere."
"And the rebellion is about this, too?" Dio asked.
"Yes, it is. You are glad?"
Dio did not answer, she seemed lost in thought. Pentaur paused, too, and
then said:
"Perhaps the world will perish through this...."

"Let it!" she answered, and it seemed to him that the fire of rebellion
was already burning in her eyes. "Let the world perish if only He will
come!"
IV
he boat was brought to the gates of Khnum's garden by the

Big Canal which united the southern part of the city with
the north—Apet-Oisit, where the throne of the world, the
Temple of Amon, stood.
Hearing that Tuta had put off his meeting with her for a
few hours, Dio decided to pass these hours—perhaps the last—with
Pentaur: she had not made up her mind yet whether she was going away the
next day. She wanted, too, to say good-bye to Amon's Temple; she had
grown to love this house of God, the largest and most beautiful in the world,
because it was through it she had entered Egypt.
Surrounded by walls, three enormous sanctuaries of Amon, Khonsu,

and Mut—the Father, the Son, and the Mother—towered above the endless
multitude of low, grey, flat houses made of river mud, like swallows' nests.
Within the walls there were copses, gardens, ponds, cattle-yards, cellars,
granaries, breweries, perfumeries and other buildings, a town within the
town, the City of God in the city of men.
During King Akhnaton's reign the place fell into decay: the holy
enclosures had been destroyed, the treasuries robbed, the sanctuaries closed,
the priests driven away and the gods desecrated.
Having reached by boat the holy Road of the Rams, Dio and her nurse
Zenra, stepped into a litter and Pentaur walked by their side.
Turning to the right into a by-road to the sanctuary of Mut, they entered
it through the northern gates.
The sacred lake of the god Khonsu, Osiris the Moon, shone, crescent-
shaped, with a silvery brilliance. The rosy granite of the obelisks, the black
basalt of the colossi, the yellow sandstone of the pylons, the green tops of
the palms, bathed in the molten gold of the afternoon sun, were mirrored in
the water with such clearness that one could see every feather in the
rainbow-coloured Falcons of the sun at the top of the pylons and every
hieroglyphic in the multi-coloured inscriptions on the yellow sandstone; it
was as though there were another world down there, the reverse of this one,
exactly like it and yet quite different.
By the shores of the lake some sandpits had been dug, probably in order
to defile the holy waters, and bricklayers were getting clay from them. The
lake in those places was shallow, its slimy bottom could be seen and the
stagnant water in the pools had a dull rainbow glitter on the surface. A huge
statue of the god Amon, of dark-red sandstone, had been thrown near by,
face downwards, and an ox, standing knee-deep in water, was scratching its
mud-coated side against the sharp end of one of the two feathers in the
god's tiara; the smell of the pig-sty came from the animal.
Next to the pits was a sanctuary of immemorial antiquity consecrated to

two goddess-mothers, Hekit the Frog, and Tuart the Hippopotamus.
At the beginning of the world the divine Frog, the midwife, crawled out
of the primaeval slime and at once began to help all women labouring of
child; she helped the birth of Khonsu-Osiris, the son of God; she helped
every dead man to rise again and be born into eternal life. Tuart, the
Hippopotamus, was as efficient a help in labour.
The copper doors of the sanctuary were locked and sealed, but in the
entry the two goddesses were hidden from the king's spies in two vaulted
niches in the wall, behind torn curtains. The huge frog made of green jade
with kind and intelligent round eyes of yellow glass, was sitting on its
cubical throne. The pig-faced Hippopotamus, in a woman's wig, was
ferociously showing its teeth; made of grey obsidian, with hanging breasts
and monstrous belly, it was standing on its hind legs, holding in its
forepaws the sign of eternal life—the looped cross Ankh.
A little girl of twelve, an Ethiopian, in the last stage of pregnancy, had

placed a wreath of lotus flowers round the neck of the goddess and,
kneeling before her, was ardently praying with childish tears for easy
travail.
Zenra wanted to sacrifice to the mother-goddesses two turtle doves for

Dio, that the virgin might at last become a mother.
They went into the portico. An old priestess, who looked rather like her
goddess, the Frog, was bathing in a copper basin of warm water two sacred
ichneumons, water animals something between a cat and a rat, beloved by
the god of the floods, Khnum-Ra. After the bath the creatures ran away,
playing; the male chased the female.
"Pew-pew-pew!" the priestess called them quietly and began feeding

them out of her hands with bread soaked in milk, muttering a prayer about a
propitious flood.
Then she went down to the lake and called:
"Sob! Sob! Sob!"
There was a splash at the other end of the lake and, thrusting out its
shining, slimy black head, a huge crocodile, some nine feet long, sacred to
Sobek, the god of the Midnight Sun, rapidly swam across in answer to the
call. Brass rings with bells glittered on its front paws, there were rings in its
ears and a piece of red glass was stuck into the thick skin of the head in the
place of the ruby that had been stripped from it. The crocodile was so tame
that it allowed its attendant to clean its teeth with acacia charcoal.
It crawled out of the water and stretched itself at the feet of the
priestess. Squatting before it she fed it with the meat and the honey cakes
brought by Zenra, fearlessly thrusting her left hand into the open jaws of the
beast; her right hand had been bitten off by the crocodile while she was still
a child.
"I wish it had eaten me altogether," the old lady used to say, "I then
wouldn't have to see what is going on now."
She did not go on to say "under the apostate king."
To be devoured by a sacred crocodile was regarded as a most happy

death: there was no need to embalm or bury the body—one went straight
from the holy belly into paradise.
With motherly tenderness the old priestess stroked the monster on its
scaly back, calling it 'Sobby,' 'little one,' 'ducky.' And it was strange to see
the beast's pig-like eyes gleam with responsive affection.
"Well, how did you like our crocodile mother?" Pentaur asked Dio with
a smile when they came out of the portico, leaving Zenra behind and telling
the litter to go on.
"I liked her very much," Dio answered, smiling also.
"Does it make you laugh?"
"No. Your Mut and our Ma is the same Heavenly Mother who blesses
all the creatures of the earth."
"How then could you...." he began and broke off. But she understood
'how then could you have killed the god Beast?'
"Our secret wisdom teaches," he said hurriedly, in order to hide her

confusion and his own, "that animals are nearer to God than men, plants are
nearer to God than animals and the dust of the ground—Mother Earth—is
nearer to God than plants; a mass of flaming dust, the sun, is the heart of the
world—God."
"Doesn't he know this?" Dio asked.
"No," Pentaur answered, guessing that she was speaking of King

Akhnaton, "if he knew he would not desecrate the Mother."
"Perhaps there is something that I, a childless virgin, don't know either,"
Dio thought.
From the sanctuary of Mut they walked towards the Temple of Amon,
along the sacred road of the Rams, huge creatures of black granite placed in
a row on either side of the pathway. On the top of the head between the
horns that curled downwards, each ram had the sun disc of Amon Ra, and
between the doubled up front legs a tiny mummy of King Amenhotep,
Akhnaton's father: the god-beast was embracing the dead king, carrying
him, as it were, into eternal life.
It seemed to Dio they all looked at her as though they would say
"Decide!"
They came up to the pylon—the huge gates shaped like a pyramid cut
off at the top, with a rainbow-coloured sun disc with rays and high posts for
flags; it stood at some distance from the Temple. On either side of it were
two granite giants, exactly alike, representing King Tutmose the Third,
Akhnaton's great-great-grandfather, the first world-conqueror. Wearing
gods' tiaras, they were sitting on their thrones with their arms folded in
everlasting rest, with an everlasting smile on the flat lips. Above them the
wretched tatters of old flags fluttered on the broken posts. The birds nesting
in the tiaras chirruped loudly, as though laughing, and the black faces of the
giants were streaked with white.
Pentaur read aloud the hieroglyphic inscription on the gates—the words

of the god to the king:
"Rejoice, my son, who hast honoured me. I give thee the earth in length
and breadth. With a joyful heart pass through it as a conqueror."
And the king's answer to the god:
"I have made Egypt the head of all nations, for together with me it has
honoured thee, god Amon on high."
From the way Pentaur read the inscription Dio understood that he was
comparing the great ancestor with the insignificant descendant.
Passing through the gate, and leaving the road ta the Khonsu sanctuary
on their left, they came out into the square. Men of all classes—beggars,
slaves and grand gentlemen—were standing there in separate groups
without speaking, as though waiting for something, and when the town
guards on duty went past looked at them sullenly from a distance. All was
quiet, but Dio suddenly remembered: "Rebellion!"
Someone came up to Pentaur stealthily from behind. The man's woollen

striped Canaan cloak, worn over the Egyptian white robe, his reddish goat's
beard, the curly hair hanging down his cheeks, the prominent ears, hooked
nose, thick lips and the hot glitter in his eyes, made Dio recognize him at
once for a Jew.
Pentaur whispered something in his ear; the man nodded silently,

glanced at Dio and disappeared in the crowd.
"Who is this?" Dio asked.
"Issachar, son of Hamuel, a Jewish priest of Amon."
"But how can an unclean Jew be a priest?"
"He is a Jew on his father's side, but an Egyptian on his mother's. Their
prophet, Moses, was also a priest in Heliopolis."
"But why is he not shaven?"
Dio knew that all Egyptian priests shaved their heads.
"He is hiding from the king's spies," Pentaur answered.
"What did you speak to him about?"
"About your meeting Ptamose."
They came to the western gates of Amon's temple; the leaf gold that
covered them glowed like fire in the light of the setting sun. Three words
had been inscribed on them in hieroglyphics of dark bronze: "Amon, great
spirit." The word Amon was effaced, but that made the other two words
glorify the Unutterable the more.
Guards were standing by the closed and sealed gates. People going past
knelt down and kissed the dust of the holy flagstones, praying in a whisper;
they would be thrown into prison for calling on the name of Amon aloud.
Dio showed the chief of the guards the ring with Tutankhaton's seal and
he let her and Pentaur through the side door of the gates.
They entered the inner court that had rows of such gigantic columns,
shaped like sheaves of papyrus, that it was hard to believe they were the
work of human hands: it seemed as though the Great Spirit had piled up
these everlasting stones as a mute praise to himself, the Unutterable.
From the yard they came into a covered antechamber, where the
daylight came sparsely from narrow windows right under the ceiling. There
was sunshine in the yard, but here it was half dark already and the thick
forest of columns, saturated with the fragrance of incense like a real forest
smelling of resin, seemed all the more huge in the twilight. And it was quiet
as in a forest; only up at the top one could hear a faint tapping that sounded
like woodpeckers. "Knock-Knock-Knock!"—and there was stillness, and
then again: "Knock-knock-knock!"
Dio raised her eyes and saw masons hung up in hammocks on long
strings, like spiders on cobwebs, hammering on the walls and the pillars up
above.
"What are they doing?" she asked.
"Effacing Amon's name," Pentaur answered with a smile. Dio smiled,

too; the knocking seemed to her absurd: how could one efface the name of
the Unutterable?
As they went further into the temple the walls narrowed down, the
ceilings grew lower, darker and more menacing, and at last an almost
complete darkness enveloped them; only somewhere in the far distance a
lamp was burning dimly. That was the Holy of Holies—Sehem, the
tabernacle, cut out in a block of red granite, where in the old days a golden
statuette of god Amon, a foot high, had been kept behind linen draperies—
the sails of the holy boat. Now Sehem was empty.
A narrow passage led from it to another tabernacle where in the past

Amon's great Ram, the sacred Animal—the living heart of the temple—lay
on a couch of purple in clouds of the ever-burning incense. But now this
tabernacle too was empty; people said that a dead dog's bones had been
thrown into it to defile the holy place.
"He does not know God's darkness either?" Dio asked.
"No," Pentaur answered, understanding again that 'he' meant the king.
"He knows that God is light, but he does not know that darkness and light
go together...."
He knelt down and Dio knelt beside him; he began to pray and she
repeated after him:
"Glory to thee, who dwellest in darkness,
Amon, the Hidden,
Lord of the silent,
Help of the humble,
Saviour of those in hell!
When they cry aloud to thee,
Thou comest to them from afar,
Thou sayest to them 'I am here!'"
They bowed down to the ground and Dio felt that the hair on her head
moved with awe: 'He is here!'
They left the temple through the eastern gates where the litter was
waiting for them. They got into it and were carried to the small temple
Gem-Aton—Sun's Radiance—which had only just been built by King
Akhnaton.
It had taken a thousand years to build Amon's temple of huge blocks of
rock, and this one had been built quickly of small stones; Amon's temple
was dark and mysterious, and this one was all open and sunny. There were
no divine images in it except Aton's disc, with rays like hands descending
from it.
They entered one of the porticos, on the wall of which there was a bas-
relief of King Akhnaton making a sacrifice to the Sun god.
Dio looked at it dumb foundered. Who was it? What was it? A human
being? No, it was some unearthly creature in human form. Neither a man
nor a woman, neither an old man nor a child; a eunuch, a decrepit still-born
baby. The arms and legs were so thin that they seemed to be nothing but
bone; narrow childish shoulders and wide, well-covered hips; a big belly; a
huge head shaped like a vegetable-marrow, bent down under its own weight
on a long thin neck, flexible like the stem of a flower; a receding forehead,
a drooping chin, a fixed stare and the smile of a madman.
Dio gazed at this face, trying in vain to recall something. All of a

sudden she remembered.
In the Charuk Palace near Thebes, where Akhnaton was born and spent
his childhood, she had seen his sculptured head: a boy looking like a girl; an
oval, egg-shaped face, childishly, girlishly charming, quiet and gentle as
that of the god whose name is Quiet-Heart.
A man dreams sometimes a dream of paradise, as though his soul

returned to its heavenly home; and long after waking he refuses to believe
that it had only been a dream and is full of sadness and yearning. Such was
the sadness in that face. The drooping eyelids were heavy as though with
sleep, the long eye-lashes seemed wet with tears and the lips wore a smile
—a trace of paradise—heavenly joy through earthly sadness, like sunshine
through a cloud.
"Can it be the same face?" Dio wondered. As in delirium the beautiful

face was distorted, grown decrepit and monstrous, and, most awful of all,
one could still see that young face in this changed one.
"Well, don't you know him?" Pentaur whispered. There was horror in
his voice and mockery, too—triumph over an enemy. "No, he is not easy to
recognize. But it is he, Joy of the Sun, Akhnaton!"
"How did they dare insult him like this!" Dio cried out.
"No one would have dared if he had not asked for it himself. It is he
who teaches painters not to lie, not to flatter. 'Living in Truth'—Ankh-em-
Maat—so he calls himself, and this is what truth is; he did not want to be a
man, so this is what he has become!"
"No, that's not it, that's not it!" a voice said behind Dio.
She turned round and recognized Issachar, son of Hamuel. "No, that's
not it. The deception is worse and more subtle!" he said looking at the face
of the bas-relief.
"What deception?" Dio asked.
"Why, this: listen to the prophecy. 'As many were astonied at Him: His
visage was so marred more than any man, and his form more than the sons
of men. And we hid our faces from Him. But He has borne our griefs and
carried our sorrows. The chastisement of our peace was upon Him: and with
His stripes we are healed.' Do you know of whom this has been said? ...
And who is this man? Accursed, accursed, accursed is the deceiver who
said 'I am the Son'!"
Slowly, as though with an effort, he averted his eyes from the bas-relief
and looking at Dio bent down to whisper in her ear:
"The high priest of Amon expects you to-day at the third hour after
sunset." And covering his head with his cloak he walked out of the temple.
For a few minutes Dio stood as though spellbound. She was so lost in
thought that she did not hear Pentaur call her twice and when he gently
touched her hand, she started.
"What is it? What are you thinking of?" he asked.

"I hardly know myself..." she answered, with a shy, as it were, guilty
smile, and then added, after a pause:
"Perhaps we don't any of us know the most important thing about

him...."
She paused again and then cried with such agony that Pentaur thought
she was like one dying of thirst and asking for water:
"Oh, if I only knew, if I only knew who he is!"
utankhaton had spread a rumour that he was the son of

King Amenhotep IV, Akhnaton's father. Tuta's mother,
Meritra, was one of the king's concubines for a day—he
had numbers of such. Gossips said, however, that Tuta's
father was not the king, but the king's namesake,
Amenhotep, the chief of the Surveying Office. Thanks to
his mother, Tuta had obtained, as a child, the rank of the prince's play-
fellow, and he rapidly made a career: royal chamberlain, chief fan-bearer on
the right hand of the divine and gracious king, treasurer of the king's
household, bread-giver of the Two Kingdoms, defender of Aton's faith and,
finally, the king's son-in-law, husband of Ankhsenbatona, Akhnaton's
twelve-year-old daughter.
No one could look up to heaven as devoutly as he did, whispering in a

honeyed voice:
"Oh, how salutary is your teaching, kind Uaenra, the only Son of the
Sun!"
Or compose such pious inscriptions for tombs: "Akhnaton, the Son of
the Sun, rose early in the morning to lighten me with his light for I was
zealous in carrying out his words," said one of those inscriptions. "I have
followed thee, O Lord Aton—Akhnaton!" said another.
This identification of the king with God seemed absurd and

blasphemous, since everyone knew that Aton was the Father and the king
the son. But when it was known that these words expressed the king's secret
doctrine about the perfect unity of the Father and the Son, people marvelled
at Tuta's cunning.
The courtiers vied with one another in trying to revile the old god
Amon. But Tuta surpassed them all: he ordered for himself a pair of plaited
sandals made of golden straps, with Amon's face on the soles so as to tread
on the unholy one with every step he took. And everyone marvelled again
—they understood that he would go far in those sandals.
Tuta had been sent to Thebes with the title of Viceroy to carry out the
decrees about taking away burial grounds from the priests and desecrating
the god Khonsu, Amon's Son.
When Dio came to the Viceroy's white house the old servant, who knew
her, met her with low bows and wanted to tell His Highness at once about
her. But hearing that Tuta was having lunch with the chief of the Lybian
mercenaries, Menheperra, a man whom she disliked, she said she would
wait and going into an inner room, lay down on a low day-couch. Watching
the slanting pink oblongs cast by the setting sun on the white ceiling
through the long narrow slits of windows high up on the wall she sank into
deep thought, as in the antechamber of Gem-Aton's temple: was she to go
or not to go?
She grew tired of thinking and dozed. Two big flies were buzzing by her
very ear as though disputing "to go or not to go?"
She woke up suddenly and grasped that it was not the buzzing of flies
but a whisper, somewhere quite close to her ear. She looked round, but there
was no one there. The whisper came from the next room, which was
divided off by a latticed partition covered with a carpet; Egyptian rooms
were sometimes arranged in this way for the sake of coolness. The speakers
were probably sitting on the matting-covered floor just by the side of Dio's
couch.
"This heartburn will be the death of me," whispered one of the voices,
dignified and elderly.
"It's the goose's liver, father," answered the other voice, high-pitched
and respectful. "Would you like some telek? There is nothing like it for
indigestion; with lemon and cardamon it is most refreshing."
There was a sound of liquid being poured out
"Have a drink too, Sparrow?"
"Your health, father!"
"Why do you call me 'father'?"
"Out of respect: you're my benefactor and that's as good as a father."
"It is a good thing you respect old people. And why do they call you
'Sparrow'?"
"Because I pick up a grain out of every bit of business like a sparrow

out of a manure heap."
"Come now, don't be so modest about it: you must have grabbed 'the
man with the pig' from the cemetery thieves the other day...."
Dio remembered that a man holding a pig by the tail was the
hieroglyphic of lapis-lazuli, the Egyptian officials' favourite bribe—Hez-
Bet: hez—to hold and bet—a pig, and that the tomb of the ancient King
Saakerra had been robbed recently.
"And so I was saying, Ahmez, son of Aban, is a foolish man and no

good will come of him," the old man's voice went on. "You may pound a
foolish man in the mortar, but his foolishness will not leave him, and it is
better to meet a savage bear in a field than a foolish man in the house!"
"But in what way is he foolish, father?"
"Why, because he never knows which way the wind is blowing. There is
trouble brewing up in the town and the Lybian soldiers are mutinous
because they haven't had their pay for the last six months. And he, the fool,
is afraid of a rising, so he was delighted when the pay-money was sent the
other day from the king's treasury and ordered it to be distributed straight
away. But I was too sharp for him—I said nothing to him but kept back the
money and at once reported the whole thing to His Highness the Viceroy.
And what do you think? He thanked me, said 'well done,' patted me on the
cheek and promised to get me a job in his service. What do you think of that
now?"
"Splendid, father! There is no one like you for giving one a hint! ... But
if there really is a rising, it will be bad, won't it?"
"Bad for some and good for others. A fool burns in the fire and a clever
man warms his hands at it...."
The whisper became so low that Dio could not hear. Then it grew louder
again:
"Impossible, impossible, father! Who could presume to do such a

thing?"
"Do you know Issachar, son of Hamuel?"
"But he is a coward, it isn't for a dirty Jew like him to do it!"
"He is a coward, but he can work himself up to a frenzy. They are all
like that, the Jews: they are cowards, but if it is anything to do with their
God they are frantic. And it is not only he—he is merely the knife, and the
hand that holds the knife is strong. Soon there will be things happening to
make one dizzy, my lad."
"It is dreadful to think of, father."
"Don't be uneasy, Sparrow—you may be a falcon yet."
Dio listened with her heart beating so violently that she was afraid they
would hear it behind the partition. She understood that a vile and evil plot
was being hatched against the king—and she seemed to have a share in it;
perhaps that was why she suffered so, unable to decide whether to go or to
stay.
Suddenly there was a sound of footsteps in the next room—not in the

one where they were whispering. Both halves of the door were flung open
and a huge hunting-cat, half panther, glided in noiselessly like a shadow;
behind it, as its guard of honour, came the runners, the fan bearers, the
bodyguards, and, last of all, walking barefoot as noiselessly as the cat—
shoes were taken off indoors—a slender and graceful young man of
medium height, with an ordinary pleasant face. He was wearing a plain
white robe, a smooth black wig, a broad necklace that came half way down
to his waist, and he held in his hand a long gilded wooden staff adorned
with a golden figure of the goddess Maat—Truth. This was the King's son-
in-law, the Viceroy of Thebes, the real or supposed son of King Amenhotep
—Tutankhaton.
He walked up to a carved ivory and ebony chair that stood on a platform

in between four pillars in the middle of the room, and sat down.
Approaching him Dio knelt before him. He kissed her on the forehead and
said:
"Rejoice, my daughter! The grace of the god Aton be with you! Leave
us," he added, addressing his suite.
When all had gone out of the room he moved to the day couch and, half
reclining on it, motioned to Dio to sit down beside him; but he did it
unobtrusively so that there was no need for her to notice the gesture unless
she chose to do so. She did not notice it and sat down opposite him on a
folding chair with a seat of plaited leather straps.
The cat walked up to her and rubbed itself against her legs, thrusting its
head between her knees and mewing loudly, unlike a cat. Dio disliked cats
and especially this one: she fancied it was a huge, black, slimy reptile. The
cat never left Tuta's side and followed him about like a shadow.
"Why are you sitting here alone? Why didn't you send in your name?"
he asked in a low caressing voice that sounded like a cat purring.
"You had a visitor."
"It was only your admirer Menheperra. Was that why you did not come
in?"
"Yes, it was."
"Ah, you wild creature! ... Come here, Ruru," he called to the cat, "You
have had enough of it?" he asked Dio.
"No, I don't mind," Dio said politely, but she would gladly have thrust
the clinging creature away.
"It is marvellous," he said, smiling and looking at her in the peculiar

masculine way she hated: 'just like spiders crawling about one's naked
body,' she used to say about these looks. "One cannot get used to you, Dio!
Each time I see you I cannot help marvelling at your beauty.... There,
forgive me, I know you don't like it!"
The cat lifted its face and looked straight into Dio's eyes with its fiery
pupils. She pushed it slightly away with her foot, afraid that the cat might
jump on to her lap.
"Come now, you are being a nuisance!" Tuta laughed, seized the cat by
its collar and, dragging it on to the couch, made it lie down, spanked it and
said "Sleep!"
"Well, how do matters stand? Are you coming?" he began in a different

and business-like voice. "Stop, wait, don't answer at once. I am not hurrying
you, but just think: what are you doing here, what are you waiting for?
Learning our dances? What for? Dance in your own way—they will like it
all the better. Foreign things are more fashionable with us nowadays than
our own...."
"I have decided..."
"Wait a minute, let me finish. I shall go away and you will remain alone
here and in these times you don't know from day to day what might
happen...."
"But I am coming!"
"Are you? Really? You won't play me false again?"
"No, now I want to go as soon as possible."
"Why so suddenly?"
She made no answer and asked:
"Are you going to-morrow for certain?"
"Yes. Why?"
"They say there may be trouble in the city."
"Oh, it's nothing. All will be over to-morrow. Of course it is a big town
and there are many fools about; they may want to die for their puppet and
then there is bound to be bloodshed, there is nothing for it...."
Dio understood that puppet meant the image of the god Khonsu.
"And does the king know it?" she asked.
"Know what?"
"That there may be bloodshed."

"No, he does not know. Why should he know? That he might revoke the
decree? If he revoked this one, others would still be in force. And what is
one to do? There is no teaching the fools without bloodshed!"
He sat up suddenly, put his feet on the floor, moved up to her, took her
by the hand and smiled in the ambiguous way, with a sort of wink, which,
again, there was no need for her to notice unless she chose to.
"You know, Dio, I have long wanted to ask you, why do you dislike me?
I have always been a friend to you. Tammuzadad saved you, but I, too, have
done something..."
Dio started and drew her hand away. Tuta pretended not to notice it and
continued to smile.
"Why do you think?...." she began, and broke off, blushing and looking
down. As always when she was alone with him she felt stiff, awkward—as
though she had done some wrong and been caught unawares.
"What do you want me for?" she asked suddenly, almost rudely.
"There, you treat me as you do Ruru: I am being nice to you and you
push me away," he laughed good-humouredly. "What do I want you for?
Feminine charm is a great power..."
"You want to get power through me?"
"Not through you, but with you!" he said quietly with deep emotion,
looking straight into her eyes.
"And I want you because of him," he went on, after a pause. "He is very
difficult to get on with; you will help me: you love him and so do I—we
shall love him together...."
She understood that he was speaking of King Akhnaton and her heart
began to beat as violently as when she was listening to the whisper behind
the partition. She felt that she ought to say something, but she was spell-
bound as in a nightmare: she wanted to push away the clinging reptile and
could not.
"You haven't been to see Ptamose yet, have you?" he asked suddenly, as
though they had often spoken about it, while, as a matter of fact, they had
never exchanged a word on the subject. Once more he caught her unawares
like a naughty little girl.
"What Ptamose?" she pretended not to understand, but did it so badly

that she was ashamed of herself.
"Come, come!" he said, with the same winking smile. "I won't betray
you, no one shall know of it. And even if they did know, what of it? I would
send you to him myself. He is a wise old man, a sage. He will tell you
everything; you will know what the war is about. Only babblers and court
flatterers imagine that we have won already. No, it is not so easy to conquer
the old faith. Our forefathers were not any stupider than we are. Amon—
Aton: is the dispute about a letter only? No, about the spirit. And indeed
Amon is the Great Spirit!"
When he had moved from the armchair to the couch he had taken with
him the staff with the gold sandals strapped to it. All of a sudden Dio bent
down, took up one of them, turned it sole upwards and pointed with her
finger to the image of Amon.
"And what have you here, prince? 'Amon the Great Spirit'?" she asked,
smiling with almost undisguised contempt, as though she were really
talking to a 'reptile.'
"There, you have caught me!" he laughed, good-naturedly, again. "Ah,

Dio, priestess of the Great Mother, you are still living on your Mountain
and refuse to come down to the earth to us poor men. And yet one day you
will come down, will get your feet muddy and bruise them against the
stones and be glad even of such sandals as these. One must have mercy, my
friend. Be sober and fast by yourself, but eat with the glutton and drink with
the drunkard. And as for the Great Spirit, I hope he will forgive me: my
sandals won't hurt him!"

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Abstract advances in endourology in East Asia. On November 19th,

1.1.1 History of EASE

© Springer Nature Singapore Pte Ltd. 2019 3

Table 1.4 Year of start of endourological procedures in EASE territories

been developed and used around the world (Miki and

Cases Table 1.5 Introduction of surgical robot da Vinci in EASE territories

Abstract 2.1 Training Models of Endourology

© Springer Nature Singapore Pte Ltd. 2019 7

Fig. 2.3 Live porcine model for laparoscopic training

Fig. 2.2 Space of the left

In addition to transurethral and laparoscopic procedures,

2.2 Virtual Reality Training

Virtual reality (AR) is defined as “Inducing targeted behav-

Fig. 2.7 AUSTEG trainers

Abstract ary change of laparoscopic procedures, redefines the horizon

© Springer Nature Singapore Pte Ltd. 2019 13

3.2 Evaluation of a Training Curriculum

3.4.1 Computerized Simulators 3.4.2.3 Ureteral Reimplantation

3.4.2.1 Partial/Radical Nephrectomy

3.4.4 Cadaveric Model Alemozaffar M, Narayanan R, Percy A, et al. Validation of a novel,

Abstract 4.1 Introduction

© Springer Nature Singapore Pte Ltd. 2019 19

4.2  he Use of Simulators Laparoscopic

4.3 Classification of Laparoscopic

Table 4.1 shows a surgical simulator classification. As indi-

Table 4.1 Classification of laparoscopic surgical simulators

Fig. 4.3 Examples of

He slowly lowered the stick without touching Yubra's head, staggered

"You judge by Yubra?" Pentaur asked.

"Yes. Have you many such?"

"It is the same thing everywhere."

"And the rebellion is about this, too?" Dio asked.

"Yes, it is. You are glad?"

"Perhaps the world will perish through this...."

he boat was brought to the gates of Khnum's garden by the

January 2019 Man Kay Li

Part I Endourology Training

1 Introduction of East Asian Society of Endourology

Part II Endourology Techniques

8 Multiple vs. Single Access PCNL �� 57

13 Robot-Assisted Radical Cystectomy: Technical Tips for Totally

Part III Advances in Endourology Technology

28 Handbook for Ureteral Stenting�� 225

29 Treatment of BPH: What Is the Gold Standard? �� 233

1.1.1 History of EASE

Abstract 2.1 Training Models of Endourology

2.2 Virtual Reality Training

3.2 Evaluation of a Training Curriculum

3.4.1 Computerized Simulators 3.4.2.3 Ureteral Reimplantation

3.4.2.1 Partial/Radical Nephrectomy

3.4.4 Cadaveric Model Alemozaffar M, Narayanan R, Percy A, et al. Validation of a novel,

Abstract 4.1 Introduction

4.2 he Use of Simulators Laparoscopic

4.3 Classification of Laparoscopic