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Objective To compare innate spatial awareness skills, using the MIST-VR system (Ethicon Ltd, Edinburgh, a computer-based virtual reality system that objectively tests spatial awareness) among three groups of people (consultant urologists, urological trainees and controls who were not surgeons), because urological surgeons require spatial awareness for endoscopic and laparoscopic surgery, but trainees are selected by academic prowess rather than surgical aptitude. Subjects and methods The MIST-VR system was used to test 122 volunteers in three groups, i.e. 39 consultant urologists, 46 urological trainees and 37 controls (not surgeons). The demographic data recorded for each group included age, sex, eyesight, handedness, and endoscopic and laparoscopic experience. Volunteers performed a repetitive series of three tasks using the system. Their performance was measured in terms of time, errors and economy of movement, as well as the duration and accuracy of diathermy in Task 3. Results The consultants were signi®cantly older than the trainees and controls (both P<0.001) and had more endoscopic experience (P=0.005). In Task 1, the trainees made signi®cantly fewer errors (P=0.045) and had a greater economy of movement (P=0.03) than the controls. In Task 2 the trainees performed the task more rapidly than the consultants (P=0.04) and controls (P=0.02). Trainees were more economical in movement than were consultants (P=0.031) and controls (P=0.046). In the more complex Task 3, trainees outperformed consultants in terms of errors (P=0.03), economy of movement (P=0.046), total diathermy time (P=0.005) and diathermy error (P=0.03). Controls performed similarly to the consultants. Although there was a trend towards better performance by trainees over controls, this was only signi®cant for time (P=0.04) and total diathermy time (P=0.011). A few participants had results that were >2SD above the mean and several people could not complete Task 3. Conclusions Urologists do not differ from the general population in terms of innate spatial ability in this setting. There are several people who may have a defect in spatial awareness but the incidence was the same in each group. Urological trainees outperformed consultants in these tasks; the reasons for this are unclear. The MIST-VR system is of no help in aptitude testing for urological trainees, although it may have a role in teaching laparoscopic surgery. Testing other psychometric components may be more important for acquiring surgical skills than innate spatial-awareness skills. Further studies are required to investigate this possibility.

Recent years have seen notable advances in virtual reality technology and increased interest in potential medical applications. Computed tomography and magnetic resonance imaging data sets, historically viewed as axial images, may now be used to construct a virtual reality endoscopic image, and navigator software systems allow the operator to 'fly' through the urinary tract. Technological evolution has improved the quality of reconstruction, as this is dependent on the software and data set, allowing virtual reality to begin to challenge endoscopic evaluation. This review describes the evolution of virtual reality in urology and the milestones of its current clinical use. Applications may become widespread in the diagnostic evaluation of common urological symptoms, the planning of surgery and the training of future urologists.