| The Surgical Technologist | JUNE 2022 268 reproductive tract pathologies as well as patient education and the creation of customized devices. 3D-printed models use images generated from CT imaging, ultrasound, or MRI, classically used to evaluate such pathologies, to create anatomic replicas, devices, implants, and surgical instruments customized to individual patients [185, 186]. Currently, the most common application of 3DP in the field of obstetrics and gynecology is the creation of patientspecific 3D-printed anatomic and pathologic models. This has very meaningful uses gynecologic surgery as they allow optimal preoperative surgical planning with improved concordance with intraoperative findings, better surgeon experience with improved conceptualization of the lesion, and ultimately improved patient outcomes [187, 188]. Recent literature has described 3D printed models being used for the successful planning of many surgical procedures, such as for complex female genital tract malformations, cervical cancer [189], multiple uterine myomas [190], endometrial cancer[191], breast cancer tumors [192], and surgical planning of complicated caesarean delivery [193]. Not only can these models be created via noninvasive imaging techniques, they can create accurate life-sized representations of the unique contours of the structures it represents to determine optimal resection margins and approach. 3DP also has a promising role in the evaluation of Mullerian anomalies and rare female genital tract malformations. A case study by Tomlin et al. reported a rare case of unilateral cervical atresia in obstructive hemivagina with ipsilateral renal anomaly (OHVIRA) that was correctly identified preoperatively via 3DP from 3D MRI, but is typically often missed by standardized CT and traditional MRI [186]. 3DP can also be applied to the creation of patientspecific medical devices and customization of instruments and tools used in surgery to decrease costs and increase patient satisfaction and comfort [194, 195]. Most medical devices are made in standardized sets of shapes and sizes and often do not provide the best fit for the patient using them. This can result in poor fit and discomfort that can subsequently lead to discontinuation and suboptimal results, thus, necessitating the ability to customize based on the patients’ unique anatomic needs. Customized pessary fabrication via a 3D-printed mold, for example, was explored by Barsky et al. to address the common factors limiting efficacy and proper mechanical fit in women with unique anatomic considerations. Likewise, 3D-printed customized vaginal stents and dilators have been successfully created to safely and comfortably fit the pediatric and adolescent population, when none currently exist [196]. Further applications of this extend to the creation of custom 3D printable gynecologic devices that can provide individualized patient-specific tissue stretching to optimize tissue healing and remodeling [197]. 3DP has also allowed for better patient education through the creation of accurate tangible models that allow patients to understand their organ anomalies or the physical context of their tumor in the presurgical discussion and decision-making process [185]. This can help surgeons demonstrate tumor location, volume, and its extent in relation to surrounding structures to help patients come to terms with the feasibility of fertility sparing surgery, such as in the treatment of early stage cervical cancer (Figure 7) [189]. 3D-printed pelvic models based on in vivo imaging can also be used for educational purposes among health professionals and sex educators. A novel 3D-printed educational anatomic kit created by Abdulcadir et al. demonstrates models of female and male reproductive anatomy permitting the representation of variations in sex development and morphology, including models of clitorises of women who have undergone female genital mutilation, all of which are based on in vivo imaging [198]. 3DP can also supplement simulation-based medical education, which has a unique place in postgraduate gynecological training. From vaginal repair models allowing residents to train in the repair of injuries resulting from sexual assault [199] to a hemorrhagic cervical cancer model that can be made to bleed, look and feel real [200], these allow residents a low-risk and lowcost opportunity to refine their surgical skills. 3.4.2. Renal. During the last decade, 3DP has gained importance in urology. This multiple dimension technology has shown diverse benefits within the urology field such as improvement of surgical skills, evaluation before hands-on exposure to real scenarios, and improvement of patient education and surgical outcomes. Additionally, when compared with cadaver and animal training, 3DP models have shown superiority due to its lower cost, easier access [202–204], and ability to achieve a realistic surgical experience in a learner-centered environment. This allows repetitive practice, graduated advancement, exposure to multiple clinical scenarios, and errors in a zero-risk platform [205, 206]. Mimicking the characteristics of the human urinary tract using 3DP has been a challenge. Nevertheless, organ models and anatomical phantoms have been created using innovative materials such as wax, hydrogel, agarose gel, polyvinyl alcohol, and silicone. These materials allow recreation of the consistency and anatomy of the genitourinary tract for training, education, and for the development of newer surgical devices [203, 207, 208]. Nowadays, 3DP is mostly used in order to train and plan for partial nephrectomies (PN), percutaneous nephrolithotomy (PCNL), pediatric laparoscopic pyeloplasty, and renal transplantation [204, 205, 209, 210]. Multiple benefits of 3DP in PN include shorter operating and ischemia times [210–212], decreased blood loss, enhanced clamping precision [208, 213], and an improved structural identification [214]; PCNL benefits of preoperative simulation have been observed in mean fluoroscopy times, number of percutaneous access attempts, need for needle repositioning [203], accuracy in stone localization, fragmentation time, and requirement for flexible nephroscopy for stone clearance [209, 215]. As for kidney transplantation, this technology has advanced; in recent years, it has been used as training material in fully immersion simulations with robotic surgery. Studies have found that residents can better understand how to set up and suture the renal artery and vein anastomoses [216], and that after simulation, they can perform the arterial, venous, and the ureterovesical anastomosis within the expected times [217]. Bendre et al. used the Global Evaluative Assessment of 12 BioMed Research International
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