Development and Validity of a Silicone Renal Tumor Model for Robotic Partial Nephrectomy Training

Emergent robot-to-open conversion - Multidisciplinary simulation training in crisis management

Anticipating and addressing unexpected intraoperative events and anatomies are some of the most challenging aspects of pediatric urologic practice; uncontrolled hemorrhage is one of the most anxiety provoking and precarious. The increasing application of the robotic platform in pediatric urology adds another layer of complexity as surgeons are not immediately at the patient's bedside. Should hemorrhage occur in robotic cases, clear communication and seamless coordination between members of the operating room team are paramount to optimize patient safety and minimize errors. This is especially important in pediatric cases for which the margin of error is narrow. Non-technical skills, including leadership, decision-making, situational awareness, stress management, and team-communication, become increasingly critical. While many programs have focused on robotic training, few prepare the operating room team and surgical trainees to manage these unforeseen, emergent intraoperative scenarios. This review discusses the role of a multidisciplinary, in situ robot-to-open conversion simulation program in addressing this educational gap, ways to approach establishing these programs, and potential barriers.

Three-dimensional computed tomography-based resection process map for robot-assisted partial nephrectomy: propensity score matching of a single-center retrospective study

BACKGROUND AND OBJECTIVES

We aimed to examine the effect of preoperative three-dimensional (3D) computed tomography (CT)-based resection process map (RPM) imaging on the outcomes of robot-assisted partial nephrectomy (RAPN).

METHODS

We retrospectively analyzed 177 patients (RPM group, n = 92; non-RPM group, n = 85) who underwent this surgery between November 2012 and April 2022. Patient-specific contrast-enhanced CT images were used to construct an RPM, a 3D representation of the kidney showing the planned tumor resection and a 5 mm safety margin. Outcome analyses were performed using propensity score matching. The primary endpoint was the trifecta achievement rate.

RESULTS

We extracted 90 cases. The trifecta achievement rate showed no significant differences between the RPM (73.3%) and non-RPM groups (73.3%). However, the RPM group had fewer Grade 3 and higher complications (0.0% vs. 13.3%, p = 0.026). The da Vinci Xi (OR 3.38, p = 0.016) and tumor diameter (OR 0.95, p = 0.013) were independent factors affecting trifecta achievement in multivariate analysis. Using RPM imaging was associated with the absence of Grade 3 and higher perioperative complications (OR 5.33, p = 0.036) in univariate analysis.

CONCLUSIONS

Using preoperative 3D CT-based RPM images before RAPN may not affect trifecta achievement, but may reduce serious complication occurrence by providing detailed information on tumor resection.

Current Standards for Training in Robot-assisted Surgery and Endourology: A Systematic Review

BACKGROUND AND OBJECTIVE

Different training programs have been developed to improve trainee outcomes in urology. However, evidence on the optimal training methodology is sparse. Our aim was to provide a comprehensive description of the training programs available for urological robotic surgery and endourology, assess their validity, and highlight the fundamental elements of future training pathways.

METHODS

We systematically reviewed the literature using PubMed/Medline, Embase, and Web of Science databases. The validity of each training model was assessed. The methodological quality of studies on metrics and curricula was graded using the MERSQI scale. The level of evidence (LoE) and level of recommendation for surgical curricula were awarded using the educational Oxford Centre for Evidence-Based Medicine classification.

KEY FINDINGS AND LIMITATIONS

A total of 75 studies were identified. Many simulators have been developed to aid trainees in mastering skills required for both robotic and endourology procedures, but only four demonstrated predictive validity. For assessment of trainee proficiency, we identified 18 in robotics training and six in endourology training; however, the majority are Likert-type scales. Although proficiency-based progression (PBP) curricula demonstrated superior outcomes to traditional training in preclinical settings, only four of six (67%) in robotics and three of nine (33%) in endourology are PBP-based. Among these, the Fundamentals of Robotic Surgery and the SIMULATE curricula have the highest LoE (level 1b). The lack of a quantitative synthesis is the main limitation of our study.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Training curricula that integrate simulators and PBP methodology have been introduced to standardize trainee outcomes in robotics and endourology. However, evidence regarding their educational impact remains restricted to preclinical studies. Efforts should be made to expand these training programs to different surgical procedures and assess their clinical impact.

PATIENT SUMMARY

Simulation-based training and programs in which progression is based on proficiency represent the new standard of quality for achieving surgical proficiency in urology. Studies have demonstrated the educational impact of these approaches. However, there are still no standardized training pathways for several urology procedures.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

Validation of a 3D-printed robot-assisted partial nephrectomy training model

Objectives

Most renal tumours can be treated with a partial nephrectomy, with robot-assisted partial nephrectomy becoming the new gold standard. This procedure is challenging to learn in a live setting, especially the enucleation and renorraphy phases. In this study, we attempted to evaluate face, content, and preliminary construct validity of a 3D-printed silicone renal tumour model in robotic training for robot-assisted partial nephrectomy.

Materials and Methods

We compared the operative results of three groups of surgeons with different experience levels (>20 partial nephrectomies, 1-20 partial nephrectomies and no experience at all) performing a robotic tumour excision of a newly developed silicone model with four embedded 3D-printed renal tumours. We evaluated the participants' performance using surgical margins, excision time, total preserved parenchyma, tumour injury and GEARS score (as assessed by two blinded experts) for construct validity. Postoperatively, the participants were asked to complete a survey to evaluate the usefulness, realism and difficulty of the model as a training and/or evaluation model. NASA-TLX scores were used to evaluate the operative workload.

Results

Thirty-six participants were recruited, each group consisting of 10-14 participants. The operative performance was significantly better in the expert group as compared to the beginner group. NASA-TLX scores proved the model to be of an acceptable difficulty level.Expert group survey results showed an average score of 6.3/10 on realism of the model, 8.2/10 on the usefulness as training model and 6.9/10 score on the usefulness as an evaluation tool. GEARS scores showed a non-significant tendency to improve between trials, emphasizing its potential as a training model.

Conclusion

Face and content validity of our 3D renal tumour model were demonstrated. The vast majority of participants found the model realistic and useful for training and for evaluation. To evaluate construct and predictive validity, we require further research, aiming to compare the results of 3D-model trained surgeons with those of untrained surgeons in real-life surgery.

Technologic advances in robot-assisted nephron sparing surgery: a narrative review

BACKGROUND AND OBJECTIVE

Nephron sparing surgery (NSS) is the preferred management for clinical stage T1 (cT1) renal masses. In recent years, indications have expanded to larger and more complex renal tumors. In an effort to provide optimal patient outcomes, urologists strive to achieve the pentafecta when performing partial nephrectomy. This has led to the continuous technologic advancement and technique refinement including the use of augmented reality, ultrasound techniques, changes in surgical approach and reconstruction, uses of novel fluorescence marker guided imaging, and implementation of early recovery after surgery (ERAS) protocols. The aim of this narrative review is to provide an overview of the recent advances in pre-, intra-, and post-operative management and approaches to managing patients with renal masses undergoing NSS.

METHODS

We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010 to 2022 without limitation on study design. We included only full-text English articles published in peer-reviewed journals.

KEY CONTENT AND FINDINGS

Partial nephrectomy is currently prioritized for cT1a renal masses; however, indications have been expanding due to a greater understanding of anatomy and technologic advances. Recent studies have demonstrated that improvements in imaging techniques utilizing cross-sectional imaging with three-dimensional (3D) reconstruction, use of color doppler intraoperative ultrasound, and newer studies emerging using contrast enhanced ultrasound play important roles in certain subsets of patients. While indocyanine green administration is commonly used, novel fluorescence-guided imaging including folate receptor-targeting fluorescence molecules are being investigated to better delineate tumor-parenchyma margins. Augmented reality has a developing role in patient and surgical trainee education. While pre-and intra-operative imaging have shown to be promising, near infrared guided segmental and sub-segmental vessel clamping has yet to show significant benefit in patient outcomes. Studies regarding reconstructive techniques and replacement of reconstruction with sealing agents have a promising future. Finally, ERAS protocols have allowed earlier discharge of patients without increasing complications while improving cost burden.

CONCLUSIONS

Advances in NSS have ranged from pre-operative imaging techniques to ERAS protocols Further prospective investigations are required to determine the impact of novel imaging, in-vivo fluorescence biomarker use, and reconstructive techniques on achieving the pentafecta of NSS.

Is It the Load That Breaks You or the Way You Carry It: How Demanding Is Endourology?

Objective: Surgical outcomes are dependent on multiple factors. Besides patient-related or procedure-related factors, several surgeon-related factors contribute to surgical outcomes. The Surgery Task Load Index (SURG-TLX) questionnaire helps to assess the impact of several stressors on the perceived demands of surgeons during surgery. In this study, we evaluate the applicability of the SURG-TLX questionnaire for endourologic procedures and set a first point of reference. Materials and Methods: Between March and August 2022, 15 urologists and urology residents at a tertiary referral center for endourology completed the SURG-TLX questionnaire after endourologic procedures. After data acquisition, all participants were asked to evaluate the applicability of the questionnaire for endourologic procedures. Results: A total of 130 procedures were included between March and August 2022. Situational stress had the lowest median score (3.0/20; interquartile range [IQR] 2.0-7.0) and task complexity the highest (5.0/20; IQR 3.0-8.0). After weighing, the dimensions showed different proportions when compared with the nonweighted scores. Distractions received the highest score (15.0/100; IQR 7.5-32.8), temporal demands (6.0/100; IQR 3.0-12.5), and situational stress the lowest (6.0/100; IQR 2.0-21.0). This was caused by the higher weight that was attributed to distractions (3.4/5), as opposed to task complexity (2.6/5). In the questionnaire regarding applicability of the SURG-TLX, the overall satisfaction (6.0/10; IQR 5.0-7.0) and clarity (6.5/10; IQR 5.0-7.5) were moderate. The user-friendliness and applicability of the questionnaire were rated high (7.0/10; IQR 5.5-8.0 and 7.0/10; IQR 6.0-8.0, respectively) and task load (3.0/10; IQR 2.0-5.0) and time load (2.0/10; IQR 2.0-3.5) low. Conclusion: The SURG-TLX questionnaire is appropriate to assess the different dimensions of workload during endourologic procedures. Furthermore, the perceived workload during endourologic procedures is relatively low.

A mechanically validated open-source silicone model for the training of gastric perforation sewing

BACKGROUND

Gastrointestinal perforation is commonly seen in emergency departments. The perforation of the stomach is an emergency situation that requires immediate surgical treatment. The necessary surgical skills require regular practical training. Owing to patient`s safety, in vivo training opportunities in medicine are restricted. Animal tissue especially porcine tissue, is commonly used for surgical training. Due to its limiting factors, artificial training models are often to be preferred. Many artificial models are on the market but to our knowledge, none that mimic the haptic- and sewing properties of a stomach wall at the same time. In this study, an open source silicone model of a gastric perforation for training of gastric sewing was developed that attempts to provide realistic haptic- and sewing behaviour.

METHODS

To simulate the layered structure of the human stomach, different silicone materials were used to produce three different model layups. The production process was kept as simple as possible to make it easily reproducible. A needle penetration setup as well as a systematic haptic evaluation were developed to compare these silicone models to a real porcine stomach in order to identify the most realistic model.

RESULTS

A silicone model consisting of three layers was identified as being the most promising and was tested by clinical surgeons.

CONCLUSIONS

The presented model simulates the sewing characteristics of a human stomach wall, is easily reproducible at low-costs and can be used for practicing gastric suturing techniques.

TRIAL REGISTRATIONS

Not applicable.

Mental workload during endoscopic sinus surgery is associated with surgeons' skill levels

Introduction

Surgeons' mental workload during endoscopic sinus surgery (ESS) has not been fully evaluated. The assessment was challenging due to the great diversity of each patient's anatomy and the consequence variety of surgical difficulties. In this study, we examined the mental workload of surgeons with various surgical skill levels during ESS under the standardized condition provided by novel-designed 3D sinus models.

Materials and methods

Forty-seven participants performed a high-fidelity ESS simulation with 3D-printed sinus models. Surgeons' mental workload was assessed with the national aeronautics and space administration-task load index (NASA-TLX). Associations between the total and subscales score of NASA-TLX and surgical skill index, including the board certification status, the number of experienced ESS cases, and the objective structured assessment of technical skills (OSATS), were analyzed. In addition, 10 registrars repeated the simulation surgery, and their NASA-TLX score was compared before and after the repetitive training.

Results

The total NASA-TLX score was significantly associated with OSATS score (p = 0.0001). Primary component analysis classified the surgeons' mental burden into three different categories: (1) the skill-level-dependent factors (temporal demand, effort, and performance), (2) the skill-level-independent factors (mental and physical demand), and (3) frustration. After the repetitive training, the skill-level-dependent factors were alleviated (temporal demand; z = -2.3664, p = 0.0091, effort; z = -2.1704, p = 0.0346, and performance; z = -2.5992, p = 0.0017), the independent factors were increased (mental demand; z = -2.5992, p = 0.0023 and physical demand; z = -2.2509, p = 0.0213), and frustration did not change (p = 0.3625).

Conclusion

Some of the mental workload during ESS is associated with surgical skill level and alleviated with repetitive training. However, other aspects remain a burden or could worsen even when surgeons have gained surgical experience. Routine assessment of registrars' mental burdens would be necessary during surgical training to sustain their mental health.

Application of three-dimensional printing technology in renal diseases

Three-dimensional (3D) printing technology involves the application of digital models to create 3D objects. It is used in construction and manufacturing and has gradually spread to medical applications, such as implants, drug development, medical devices, prosthetic limbs, and in vitro models. The application of 3D printing has great prospects for development in orthopedics, maxillofacial plastic surgery, cardiovascular conditions, liver disease, and other fields. With in-depth research on 3D printing technology and the continuous update of printing materials, this technology also shows broad development prospects in renal medicine. In this paper, the author mainly summarizes the basic theory of 3D printing technology, its research progress, application status, and development prospect in renal diseases.

The use of individualized 3D-printed models on trainee and patient education, and surgical planning for robotic partial nephrectomies

3D printing is a growing tool in surgical education to visualize and teach complex procedures. Previous studies demonstrating the usefulness of 3D models as teaching tools for partial nephrectomy used highly detailed models costing between $250 and 1000. We aimed to create thorough, inexpensive 3D models to accelerate learning for trainees and increase health literacy in patients. Patient-specific, cost-effective ($30-50) 3D models of the affected urologic structures were created using pre-operative imaging of 40 patients undergoing partial nephrectomy at Thomas Jefferson University Hospital (TJUH) between July 2020 and May 2021. Patients undergoing surgery filled out a survey before and after seeing the model to assess patient understanding of their kidney, pathophysiology, surgical procedure, and risks of surgery. Three urological residents, one fellow, and six attendings filled out separate surveys to assess their surgical plan and confidence before and after seeing the model. In a third survey, they ranked how much the model helped their comprehension and confidence during surgery. Patient understanding of all four subjects significantly improved after seeing the 3D model (P < 0.001). The urology residents (P < 0.001) and fellow (P < 0.001) reported significantly increased self-confidence after interacting with the model. Attending surgeon confidence increased significantly after seeing the 3D model (P < 0.01) as well. Cost-effective 3D models are effective learning tools and assist with the evaluation of patients presenting with renal masses, and increase patient, resident, and fellow understanding in partial nephrectomies. Further research should continue to explore the utility of inexpensive models in other urologic procedures.

New imaging technologies for robotic kidney cancer surgery

Objective

Kidney cancers account for approximately 2% of all newly diagnosed cancer in 2020. Among the primary treatment options for kidney cancer, urologist may choose between radical or partial nephrectomy, or ablative therapies. Nowadays, robotic-assisted partial nephrectomy (RAPN) for the management of renal cancers has gained popularity, up to being considered the gold standard. However, RAPN is a challenging procedure with a steep learning curve.

Methods

In this narrative review, different imaging technologies used to guide and aid RAPN are discussed.

Results

Three-dimensional visualization technology has been extensively discussed in RAPN, showing its value in enhancing robotic-surgery training, patient counseling, surgical planning, and intraoperative guidance. Intraoperative imaging technologies such as intracorporeal ultrasound, near-infrared fluorescent imaging, and intraoperative pathological examination can also be used to improve the outcomes following RAPN. Finally, artificial intelligence may play a role in the field of RAPN soon.

Conclusion

RAPN is a complex surgery; however, many imaging technologies may play an important role in facilitating it.

Novel high-quality and reality biomaterial as a kidney surgery simulation model

Surgical training using live animals such as pigs is one of the best ways of achieving skilled techniques and fostering confidence in preclinical medical students and surgeon trainees. However, due to animal welfare ethics, laboratory animals’ usage for training should be kept to a minimum. We have developed a novel kidney organ model utilizing a simple procedure in which the kidney is first refluxed with N-vinyl-2-pyrrolidone (NVP) solution for 1 hour in its bath, followed by permeation for 23 hours, with a subsequent freshwater refluxed for 48 hours in the washing step. Surgical simulation of the prepared kidney model (NVP-fixed kidney) was compared with three types of other basic known simulation models (fresh kidney, freeze-thaw kidney, and FA-fixed kidney) by various evaluations. We found the NVP-fixed kidney to mimicked fresh kidney function the most, pertaining to the hardness, and strength of the renal parenchyma. Moreover, the NVP-fixed kidney demonstrated successful blood-like fluids perfusion and electrocautery. Further, we confirmed that surgical training could be performed under conditions closer to actual clinical practice. Our findings suggest that our model does not only contribute to improving surgical skills but also inspires the utilization of otherwise, discarded inedible livestock organs as models for surgical training.

Development of a 3D Printed Lung Model Made of Synthetic Materials for Simulation

BACKGROUND

 Considering the complexity of lung structures and the difficulty of thoracoscopic surgery, simulation-based training is of paramount importance for junior surgeons. Here, we aim to design a high-fidelity lung model through utilizing the three-dimensional (3D) printing technology combined with synthetic materials to mimic the real human lung.

METHODS

 The 3D printed lung model was manufactured based on the computed tomography images of a randomly selected male patient. Synthetic materials were used for the construction of lung parenchyma, blood vessels, and bronchi. Then, the model was assessed in terms of its visual, tactile, and operational features by participants (the senior surgeons, junior surgeons, and medical students), who were asked to complete the specially designed survey-questionnaires.

RESULTS

 A 3D printed model of the right lung made of synthetic materials was successfully fabricated. Thirty subjects participated in our study (10 senior surgeons, 10 junior surgeons, and 10 medical students). The average visual evaluation scores for senior surgeons, junior surgeons, and medical students were 3.97 ± 0.61, 4.56 ± 0.58, 4.76 ± 0.49, respectively. The average tactile evaluation scores were 3.40 ± 0.50, 4.13 ± 0.68, 4.00 ± 0.64, respectively. The average operation evaluation scores were 3.33 ± 0.83, 3.93 ± 0.66, 4.03 ± 0.66, respectively. Significant lower scores were obtained in the group of the senior surgeons compared with the other two groups.

CONCLUSION

 A high level of fidelity was exhibited in our 3D printed lung model and it could be applied as a promising simulator for the surgical training in the future.

3D Printing of Physical Organ Models: Recent Developments and Challenges

Physical organ models are the objects that replicate the patient-specific anatomy and have played important roles in modern medical diagnosis and disease treatment. 3D printing, as a powerful multi-function manufacturing technology, breaks the limitations of traditional methods and provides a great potential for manufacturing organ models. However, the clinical application of organ model is still in small scale, facing the challenges including high cost, poor mimicking performance and insufficient accuracy. In this review, the mainstream 3D printing technologies are introduced, and the existing manufacturing methods are divided into "directly printing" and "indirectly printing", with an emphasis on choosing suitable techniques and materials. This review also summarizes the ideas to address these challenges and focuses on three points: 1) what are the characteristics and requirements of organ models in different application scenarios, 2) how to choose the suitable 3D printing methods and materials according to different application categories, and 3) how to reduce the cost of organ models and make the process simple and convenient. Moreover, the state-of-the-art in organ models are summarized and the contribution of 3D printed organ models to various surgical procedures is highlighted. Finally, current limitations, evaluation criteria and future perspectives for this emerging area are discussed.

New Technologies for Kidney Surgery Planning 3D, Impression, Augmented Reality 3D, Reconstruction: Current Realities and Expectations

Purpose of review

We aim to summarize the current state of art about 3D applications in urology focusing on kidney surgeries. In addition we aim to provide a snapshot about future perspective of intraoperative applications of augmented reality (AR).

Recent findings

A variety of applications in different fields have been proposed. Many applications concern current realities and 3D reconstruction, while some others are about future perspective. The majority of recent studies have focused their attention on preoperative surgical planning, patient education, surgical training, and AR.

Summary

The disposability of 3D models in healthcare scenarios might improve surgical outcomes, learning curves of novice surgeons and residents, as well as patients’ understanding and compliance, allowing a more shared surgical decision-making.

Ex Vivo Porcine Model for Robot-Assisted Partial Nephrectomy Simulation at a High-Volume Tertiary Center: Resident Perception and Validation Assessment Using the Global Evaluative Assessment of Robotic Skills Tool

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and effectiveness of an ex vivo porcine training model as a useful tool to improve surgical skill and confidence with robot-assisted partial nephrectomy (RAPN) among urology residents. Methods: A 2.5 cm circular area of ex vivo porcine kidneys was marked as the area of the tumor. Tumor excision and renorrhaphy was performed by trainees using a da Vinci Si robot. All residents ranging from postgraduate year (PGY) 2 to 5 participated in four training sessions during the 2017 to 2018 academic year. Each session was videorecorded and scored using the global evaluative assessment of robotic skills (GEARS) by faculty members. Results: Twelve residents completed the program. Initial mean GEARS score was 16.7 and improved by +1.4 with each subsequent session (p = 0.008). Initial mean excision, renorrhaphy, and total times were 8.2, 13.9, and 22.1 minutes, which improved by 1.6, 2.0, and 3.6 minutes, respectively (all p < 0.001). Residents' confidence at performing RAPN and robotic surgery increased after completing the courses (p = 0.012 and p < 0.001, respectively). Overall, residents rated that this program has greatly contributed to their skill (4/5) and confidence (4.1/5) in robotic surgery. Conclusions: An ex vivo porcine simulation model for RAPN and robotic surgery provides measurable improvement in GEARS score and reduction in procedural time, although significant differences for all PGY levels need to be confirmed with larger study participation. Adoption of this simulation in a urology residency curriculum may improve residents' skill and confidence in robotic surgery.

Novel measurement tool and model for aberrant urinary stream in 3D printed urethras derived from human tissue

Background

An estimated 10% of male adults have split or dribbled stream leading to poor hygiene, embarrassment, and inconvenience. There is no current metric that measures male stream deviation.

Objective

To develop a novel method to measure spray in normal and abnormal anatomical conformations.

Design, setting, and participants

We developed a novel platform to reliably describe spray. We used cadaveric tissues and 3D Printed models to study the impact of meatal shape on the urinary stream. Cadaveric penile tissue and 3D printed models were affixed to a fluid pump and used to simulate micturition. Dye captured on fabric allowed for spray detection.

Outcome measurements and statistical analysis

Spray pattern area, deviation from normal location, and flowrates were recorded. Computational fluid dynamic models were created to study fluid vorticity.

Results and limitations

Obstructions at the penile tip worsened spray dynamics and reduced flow. Ventral meatotomy improved flowrate (p<0.05) and reduced spray (p<0.05) compared to tips obstructed ventrally, dorsally or in the fossa navicularis. 3D models do not fully reproduce parameters of their parent cadaver material. The average flowrate from 3D model was 10ml/sec less than that of the penis from which it was derived (p = 0.03). Nonetheless, as in cadavers, increasing obstruction in 3D models leads to the same pattern of reduced flowrate and worse spray. Dynamic modeling revealed increasing distal obstruction was correlated to higher relative vorticity observed at the urethral tip.

Conclusions

We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the urethra and corrective surgeries on the urine stream that would not be feasible in patients. These novel methods require further validation, but offer promise as a research and clinical tool.

Personalised three-dimensional printed transparent kidney model for robot-assisted partial nephrectomy in patients with complex renal tumours (R.E.N.A.L. nephrometry score ≥7): a prospective case-matched study

OBJECTIVES

To evaluate the effectiveness of a three-dimensional (3D) printed transparent kidney model as a surgical navigator for robot-assisted partial nephrectomy (RPN) in patients with complex renal tumours, defined by a R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score of ≥7.

PATIENTS AND METHODS

A total of 80 patients who underwent RPN were included in the present prospective case-matched study (case group [n = 40, application of 3D-printed transparent kidney model during RPN] vs matching group [n = 40, routine protocol]). The RPNs were performed by a single experienced surgeon. The RPN procedure consisted of six steps: (i) preparation of the renal hilar vessel for clamping, (ii) tumour detection and dissection, (iii) robotic ultrasonography, (iv) tumour resection, (v) calyx repair and haemostasis, and (vi) renorrhaphy. The time for each step, console time, and warm ischaemia time were compared between the two groups as a surrogate marker for surgical effectiveness.

RESULTS

Both groups were well-balanced for all baseline characteristics. The use of the model reduced the console time by ~20% compared to the matched group (64.6 vs 78.5 min, P = 0.001). On multivariate logistic regression analysis, tumour radius (P < 0.001) and application of the model (P = 0.009) were identified as significant predictors of a console time of ≤70 min.

CONCLUSION

We established the usefulness of a personalised 3D-printed transparent kidney model for more effective RPNs. Use of the 3D-printed transparent kidney model reduced the operative time even for complex renal tumours and would be expected to broaden the indications for PN.

[Use of personalized 3D printed kidney models for partial nephrectomy]

Partial nephrectomy is a first-line treatment option for the management of renal tumors. It is a surgical procedure whose complexity and stakes vary according to the specific anatomy of the patient and his tumor. 3D modeling and 3D printing have become a means of representing and thus visualizing the tumor lesion and its anatomical relationships within the organ. This mode of visualization allows the surgeon and his team, but also the patient, to easily realize the tumor complexity, the predictable difficulty of the surgery and therefore the risks of complications. Various publications have reported the benefit to the patient in terms of pre-therapy education. Some have shown a benefit for the operator in terms of surgical planning. Finally, studies on preoperative surgical simulation showed shorter kidney lumpectomy times and less bleeding when surgeons were able to train before the operation on the corresponding 3D printed model. 3D printing therefore represents an innovative tool that would improve patient management prior to partial nephrectomy, through the information it can deliver, but also through surgical simulation.

3D-printed models and virtual reality as new tools for image-guided robot-assisted nephron-sparing surgery: a systematic review of the newest evidences

PURPOSE OF REVIEW

Nowadays, kidney cancer surgery has been focusing on a patient-tailored management, expanding the indication to nephron-sparing surgery (NSS). Starting from computer tomography images, 3D models can be created, allowing a never experienced before understanding of surgical anatomy. Once obtained the models can be printed or virtually visualized with the aid to assist the surgeon in preoperative planning and simulation or intraoperative navigation. The aim of this systematic review is to assess the preoperative and intraoperative impact of 3D printed and virtual imaging for robotic NSS.

RECENT FINDINGS

Ten articles were found to meet the inclusion criteria and reviewed. An 'intermediate' score was assessed to the overall articles' quality. A moderate/high risk of bias was recorded for all the studies.

SUMMARY

3D-printed models were considered to be more useful during both preoperative simulations and patients' counseling. These models guaranteed a better comprehension of anatomical structures and surgical procedure. Costs and quality of the materials available represent the two main limits of this developing technology.Instead, in a virtual reality setting the preoperative planning was enhanced by using 3D virtual models in a mixed reality environment. Intraoperatively, the possibility to overlap the 3D model to real anatomy allowed augmented reality procedures. This technology is still a 'newborn' and is constantly evolving, expanding day by day the range of its potential applications.

Innovation in Urology: Three Dimensional Printing and Its Clinical Application

Three-dimensional (3D) printing allows rapid prototyping of novel equipment as well as the translation of medical imaging into tangible replicas of patient-specific anatomy. The technology has emerged as a versatile medium for innovation in medicine but with ever-expanding potential uses, does 3D printing represent a valuable adjunct to urological practice? We present a concise systematic review of articles on 3D printing within urology, outlining proposed benefits and the limitations in evidence supporting its utility. We review publications prior to December 2019 using guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Of 117 identified articles, 67 are included highlighting key areas of research as the use of patient-specific models for patient education, surgical planning, and surgical training. Further novel applications included printed surgical tools, patient-specific surgical guides, and bioprinting of graft tissues. We conclude to justify its adoption within standard practice, further research is required demonstrating that use of 3D printing can produce; direct and measurable improvements in patient experience, consistent evidence of superior surgical outcomes or simulation which surpasses existing means' both in fidelity and enhancement of surgical skills. Although exploration of 3D printing's urological applications remains nascent, the seemingly limitless scope for innovation and collaborative design afforded by the technology presents undeniable value as a resource and assures a place at the forefront of future advances.

Current Status of Simulation Training in Urology: A Non-Systematic Review

Simulation has emerged as an effective solution to increasing modern constraints in surgical training. It is recognized that a larger proportion of surgical complications occur during the surgeon's initial learning curve. The simulation takes the learning curve out of the operating theatre and facilitates training in a safe and pressure-free environment whilst focusing on patient safety. The cost of simulation is not insignificant and requires commitment in funding, human resources and logistics. It is therefore important for trainers to have evidence when selecting various simulators or devices. Our non-systematic review aims to provide a comprehensive up-to-date picture on urology simulators and the evidence for their validity. It also discusses emerging technologies and future directions. Urologists should embed evidence-based simulation in training programs to shorten learning curves while maintaining patient safety and work should be directed toward a validated and agreed curriculum.

Review of the effect of 3D medical printing and virtual reality on urology training with ‘MedTRain3DModsim’ Erasmus + European Union Project

Background/aim

It is necessary to incorporate novel training modalities in medical education, especially in surgical fields, because of the limitations of cadaveric training. Traditional medical education has many drawbacks, such as residency working hour restrictions, patient safety conflicts with the learning needs, and the lack of hands-on workshops. The MedTRain3DModsim Project aimed to produce 3-dimensional (3D) medical printed models, simulations, and innovative applications for every level of medical training using novel worldwide technologies. It was aimed herein to improve the interdisciplinary and transnational approaches, and accumulate existing experience for medical education, postgraduate studies, and specialty training.

Materials and methods

This project focused on models of solid organs and the urinary system, including the kidney, prostate, ureter, and liver. With 3D medical printing, it is possible to produce a body part from inert materials in just a few hours with the standardization of medical 3D modeling.

Results

The target groups of this project included medical students and residents, graduate students from engineering departments who needed medical education and surgical training, and medical researchers interested in health technology or clinical and surgical an atomy.

Conclusion

It was also intended to develop a novel imaging platform for education and training by reevaluating the existing data using new software and 3D modalities. Therefore, it was believed that our methodology could be implemented in all related medical fields.

An overview on 3D printing for abdominal surgery

BACKGROUND

Three-dimensional (3D) printing is a disruptive technology that is quickly spreading to many fields, including healthcare. In this context, it allows the creation of graspable, patient-specific, anatomical models generated from medical images. The ability to hold and show a physical object speeds up and facilitates the understanding of anatomical details, eases patient counseling and contributes to the education and training of students and residents. Several medical specialties are currently exploring the potential of this technology, including general surgery.

METHODS

In this review, we provide an overview on the available 3D printing technologies, together with a systematic analysis of the medical literature dedicated to its application for abdominal surgery. Our experience with the first clinical laboratory for 3D printing in Italy is also reported.

RESULTS

There was a tenfold increase in the number of publications per year over the last decade. About 70% of these papers focused on kidney and liver models, produced primarily for pre-interventional planning, as well as for educational and training purposes. The most used printing technologies are material jetting and material extrusion. Seventy-three percent of publications reported on fewer than ten clinical cases.

CONCLUSION

The increasing application of 3D printing in abdominal surgery reflects the dawn of a new technology, although it is still in its infancy. The potential benefit of this technology is clear, however, and it may soon lead to the development of new hospital facilities to improve surgical training, research, and patient care.

A Systematic Review of the Clinical Value and Applications of Three-Dimensional Printing in Renal Surgery

The purpose of this systematic review is to collate and analyse the current literature which examines clinical applications of 3D printing for renal disease, alongside cost and time duration factors associated with the printing process. A comprehensive search of the literature was performed across five different databases to identify studies that qualitatively and quantitatively assessed the value of 3D-printed kidney models for renal disease. Twenty-seven studies met the selection criteria for inclusion in the review. Twenty-five were original studies, and two were case reports. Of the 22 studies reporting a qualitative evaluation, the analysis of findings demonstrated the value of the 3D-printed models in areas of clinician and patient education, and pre-surgical simulation for complex cases of renal disease. Of five studies performing a quantitative analysis, the analysis of results displayed a high level of spatial and anatomical accuracy amongst models, with benefits including reducing estimated blood loss and risk of intra-operative complications. Fourteen studies evaluated manufacturing costs and time duration, with costs ranging from USD 1 to 1000 per model, and time duration ranging from 15 min to 9 days. This review shows that the use of customised 3D-printed models is valuable in the education of junior surgeons as well as the enhancement of operative skills for senior surgeons due to a superior visualisation of anatomical networks and pathologic morphology compared to volumetric imaging alone. Furthermore, 3D-printed kidney models may facilitate interdisciplinary communication and decision-making regarding the management of patients undergoing operative treatment for renal disease. It cannot be suggested that a more expensive material constitutes a higher level of user-satisfaction and model accuracy. However, higher costs in the manufacturing of the 3D-printed models reported, on average, a slightly shorter time duration for the 3D-printing process and total manufacturing time.

Cost, training and simulation models for robotic-assisted surgery in pediatric urology

INTRODUCTION

Laparoscopic procedures in pediatric urology have been shown to be safe and effective over the last number of years. Coupled with this is the technological trend to provide minimally invasive options for even the most complex pediatric patients. Whilst robotic platforms continue to try to demonstrate superior patient outcomes in adults with mixed results, the utilization of robotic platforms for pediatric urology is increasing.

METHODS

A review of the current literature was undertaken to assess the evidence for training models and cost-effectiveness of robotic-assisted pediatric urology.

CONCLUSIONS

A growing body of evidence in this field has demonstrated that robotic platforms are safe and effective in children and can provide additional reconstructive benefits due to motion scaling, magnification, stereoscopic views, instrument dexterity and tremor reduction. The main drawbacks remain the financial implications associated with this platform through purchase, maintenance, and disposable costs. This review addresses some of the addresses issues pertaining to cost, training and simulation for robotic-assisted surgery in pediatric urology.

Expanding the Indications of Robotic Partial Nephrectomy for Highly Complex Renal Tumors: Urologists' Perception of the Impact of Hyperaccuracy Three-Dimensional Reconstruction

OBJECTIVES

To assess the role of three-dimensional (3D) reconstruction in aiding preoperative planning for highly complex renal tumors amenable to robotic partial nephrectomy (RPN).

MATERIALS AND METHODS

Computed tomography (CT) scans and respective 3D reconstructions of 20 highly complex renal tumors were displayed to the attendees/urologists of the 6th Techno-Urology Meeting ( www.technourologymeeting.com ). These 20 cases had already undergone RPN performed by a single experienced surgeon. The attendees were asked to watch the videos of the CT scans first, and then the respective 3D reconstructions of 5 of the 20 cases who were randomly selected. A purpose-built questionnaire collected responders' surgical experience and surgical indication (RPN versus nephrectomy) after viewing the CT scan and the respective 3D reconstructions.

RESULTS

Twenty expert urologists, 27 young urologists, and 61 residents (total = 108) participated in the study. Five hundred forty-two views of the cases were obtained. Based on CT scans, RPN was indicated in 256 cases (47.2%). After viewing the respective 3D reconstructions, in 148 cases the responders changed their idea: indication to RPN raised in 404 cases (74.5%) (P < .001). The opinions changed regardless of the surgical experience.

CONCLUSIONS

The findings of this study are encouraging, and they might represent a significant step toward the validation of the use of 3D reconstruction for surgical planning in patients undergoing robotic kidney surgery. The use of this technology might translate into a larger adoption of nephron-sparing approach. Further investigation in this area is warranted to corroborate these findings.