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3D printed model for flexible ureteroscopy training, a low-cost option for surgical training
Modelo impreso en 3D para entrenamiento en ureteroscopia flexible, una opción de bajo coste para el entrenamiento quirúrgico
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"apellidos" => "Aguado-Maestro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Cansino Alcaide" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J.R." "apellidos" => "Pérez-Carral" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "L." "apellidos" => "Martínez-Piñeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Traumatología, Hospital Universitario Río Hortega, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Modelo impreso en 3D para entrenamiento en ureteroscopia flexible, una opción de bajo coste para el entrenamiento quirúrgico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 309 "Ancho" => 400 "Tamanyo" => 12535 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endoscopic view of the renal pelvis and upper and middle calyceal groups.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Flexible ureterorenoscopy is a surgical technique widely used in urology for the treatment of urinary lithiasis as well as for the diagnosis and treatment of upper urinary tract tumors.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Surgical training in urology residency is mainly based on actual patients during routine clinical practice in the operating room, under the supervision of an experienced urologist. In addition, it requires a high number of cases and involves more time in the operating room dedicated to teaching, as well as a risk of damage of the flexible ureteroscope.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Most of these surgical techniques have a considerable learning curve, which may lead to a high risk of causing iatrogenic harm during residency and first years of professional experience. Moreover, the opportunities for trainees have been limited by the financial pressure to reduce operative times and the complexity of cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To address this aspect of surgical learning, alternative training methods have been developed based on artificial, cadaveric, animal models and recently, virtual reality systems. However, access to many of these simulators is limited, due to their high cost of acquisition and expensive maintenance.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The European Association of Urology, in its training/assessing curriculum for the Endoscopic Stone Treatment STEP 1, task 4, flexible ureteroscopy, uses the Key-Box (K-Box®, Porgès-Coloplast) as a model with numbered calyces for standardized control which allows familiarization with the movements of the device with rotation, in/out, and deflection exercises.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this study is to present the construction of a 3D printed model of the upper urinary tract. The model allows the use of real instruments such as flexible ureteroscopes and baskets in order to acquire skills in their handling, both in the orientation and exploration of the renal calyces as well as in stone mobilization and removal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This training program is expected to provide trainees with psychomotor skills and confidence necessary to start the procedure in a real-world scenario, shortening the learning curve and reducing possible complications on the patient or on the equipment used.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">For the elaboration of the 3D printed three-dimensional model, a computed axial tomography of a right kidney in excretory phase (CT urogram) of an actual patient was taken as a starting point (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The axial cuts in soft-tissue density were exported in DICOM format.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Segmentation of the upper urinary tract was performed using the open-source software Horos™ (version 4.0.0), performing surface rendering to obtain a three-dimensional mesh that was exported in Standard Triangle Language (STL) format. The three-dimensional model was processed using Autodesk® Meshmixer software (version 3.5, Autodesk, Inc., San Rafael, California, USA) and included within a rectangular prism, generating a solid block with the hollow urinary tract inside using Boolean tools.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After performing tests with the original ureter, it was decided to generate an artificial ureter by adding a 5 mm diameter cylinder next to the outlet of the renal pelvis to facilitate the introduction of the ureteroscope (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), achieving a larger caliber and diameter for practice.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Two types of models were generated: a single-block model, and another resulting from a division along the major axis of the renal pelvis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) into two blocks. Slots were added to the double-block model in order to favor fastening with elastic bands. The structures were exported again in STL format and prepared for printing with Cura software (version 4.4, Ultimaker, Utrecht, The Netherlands). Since a non-expandable impression material is used, a ×1.2 scale model was programmed to favor the mobility of the ureteroscope within the renal pelvis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">For printing, the Fused Deposition Modelling (FDM) printer was used (Ultimaker S5 Ultimaker, Utrecht, The Netherlands), with white PLA (polylactic acid) filament (Smartfil PLA, Smartmaterials 3D, Jaén, Spain).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The weight of the single-block model was 373 g. The estimated cost of the material was 8.77 € (47.17 m of filament) and the printing time was 18 h 21 m. The model divided into 2 blocks had an estimated weight of 420 g, with an estimated cost of the material of 9. 88 € (53.15 m of filament) and a printing time of 21 h 31 m.</p><p id="par0070" class="elsevierStylePara elsevierViewall">An Innovex single use flexible ureteroscope (Palex) was employed. The endoscopic view is depicted in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>. Nitinol baskets type Front® and No-Tip® (Coloplast) were used for stone mobilization and removal. Natural stones of 4–5 mm were used for the simulation of the stones.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The endourological material, such as flexible ureteroscope and baskets, was recycled and disinfected for teaching use.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Based on the training curriculum for endoscopic stone treatment STEP 1 of the European Association of Urology (task 4), the double-block model had the calyces numbered from 1 to 4 from upper to lower calyx.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The aim of the exercise was to introduce the flexible ureteroscope and navigate within the 3D model, reaching each of the numbered calyces.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Natural stones of 4–5 mm were introduced inside the renal calyces; the objective of this exercise was mobilization and removal.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">The 3D printed model allowed trainees to perform orientation exercises based on the correct visualization of the numbers placed in the renal calyces in descending order (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">By using Front® and No-Tip® type nitinol baskets, the mobilization of stones between the calyceal groups was achieved, as well as the removal of stones smaller than 4 mm from the 3D model (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Given their difference in the opening (frontal/lateral) of the baskets, the use of both types helps us familiarize us with the different techniques for stone removal.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Both exercises were completely performed by endourologists with extensive experience in this type of intervention and by residents with different years of training.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">It is well known that the key factor to the acquisition of surgical skills is practice and performance of procedures, with the establishment of the so-called “learning curves” whose length will depend on the complexity of the procedure to be performed.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Practicing on simulation-based models facilitates the acquisition of new skills and shortens learning curves. It also allows ample opportunity for expert urologists to provide constructive feedback to the urology trainees. Unlike the actual operating room environment, simulation allows the expert surgeon to focus on the needs of the trainee, rather than the patient’s needs.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Surgical simulation provides an opportunity for skill acquisition in a safe and reproducible environment. It is well known that both low and high-cost simulators have shown to be effective in learning a surgical technique while reducing the learning curve.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Simulation models are classified according to their fidelity to reality. Alessi, in the year 2000, defined fidelity in the context of simulation as the “degree to which a simulation reproduces reality”. This is why fidelity can be equated with credibility/reality.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The degree of fidelity is closely associated to the type of simulator used. Authors such as Jeffries point out that fidelity levels are directly associated to the level of technology and the technical characteristics of the simulator, with the simulator and the simulation environment being the main determinants of realism. In this sense, we can classify simulation levels as high and low fidelity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Based on the above classification, a low-fidelity simulation is considered less realistic, as it depends both on the use of technology and on the visual representation, tissue texture, and proposed surgical exercises.</p><p id="par0140" class="elsevierStylePara elsevierViewall">An example of a low-fidelity model is the Toronto model created for urological practice consisting of a Penrose representing the urethra, an inverted polystyrene cup representing the bladder, and two 8 mm diameter straws as bilateral ureters at a cost of 13 €.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In contrast, high-fidelity models such as those created by Uro-Scopic Trainer™ (Limbs and Things Ltd., Bristol, UK) or virtual reality simulators such as UROMentor™ (Simbionix, Cleveland, Ohio, USA) use technology to create virtual reality. These models can exceed 2000 €.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11,12</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">As for our device, the cost of the plastic materials used for the creation of the model presented in our publication was less than 20 €.</p><p id="par0155" class="elsevierStylePara elsevierViewall">A randomized, controlled clinical trial in final-year medical students conducted in 2002 using low-fidelity and high-fidelity models showed that hands-on training with simulation models improved the endourological performance more than receiving only didactic sessions (p 0.01). With respect to model fidelity, the low-fidelity group did significantly better than the didactic group (p < 0.05). However, no significant differences were found between the high and low fidelity groups (p > 0.05).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">An interesting study performed for the validation of a training model for flexible ureteroscopy was the Key-Box® (Porgès-Coloplast). This low-fidelity model does not reproduce the exact anatomy of the renal collecting system but creates an environment that forces manipulation of the flexible ureteroscope, similar to the specific movements to be performed during flexible ureteroscopy in humans.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The study was conducted with medical students randomized into two groups based on previous practice in a training model. One group underwent a 10-day practice prior to the evaluation of flexible ureteroscopy skills, while the control group had no prior practice in training models.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The results of the study concluded that specific training increases success rates both in the ureteroscope manipulation and in the use of the nitinol basket exercises, successfully reducing the time to complete the procedure. The trained group obtained a duration of 76.3 ± 11.6 s compared to 172.5 ± 6.3 s of the control group (p < 0.001).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Another study conducted in 2011 compared several ureteroscopy training models for skill learning, 2 used non-virtual reality (Uro-scopic Trainer; Endo-Urologie-Modell) and one used virtual reality (URO Mentor).</p><p id="par0180" class="elsevierStylePara elsevierViewall">A higher realism of the flexible ureteroscope domain was described in the non-virtual reality-based models, compared to the virtual model. However, the realism of respiratory movements achieved by the virtual model was highlighted. The results showed that virtual reality-based and non-virtual reality-based training models provide almost comparable levels of training skills.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In the past year 2020 a study validated a 3D printed silicone model for flexible ureterorenoscopy training. This study compared skill acquisition between 3 groups (novice, intermediate and expert).</p><p id="par0190" class="elsevierStylePara elsevierViewall">Among its results, it was observed that the total navigation times were 504, 293 and 133 s for the novice, intermediate and expert groups, respectively, showing statistical significance (p = 0.02). This study demonstrated that the model used for skill assessment allowed differentiating between levels of expertise in terms of reduction in navigation time. In addition, it obtained a median score of 8.6 out of 10 for the utility of the model and 6.75 out of 10 for its realism.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Using the same surgical training models: Uro-Scopic Trainer and URO Mentor, Chou et al. evaluated learning outcomes in basic ureteroscope skills in inexperienced medical students. The authors found no significant differences between the two training models in their ability to perform the steps of the procedure and concluded that either training modality could improve initial surgical performance in medical students.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">As can be seen in the aforementioned studies, a clear relationship seems to be established between the use of flexible ureteroscopy practice models and the speed of skill acquisition in the handling of the devices.</p><p id="par0205" class="elsevierStylePara elsevierViewall">In our article we tried to verify whether the 3D printed model was valid to perform exercise 4 proposed by the European Association of Urology school in the Endoscopic Stone Treatment Training Curriculum.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Once proving a feasible execution of the model, as shown in the results section, we are able to plan comparative studies that will allow us to compare the learning outcomes with the methodology of the aforementioned studies.</p><p id="par0215" class="elsevierStylePara elsevierViewall">To date, several studies have been published emphasizing the valuable benefits offered by 3D printing for pre-surgical training in selected or complex cases, especially in the oncologic and reconstructive surgery scenario. However, it has not been widely used for stone treatment to date and only publications with low numbers of patients have been found. Still, we believe that our model can introduce 3D printing for training and surgical planning aspects in endourology.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17–19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">The model developed in 3D printing from an actual urinary tract, mainly aimed at urology trainees, is feasible, inexpensive, and useful for surgical training in flexible ureteroscopy, navigation techniques and the use of baskets.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Further studies are needed to obtain more powerful conclusions that allow us to objectify real skill acquisition.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">This research has not received any type of financial support.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1640139" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1462417" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1640140" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1462418" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-04-23" "fechaAceptado" => "2021-07-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1462417" "palabras" => array:4 [ 0 => "Flexible ureteroscopy" 1 => "Surgical simulation" 2 => "3D model" 3 => "Surgical training" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1462418" "palabras" => array:4 [ 0 => "Ureteroscopia flexible" 1 => "Simulación quirúrgica" 2 => "Modelo 3D" 3 => "Entrenamiento quirúrgico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Training in experimental models is a valid option that improves the outcomes and shortens surgical learning curves.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our objective was to develop a 3D printed plastic model for teaching, training and education in flexible ureteroscopy, analyzing costs and suitability for the practice of this surgical technique.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A 3D printed model was developed based on a CT scan from a real-life patient’s upper urinary tract. Horos™ software was used for segmentation and an FDM-Ultimaker for 3D printing.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Renal calyces were numbered to be identified, as in the European Association of Urology Endoscopic Stone Treatment training curriculum, Task 4.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The following were used: Innovex single-use flexible ureteroscope (Palex) and nitinol baskets (Coloplast).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Printing time was 19 h, with a total cost of €8.77.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The three-dimensional model allowed the insertion of the flexible ureteroscope and the exploration of the renal calyces by urologists in training as well as in current practice of the specialty without difficulty.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The model also allowed the use of baskets and the mobilization and removal of previously placed stones.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">We unveil a valid three-dimensional model for flexible ureteroscopy training exercises with reasonable costs, which will allow acquiring the necessary skills and confidence to initiate the procedure in a real-life scenario.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La práctica en modelos experimentales es una opción válida que mejora los resultados y acorta las curvas de aprendizaje de las técnicas quirúrgicas.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue desarrollar un modelo en plástico, impreso en 3D para la docencia, entrenamiento y formación en ureteroscopia flexible, analizando costes e idoneidad para la práctica de esta técnica quirúrgica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se elaboró un modelo impreso en 3D a partir de una tomografía axial computarizada de una vía urinaria superior de un paciente real. La segmentación se llevó a cabo mediante el <span class="elsevierStyleItalic">software</span> Horos™ y la impresión mediante una impresora FDM-Ultimaker.</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Se numeró los cálices renales para ser identificados, como en el plan de formación de tratamiento endoscópico de litiasis, ejercicio 4, de la Asociación Europea de Urología.</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Se utilizaron: un ureteroscopio flexible desechable Innovex (Palex) y cestillas de nitinol (Coloplast).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">El tiempo de impresión fue de 19 horas, con un coste total de 8,77 €.</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">El modelo tridimensional permitió la introducción del ureteroscopio flexible y la exploración de los cálices renales por parte de urólogos tanto en formación como en ejercicio actual de la especialidad sin dificultad.</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">El modelo también permitió la utilización de cestillas y la movilización y extracción de litiasis previamente colocadas.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Damos a conocer un modelo tridimensional válido para ejercicios de formación en ureteroscopia flexible con unos costes razonables, que permitirá adquirir la destreza y la confianza necesaria para iniciar el procedimiento en un escenario real.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Trelles Guzmán CR, Mainez Rodríguez JA, Aguado-Maestro I, Cansino Alcaide R, Pérez-Carral JR, Martínez-Piñeiro L. Modelo impreso en 3D para entrenamiento en ureteroscopia flexible, una opción de bajo coste para el entrenamiento quirúrgico. Actas Urol Esp. 2022;46:16–21.</p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 653 "Ancho" => 1250 "Tamanyo" => 125680 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT urogram of the right kidney used as a reference for the model.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 860 "Ancho" => 1250 "Tamanyo" => 83265 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Creation of a solid block with the hollow urinary tract inside.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 643 "Ancho" => 500 "Tamanyo" => 42258 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">3D printing of *double-block and **single-block model of the hollow upper urinary tract.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 309 "Ancho" => 400 "Tamanyo" => 12535 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endoscopic view of the renal pelvis and upper and middle calyceal groups.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 787 "Ancho" => 1300 "Tamanyo" => 81254 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Endoscopic image. (B) Double-block model. Navigation and identification of the calyces. 1: Superior calyceal group; 2: superior-middle calyceal group; 3: inferior-middle calyceal group; 4: inferior calyceal group.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 496 "Ancho" => 1000 "Tamanyo" => 47704 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Stone mobilization and removal with basket.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence for Ureterorenoscopy and Laser Fragmentation (URSL) for large renal stones in the modern era" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. 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