Procedural simulators for teaching and learning vasectomy techniques: a scoping review

Introduction

Vasectomy is the most frequently performed surgery in male adults. Although it a simple office procedure, adequate training is often lacking in both urology (1) and family medicine (2). Mastering vasectomy skills requires many hours of practice and many supervised cases before it can be safely performed in humans without supervision.

Simulation on procedural model is highly desirable in such a situation. A systematic literature review of 609 studies and over 35,000 learners demonstrated that simulation is consistently associated with improved knowledge and skills (3). Basic skills of surgical techniques may be acquired by novice learners with low level of physical resemblance (low fidelity) simulators (4). However, higher fidelity simulators, enabling simulated tasks similar to the real tasks to be performed, are fundamental for transferring knowledge and skills from simulated to clinical practice (4-6). The characteristics of the simulator (scrotal model) used for vasectomy training would therefore be a major determinant of the quality of the surgery ultimately performed in humans.

All North American and European clinical practice guidelines recommend that surgeons use a minimal invasive technique such as the no-scalpel vasectomy (NSV) technique to isolate and deliver the vas deferens (7-11). The best evidence of reduced risk of surgical complications was shown with NSV (12,13).

The urological associations all recommend mucosal cautery and fascia interposition to occlude the vas deferens (7-11). Combining these two techniques appears to yield the lowest occlusive failure risk (8,14). Surgeons may, however, use other occlusion techniques if they achieve acceptable occlusive efficacy (<1%) with their preferred technique (8,10,11).

The objectives of this scoping review (15,16) were to identify the available simulators for teaching and learning vasectomy and to assess whether these simulators could potentially assist in transferring skills of all surgical steps of the most recommended vasectomy techniques in clinical practice. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-113/rc) (17).

Methods

We used three data sources to search for the available simulators for teaching and learning vasectomy. First, we performed an unrestricted search for language, year, and type of publication of the Medline database with PubMed using two sets of keywords presented in Table 1. The first set (Search #1) was specifically focusing on scrotal models. The second set (Search #2) was broader, covering all aspects of vasectomy education and simulation. We performed the searches up to December 2023.

For all searches, the eligible articles had to describe a simulator (scrotal model) relevant for teaching or learning vasectomy. Two of the authors (Z.Y.A. and M.L.) independently screened the title and abstract of articles to assess eligibility. For each eligible article, they additionally searched the references of similar articles suggested by PubMed and those cited in the selected articles (snowball strategy). The authors compared their results and came to a consensus on the final selection of articles.

Second, we conducted a Web search using Google search engines (Google, Google Images, and Google Videos/YouTube). Several independent searches were carried out using the following terms: “scrotal model”, “scrotal model vasectomy”, “vasectomy teaching”, “vasectomy training”, “male pelvic simulator”, and “urology teaching”. We explored the first six pages of each Google search. Z.Y.A. initially conducted the searches and M.L. re-examined retained documents. Moreover, both independently screened all retrieved documents/links to search for additional eligible documents.

Third, we e-surveyed the members of the Vasectomy Network, an international Google Group on vasectomy, regarding the existence of simulators used for teaching and learning vasectomy.

We present the results in a narrative format. First, we describe the characteristics and show photographs of retrieved simulators. We present our appraisal of realism of external and internal scrotal structures including the visual and haptic (sense of touch), realism of the simulators, reusability, stability on a work surface, and cost of the models (Table 2). Second, we present the potential suitability of the models to adequately and realistically simulate all steps of the most recommended vasectomy technique (local anesthesia, NSV technique—three-finger technique, vas isolation, and vas delivery, mucosal cautery, and fascial interposition) (Table 3). We also present our appraisal, on three point scales, of the following functional characteristics of the models: visual and haptic (sense of touch) realism of external scrotal structure (fully, partially, or not looks/feels like human anatomy), anatomical realism of internal structures (all internal scrotal structures—testicle, cord, vas, and fascia—are present; apart from the vas, one of the internal scrotal structures—testicle, cord, or fascia—is missing; apart from the vas, all other internal scrotal structures are missing). Haptic realism of internal scrotal structures (all, some, or none of internal structures feel like human anatomy), stability on work surface (stable, ± stable, not stable), reusability (more than 10 times, 2 to 10 times, only once), and cost in US dollars (Table 2). Second, we present the potential suitability of the models in terms of structure and visual/haptic realism to assist skill transfer (suitable, ± suitable, not suitable) of all steps of the most recommended vasectomy technique (local anesthesia, NSV technique—three-finger technique, vas isolation, and vas delivery−, mucosal cautery, and fascial interposition) (Table 3).

To perform these evaluations, B.P., a simulation procedure specialist, and M.L., an experienced vasectomy provider and trainer, together examined and manipulated all models, M.L. using NSV instruments. We had on hand one commercial simulator (Gaumard^® S-518) and one homemade simulator (Wilson’s model). We built all the other homemade simulators based on pictures and description available. Then, B.P. and M.L. independently scored each simulator according to the criteria mentioned above. They made consensus and all co-authors further discussed and approved results.

In order to strengthen our results, we sent our appraisal to the creator of some models (John Curington, Ramchandra Murti Kaza, and Charles Wilson) to obtain their comments on our evaluation of their model. All co-authors discussed comments and suggested changes received.

Results

We identified 17 and 724 articles with PubMed Search #1 and #2, respectively (Figure 1). We reviewed the full text of 6 and 12 potentially relevant articles identified with Search #1 and #2, respectively. We retained two articles, identified with both searches, describing simulators specific to teaching and learning vasectomy: the simple gauze and tubing model (19) and the Coe and Curington’s model (20).

Figure 1 Flow diagram of the PubMed searches (December 2023). The first set (Search #1) was specifically focusing on scrotal models. The second set (Search #2) was broader, covering all aspects of vasectomy education and simulation.

We found 32 potentially relevant vasectomy simulators with the Web searches. Four, designed for teaching and learning vasectomy, were eligible: The University of Wisconsin-Madison model (21) adapted from the Coe and Curington’s model (20), and the three Gaumard^® models (18,23,24).

Finally, the members of the Google Group Vasectomy Network identified four additional eligible simulators for teaching and learning vasectomy: the Wilson’s model (personal communication Dr. Charles Wilson), the balloon model (personal communication Dr. Mandy Gittler), the Kaza’s model (personal communication Dr. Ramchandra Murti Kaza), and the Weissman’s model (22). Two additional models, the General Doctor^® GD/F9G Vasoligation Training Simulator (25), and the Vasectomy Training Model from the DM Model Manufacturing Company were located (26). These were available on Alibaba.com online store. We excluded these for further detailed evaluation based on pictures, videos, and information obtained from the companies. It was obvious that NSV could not be simulated with these models. With the General Doctor^® GD/F9G Vasoligation Training Simulator (25), the simulated vas can only be accessed by pulling out and separating the scrotum from the simulated pelvis in order to expose and ligate the vas. The penis of the Vasectomy Training Model from the DM Model Manufacturing Company (26) is molded on the scrotum covering the median raphe and preventing any access to the vas with the NSV technique.

We thus retrieved 10 relevant vasectomy simulators. Apart from the Gaumard^® models, all are homemade models. The following sections describe the characteristics of these vasectomy simulators and our assessment of their potential suitability to assist in transferring vasectomy skills into practice.

Characteristics of vasectomy simulators

The Gaumard^® scrotal models (18,23,24)

Gaumard^®, a USA-based company manufacturing and distributing a large range of training simulators for healthcare, commercializes three vasectomy-training models. The first is the No-Scalpel Vasectomy Skills Trainer S-518 (Figure 2A) (18). It is made of semi-rigid silicone. The base mimics the shape of a male pelvis. Three skin tones are available. The model comes with two removable scrotal skins and two testicles connected to long latex or silicon tube covered with a thin layer of latex or silicon, simulating the vas deferens and the internal spermatic fascia, respectively. Undamaged vas assemblies can be repositioned into the scrotum for repeating simulated practice.

Figure 2 Retrieved simulators (scrotal models) for teaching and learning vasectomy. (A) Gaumard^®, no-scalpel vasectomy skills trainer S-518 model (S230.11 and S230.200 not shown) (18,23,24); (B) Gauze and latex tubing model (19); (C) Coe and Curington’s model (20); (D) Department of Urology, University of Wisconsin School of Medicine and Public Health model adapted from Coe and Curington’s model (21); (E) Wilson’s model; (F) Weissman’s model (22); (G) Kaza’s model; (H) Ballon model. Photographs (A-F) by Michel Labrecque; (G) by Ramchandra Murti Kaza; (F) by Mandy Glitter.

The second and third models, the ZACK™ Multipurpose Male Care Simulator S230.11 and the Advanced ZACK™ Multipurpose Male Care Simulator S230.200 (not shown) (23,24) allow learning and teaching of other procedures in addition to vasectomy, such as bladder catheterization, and prostate, testicular, and rectal examination. Based on the pictures shown on the Gaumard^® website (https://www.gaumard.com/), the vasectomy specific components of the ZACK™ Multipurpose Male Care Simulator S230.11 are the same as those included with the S-518 model. The scrotum of the Advanced ZACK™ Multipurpose Male Care Simulator S230.200 appears to be more realistic and softer allowing simulated palpation of testicular tumors.

Our detailed assessment was limited to the S-518 model, specifically designed as a vasectomy simulator (Tables 2,3). This model is realistic in terms of anatomical representation. It is relatively small and light for transportation, although stable on workplace. However, semi-rigid silicon simulated scrotum of the S-518 model affects tactile sensation and does not adequately mimic human skin. The reusability of the scrotal skin is limited. The simulated scrotum tears easily. The simulated fascia rips off if pulled. The replaceable scrotal part detaches unexpectedly with manipulation.

Homemade models

Gauze and latex tubing model (19)

This simple model was described in 1991 (19), in the early years of introduction of NSV in USA. It consists of a surgical gauze (usually 3×3 inches) that simulates the scrotal skin and a piece of plastic (or latex) tubing that represents the vas deferens (Figure 2B). Although the realism of this simple model is very limited, it allows basic simulation of some of the NSV steps. The three-finger technique can be simulated after placing the latex tubing under the gauze which represents the anterior wall of the scrotum. Grasping the vas with the ring forceps and opening the skin with the dissection forceps for exposing the vas can also be simulated. However, delivering the vas by pulling it out of the scrotum and occluding the vas cannot be simulated with this model.

Coe and Curington’s models (20,21)

Inspired by a model originally created in 1995 by Pfenninger (27), Coe and Curington developed an improved version (20). It is composed of a piece of bicycle inner tube (two 1/4 inches wide), a strip of latex tubing (1/8 inch outer diameter, 1/16 inch diameter internal, and 1/32 inch thick), and of Penrose drain (1/4 inch wide) simulating the scrotum, the vas deferens, and the vas sheath, respectively (Figure 2C) (20). It is inexpensive and reusable on different segments of the bicycle inner tube. It is lightweight and easy to carry. It is, however, unstable on the work surface. The Department of Urology of the University of Wisconsin School of Medicine and Public Health remedied the lack of stability, by clipping the Coe and Curington’s model on a wooden board with a binder clip (Figure 2D) (21), a feature originally suggested by Pfenninger (27).

Other homemade models

Several physicians who perform NSV also created their own simulators with everyday materials. They stand out for their simplicity, but also for their innovation. Members of the Vasectomy Network identified the following simulators:

• The Wilson’s model (Figure 2E) is made with a small woven polypropylene string fold to mimic the two vasa deferens and inserted in an Ultrasuede^® fabric pouch (scrotum) padded with loose polyester batting. This model requires sewing work to maintain components in place. It may be fixed on a clipboard, stabilizing the simulator on the work surface.
• The Weissman’s model (22) (Figure 2F) consists in a small urinary catheter (vas deferens) inserted into two perforated plastic balls (testicles) and each wrapped in a lubricated latex condom (fascia). The assembly is inserted into a tightly knitted sock (scrotum) and fixed on a clipboard.
• The Kaza’s model (Figure 2G) requires a scalp vein set tubing (vas deferens) which is first inserted into the middle finger of a latex glove (scrotum). The glove is then mounted on an empty plastic bottle to ensure the stability of the model, which can be further tapped on the working surface for increasing stability.
• The balloon model (Figure 2H) is simply a latex tube (vas deferens) and a gauze that are inserted into a deflated balloon (scrotum).

The visual and haptic realism of internal and external structures of these “do-it-yourself” models are limited (Table 2). Almost all can be used a few times before replacing some components and are easy to rebuild except for the Wilson’s model that needs sewing work. They can be built rapidly at minimal cost provided the various components are available.

Potential suitability of simulators to assist in transferring vasectomy skills into practice

Table 3 describes our appraisal of the potential suitability of the retrieved simulators to assist in transferring skills of surgical steps of vasectomy into practice. All allow the practice of most steps of the recommended vasectomy techniques but with some limits in terms of visual and haptic realism.

Correct hand positioning of the three-finger NSV technique can be practiced on all models, even with the simple gauze and tubing model. As holding the vas with the three-finger NSV technique is possible on all models, the gestures of anesthesia can also be simulated. Surgeons can practice correct hands positioning and manipulation of the syringe and needle of the mini-needle technique (28) or the Madajet^® device (29) technique, but without simulated assessment of the anesthesia effect. Isolating the vas from the other scrotal structures while positioning it under the median raphe a key step of NSV is, however, not possible to simulate adequately on any model as none includes a cord-like scrotal structure.

Vas exposure with the NSV technique (grasping the vas with the ring clamp, puncturing, and stretching the scrotal skin with the dissecting forceps, and delivering the vas) can be simulated with all the models. However, completing vas delivery with NSV requires to pull on the bared vas after grasping it with the ring forceps. This can only be achieved with models that are fixed/clipped on the working surface. Once fixed on the working surface, the choice of the material for skin (Ultrasuede^®), filling (loose polyester batting), and vas (woven propylene) used in the Wilson’s model provides the best haptic realism for vas delivery.

Striping down the vas sheath—the last step of NSV technique—cannot be adequately simulated with any model. Even if some models include a simulated fascia (a Penrose latex drain), it is not tightly attached to the vas and provides limited realism of the human anatomy. Fascial interposition is not possible to simulate with such thin and fragile simulated fascia; it tears with the manipulations required to perform fascial interposition. Mucosal cautery can be partially simulated in all models that use hollow latex tubing to simulate the vas.

Discussion

Our scoping review shows that various procedural simulators for teaching and learning vasectomy exist. As most simulators are homemade models, it is surprising that a systematic review on low-cost simulation models in urology published in 2020 did not mention any vasectomy simulator (30).

None of the simulators identified in our study allows adequate simulation of all surgical steps of the vasectomy techniques most recommended by urological associations (7-11). Nevertheless, most models permit practicing surgical gestures of NSV, such as positioning hands for the three finger-technique, simulating local anesthesia, grasping the vas with the ring clamp, and delivering the vas with the dissecting forceps.

Low level of physical resemblance simulators may be sufficient for unexperienced surgeons to learn the basics of these NSV surgical skills (4,5). However, no model fully simulates the visual and haptic characteristics of the human scrotum and content. Simulators with physical characteristics similar to the human anatomy and allowing accurate simulation of the real tasks are essential to mastering fine motor skills and transferring these skills into clinical practice (4). Adequate cognitive load is essential to foster surgical competency in the learner (31).

Moreover, none of the retrieved vasectomy simulators appears to be suitable to simulate adequately vas isolation and fascial interposition techniques. Fascial interposition, although a recommended key step of vas occlusion (7-11), is difficult to master and surgeons often not perform it because they do not master this specific skill (32). The availability of a simulator allowing to simulate this vas occlusion step would be desirable.

We did not identify clear pedagogical advantages of the commercial model assessed over the better designed homemade models such as the Coe and Curington’s model clipped on a wooden board (21), the Wilson’s model, and the Weissman’s model (22). The professional look of the commercial model does not translate into the haptic realism of the external and internal scrotal structures needed to optimize the learning experience. Moreover, the “do-it-yourself” models cost a small fraction of the price of the commercial simulators. Time devoted to gather all components required to build homemade models must however be taken into account. Some simple models lack stability on work surface. Fixing the assembly on a clipboard or a wooden board easily improves model stability.

Our study has limitations. We may not have retrieved some vasectomy simulators. Our search strategy was however extensive (sensitive and specific literature searches with PubMed, multiple Web searches with Google, and survey of vasectomy surgeons). Most simulators were found through Google searches and by members of the Vasectomy Network. This finding indicated the importance of using multiple sources of information when conducting a scoping review to obtain a comprehensive overview on the targeted topic (15,16).

Apart from retrieving existing vasectomy simulators and describing their characteristics, we assessed potential suitability of the simulators in transferring surgical skills into practice. Our assessment criteria were however based on expert opinions and were not validated. In addition, only one member of the research team tried all models with NSV instruments. To overcome these limitations, in part, we sought the opinion of the creators of three handmade simulators. All three were experienced vasectomy providers and trainers. Although they could have overestimated the quality of their own model, it did not appear to be the case. Their evaluations were similar to ours and complemented our findings.

Definite determination of the suitability of simulators would have required performing a comparative study involving teachers and learners trying and comparing simulators with each other and to real practice. This could be the object of further research. However, such a study would be challenging to conduct. The present study already provides a broad expert perspective on several vasectomy models.

Conclusions

Our review identified 10 relevant vasectomy simulators. Almost all are homemade models. Most can help new learners acquire some basic skills of recommended vasectomy techniques (7-11). The commercial simulators available have no advantages over the “do-it-yourself” simulators. There appears to be a need to develop and test higher level of fidelity vasectomy simulators. Meeting this need would be particularly relevant for clinical settings where the number of patients is limited for adequate hands-on training. Our analysis should guide the development of vasectomy simulators aiming at easier and better transfer of skills into practice.

Acknowledgments

We would like to acknowledge the expertise and contribution of Drs. John Curington, Ramchandra Murti Kaza, and Wilson for their thoughtful comments on our evaluation of their scrotal models.

Funding: This study was supported by a grant from the Support Program for Educational Innovation in Health Sciences of the Gilles-Cormier Fund of the Faculty of Medicine of Université Laval (INNOV_FGC2020).

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-113/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-113/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-113/coif). C.D., M.L., and B.P. report grant from the Support Program for Educational Innovation in Health Sciences of the Gilles-Cormier Fund of the Faculty of Medicine of Université Laval (INNOV_FGC2020), which was used to conduct this review and the initial research and development activities to create a new vasectomy simulator taking into account the findings of this review. M.L. is a member of the AUA vasectomy guideline committee (unpaid). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wagner KE, Soyster ME, Bartels C, et al. Improving resident learning on vasectomy: a national survey on urology resident vasectomy training. Can J Urol 2021;28:10941-5. [PubMed]
2. Patel J, Nguyen BT, Shih G, et al. Vasectomy Training in Family Medicine Residency Programs: A National Survey of Residency Program Directors. Fam Med 2022;54:438-43. [Crossref] [PubMed]
3. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306:978-88. [Crossref] [PubMed]
4. Consorti F, Panzera G. Low versus high level of physical resemblance in simulation for the acquisition of basic surgical skill: a meta-analysis. BMJ Simul Technol Enhanc Learn 2021;7:422-7. [Crossref] [PubMed]
5. Hoogenes J, Matsumoto ED. Chapter 10: Simulation Surgical Models: Surgeon Perspectives. In: Farhat WA, Drake J. editors. Bioengineering for Surgery. Sawston, Cambridge, UK: Chandos Publishing; 2016:167-88.
6. Tulving E, Thomson DM. Encoding specificity and retrieval processes in episodic memory. Psychological Review 1973;80:352-73. [Crossref]
7. Dohle GR, Diemer T, Kopa Z, et al. European Association of Urology guidelines on vasectomy. Eur Urol 2012;61:159-63. [Crossref] [PubMed]
8. Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guideline. J Urol 2012;188:2482-91. [Crossref] [PubMed]
9. Guideline Faculty of Sexual and Reproductive Healthcare Clinical Guideline. Male and Female Sterilisation. Royal College of Obstetricians and Gynaecologists (RCOG). Available online: https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-sterilisation-cpd-sep-2014/, accessed June 5 2024
10. Zini A, Grantmyre J, Chow V, et al. UPDATE - 2022 Canadian Urological Association best practice report: Vasectomy. Can Urol Assoc J 2022;16:E231-6. [Crossref] [PubMed]
11. Hupertan V, Graziana JP, Schoentgen N, et al. Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy. Prog Urol 2023;33:223-36. [Crossref] [PubMed]
12. Labrecque M, Dufresne C, Barone MA, et al. Vasectomy surgical techniques: a systematic review. BMC Med 2004;2:21. [Crossref] [PubMed]
13. Cook LA, Pun A, Gallo MF, et al. Scalpel versus no‐scalpel incision for vasectomy. Cochrane Database Syst Rev 2014;2014:CD004112. [PubMed]
14. Sokal DC, Labrecque M. Effectiveness of vasectomy techniques. Urol Clin North Am 2009;36:317-29. [Crossref] [PubMed]
15. Munn Z, Peters MDJ, Stern C, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18:143. [Crossref] [PubMed]
16. Peters MDJ, Marnie C, Colquhoun H, et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 2021;10:263. [Crossref] [PubMed]
17. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018;169:467-73. [Crossref] [PubMed]
18. No-Scalpel Vasectomy Skills Trainer (S518). Gaumard Scientific. Available online: https://www.gaumard.com/s518. Accessed June 5 2024.
19. Harper PB. Dr. Philip Li trains U.S. doctors in no-scalpel vasectomy. AVSC News 1991;29:5. [PubMed]
20. Coe TM, Curington J. An inexpensive yet realistic model for teaching vasectomy. Int Braz J Urol 2015;41:373-8. [Crossref] [PubMed]
21. Vasectomy Model. Department of Urology. Available online: https://urology.wisc.edu/education-and-training/urology-simulation-education-program/vasectomy-model/. Accessed December 16 2023.
22. Weissman Vasectomy Model. Vasectomy Resources. Available online: https://www.vasdoc.org/vasectomy-models/weissman-model/. Accessed June 5 2024.
23. Advanced ZACKTM Multipurpose Men’s Healthcare Task Trainer (S230.200). Gaumard Scientific. https://www.gaumard.com/s230-200. Accessed June 5 2024.
24. ZACKTM Multipurpose Male Care Simulator (S230.11). Gaumard Scientific. Available online: https://www.gaumard.com/s230-11. Accessed June 5 2024.
25. Doctor G. GD/F9G Vasoligation Training Simulator. Available online: http://en.honglian8.com/products/Products-del9958.html. Accessed June 5 2024.
26. DM Model Manufacturing Company. Vasectomy Training Model. Available online: https://dm-model.en.alibaba.com/search/product?SearchText=Vasectomy. Accessed June 5 2024.
27. Pfenninger JL, Fowler GC, Pfenninger JL. Pfenninger and Fowler's procedures for primary care. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2011.
28. Shih G, Njoya M, Lessard M, et al. Minimizing pain during vasectomy: the mini-needle anesthetic technique. J Urol 2010;183:1959-63. [Crossref] [PubMed]
29. Weiss RS, Li PS. No-needle jet anesthetic technique for no-scalpel vasectomy. J Urol 2005;173:1677-80. [Crossref] [PubMed]
30. Pelly T, Shanmugathas N, Bowyer H, et al. Low-cost simulation models in Urology: a systematic review of the literature. Cent European J Urol 2020;73:373-80. [PubMed]
31. Howie EE, Dharanikota H, Gunn E, et al. Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training. J Surg Educ 2023;80:311-22. [Crossref] [PubMed]
32. Labrecque M, Pile J, Sokal D, et al. Vasectomy surgical techniques in South and South East Asia. BMC Urol 2005;5:10. [Crossref] [PubMed]