Urologists developed endoscopy in surgery with a focus on lower tract endoscopy in the late nineteeth and early twentieth centuries, with pioneers such as Grunfeld, Nitze, Ringleb, Goldschmidt, Desormeaux, Kelly, Brenner, and Casper. Luminaries such as Beer, Luys, Young, Davis, Buerger, Albarran, Heitz‐Boyer, Goldschmidt, Stern, McArthy, Nesbit, Alcock, and Flocks continued to evolve the techniques and equipment. Retrograde and antegrade endourologic approaches to the upper tract were introduced by Cromwell and Kelly and subsequently developed by Marshall, Rupel and Brown, Fernstrom and Johansson, Goodwin, Bagley, Clayman, Smith, Lange, Segura, and Amplatz [1, 2].

The term “endourology” was coined by Drs. Elwin Fraley, Arthur Smith, Paul Lange, and Ralph Clayman and their team at the University of Minnesota. The principles and techniques associated with endourology has become a cornerstone for what we teach trainees in order to practice modern‐day urology [3]. Medical educators for endourology continually search for the optimum modalities and methods for both skills training and competency assessment.

Taxonomies for the acquisition of technical skills outside of surgery have been developed by Dreyfus and Dreyfus, Dave, and several others [4, 5]. Figure 10.1 shows a combination of these two taxonomies and provides a matrix for classifying and understanding the progression of technical skill for urology [6].

As a trainee moves from what Dave’s taxonomy describes as imitation to manipulation, what is happening according to Dreyfus and Dreyfus is a maturation of recollection of knowledge from non‐situational to situational. This probably represents the “low bar” for the end of a training program prior to practice as it stands today. As someone evolves from manipulation to precision, their recognition of cues and knowledge moves from decomposed to a more holistic view. This translates to moving from “competent” to “proficient” and represents what happens early in one’s independent practice. Note that there are still errors being performed as one’s brain wants to begin multitasking and shifting to “automaticity” mode that represents less cognitive load. The evolution from precision to articulation is when we can start to multitask and represents a parallel transformation to “expertise.” Here, our decision‐making abilities become less analytical and more intuitive, freeing up the cognitive load to be able to multitask. This is probably where most practicing endourologists are functioning for most skills that are performed on a regular basis. Becoming a true “master” represents high‐functioning on autopilot. At this level, an individual’s awareness has evolved from monitoring the situation to completely being absorbed (virtuoso). Invention and skillful troubleshooting happen naturally during this phase.

The Halstedian apprenticeship model heavily relies upon the accumulation of considerable operative experience gathered during several years of demanding training [7]. Such “on the job training,” with the combination of attestations, case volumes, skills evaluations, and index cases, has been accepted as effective, although correlation to “objective” performance educational outcomes has been poorly studied for endourology.

In parallel, the evolution of endourology has been accelerated and represents a core skillset for the practicing urologist. There are unique learning objectives for endourology related to image‐guided surgery, rigid and flexible scope manipulation, advanced Seldinger techniques, endoluminal manipulations, laparoscopy, and robotics. The learning curves associated with these skillsets represent [3] possible barriers to optimal practice and endourology fellowships are often required to obtain proficiency and expertise in these skills. The increasing awareness of patient safety, along with the growing debate on the ethicality of completing initial learning curves on patients, and the necessity of assessing the competency in a more reasonable fashion, also urge the clinical providers to seek an adjunct modality to enhance the traditional education and training pattern.

Surgical performance in endourology is based on a combination of both technical and nontechnical skills. Medical simulation provides a no‐risk platform for learners not only to acquaint and develop new skills, but also to refine and perfect their abilities to achieve expertise and mastery [3]. When integrated into medical education, simulation not only enables the trainees to bypass the early error‐prone period and reduce the steepness of the technical skills learning curve [7], but also develop nontechnical skills during training, which all contribute to secure the patient’s safety and well‐being [8].