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Farinha et al. Mini-invasive Surg 2023;7:38 https://dx.doi.org/10.20517/2574-1225.2023.50 Page 3 of 14

the TM to clinical PN were included. Other inclusion criteria were the use of objective metrics to measure
task execution or subjective assessments of PN performance using the scores of global evaluative assessment
of robotic skills (GEARS) or global operative assessment of operative skills (GOALS) [9,13-29] .

Disagreements regarding eligibility were resolved by discussion between the two investigators until a
consensus was reached regarding the studies to be included. The level of evidence was assigned according to
[30]
the Oxford Center for Evidence-based Medicine definitions . This article does not contain any studies
involving animals performed by any of the authors.

RESULTS
Study selection
Figure 1 shows the flow of studies through the screening process. A total of 331 papers were blindly
screened by two reviewers (Farinha RJ and Mazzone E) by reading all titles and abstracts, with 16 of these
records included for further evaluation based on predefined eligibility criteria. At this point, the final
evaluation for inclusion in the quantitative analysis was carried out by three reviewers (Gallagher AG,
Farinha RJ, and Mazzone E), who selected 14 manuscripts.

Evidence synthesis
Training models
The final screened manuscripts included four animal-based, eight 3D printed, and two VR TM studies for
PN procedural training. Animal TMs were used in vivo , but more commonly, ex vivo [9,15,16] models
[14]
employing porcine kidneys were employed. Pseudo-tumors were created either through percutaneous
injection of liquid plastic , gluing a styrofoam ball to the renal parenchyma , or simply demarcating an
[30]
[14]
area to be resected [9,15] . The pseudo-tumoral areas were established in accessible portions of the renal
parenchyma, with sizes varying between 2 and 3.8 cm [9,14,16,31] , and perfusion was emulated in two of the
models [16,32] [Table 1].

The 3D printed models were based on computed tomography (CT) or magnetic resonance imaging (MRI)
images of real patients and, therefore, were patient-specific. Usually, a mold is 3D printed [17,19,23,25] and filled
with polyvinyl acetate (PVA-C) [18,19] , silicone [17,23,25,26] , agarose gel , or N-composite gel . Being used for
[29]
[24]
preoperative rehearsal [17,19,23-26] , they included pseudo-tumors with 1.5 to 4.7 cm, vascular structures for
“blood” perfusion [17,19] and sometimes other anatomical structures (i.e., renal hilum, pelvicalyceal system,
colon, spleen, and anterior abdominal wall [19,26,29] [Table 1].

VR and augmented reality (AR) technologies were used to develop PN simulation platforms [27,28] , with the
goal of teaching surgical anatomy (knowledge), technical skills, and operative steps (basic and procedural
[28]
skills). Using the CT images of patients, preoperative rehearsal was possible , and the integration of
computer-based performance metrics allowed the assessment of surgical performance [Table 1].
[27]
The most common emulated core tasks were tumor excision [9,14,16-19,23,24,26,29,31,32] and renorrhaphy [15,17,19,23,24,27,29,32] .
The 3D TMs also emulated the control of hemostasis , renal hilum dissection , renal
[14]
[19]
[19]
[17]
artery clamping [17,19] , instrument choice , colon mobilization , port placement , intraoperative
[17]
ultrasound [17,19] , and specimen entrapment .
[17]
Studies
The level of evidence of all included studies was ≥ 3b; different face, content, and construct validation
studies were identified, and a summary is presented in Table 2.