3D printing in gynecology
In terms of technology adoption life cycle, gynecologic surgery appears to fall into the late majority or laggards category as opposed to early adopters like the field of dentistry. In 2015, Yoong et al14 reported their application of 3D printing in ob/gyn with a report of a 10-cm broad ligament hematoma following cesarean section with known extension of the hysterotomy. The model was generated from pelvic MRI and demonstrated the spatial relationship of the hematoma to the surrounding pelvic structures. The authors suggested that 3D printing has the potential to augment team-based surgical planning and patient education.
In 2017, Bartellas et al15 reported creation of a 3D printed realistic hemorrhagic cervical cancer model. Historical cervical cancer models were used rather than actual patient images. Computer-aided design models were generated, which were in turn converted to STL files and subsequently sent to 3D printers. Simulation make-up was then applied to the 3D printed models and ob/gyn residents underwent simulation training with the cervices. Participants completed a post-simulation survey assessing accuracy, realism and value in education. The models were judged to be realistic and rated highly in simulation value.
Modeling in gynecologic surgery
Two studies describe use of a 3D printed model specifically for gynecologic surgery. The first study, by Aluwee,16 reported on preoperative 3D printing of five uteri with endometrial cancer. STLs were generated from MRI images with 3D models subsequently printed. CT images of the generated models were compared to the patient MRIs and compared quantitatively. Surgeons found the slight measurable errors to be acceptable and the models to be useful for preoperative planning. Both surgeons and patients found the 3D models to be an effective tool for patient education.
In 2017, Ajao et al17 described reconstruction of a deep infiltrating endometriosis nodule involving the posterior uterine wall and rectum in a 49-year-old patient. A 3-Tesla magnet was used to acquire an MRI image of the pelvis, including 3D images capturing 1-mm image slices. The stored DICOM files were then converted to STL files. A representative 3D model was then generated. The patient underwent a total laparoscopic hysterectomy, left salpingo-oophorectomy, right salpingectomy, and resection of endometriosis. Intraoperatively, the patient’s uterus was normal size, but her left ovary was adherent to the pelvic sidewall. Intraoperatively, a 2- to 3-cm rectovaginal nodule was encountered, corresponding to the lesion noted on the 3D printed model. Because of logistics associated with timing of MRI to model availability, the model was not available prior to surgery and was retrospectively compared to the intraoperative findings. The model was concordant with the intraoperative finding in regard to nodule location and topographical relation to surrounding structures (See figure 3A-C). The authors theorize that 3D printing for deep infiltrating endometriosis could prove to be a beneficial adjunct to established preoperative imaging modalities.
As in other surgical fields, 3D printing in gynecologic surgery has the potential to impact preoperative planning and surgical decision-making, patient education and counseling, and resident/fellow education. There are several limitations that will likely impede the widespread adoption of this technology into gynecologic surgery in its current iterations. The current cost per model averages $1500.17 Further studies are needed to establish the clinical benefits of use of 3D printing in gynecologic surgery. Given the lack of evidence to justify its use and until the price per model is significantly reduced, established imaging modalities such as pelvic ultrasound and MRI will continue to be the standard of care. In addition, because use of 3D printing in gynecologic surgery remains investigational and subject to approval by institutional review boards, insurance coverage for the technology can be expected to be several years away.