ABSTRACT

The aim of this study was to compare virtual reality simulation with other methods of teaching
interventional radiology. We searched multiple databases—Cochrane Library; Medline
(PubMed); Embase; Trip Medical; Education Resources Information Center; Cumulative Index
to Nursing and Allied Health Literature; Scientific Electronic Library Online; and Latin-American
and Caribbean Health Sciences Literature—for studies comparing virtual reality simulation and
other methods of teaching interventional radiology. This systematic review was performed in
accordance with the criteria established by the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses and the Best Evidence Medical Education (BEME) Collaboration.
Eligible studies were evaluated by using the quality indicators provided in the BEME Guide No.
11 and the Kirkpatrick model of training evaluation. After the eligibility and quality criteria had
been applied, five randomized clinical trials were included in the review. The Kirkpatrick level
of impact varied among the studies evaluated, three studies being classified as level 2B and
two being classified as level 4B. Among the studies evaluated, there was a consensus that
virtual reality aggregates concepts and is beneficial for the teaching of interventional
radiology. Although the use of virtual reality has been shown to be effective for skill acquisition
and learning in interventional radiology, there is still a lack of studies evaluating and
standardizing the employment of this technology in relation to the numerous procedures that
exist within the field of expertise.
INTRODUCTION

Learning is defined as the smallest independent struc- tural experience that contains na
objective, na activity to carry out, and na assessment. Being able to acquire learning means
being aware of that process as a whole, which encompasses knowledge, skill, and attitude.

In recent decades, minimally invasive procedures have replaced many open surgical
procedures, one of the key aims being to reduce surgical morbidity and mortality. To that
end, new resources are being tested in order to improve surgical skills in the current setting, in
which procedures are becoming increasing invasive and complex.

Radiol Bras. 2021 Jul/Ago;54(4):254–260

Because instruction in catheter-based endovascular inter-ventions has become continuous in

Virtual reality (VR) is a technology that aims to im-merse the user in a particular location,
through the per-ceptual deprivation of the actual environment, using computerized equipment
or previously captured video to create a setting resembling aspects of the real world(2,8).
Simulators based on this technology mimic realistic situ-ations and relevant scenarios, which
can then be explored by various professionals. In interventional radiology, VR has been
increasingly used for improving procedural skills, being widely employed for the teaching and
improvement of surgical techniques, such as angiography, angioplasty, vascular
catheterization, catheter placement under fluo-roscopic guidance, and stent placement, as
well as for the teaching of basic procedures such as the Seldinger tech-nique. Currently, VR
involves numerous devices and technologies, which can be adapted to work with a variety of
equipment used around the world. However, in a study published in 2019, Nesbitt et al. stated
that a VR simulator (VRS) cannot be purchased for less than £100,000.

The handling of basic materials, such as guidewires, catheters, drains, thermal ablation
equipment, and nee-dles, typically presents a challenge at the beginning of the learning
process in interventional radiology(14). Therefore, seeking to enrich the medical teaching
methodology, ad-ministrators have combined VR with traditional methods, thus broadly
aggregating concepts to increase effective-ness as well as to improve surgical skills. Preliminary
studies comparing the combined use of VR and traditional teaching have obtained promising
results regarding the employment of VR as a teaching method.

The aim of this study was to identify, systematically evaluate, and summarize the best
available scientific evi-dence comparing VR with various other methods of teach-ing
interventional radiology.
METHODS STUDY MODELS

This systematic review was conducted in accordance with the guidelines established by the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses and by the Best Evidence
Medical Education (BEME) Collabo-ration (https://www.bemecollaboration.org/). It was regis-
tered in advance via the Open Science Framework (https:// osf.io/wn762). The study was
deemed exempt from formal institutional review by our institutional review board be-cause no
human or animal subjects were involved.

SEARCH STRATEGIES

We searched the following databases: Cochrane Li-brary; Medline (PubMed); Embase; Trip
Medical; Educa-tion Resources Information Center; Cumulative Index to Nursing and Allied
Health Literature; Scientific Electronic, Library Online; and Latin-American and Caribbean
Health Sciences Literature. As search terms, we used US National Library of Medicine Medical
Subject Headings, as follows: interventional radiology; virtual reality; augmented reality;
video games; computer simulation; education medical; teaching; and simulation training. We
imposed no restrictions regarding language, origin, date of publication, publication status, or
population evaluated. Reference lists of the studies selected and the main reviews on the
subject were also evaluated. Manual searches were also carried out in the reference lists. All
searches were performed on July 29, 2020.

INCLUSION CRITERIA

We included studies that compared VR with other methods for teaching interventional
radiology. The comparator methods included the use of a pulsatile human cadaver model
(PHCM), the traditional cadaver model, didactic classes, and the porcine model.

STUDY SELECTION OF STUDIES AND DATA EXTRACTION

Eligibility was determined on the basis of the relevance of the articles or their abstracts and
the relevance of the respective journals. The identification of eligible stud- ies was carried out
in two stages by two reviewers, working independently. Disagreements were resolved by
consensus. In the first stage, after excluding duplicates, the reviewers evaluated titles and
abstracts, thus pre-selecting potentially eligible studies. In the second stage, the full texts of
those same studies were assessed in order to confirm eligibility. The selection process was
performed with The Rayyan QCRI software(16).

EVALUATION OF METHODOLOGICAL QUALITY

The Cochrane Collaboration tool was applied in order to assess the risk of bias for individual
studies and across studies. Eligible studies were evaluated by using the quality indicators
provided in BEME Guide No. 11 and the Kirkpatrick model of training evaluation described in
BEME Guide No. 8 by Steinert et al. The tools are based on instruments that cover a wide
range of methodological issues in studies evaluating teaching methodology.
RESULTS

The systematic review yielded 5,189 articles, of which 50 were found to be duplicates. After
the two independent evaluators had read the titles and abstracts of the remaining 5,139
articles, using the Rayyan online platform, 51 articles were chosen for full-text reading.

Studies that did not compare teaching methods evaluated were excluded, as were those that
did not employ the quality indicators provided in BEME Guide No.11(9), those analyzing
factors other than medical teaching, and randomized clinical trials unrelated to the field of
inter- ventional radiology. Thus, 46 studies were excluded, resulting in a final sample of five
studies.