Prostate anatomy has become better understood in the past 20 years as techniques have been refined and improved for radical prostatectomy [1,2]. In particular, our understanding of the neurovascular bundles has become of paramount importance in striving to preserve erectile function in men undergoing surgery for prostate cancer [3-5]. With the increasingly complex surgical terminology and techniques, it is important that those learning nerve-sparing radical prostatectomy (NSRP) techniques understand the basic principles of surgical anatomy so that the new surgical terminology can be placed in context. For example, terms such as intrafascial, interfascial, and non-nerve-sparing surgery are all commonly used in the literature. Although videos and written descriptions may assist in learning such terms, ultimately, practicing surgery is the best facilitator of learning. Owing to various constraints upon training, however, this is not always possible or practical. It is therefore imperative that the urology community develop simple, low-cost models that can be used in informative and brief workshops to allow surgical trainees to study anatomical and surgical concepts before embarking on surgery.

Surgical skills laboratories have become important tools for educating and training surgeons. Although the end-points of improving patient outcome are yet to be fully defined, there are more conceptual areas of surgery that may benefit trainees provided integration between anatomy and surgical practice is maintained [6-8]. Furthermore, with newly enforced work hour restrictions, opportunities to acquire operative skills are limited, necessitating the development of alternative strategies of education [9]. This combined with the paucity of donated cadavers and the inherent ethical and cost issues in dealing with live and deceased animals in laboratories have forced educators to develop and consider creative workshops that require none of these elements [10-12].

From a urological point of view, a model for teaching prostate anatomy and placing into context the complex terminology such as that used in NSRP while also allowing the simulation of surgical maneuvers appears to be one of the most relevant models in need of development. This is also true for open simple prostatectomy, an operation that, although still required, is less common. Accordingly, an instructive model may improve conceptual understanding of such a procedure.

The objectives of this study were therefore to develop inexpensive and easily constructed but anatomically accurate models of the prostate that do not involve human or animal elements to teach the terminology and practical aspects of NSRP and simple prostatectomy.

Simulation of surgical procedures is considered to be a huge paradigm shift in surgical education and skills acquisition. Certainly, simulation is now accepted as a new concept not only for surgery but also for broader health education [14]. The driving force behind such a shift is a complex mix of shorter work hours with reduced training time, a greater number of trainees with a reduced patient workload for educational opportunities, a demand to acquire "proven" surgical skill before practicing on patients in a bid to reduce medical errors, and a shift to outcome-based education with its requirements for assessment and demonstration of competence [9,15]. These reasons have spurred the development of alternative strategies of education with surgical skills laboratories being a central focus. Certainly, skills laboratories can be used to demonstrate specific skills transferable to the operating room at their highest level (e.g., nephrectomy in a live porcine model), but they may also be used further "downstream": that is, to reaffirm basic principles of anatomy and steps of surgical procedures as well as to provide experience with the use of instruments that, although not designed to, may approach levels expected in competency testing. In other words, not every exercise in a skills laboratory need be done on human cadavers or live animal models to benefit training surgeons. We were able to create low-fidelity yet highly anatomically correct, inexpensive, and simple models that are useful for teaching urological surgery, with a focus more on the anatomy and procedural levels rather than the competency level. The models may be used for open, laparoscopic, or robotic-assisted radical and simple prostatectomy and may in the future be modified or tested so that they can become competency tools.

Evidence-based medicine is now entrenched in all specialties, including urology [16]. As such, overriding all of these new educational devices is the need for validation of the tools in a preliminary sense as not only educational devices but also for transference into real-life practice [17]. Both remain a challenge. In this manner, some models will be suitable for teaching anatomy and procedural steps, as our model appears to be, whereas others will be better for technical competency assessment and transferal; some will fall between. In a graduated way, low-fidelity models may assist with the initial experience of teaching procedures (e.g., robot-assisted radical prostatectomy) to surgeons-in-training by providing a forum for standardized learning, training, and evaluation as we move away from the master-apprentice educational system [18].

Surgical models were created in the early 1960s to establish the surgical skills of training surgeons for transurethral procedures [19] and are not likely to disappear soon [12,20]. Clearly, there will always be a place for cadaveric or animal models, but the current constraints on resources as well as ethical issues mean that low-fidelity models that are inexpensive and simple to construct are necessary [12,20,21]. It may be argued that surgical simulation may also fill the void in some instances, and even virtual reality is being proposed and investigated for use in a variety of urological procedures [22-24]. Although increasingly studied in urology, such educational tools do not allow the surgeon to hold real instruments and to practice on a cheap and easily made model that is tangible and anatomically correct. Many clinicians are questioning the validity of surgical skills laboratories that use and develop simulators and their true place in surgical education. For example, some have debated whether simulators are really just pseudo "video-games" or are really helpful [25]. The lines between the two may truly be blurred in laparoscopy. Some evidence suggests that indeed video games are helpful for surgical skill acquisition [26]. Even innovative ideas such as gaze training for laparoscopy rather than focusing on the instruments themselves has been suggested [27].

The final question to answer is whether models may also help to compensate for the lack of anatomy now taught at medical schools. Much has been written on the potential penalty of insufficient anatomy education at the undergraduate level, which may lead to incompetent anatomists and health care professionals, leaving patients to face dire repercussions [28]. Evidence suggests that textbooks and even in some cases contemporary multimedia tools have failed to keep pace with advances in surgical anatomy, which also delays educational flow to clinicians [1,2]. In our model, principles of anatomy are reinforced. When combined with appropriate diagrams and interactive lectures, the model certainly acts as an educational model. Models also need to be adaptable to have a place in open and laparoscopic (and robotic) surgery, because these techniques are progressing, and training the next generation of surgeons is essential [29,30].

The limitation of any low-fidelity model is that it does not exactly mimic the tissues encountered in surgery. Furthermore, there is no active physiology, so the tissues do not bleed. However, in the radical prostatectomy model, capsular incisions can be noted and discussed. Also, in the simple prostatectomy model, the ability to remove the pulp with minimal disruption (as evidenced by squeezed pulp) and evidence of citrus juice around the model provide some life-like responses. Furthermore, tissues may be torn, so there is some degree of passive tissue physiology. It may be possible to add pulsating bleeding vessels at low cost and with minimal equipment to such models, and we are working on this for future models.

Low-fidelity models are achievable in urology for the demonstration of prostate anatomy and for surgical practice and need not be expensive, cumbersome, or complex to construct. Importantly, these models can be utilized to study both the terminology and the practical aspects of NSRP and simple prostatectomy. The models will require further validation as educational and competency tools, but as we move to an era where human donors and animal experiments become less ethical and more difficult to complete, so too will low-fidelity models become more attractive.