Accepted Manuscript

Title: Upper and Lower Urinary Tract Endoscopy Training on Thiel-

Embalmed Cadavers

Author: Uros Bele, Robi Kelc

PII: S0090-4295(16)00299-5
DOI: http://dx.doi.org/doi: 10.1016/j.urology.2016.01.040
Reference: URL 19685

To appear in: Urology

Received date: 27-10-2015

Accepted date: 19-1-2016

Please cite this article as: Uros Bele, Robi Kelc, Upper and Lower Urinary Tract Endoscopy
Training on Thiel-Embalmed Cadavers, Urology (2016), http://dx.doi.org/doi:
10.1016/j.urology.2016.01.040.

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Title: Upper and lower urinary tract endoscopy training on Thiel-embalmed cadavers

Key words: anatomy, cystoscopy, minimally invasive surgery, simulation, ureteroscopy.

Authors: Uros BELE1,2, Robi KELC2

Affiliations:
1
Department of Urology, University Medical Centre Maribor, Ljubljanska ulica 5, SI-2000

Maribor, Slovenia.
2
Institute for anatomy, histology and embryology, Faculty of Medicine, University of

Maribor, Taborska ulica 8, SI-2000 Maribor, Slovenia.

Correspondence address:

Uros BELE, Department of Urology, University Medical Centre Maribor, Ljubljanska ulica 5,

SI-2000 Maribor, Slovenia.

Tel.: +386 40 731 510

Fax: +386 2 332 48 30

E-mail: uros.bele@gmail.com

Abstract word count: 239 words

Manuscript word count: 2168 words

Page 1 of 23
ABSTRACT

Objective

To evaluate Thiel-embalmed cadavers as a new training model for urological endoscopy

procedures.

Methods

Twelve urologists performed upper and lower urinary tract endoscopies on five different

Thiel-embalmed cadavers to evaluate this potentially new training model in urological

endoscopic procedural training. Using a 5-point Likert scale, the participants assessed the

quality of the tissue and the overall experience of the endoscopy in comparison to a live

patient procedure.

Results

Thiel-embalmed cadavers have shown to mimic live patient endoscopy of the upper and

lower urinary tract in terms of almost identical overall anatomical conditions and

manipulation characteristics of the tissue. The mucosa of the urethra and ureters showed

similar colours and consistency in comparison to a live patient, while bladder mucosa was

lacking the visibility of the vessels, thus was unsuitable for identifying any mucosal

abnormalities. The flexibility of the muscles allowed the proper patient positioning, while the

loss of muscle tonus made ureteroscopy more difficult though sufficiently comparable to the

procedure done in a live patient.

Page 2 of 23
Conclusion

Thiel-embalmed cadavers have already been proven to be a suitable training model for

several medical procedures. They are known for preserving tissue colour, consistency and

flexibility without the irritant odours or risk of infection, which makes them resemble live

patients with real life surgical challenges. The results of our study strongly suggest that

despite some minor drawbacks, Thiel-embalmed cadavers are a suitable simulation model

for initial training of urethro-cystoscopy and ureteroscopy.

INTRODUCTION

Traditionally, surgical skills have been acquired while learning on patients, using the

Halstedian model: “see one, do one, teach one”. Although this model has educated

generations of surgeons, it is associated with longer operative times and an increased rate of

surgery-related complications during the early phase of the learning curve, which could have

an impact on patient safety1. With rapid progress in medical technology and constant

advances in minimally invasive surgical techniques, there is a continuous need for improving

one’s surgical skills. Nowadays, for the purposes of fundamental training, training models

are available that mimic live patient surgery and provide the necessary procedural

experiences in the initial learning curve, without putting the patient at potential risk2.

In the field of endoscopic urological procedures, several training models have been

described in the literature, including virtual reality (VR) simulators, bench-top models,

animal models and human cadavers, all of which are acknowledged to improve surgical

skills3. Yet, human cadaver training models have shown superiority over other training

models and have been proven to be highly effective for urology procedural training4.
3

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Different types of cadavers have been successfully used for the purposes of surgical training,

including fresh or fresh-frozen cadavers (FFC)4,5, formalin embalmed cadavers and Thiel-

embalmed cadavers6. Lately, more and more studies include cadavers prepared with the less

spread Thiel embalming method, since it is known for preserving colour, consistency and

flexibility of the cadaver’s tissue7. Although Thiel-embalmed cadavers have been shown to

be at least equally, if not superior, to FFC or formalin cadavers in all anatomical aspects and

also for advanced surgical training courses8, only around 10% of anatomical institutes

globally use this type of embalmed9.

Based on a recent publication10, there is limited data available regarding the efficacy of using

Thiel-embalmed cadavers for learning urological endoscopy procedures. The aim of our

study was to identify the advantages and disadvantages of upper and lower urinary tract

endoscopy training on Thiel-embalmed cadavers and to establish whether such training

would be appropriate for the initial learning of the above-mentioned endoscopic

procedures.

MATERIALS AND METHODS

In this study we are comparing the experience of upper and lower urinary tract endoscopic

examinations performed by urologists on cadavers to live patient experience. Urologists,

who participated in our study, were all fully trained, certified urologists, who regularly (on a

week basis) perform urological endoscopic procedures.

Page 4 of 23
For the study we used five different cadavers, embalmed with the Thiel method, which is

known for preserving colour, consistency and flexibility of the tissue7,11.

Twelve urologists were asked to perform a cysto-urethroscopy and ureteroscopy

respectively, using a rigid Ch 20 cystoscope and semi-rigid 8 Fr. ureteroscope. For

urethroscopy we used 0° optics, which was later changed to 70° optics for cystoscopy. For

ureteroscopy we used 6° optics. The endoscopies were performed with a camera; photos

were taken using MediCapture USB170 capturing device (Medicapture Inc., Plymouth

Meeting, USA).

After performing the endourological examinations, the participants were asked to

anonymously fill out a standardized questionnaire, consisting of fourteen questions. Using a

5-point Likert scale, in the first 12 questions participants graded the quality of the tissue and

the experience of the endoscopy in comparison to a live patient. In the last two questions

participants expressed their opinion, whether they find such endoscopic training useful for

initial training of cystoscopy and ureteroscopy. The collected data was statistically analysed

using Tableau software, where mean values with standard deviations (SD) for each answer

were calculated.

RESULTS

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The participants of our study evaluated the odour of the procedure room, where they

performed the endoscopies on Thiel-embalmed cadavers, as totally undisturbing or even

odourless (4,83 ± 0,39) (Figure 1).

At the beginning of the endoscopic procedures, participants evaluated the urethroscopy

they performed. The majority stated that the passage of the cystoscope through the

cadaver’s urethra is highly comparable to that in a living patient, with the mean value of 4,33

± 0,49. They also described the urethral mucosa (Figure 2A, 2B) to be very similar in

comparison to a live patient (3,42 ± 1,00), thus making the urethroscopy realistic when

comparing the procedure performed on a live patient (3,75 ± 0,75).

The overall anatomical features of the bladder were found very similar to those in a living

person (3,83 ± 0,72), with comparable manipulation (hydrodistention) characteristics (3,50 ±

0,67). As expected in a cadaver, the mucosa of the bladder was lacking the vivid red colour

and visibility of the vessels (Figure 2C, 2D), which makes the bladder mucosa of a Thiel-

embalmed cadaver hardly comparable to a live patient (2,67 ± 0,65), and thus unsuitable for

estimating the mucosal abnormalities of the bladder.

Before proceeding to ureteroscopy, participants evaluated the visibility and anatomical

features of the ureteral ostia in the bladder (Figure 3A, 3B), which were found to be similar

to those in a living patient (3,58 ± 1,00). After switching to a semi-rigid ureteroscope,

participants performed an ureteroscopy, which was found to be sufficiently comparable to a

procedure performed in a living patient (3,25 ± 0,62). While the mucosa of the ureters

Page 6 of 23
(Figure 3C, 3D) seems to be very comparable to a live patient (3,75 ± 0,87), most problems

resulted in the passage of the ureteroscope through the ostia (3,17 ± 0,83) and the ureter

itself (3,08 ± 0,90), which was, lacking the muscle tonus in a cadaver, more challenging than

in a living patient. Pyeloscopy was not routinely performed by the participants of the study,

thus the ability of Thiel embalmed cadavers to mimic patient renal mucosa could not be

evaluated.

Despite some difficulties participants had during the endoscopic procedures on Thiel-

embalmed cadavers, the urethro-cystoscopy (4,42 ± 0,79) and ureteroscopy (3,83 ± 0,72)

were still found to be useful for initial training of these procedures.

COMMENT

Hands-on training workshops constantly grow in their popularity12. With new training

models available, we have the possibility of improving patient safety by removing the patient

from the surgeon’s initial stages of procedural learning curve13. That is why we are on a

continuous search for new training models that would mimic the real patient. Several VR

simulators and bench-top models have already proven its place in urology procedural

training2, although such simulations might be anatomically inferior to a human cadaver

model for visceral surgery14. Reports suggest that fresh-frozen cadavers (FFC)4,5, formalin

embalmed cadavers and Thiel-embalmed cadavers6 may be used for surgical training, all of

which have their advantages and faults.

Page 7 of 23
Promising results have been shown on fresh frozen cadavers, which have been proven a

suitable training model for performing surgical procedures, offering life-like anatomical

conditions, with preserved tissue planes, realistic tissue handling and haptic feedback 4,15. On

the other hand, they lack durability, can potentially be infectious and are not eligible for

reuse in multiple training courses, since the tissue of a fresh frozen cadaver was described to

stay viable only for 72 hours4,6,7.

Eisma et al6 showed that formalin-embalmed cadavers do not resemble live patient

characteristics, when used for surgery training and have stated a clear preference for Thiel-

embalmed cadavers, especially for procedures that require good tissue flexibility, such as

urological endoscopic procedures. In comparison to formalin-embalmed cadavers, Thiel’s

embalming method uses low concentration of formaldehyde, chlorocresol and morpholine,

thus minimizing the irritating effect of these harmful substances while retaining its excellent

bactericidal and fungicidal properties. The Thiel embalming method is rather based on an

embalming fluid, consisting of water with added glycol, boric acid, ethylenglycol, ammonium

nitrate, potassium nitrate and 4-chlor-3-methylphenol. This embalming fluid is firstly

introduced into the cadaver in a perfusion into the femoral artery and the superior sagittal

sinus. After that, the cadaver is submerged for 3 to 6 months in the embalming fluid. That

way, the cadaver’s tissue preserves colour, consistency and flexibility of the muscles, but

also internal organs6,7,16,17, which is very useful for teaching endoscopic procedures, allowing

the right positioning of the patient and comparable visual and tactile feed-back as in a live

patient.

Page 8 of 23
The results of our study have shown that Thiel-embalmed cadavers are a useful training

model for the initial learning of urethro-cystoscopy and ureteroscopy, with some minor

drawbacks when compared to a live patient. The general setting of the working environment

was well accepted by the urologists, with no detectable odour that would compromise their

endoscopic procedure, which correlates with the findings of other studies6,8. The soft

embalmed cadavers allow an easy passage of the cystoscope through the urethra, similar to

a live patient experience. Similar findings were reported by Ahmad et al, who performed

cystoscopy and transurethral resection of prostate (TURP) on a Thiel embalmed cadaver.

They experienced no difficulties while introducing a cystoscope and resectoscope threw the

urethra and report of preserved anatomical landmarks of the bladder, prostate and urethra,

with the same resection experience as observed in clinical practice18.

Flexibility of the muscles in a Thiel-embalmed cadaver allows the perfect positioning of the

cadaver to perform the ureteroscopy. Although the ostia of the ureters are visually similar to

a live patient, there have been some difficulties in the passing of the guide wire and

ureteroscope through the ostia and the ureters. The loss of muscle tonus with consequently

no counter-pressure of the ostia and ureter wall could explain that observation. Although we

noted some minimal differences between individual cadavers, the data collected suggests

that this part of ureteroscopy is more difficult though sufficiently comparable to the

procedure done in a live patient.

The cadavers’ mucosa of the urethra and ureters seems to resemble the mucosa of a live

patient. The problem is the mucosa of the bladder, as it lacks the vivid, red colour and the

visibility of the vessels. Although the participants found the overall anatomical landmarks

Page 9 of 23
and characteristics of the bladder, its manipulation and hydrodistesion features similar to

those in a living patient, the mucosa showed to be hardly comparable, thus unsuitable for

identifying any mucosal abnormalities of the bladder. This drawback could be overcome

during the preparation process of the cadavers. Like other soft tissues in Thiel embalming

method, the vessels too are flexible and collapse in the absence of pressure. It has been

shown that infusing the arteries with red-coloured latex during the embalming process

prevents them from collapsing and consequently makes the small arteries more visible and

red coloured6,19. This additional vessel infusion might improve the visibility of the mucosal

vessels in the bladder and further improve the suitability of Thiel-embalmed cadavers for

lower urinary tract endoscopy training.

The main disadvantage of Thiel-embalmed cadavers described in the literature is the high

expanses needed for preparation and maintenance of such cadavers, which are estimated to

around $1200 per cadaver. This disadvantage can be overcome with multiple cadaver use for

teaching different urological procedures, such as endoscopic, angiographic and pyelographic

procedures10. Furthermore, as already suggested for fresh frozen cadavers20, a single Thiel-

embalmed cadaver could be used for multiple, coordinated training of other minimally

invasive urological procedures, such as laparoscopic or robot-assisted prostatectomy and

nephrectomies, and also for other surgical procedures, such as bronchoscopies21, oral

surgery and implantology22, thyroid surgery6 and peripheral nerve block training23. Finally,

after being used for surgical training, these cadavers are still appropriate for dissection and

human musculoskeletal system lectures for undergraduate students6, which further more

improves the cost-effectiveness of this training model.

10

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Nevertheless, our study also has some limitations, the main being the lack of a control group

that would enable direct comparison between different training models. Our study was

aimed to evaluate Thiel embalmed cadavers as a potentially suitable training model, without

a direct comparison to fresh frozen cadavers (FFC) and/or formalin-embalmed cadaver.

Performing urological endoscopy on formalin-embalmed cadavers would be difficult and

incomparable to a live patient procedure, because of the tissue rigidity and loss of tissue

colour and consistency. Secondly, there have already been some studies published, showing

benefits of training on FFC, performing cystourethroscopy24 and flexible ureteroscopy25.

Although no studies with direct comparison of different cadaver models have been carried

out to our knowledge, it would be interesting to perform such a study in the future.

Further, the question of tissue suitability for repeated urological endoscopic procedures

remains somehow open. During our study, we did not detect any significant tissue

degradation, although each cadaver was only used for 2 or maximal 3 procedures (12

urologists, 5 cadavers). We did notice some bladder and ureter distension after the first

procedure, because of the absence of muscle tonus in cadavers. However, anatomical

landmarks and endoscopic techniques remained the same after the first use. Still, more

studies are need to identify the number of repeated endoscopic procedures, that can be

performed on a single Thiel embalmed cadaver.

CONCLUSION

11

Page 11 of 23
Thiel-embalmed cadavers have already been proven to be a suitable training model for

several medical procedures. They are known for preserving tissue colour, consistency and

flexibility without the irritant odours or risk of infection, which makes them resemble live

patients with real life surgical challenges. Regardless some difficulties concerning the

preparation and maintenance of Thiel-embalmed cadavers, the results of our study strongly

suggest that despite minor drawbacks, Thiel-embalmed cadavers are a suitable simulation

model for initial training of urethro-cystoscopy and ureteroscopy.

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doi:10.1016/j.eururo.2008.06.036.

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4. Ahmed K, Aydin A, Dasgupta P, Khan MS, McCabe JE. A Novel Cadaveric Simulation

Program in Urology. J Surg Educ. 2015;72(4):556-565. doi:10.1016/j.jsurg.2015.01.005.

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5. Levine RL, Kives S, Cathey G, et al. The use of lightly embalmed (fresh tissue) cadavers

for resident laparoscopic training. J Minim Invasive Gynecol. 2006;13(5):451-456.

doi:10.1016/j.jmig.2006.06.011.

6. Eisma R, Mahendran S, Majumdar S, Smith D, Soames RW. A comparison of Thiel and

formalin embalmed cadavers for thyroid surgery training. Surg J R Coll Surg Edinb Irel.

2011;9(3):142-146. doi:10.1016/j.surge.2010.09.001.

7. Thiel W. [The preservation of the whole corpse with natural color]. Ann Anat Anat Anz

Off Organ Anat Ges. 1992;174(3):185-195.

8. Giger U, Frésard I, Häfliger A, Bergmann M, Krähenbühl L. Laparoscopic training on

Thiel human cadavers: a model to teach advanced laparoscopic procedures. Surg

Endosc. 2008;22(4):901-906. doi:10.1007/s00464-007-9502-7.

9. Benkhadra M, Gérard J, Genelot D, et al. Is Thiel’s embalming method widely known? A

world survey about its use. Surg Radiol Anat SRA. 2011;33(4):359-363.

doi:10.1007/s00276-010-0705-6.

10. Healy SE, Rai BP, Biyani CS, Eisma R, Soames RW, Nabi G. Thiel Embalming Method for

Cadaver Preservation: A Review of New Training Model for Urologic Skills Training.

Urology. 2015;85(3):499-504. doi:10.1016/j.urology.2014.11.009.

11. Thiel W. [Supplement to the conservation of an entire cadaver according to W. Thiel].

Ann Anat Anat Anz Off Organ Anat Ges. 2002;184(3):267-269.

12. Greenwald D, Cohen J. Evolution of endoscopy simulators and their application.

Gastrointest Endosc Clin N Am. 2006;16(3):389-406. doi:10.1016/j.giec.2006.03.008.

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13. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation for patient safety.

Qual Saf Health Care. 2010;19(Suppl 2):i34-i43. doi:10.1136/qshc.2009.038562.

14. Gilbody J, Prasthofer AW, Ho K, Costa ML. The use and effectiveness of cadaveric

workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl.

2011;93(5):347-352. doi:10.1308/147870811X582954.

15. Lewis CE, Peacock WJ, Tillou A, Hines OJ, Hiatt JR. A novel cadaver-based educational

program in general surgery training. J Surg Educ. 2012;69(6):693-698.

doi:10.1016/j.jsurg.2012.06.013.

16. Groscurth P, Eggli P, Kapfhammer J, Rager G, Hornung JP, Fasel JD. Gross anatomy in

the surgical curriculum in Switzerland: improved cadaver preservation, anatomical

models, and course development. Anat Rec. 2001;265(6):254-256.

17. Jaung R, Cook P, Blyth P. A comparison of embalming fluids for use in surgical

workshops. Clin Anat N Y N. 2011;24(2):155-161. doi:10.1002/ca.21118.

18. Ahmad S, Byrne D, Nabi G. Training Model for Transurethral Resection of Prostate Using

Human Cadavers Embalmed by Thiel’s Method. J Endourol Part B Videourology.

2013;27(6). doi:10.1089/vid.2013.0026.

19. Thiel W. [An arterial substance for subsequent injection during the preservation of the

whole corpse]. Ann Anat Anat Anz Off Organ Anat Ges. 1992;174(3):197-200.

20. Blaschko SD, Brooks HM, Dhuy SM, Charest-Shell C, Clayman RV, McDougall EM.

Coordinated Multiple Cadaver Use for Minimally Invasive Surgical Training. JSLS.

2007;11(4):403-407.
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21. Nemetz W, Fasel JH, Bonniaud P, et al. Bronchoscopy and cricothyrotomy: results from

cadavers embalmed with Thiel’s method compared to other embalming methods and

living subjects. Acta Medico-Bioteh. 2008;01(01):25-36.

22. Hölzle F, Franz E-P, Lehmbrock J, et al. Thiel embalming technique: a valuable method

for teaching oral surgery and implantology. Clin Implant Dent Relat Res.

2012;14(1):121-126. doi:10.1111/j.1708-8208.2009.00230.x.

23. Munirama S, Satapathy AR, Schwab A, et al. Translation of sonoelastography from Thiel

cadaver to patients for peripheral nerve blocks. Anaesthesia. 2012;67(7):721-728.

doi:10.1111/j.1365-2044.2012.07086.x.

24. Bowling CB, Greer WJ, Bryant SA, et al. Testing and validation of a low-cost cystoscopy

teaching model: a randomized controlled trial. Obstet Gynecol. 2010;116(1):85-91.

doi:10.1097/AOG.0b013e3181e45a52.

25. Huri E, Skolarikos A, Tatar İ, et al. Simulation of RIRS in soft cadavers: a novel training

model by the Cadaveric Research On Endourology Training (CRET) Study Group. World J

Urol. August 2015. [Epub ahead of print] doi:10.1007/s00345-015-1676-3.

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Figure 1: summarizes the data obtained from the questionnaires. The questions were

anonymously answered by participants, using a 5-point Likert scale (5 = strongly

agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). Mean values for

each question are written in circles.

Figure 2: Cysto-urthroscopy on a Thiel-embalmed cadaver. “A” bulbar urethra, “B”

prostatic urethra, “C” mucosa (with vessels) of the bladder, “D” trabeculation of the

bladder.

Figure 3: Cystoscopy and ureteroscopy on a Thiel-embalmed cadaver. ”A” trigone of

bladder with both ureteral orifices, “B” ureteral orifice, “C” guide-wire in the ureter

during ureteroscopy, “D” renal pelvis.

16

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 Editorial Comment. RE: Upper and lower urinary tract endoscopy training on

Thiel-embalmed cadavers.

David A. Duchene, MD

Associate Professor of Urology

University of Kansas Medical Center

3901 Rainbow Boulevard, MS 3016

Kansas City, Kansas 66160

(O) 913-588-6982

(F) 913-945-8728

dduchene@kumc.edu

dduchene24@hotmail.com

Word Count: 292

Conflict of Interest/Disclosure for David A. Duchene, MD

No conflict of interest exists for this Editorial Comment.

Source of Funding: None

17

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Editorial Comment. RE: Upper and lower urinary tract endoscopy training on

Thiel-embalmed cadavers.

This manuscript describes use of Thiel-embalmed cadavers for training in

cystoscopy and semirigid ureteroscopy. The authors demonstrate that Thiel-

embalmed cadavers are suitable to perform endoscopic procedures in the training

environment. Although they don’t have a control or comparison group, their findings

suggest that a Thiel-embalmed cadaver is superior to formalin-embalmed cadavers

or fresh frozen cadavers due to lack of odor and preservation of tissue flexibility in the

Thiel-embalmed cadaver.

I cannot disagree that it appears the Thiel-embalmed cadaver is an

“acceptable” endoscopic urological training model. However, it seems that other

available training models are much more cost effective and appropriate for trainees in

endoscopic procedures. The authors only used the cadavers for 2 or 3 procedures

and noticed some distension in the tissues after the first use. They also comment

that the mucosa of the urethra and ureters were comparable to a live patient, but that

the bladder mucosa was not adequately preserved with the embalming method to

distinguish mucosal abnormalities. At $1200 per cadaver for only 2 or 3 urethroscopy

and distal ureteroscopy (no performance of pyeloscopy and inadequate cystoscopy),

it is a costly model. When one adds the additional concerns of ethical issues, space

for preservation and storage, and possible disease transmission (viruses, prions,

bacteria, fungi), then the cost may be much higher to the institution and trainee.

Several virtual reality simulators and bench top models are commercially

available for endoscopic training. Even a simple silastic tubing model may perform

similarly to a Thiel-embalmed cadaver and it would be much cheaper in cost and

18

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easier to obtain. Unless a large difference in skill acquisition is shown by training on

cadaver models instead of available inanimate models, we should minimize the use

of cadavers as training models for endoscopy in urology.

19

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Title: AUTHOR REPLY. RE: Upper and lower urinary tract endoscopy training on Thiel-

embalmed cadavers

Key words: anatomy, cystoscopy, minimally invasive surgery, simulation, ureteroscopy.

Authors: Uros BELE1,2, M.D.

Robi KELC2, M.D.

Affiliations:
1
Department of Urology, University Medical Centre Maribor, Ljubljanska ulica 5, SI-2000

Maribor, Slovenia.
2
Institute for anatomy, histology and embryology, Faculty of Medicine, University of

Maribor, Taborska ulica 8, SI-2000 Maribor, Slovenia.

Correspondence address:

Uros BELE, Department of Urology, University Medical Centre Maribor, Ljubljanska ulica 5,

SI-2000 Maribor, Slovenia.

Tel.: +386 40 731 510

Fax: +386 2 332 48 30

E-mail: uros.bele@gmail.com

Author Reply word count: 362 words

20

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We are thankful for a considered editorial comment on our article, in which the author

addresses some major concerns regarding the use of Thiel-embalmed cadavers as a training

model. We do agree that virtual reality (VR) simulators and benchtop models are suitable

training models, that have been shown useful in urological training 1 and can be used

repeatedly for several training sessions. Nevertheless, they might be anatomically inferior

and might not provide a realistic haptic feedback2. As stated in our article, we noticed a

minimal, probably non-significant bladder and ureter distension of the Thiel-embalmed

cadavers after the first use, due to the absence of muscle tonus in cadavers. Despite that,

anatomical landmarks and endoscopic techniques remained the same, but we do agree that

it is necessary to identify the number of repeated endoscopic procedures, that can be

performed on a single Thiel-embalmed cadaver.

The use of Thiel-embalmed cadavers for surgical training might be most cost effective in

medical centers, who already use this embalming method to teach undergraduate anatomy,

thus have the infrastructure needed to preserve these cadavers. Other economic concerns

can be easily overcome in multiple cadaver use. The cadavers itself remain usable for a few

years and can be used for teaching different urological and surgical procedures, and

afterwards for dissection and human musculoskeletal system lectures for undergraduate

students, which makes this training model very cost-effective. On the other hand, VR

simulators are much more expensive and offer only a limited variety of procedures, that can

be performed.

21

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We realize that the use of cadavers in surgical workshops might raise ethical questions in

some countries, but general concerns of disease transmission are unnecessary. Several

studies confirmed that Thiel-embalmed cadavers have appropriate antibacterial and

antifungal properties3,4, that in combination with standard antiseptic surgical precautions

result in a save training environment.

Despite the fact that our study did not have a control or comparison group, we strongly

believe that Thiel-embalmed cadavers are a suitable and cost effective training model, which

was already descibed for laparoscopic training5. Nonetheless, a direct comparison of

different cadaver and inanimate training models should be carried out, to identify a

potential difference in skill acquisition between different training models.

REFERENCES:

1. Schout BMA, Hendrikx AJM, Scherpbier AJJA, Bemelmans BLH. Update on Training

Models in Endourology: A Qualitative Systematic Review of the Literature between

January 1980 and April 2008. Eur Urol. 2008;54(6):1247-1261.

doi:10.1016/j.eururo.2008.06.036.

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