Design of a non-biohazardous Simulation Model for Inflatable Penile Prosthetic Placement Using 3D Printing Technology: A Feasibility and Utility Study for Socially Distanced Education using Mixed reality technologies for remote proctoring

Introduction and Objective Today's educational landscape continues to evolve due to a technology infrastructure that enables increased accessibility and efficiency for students and educators. In an era when reduced opportunity for traditional teacher- student (“face-to-face”) learning is juxtaposed with the exponential growth of internet-based education (“e- Learning”), modern surgical educators are increasingly discovering ways to further utilize remote training platforms for advanced surgical training [1], [2], [3], [4]. While virtual reality is an artificial environment that is created with software and presented to the user in such a way that the user suspends belief and accepts it as a real environment, Augmented Reality (AR) technology superimposes a computer-generated image on a user's view of the real world, thus providing a composite view. Mixed reality (MR) technologies is a form of AR that allows for the fusion of two video streams for real time overlay of a remote instructors’ hands onto the trainee's view. Our objective is to examine the utility and feasibility of remote proctoring for Inflatable Penile Prothesis (IPP) surgical skills training using a previously validated full-procedural non-biohazardous hydrogel simulation model fabricated using 3D printing and hydrogel casting [5] when combined with Mixed Reality technologies. Methods 9 urology residents at the University of Rochester (PGY 1–4) were paired and remotely proctored by an expert at Boston University. During inflatable penile prothesis training sessions, participants and proctor were given a model, with a full surgical setup. Pre-learning included a narrated full-procedural demonstration by the proctor followed by a full procedure IPP simulation guided by proctor feedback. The trainees were wearing a Vuzix M4000 smart glasses (Rochester, NY) that house an ultra-bright see-through display utilizing waveguide optics to project a remote instructors’ hands onto the trainee's view through a MR technology application. Pre- and post-training surveys assessed confidence (0–100) and procedural knowledge (15 questions). Opinions on virtual learning and its application to this training session were collected. Results 66.7% residents had not performed a prior live IPP placement, while the remaining had completed a median (IQR) of 6 (4.5–8) cases. All measures of confidence and knowledge significantly increased after remote session (Table 1). Scores of the knowledge assessment increased by 13% [±7–18, p = 0.04] following the remote session which was reflected in a 48% [±22–46, p=<0.001], 22% [±9–27, p=<0.05] and 18% [±12–31, p = 0.005] increase in participants confidence in the ability to perform a simulated IPP procedure, knowledge of IPP procedural steps and knowledge of applied anatomy respectively. 77.8% (7/9) of residents had never experienced hands-on remote training due to the limited number of opportunities. All residents (100%) found the remote training session valuable and beneficial for training IPP skills as well as learning steps of the procedure. The residents highly rated the ability to practice complex skills with zero-patient harm (88.9%, 8/9), the non-biohazardous nature of the model (66.7%, 6/9), and having their own hydrogel training model (88.9%, 8/9). 66.7%, preferred a hybrid (virtual combined with in-person learning) for future sessions. Limitations include the low sample participants. Conclusions Remote proctoring using a MR technologies and non-biohazardous IPP simulation model is feasible with improvement in both confidence and procedural knowledge thus providing its utility. This approach has the potential to provide opportunities for hands-on distance training with remote experts in a safe environment.