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Table of Contents
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 264-266

A Reflection on the Use of Additive Manufacturing in Nephrology for Education and Surgical Planning

1 Department of Mechanical Engineering, Faculty of Engineering and Technology, Jamia Millia Islamia (A Central University), New Delhi, India
2 Centre for Management Studies, Jamia Millia Islamia (A Central University), New Delhi, India
3 Department of Mechanical Engineering, Cambridge Institute of Technology, Ranchi, Jharkhand, India

Date of Submission08-Aug-2020
Date of Acceptance11-Nov-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Azhar Equbal
Department of Mechanical Engineering, Faculty of Engineering and Technology, Jamia Millia Islamia (A Central University), New Delhi - 110 025
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_101_20

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Additive manufacturing (AM) or three-dimensional printing (3DP) is a new technology known for rapid fabrication of customized or finely detailed parts with decreased cost. The technology uses the principle of layer by layer-based manufacturing of parts following the bottom-up approach. In recent years, AM technologies have seen a rapid development in various fields of engineering, medical, and aeronautics. Development in technology and biomaterials has made AM more novel and approachable techniques for complex medical treatments. In the current work, a reflection on the use of AM technology in the field nephrology has been presented. At present, AM technologies are used in conceptualizing and fabricating urological instruments, planning surgeries, and educating the apprentices and patients. The review primarily aimed to present the use of AM for education and surgical planning in nephrology. The study will also discuss the limitation and future scope of AM in the field of nephrology.

Keywords: Additive manufacturing, biomaterials, nephrology, technology, three-dimensional printing

How to cite this article:
Equbal A, Akhtar S, Equbal MA. A Reflection on the Use of Additive Manufacturing in Nephrology for Education and Surgical Planning. Apollo Med 2020;17:264-6

How to cite this URL:
Equbal A, Akhtar S, Equbal MA. A Reflection on the Use of Additive Manufacturing in Nephrology for Education and Surgical Planning. Apollo Med [serial online] 2020 [cited 2021 Jan 25];17:264-6. Available from: https://www.apollomedicine.org/text.asp?2020/17/4/264/305343

  Introduction Top

Additive manufacturing (AM), also coined as three-dimensional printing (3DP), was developed initially in 1986; however, at present, it is well known for its rapid fabrication of customized and finely detailed part.[1] In recent time, the AM technology is preferred for fabrication of any complex part geometries in a short span and with decreased cost possibly if used for batch or mass production. The principle of AM relies on layer-wised deposition of part material, preferably with a support material at the bottom for simple part geometries and location of support structures at the thin or overhanging portion if complex part is to be fabricated.[2] The part is fabricated either by using powder, filaments, granules, etc., but principle will remain the same.[3] There will be proper fusion of parts to produce sound bounding between them.[4] Some of the well-known AM techniques are fused deposition bonding, stereolithography, selective laser sintering, selective laser melting, and laminated object manufacturing.[5] Previously, AM is known for using plastics and powder material for fabrication of parts. However, with the development in material science and technology, metal and ceramic can also be used as printing materials. Recent studies show that the use of biomaterials in AM is very promising, particularly toward scientific applications, and the developed approach is making a major gain in commercial biomedical devices. Both natural and synthetic biomaterials can be printed.[6] With the increase in use of AM technology toward the production of biomedical devices, the possibility of use of AM in various medical application increases. Numbers of researchers have investigated the possibility of AM in various clinical applications.[7-10] Continuing in the same direction, the present paper is dedicated toward reflecting the possible application of AM in nephrological sector. The survey highlights the use of AM or 3DP technology in education and surgical planning in nephrology. The survey is not exhaustive but tries to address the major studies showing the use of AM in nephrology.

  Additive Manufacturing in Nephrology Top

Various models fabricated by AM technologies found numerous applications within urological surgery. [11,12] Prototypes or replicas generated through AM can be used in medical education. It can also be used as a working model for enhancing the knowledge and can also serve as a model for the patients for explaining of surgical procedure. The reflective study is explained on the basis of important researches showing the use of AM in nephrology. Disease related to renal systems seems to be the most highlighted area where AM is applied. 3D model of the kidney is made of silicone, wax, or polymers using data from computed tomography (CT) and magnetic resonance imaging (MRI). These materials used as 3D replacement of original organs have the shape and elasticity of the living organ and have similar mechanical strength.[1] For the study related to use of AM in nephrology concerning with education and surgical planning, some eminent research work is discussed. The workflow of preparation of low-cost replicas of silicone kidney for laparoscopic training and surgical simulation of complex nephron-sparing surgeries was given by Smektala et al.[13] The various steps in the workflow are explained, and they prepared five models of silicone kidney for five nephrology patients undergoing laparoscopic partial nephrectomy. The average cost of printing mold and casting of silicone replicas was calculated as $14.4 and $7.4, but they mentioned that the study was performed in Poland where the cost is lower as compared to other countries. Diwedi et al.[14] also prepared 3D-printed renal tumor mold and suggested that the cost of preparation of mold in the U.S.A is in the range of $20–$350. von Rundstedt et al.[15] suggested that one of the major advantages of AM is in providing detailed anatomic knowledge before surgery as well as tactile feedback. The enhanced anatomical knowledge can help in achieving better surgical outcome by allowing urologist to train them and plan their procedure better with 3D model of kidney fabricated. This is especially helpful in complex cases with higher complications. By performing the operative procedure with 3D replica of patient kidney, surgical approach in addition to risk and limitations can be realized better, and it will become clearer before the actual procedure. If any complication is realized, it can be corrected with a change before actual case for better possible outcome. To improve the accuracy and understanding of medical students when diagnosing malignant tumors, AM was approached by Knoedler et al.[16] As a resource material, students of 1st year were provided CT scans and 3D-printed models of cancerous kidneys. When asked to diagnose the 3D-printed models of kidney, the students realized that their assessment improved in three of four metrics of the renal nephrometry score when compared only with CT scans. 3D-printed models of cancerous prostrates were also used by Ebbing et al.[17] to enable medical students to locate tumors. When only MRI was used, the difference between accuracy of expert and students was 47% which reduced significantly by 30% (to 17%) when students use 3D model of kidney for their understanding.

To improve the surgical outcome in terms of operative time, blood loss, and warm ischemia time during partial nephrectomy, simulation with 3D model of operation or operative procedure is also a potential application. A study by Golab et al.[18] has shown that a silicone 3D kidney model was created from digital CT scan images of three patients with complex renal masses. Before the actual surgery of patients, a laparoscopic simulation of operation was performed on their respective silicone model in which tumor was removed and renorrhaphy was performed. It was concluded that the average time of live partial nephrectomy of the patient was only 1 min less than silicone model and the warm ischemia time was reduced by less than 9 min. The author proposes that training and simulation with silicone model helped in improving the operative efficiency during live case. For complex renal tumor cases where multiple teams of doctors from different specialization are required, AM with modeling can help them enhance communication among them. In an investigation reported by Golab et al.,[19] AM with tumor modeling from digital imaging was used to plan a very complicated operation where removal of malignant renal cell carcinoma with tumor extending to right atrium requires surgeons from vascular and cardiothoracic specialization. They reported that the AM-printed kidney tumor model plays an important and key role for communication between various surgeons and physicians both before surgery and during surgery. The teaching methodology adopted by the Center for Research in Education and simulation technology also supports the use of AM to benefit the education of residents by using anatomic models and surgical simulations.[20] The 3D-printed model scans of kidneys also enhance the understanding of patients and their families with regard to surgery, presurgery, and postsurgery anatomy of the kidney and overall change in renal function.[21] Bernhard et al.[22] proposed that for the patients who diagnose with renal mass and who are referred for partial nephrectomy real-time demo and counseling, the patient with a 3D-specific kidney model led to increased patient satisfaction.

  Conclusion Top

The discussion presented in the above section shows the use of AM or 3DP technology in nephrology The study suggests that AM can be used as a powerful and important tool to study the anatomy of kidney whether it is preoperative anatomy or postoperative anatomy. The study also explains the use of AM-printed kidney can serve as a working model to educate the medical students, residents, and most importantly patients and their families about the renal mass, its effects, and postoperative results of partial nephrectomy, which consoles and satisfies the patient to go for operative procedure. In addition, simulation studies of 3D model of operative procedure help in better realization of surgical procedure, suggesting any change before the procedure to improve effectiveness of procedure. The simulation studies in addition to CT and MRI can help the medical students to better understand the kidney anatomy and the surgical planning involved. The simulation study also helps understand the requirement of support of physicians from different specialization where 3D model of kidney serves as a tool for better communication among physicians from different specialization. The simulative study will also help in saving time, blood loss, and warm ischemia time during surgical planning. Thus, AM or 3DP in today's medical field plays really a vital role in nephrology and urology.

Limitation and future scope

Most studies in nephrology relating them with AM or 3DP have very small sample size, making it difficult to draw exclusive conclusions about the effect of AM or 3DP in outcome after surgical procedures and also the extrapolation of these results to other patients. The cost involved in material creation, i.e., cost of hardware and software, is also very high in the current healthcare profession, where resources are already high priced. Other important issues such as material compatibility, ethical implication, and regulatory compliance remain challenging in clinical practice.

With the development in AM and technology, customization of products will continually improve. There is still more scope for personalized medication and drug development at lower cost of production due to flexibility provided by AM in molecular arrangement. One of the coolest and least established applications of AM is 3D bioprinting of actual cell cultures for transplantation. Furthermore, successful fabrication of any surgery-ready major organs is yet to be realized.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chen MY, Skewes J, Desselle M, Wong C, Woodruff MA, Dasgupta P, et al. Current applications of three-dimensional printing in urology. BJU Int 2020;125:17-27.  Back to cited text no. 1
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Equbal A, Equbal MI, Sood AK. PCA-based desirability method for dimensional improvement of part extruded by fused deposition modelling technology. Prog Addit Manufact 2019;4:269-80.  Back to cited text no. 3
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[PUBMED]  [Full text]  
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Dwivedi DK, Chatzinoff Y, Zhang Y, Yuan Q, Fulkerson M, Chopra R, et al. Development of a patient-specific tumor mold using magnetic resonance imaging and 3-dimensional printing technology for targeted tissue procurement and radiomics analysis of renal masses. Urology 2018;112:209-14.  Back to cited text no. 14
von Rundstedt FC, Scovell JM, Agrawal S, Zaneveld J, Link RE. Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy. BJU Int 2017;119:598-604.  Back to cited text no. 15
Knoedler M, Feibus AH, Lange A, Maddox MM, Ledet E, Raju T, et al. Individualized physical 3-dimensional kidney tumor models constructed from 3-dimensional printers result in improved trainee anatomic understanding. Urology 2015;85:1257-61.  Back to cited text no. 16
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Golab A, Smektala T, Kaczmarek K, Stamirowski R, Hrab M, Slojewski M. Laparoscopic partial nephrectomy supported by training involving personalized silicone replica poured in three-dimensional printed casting mold. J Laparoend Adv Surg Tech Part A 2017;27:420-2.  Back to cited text no. 18
Golab A, Slojewski M, Brykczynski M, Lukowiak M, Boehlke M, Matias D, et al. Three-dimensional printing as an interdisciplinary communication tool: Preparing for removal of a giant renal tumor and atrium neoplastic mass. Heart Surg Forum 2016;19:E185-6.  Back to cited text no. 19
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