Artificial urinary sphincter (AUS) implantation is a gold standard treatment choice for moderate to severe male urinary incontinence after prostatectomy. The long learning curve of the surgery, technical difficulties various approach and non-standard surgical training program with lack of physical simulator on market lead us to produce 3D printed physical simulator which is suitable for real patient anatomy and size.
The aim of the study is to produce and evaluate efficacy of novel CT-reconstructed 3D printed AUS surgical training model by using novel worldwide technologies for increase awareness of 3D technology in surgical training, surgical planning, patient education with interdisciplinary fashion.

We completed this study as EuroSOMT (finalized Erasmus+ KA220HED project done by Hacettepe, Katholic Leuven, Perugia, Chosun Universities and ICS between 2020-2022) Working Group. The study was carried out during 2 different learning teaching & training events held in Hacettepe and KU Leuven. 3 different models were determined from different cases. All models had similar anatomical features. MIMICS Innovation suite was used for the segmentation and digital anatomical model production. FormLabs 3B and other FDM based 3D printers used for 3D printing. All models were designed by quoting the anatomy of patients who actually had incontinence in life.
 
In the first year of the study, 3D modeling, 3D medical processes and related studies were carried out and in the second year, training was given to the trainees in 3 separate events. The AUS surgical training curriculum consisted of the following steps according to the anatomical education model;PATIENT POSITIONING, PERINEAL INCISION, FROM SKIN TO URETHRA, EXPOSURE AND RELEASE OF BULBAR URETHRA, CUFF MEASURING, ABDOMINAL INCISION, BALLOON PLACEMENT, CONTROL PUMP PLACEMENT,CUFF PLACEMENT, CUFF TUBE TUNNELING TO GROIN, PERINEAL CLOSURE and FILLING AND CONNECTING THE DEVICE. Pelvic and perineal views of the model can be seen in Figure 1. 

Two challenge situations were determined for the AUS training model. In addition, a short video of 5 minutes was shown to the participants. After the theoretical training, the first case trial of surgery was made in practice with a mentor, and the participant was trained in the main model after which the scoring was done according to non-technical and technical skills.

We evaluated 40 participants (30 males and 10 females) from 5 different countries (26 Turkey, 4 Italy, 4 Belgium, 4 Macedonia and 2 Indonesia) results in two learning teaching & training events. 40% of the participants were medical students and 60% of them Urology residents. 70% of them had no previous experience about the AUS surgery. 90% of them had high interest on surgical simulators. About the surgical step evaluation, mean value was 3,89 in Likert scale (1 poor, 2 marginal, 3 acceptable, 4 good and 5 very good). We also assessed objective structured assessment of technical skill (OSATS) of the participants including Gentleness, Time and Motion, Instrument handling, Flow of operation, Tissue exposure and Summary score with the mean value 3,71 in same Likert scale. The detailed results can be seen in Figure 2.

At the end of the training activities with the analysis of the results; all participants completed the end-to-end surgery training and were successful in placing the cuff.. We have similar results after standard education at different educational levels. Especially depending on the material used in the model, the placement of the retropubic balloon gave difficulty to the participants.

As a conclusion, we believe that this is the first usage experience report of the customized 3D printed AUS anatomical model produced from real patient’s radiological data with anatomical accuracy. It can be modified to more realistic and efficient one with increasing numbers of the participant’s feedback.

Continence 7S1 (2023) 100975
DOI: 10.1016/j.cont.2023.100975