A lack of standardized training curriculum and appropriate simulators in functional urological and urogynecological surgery is a fact. Possible reasons of this limitation are increasing complexity in surgeries with complex pelvic anatomy, high cost in simulators on market, lack of standardized training curriculum neither during residency and fellowship period, simulation-based standard fundamental functional urological surgery training modules. EuroSOMT ERASMUS+ project aimed to create simulators which are produced with using 3D printing and virtual reality technology via consensus of project outcomes and experts’ view from EuroSOMT Working Group of ICS Institute School of Modern Technology, ICS Standardization Committee. In this study, we presented the first preliminary results of male / female 3Dprinted physical simulators in terms of techiqual properties, we compared the details of the printing processes of 3D physical simulators to be used in the training of sling surgeries in female and male.

The steps of preparation of simulation-based training modules and curriculum in the scope of EuroSOMT project are; production of patient-specific CT-reconstructed 3D printed models with using patient/cadaver radiologic data, creation of VR/AR models with using the same 3D modeling scans, establishment appropriate syllabus and preparation evaluation documents,  assessment of skills (technical and cognitive) in learning-training and teaching activities (3 times in a year), preparation of e-learning videos. 
We determined totally 17 surgical procedures (10 female, 7 male), enrolled to the curriculum for preparation procedure-based simulators. For each procedure, standard steps were determined in the curriculum. 3D printing technology was used for physical, virtual reality technology was used for non-physical simulators. All anatomical models will be provided by real-patient CT or MRI radiologic images, 3D reconstructed with using Mimics software and 3-matic.

We used following steps for the reconstruction and 3D printing of the customized anatomical models. First the extraction of CT or MRI data, from patients or cadavers, with a medical imaging device and generating the DICOM  files from them with MIMICS software, secondly masking the area of interest and extracting the .STL  files of the 3D models with MIMICS and 3D surface rendering, and texturing for the realistic human and surgery tool model with 3DS MAX and Z-Brush and finally printing them with FormLabs2 3D printer. We used white and elastic resin for skeleton and soft tissue and organs respectively (1,2). For 3D printing process, we used streolithography method in which laser printing modality used. The 3D printer brand was FormLabs 2 Bio.

Production time, resin type and quantities of 3D printed male and female physical simulators are shown in Figure 1. Anterior, posterior and inferior(perineal) aspect of the male (upper row) and female(lower row) pelvic models can be seen respectively in Figure2.

Approximately the same time (300 hours) was spent for models of both male and female. Since the skeleton of the male model was larger, approximately 1.5 times more white resin was used. It is more difficult to segment and model the soft tissues and organs (eg. vagina) of the female model from radiological images and also print it successfully. However, before 3D printing, for each model, we determined exact anatomic structures which were important for male and female fucntional urologic surgeries. With this regard, we decided to make 3D modeling and segmentation in terms of bone, muscle, ligamanents and organs. Following the seperate production of the structures, post-process period was achieved to implement the anatomic models to physical surgical simulators. However, the models were prepared as a useful propertieis to do endoscopic examination and surgery as well.

If a personalized model is to be produced in functional urology, the beginning processes should be made in this way and the type and amount of material should be determined by considering the anatomical differences between male and female. 3D printhed models are useful and promiding modality for teaching process for residents and young urologists in terms of complexity of functional urologic surgeries. Anatomic comparison shoud be take into account between male and female 3D printed models before start creation the physical simulator.

Tatar I, Huri E, Selçuk I, Moon YL, Paoluzzi A, Skolarikos A. Review of the effect of 3D medical printing and virtual reality on urology training with ‘MedTRain3DModsim’ Erasmus + European Union Project. Turk J Med Sci. 2019 Oct 24;49(5):1257-1270. doi: 10.3906/sag-1905-73. PMID: 31648427; PMCID: PMC7018298.
Tatar I, Selçuk I, Huri E. Evaluation of a 3d printed female anatomical model for the hands on training of trans-obturator tape (TOT) and tension free vaginal tape (TVT) sling procedures. Int J Morphol. 2020 38(2): 292-298 doi: 10.4067/S0717-95022020000200292