Three-Dimensional Printing of a Hemorrhagic Cervical Cancer Model for Postgraduate Gynecological Training

Evaluating the value of individualized 3D printed models for examination, diagnosis and treatment planning of cervical cancer

BACKGROUND

3D printing holds great potential of improving examination, diagnosis and treatment planning as well as interprofessional communication in the field of gynecological oncology. In the current manuscript we evaluated five individualized, patient-specific models of cervical cancer FIGO Stage I-III, created with 3D printing, concerning their value for translational oncology.

METHODS

Magnetic resonance imaging (MRI) of the pelvis was performed on a 3.0 Tesla MRI, including a T2-weighted isotropic 3D sequence. The MRI images were segmented and transferred to virtual 3D models via a custom-built 3D-model generation pipeline and printed by material extrusion. The 3D models were evaluated by all medical specialties involved in patient care of cervical cancer, namely surgeons, radiologists, pathologists and radiation oncologists. Information was obtained from evaluated profession-specific questionnaires which were filled out after inspecting all five models. The questionnaires included multiple-select questions, questions based on Likert scales (1 = "strongly disagree " or "not at all useful " up to 5 = "strongly agree " or "extremely useful ") and dichotomous questions ("Yes" or "No").

RESULTS

Surgeons rated the models as useful during surgery (4.0 out of 5) and for patient communication (4.7 out of 5). Furthermore, they believed that the models had the potential to revise the patients' treatment plan (3.7 out of 5). Pathologists evaluated with mean ratings of 3.0 out of 5 for the usefulness of the models in diagnostic reporting and macroscopic evaluation. Radiologist acknowledged the possibility of providing additional information compared to imaging alone (3.7 out of 5). Radiation oncologists strongly supported the concept by rating the models highly for understanding patient-specific pathological characteristics (4.3 out of 5), assisting interprofessional communication (mean 4.3 out of 5) and communication with patients (4.7 out of 5). They also found the models useful for improving radiotherapy treatment planning (4.3 out of 5).

CONCLUSION

The study revealed that the 3D printed models were generally well-received by all medical disciplines, with radiation oncologists showing particularly strong support. Addressing the concerns and tailoring the use of 3D models to the specific needs of each medical speciality will be essential for realizing their full potential in clinical practice.

Additive manufacturing and three-dimensional printing in obstetrics and gynecology: a comprehensive review

Three-dimensional (3D) printing, also known as additive manufacturing, is a technology used to create complex 3D structures out of a digital model that can be almost any shape. Additive manufacturing allows the creation of customized, finely detailed constructs. Improvements in 3D printing, increased 3D printer availability, decreasing costs, development of biomaterials, and improved cell culture techniques have enabled complex, novel, and customized medical applications to develop. There have been rapid development and utilization of 3D printing technologies in orthopedics, dentistry, urology, reconstructive surgery, and other health care areas. Obstetrics and Gynecology (OBGYN) is an emerging application field for 3D printing. This technology can be utilized in OBGYN for preventive medicine, early diagnosis, and timely treatment of women-and-fetus-specific health issues. Moreover, 3D printed simulations of surgical procedures enable the training of physicians according to the needs of any given procedure. Herein, we summarize the technology and materials behind additive manufacturing and review the most recent advancements in the application of 3D printing in OBGYN studies, such as diagnosis, surgical planning, training, simulation, and customized prosthesis. Furthermore, we aim to give a future perspective on the integration of 3D printing and OBGYN applications and to provide insight into the potential applications.

Individualized medicine using 3D printing technology in gynecology: a scoping review

OBJECTIVE

Developments in 3-dimensional (3D) printing technology has made it possible to produce high quality, affordable 3D printed models for use in medicine. As a result, there is a growing assessment of this approach being published in the medical literature. The objective of this study was to outline the clinical applications of individualized 3D printing in gynecology through a scoping review.

DATA SOURCES

Four medical databases (Medline, Embase, Cochrane CENTRAL, Scopus) and grey literature were searched for publications meeting eligibility criteria up to 31 May 2021.

STUDY ELIGIBILITY CRITERIA

Publications were included if they were published in English, had a gynecologic context, and involved production of patient specific 3D printed product(s).

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were manually screened and assessed for eligibility by two independent reviewers and data were extracted using pre-established criteria using Covidence software.

RESULTS

Overall, 32 studies (15 abstracts,17 full text articles) were included in the scoping review. Most studies were either case reports (12/32,38%) or case series (15/32,47%). Gynecologic sub-specialties in which the 3D printed models were intended for use included: gynecologic oncology (21/32,66%), benign gynecology (6/32,19%), pediatrics (2/32,6%), urogynecology (2/32,6%) and reproductive endocrinology and infertility (1/32,3%). Twenty studies (63%) printed 5 or less models, 6/32 studies (19%) printed greater than 5 (up to 50 models). Types of 3D models printed included: anatomical models (11/32,34%), medical devices, (2/32,6%) and template/guide/cylindrical applicators for brachytherapy (19/32,59%).

CONCLUSIONS

Our scoping review has outlined novel clinical applications for individualized 3D printed models in gynecology. To date, they have mainly been used for production of patient specific 3D printed brachytherapy guides/applicators in patients with gynecologic cancer. However, individualized 3D printing shows great promise for utility in surgical planning, surgical education, and production of patient specific devices, across gynecologic subspecialties. Evidence supporting the clinical value of individualized 3D printing in gynecology is limited by studies with small sample size and non-standardized reporting, which should be the focus of future studies.

3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule's circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as "no correlation", "low correlation", or "high correlation" referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective "high correlation" with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

Development of a Three-Dimensionally Printed Ultrasound-Guided Peripheral Intravenous Catheter Phantom

Introduction

Ultrasound-guided peripheral intravenous catheter (US-PIVC) placement is an effective technique to establish PIV access when the traditional approach fails. Many training programs utilize commercial or homemade phantoms for procedural training. However, commercial products tend to be expensive and lack realism, while homemade blocks tend to be single-use and degrade easily. Thanks to the increasing availability of three-dimensional (3D) printers in academic settings, we sought to design and develop a reusable 3D-printed US-PIVC phantom and to evaluate its utility in terms of time needed to achieve IV placement and perceived realism compared to a commercial model among a group of emergency medicine (EM) physicians.

Methods

The upper extremity vascular phantom was constructed using 3D printing and casting techniques. A convenience sampling of EM physicians was timed by placing a US-PIVC in the 3D-printed and commercial models. Participants were also surveyed to assess their impression of the realism of the models. The primary outcome was the time required for US-PIVC placement in the 3D-printed model compared to the commercial model. Secondary outcomes were the assessment of differences in perceived realism and total cost between the two models.

Results

Twenty-one EM physicians completed the study. There were no significant differences in the mean time (seconds) for US-PIVC placement in the 3D-printed model (31, SD: 21) compared to the commercial model (30, SD: 18), p=0.77. Mean realism score trended higher for the 3D-printed model (3.6, SD: 0.9) compared to the commercial model (3.1, SD: 1.0), p=0.10. The total cost for the 3D-printed model was $120, with the interchangeable replacement part costing $21, which was much cheaper compared to the commercial phantom, which cost $549.

Conclusion

We developed a 3D-printed reusable US-PIVC phantom, and it proved to be more economical without sacrificing the realism and time required for US-PIVC placement when compared to a commercial phantom.

A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education

We conducted a comprehensive review of surgical simulation models used in robotic surgery education. We present an assessment of the validity and cost-effectiveness of virtual and augmented reality simulation, animal, cadaver and synthetic organ models. Face, content, construct, concurrent and predictive validity criteria were applied to each simulation model. There are six major commercial simulation machines available for robot-assisted surgery. The validity of virtual reality (VR) simulation curricula for psychomotor assessment and skill acquisition for the early phase of robotic surgery training has been demonstrated. The widespread adoption of VR simulation has been limited by the high cost of these machines. Live animal and cadavers have been the accepted standard for robotic surgical simulation since it began in the early 2000s. Our review found that there is a lack of evidence in the literature to support the use of animal and cadaver for robotic surgery training. The effectiveness of these models as a training tool is limited by logistical, ethical, financial and infection control issues. The latest evolution in synthetic organ model training for robotic surgery has been driven by new 3D-printing technology. Validated and cost-effective high-fidelity procedural models exist for robotic surgery training in urology. The development of synthetic models for the other specialties is not as mature. Expansion into multiple surgical disciplines and the widespread adoption of synthetic organ models for robotic simulation training will require the ability to engineer scalability for mass production. This would enable a transition in robotic surgical education where digital and synthetic organ models could be used in place of live animals and cadaver training to achieve robotic surgery competency.

Development of a novel 3D-printed multifunctional thorax model simulator for the simulation-based training of tube thoracostomy

Tube thoracostomy is a high-acuity, low-occurrence (HALO) procedure with significant morbidity when performed incorrectly; this is amendable through simulation. Commercially available trainers exist but often have limited realism or exorbitant cost. Three-dimensional (3D) printing produces realistic and cost-effective models suitable for simulation, but no simulator has been developed for tube thoracostomy. The aim of this paper is to describe the initial development of a multifunctional 3D-printed thorax trainer for the instruction of tube thoracostomy. The thorax model was developed in conjunction with a multi-disciplinary team using 3D-printing capable software. An existing ribcage model was modified and printed in separate elements, including bony portions (ribcage, sternum and clavicles), flexible joints, skin, heart and lungs and then assembled. The total printing cost was $180 CAD. Future research will focus on incorporating the model's ability to simulate other HALO procedures and evaluating it as a training adjunct.

Radiological Society of North America (RSNA) 3D printing Special Interest Group (SIG): guidelines for medical 3D printing and appropriateness for clinical scenarios

Medical three-dimensional (3D) printing has expanded dramatically over the past three decades with growth in both facility adoption and the variety of medical applications. Consideration for each step required to create accurate 3D printed models from medical imaging data impacts patient care and management. In this paper, a writing group representing the Radiological Society of North America Special Interest Group on 3D Printing (SIG) provides recommendations that have been vetted and voted on by the SIG active membership. This body of work includes appropriate clinical use of anatomic models 3D printed for diagnostic use in the care of patients with specific medical conditions. The recommendations provide guidance for approaches and tools in medical 3D printing, from image acquisition, segmentation of the desired anatomy intended for 3D printing, creation of a 3D-printable model, and post-processing of 3D printed anatomic models for patient care.

Evaluation of an Innovative Bleeding Cricothyrotomy Model

Objectives

Emergency medicine (EM) residents are required to perform a cricothyrotomy during training as per the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Cricothyrotomy is a rare procedure, comprising 0.45% of emergency department airway management procedures. Procedural competence in utilizing a realistic trainer is of utmost importance. We have developed a cricothyrotomy trainer using a fused deposition modeling (FDM) three-dimensional (3D) printer and innovative bleeding tissue to enhance fidelity. We aim to evaluate the trainer’s realism.

Methods

Implementation occurred during a difficult airway educational lab for EM residents in April 2018. Participants completed anonymous written surveys after performing a cricothyrotomy on the trainer. The survey evaluated the realism of the trainer and compared it to other available models by utilizing five-point visual analog scales (VAS). The participants rated their comfort level in performing the procedure pre- and post-educational lab on a five-point VAS. Demographic data included postgraduate year, prior clinical cricothyrotomy experience as a primary operator versus as an assistant, and previous trainer experience. The survey included open-response suggestions for trainer improvement. 

Results

Forty-three EM residents completed the survey (82.7%, 43/52). The mean realism rating of the trainer was 3.81 (95% CI = 3.54-4.1). The participants reported previous training on cadaver (62.8%, 27/43), porcine (46.5%, 20/43), and manikin (67.4%, 29/43) models prior to using this trainer. The bleeding cricothyrotomy trainer was rated higher than other models (4.45, 95% CI = 4.28-4.63). Participants noted improved comfort with performing the cricothyrotomy after the educational lab (average improvement of 1.23±0.75). Participants specifically commented on the realism of the bleeding and skin texture; however, they also recommended a reduction in the size of the cricothyroid membrane space. 

Conclusion

The innovative bleeding cricothyrotomy trainer has greater fidelity and reported superiority when compared to other commonly used nonbleeding models. This trainer provides a more advanced platform to teach an infrequent yet critical procedural skill to emergency medicine residents.

Tissue and Organ 3D Bioprinting

Three-dimensional (3D) bioprinting enables the creation of tissue constructs with heterogeneous compositions and complex architectures. It was initially used for preparing scaffolds for bone tissue engineering. It has recently been adopted to create living tissues, such as cartilage, skin, and heart valve. To facilitate vascularization, hollow channels have been created in the hydrogels by 3D bioprinting. This review discusses the state of the art of the technology, along with a broad range of biomaterials used for 3D bioprinting. It provides an update on recent developments in bioprinting and its applications. 3D bioprinting has profound impacts on biomedical research and industry. It offers a new way to industrialize tissue biofabrication. It has great potential for regenerating tissues and organs to overcome the shortage of organ transplantation.

Modelling and Manufacturing of a 3D Printed Trachea for Cricothyroidotomy Simulation

Cricothyroidotomy is a life-saving medical procedure that allows for tracheal intubation. Most current cricothyroidotomy simulation models are either expensive or not anatomically accurate and provide the learner with an unrealistic simulation experience. The goal of this project is to improve current simulation techniques by utilizing rapid prototyping using 3D printing technology and expert opinions to develop inexpensive and anatomically accurate trachea simulators. In doing so, emergency cricothyroidotomy simulation can be made accessible, accurate, cost-effective and reproducible.

Three-dimensional modelling software was used in conjunction with a desktop three-dimensional (3D) printer to design and manufacture an anatomically accurate model of the cartilage within the trachea (thyroid cartilage, cricoid cartilage, and the tracheal rings). The initial design was based on dimensions found in studies of tracheal anatomical configuration. This ensured that the landmarking necessary for emergency cricothyroidotomies was designed appropriately. Several revisions of the original model were made based on informal opinion from medical professionals to establish appropriate anatomical accuracy of the model for use in rural/remote cricothyroidotomy simulation.

Using an entry-level desktop 3D printer, a low cost tracheal model was successfully designed that can be printed in less than three hours for only $1.70 Canadian dollars (CAD). Due to its anatomical accuracy, flexibility and durability, this model is great for use in emergency medicine simulation training. Additionally, the model can be assembled in conjunction with a membrane to simulate tracheal ligaments. Skin has been simulated as well to enhance the realism of the model. The result is an accurate simulation that will provide users with an anatomically correct model to practice important skills used in emergency airway surgery, specifically landmarking, incision and intubation. This design is a novel and easy to manufacture and reproduce, high fidelity trachea model that can be used by educators with limited resources.