3D prostate MRI reconstruction for congitive robot assisted radical prostatectomy: Is it able to reduce the positive surgical margin rate?

Visual extended reality tools in image-guided surgery in urology: a systematic review

PURPOSE

The aim of this systematic review is to assess the clinical implications of employing various Extended Reality (XR) tools for image guidance in urological surgery.

METHODS

In June 2023, a systematic electronic literature search was conducted using the Medline database (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy was designed based on the PICO (Patients, Intervention, Comparison, Outcome) criteria. Study protocol was registered on PROSPERO (registry number CRD42023449025). We incorporated retrospective and prospective comparative studies, along with single-arm studies, which provided information on the use of XR, Mixed Reality (MR), Augmented Reality (AR), and Virtual Reality (VR) in urological surgical procedures. Studies that were not written in English, non-original investigations, and those involving experimental research on animals or cadavers were excluded from our analysis. The quality assessment of comparative and cohort studies was conducted utilizing the Newcastle-Ottawa scale, whilst for randomized controlled trials (RCTs), the Jadad scale was adopted. The level of evidence for each study was determined based on the guidelines provided by the Oxford Centre for Evidence-Based Medicine.

RESULTS

The initial electronic search yielded 1,803 papers after removing duplicates. Among these, 58 publications underwent a comprehensive review, leading to the inclusion of 40 studies that met the specified criteria for analysis. 11, 20 and 9 studies tested XR on prostate cancer, kidney cancer and miscellaneous, including bladder cancer and lithiasis surgeries, respectively. Focusing on the different technologies 20, 15 and 5 explored the potential of VR, AR and MR. The majority of the included studies (i.e., 22) were prospective non-randomized, whilst 7 and 11 were RCT and retrospective studies respectively. The included studies that revealed how these new tools can be useful both in preoperative and intraoperative setting for a tailored surgical approach.

CONCLUSIONS

AR, VR and MR techniques have emerged as highly effective new tools for image-guided surgery, especially for urologic oncology. Nevertheless, the complete clinical advantages of these innovations are still in the process of evaluation.

Virtual reality tumor navigated robotic radical prostatectomy by using three‐dimensional reconstructed multiparametric prostate MRI and 68 Ga‐PSMA PET/CT images: A useful tool to guide the robotic surgery?

Objectives

To evaluate the use and benefits of tumor navigation during performing robotic assisted radical prostatectomy (RARP).

Patients and Methods

Borders of the visible tumor(s) was/were and surrounding structures marked on multiparametric prostate magnetic resonance imaging (mpMRI) and ⁶⁸Ga‐labeled prostate‐specific membrane antigen ligand using positron emission computed tomography (Ga68 PSMA‐PET/CT). Three dimensional (3D) reconstruction of the images were done that were transferred to virtual reality (VR) headsets and Da Vinci surgical robot via TilePro. Images were used as a guide during RARP procedures in five cases. Indocyanine green (ICG) guided pelvic lymph node dissection (n = 2) and Martini Klinik Neurosafe technique (n = 2) were also applied.

Results

Mean patient age was 60.6 ± 3.7 years (range, 56‐66). All VR models were finalized with the agreement of radiologist, urologist, nuclear physician, and engineer. Surgeon examined images before the surgery. All VR models were found very useful particularly in pT3 diseases. Pathological stages included pT2N0 (n = 1), pT3aN0 (n = 1), pT3aN1 (n = 2), and pT3bN1 (n = 1). Positive surgical margins (SMs) occurred in two patients with extensive disease (pT3aN1 and pT3bN1) and tumor occupied 30% and 50% of the prostate volumes. Mean estimated blood loss was 150 ± 86.6 cc (range, 100‐300). Mean follow‐up was 3.4 ± 1.7 months (range, 2‐6). No complication occurred during perioperative (0‐30 days) and postoperative (30‐90 days) periods in any patient.

Conclusions

3D reconstructed VR models by using mpMRI and Ga68 PSMA‐PET/CT images can be accurately prepared and effectively applied during RARP that might be a useful tool for tumor navigation. Images show prostate tumors and anatomy and might be a guide for the console surgeon. This is promising new technology that needs further study and validation.

Development and validation of 3D printed virtual models for robot-assisted radical prostatectomy and partial nephrectomy: urologists' and patients' perception

PURPOSE

To test the face and content validity of 3D virtual-rendered printed models used before robot-assisted prostate cancer and nephron-sparing surgery.

METHODS

Patients who underwent live surgery during an international urological meeting organized in January 2017 were enrolled. Those with organ-confined prostate cancer underwent robot-assisted radical prostatectomy. Patients with a single renal tumor underwent minimally invasive nephron-sparing surgery. High-resolution (HR) imaging was obtained for all patients. Those with kidney tumors received contrast-enhanced CT scan with angiography; those with prostate cancer underwent mp-MRI. Images in DICOM format were processed by dedicated software. The first step was the rendering of a 3D virtual model. The models were then printed. They were presented during the live surgery of the urological meeting. All the participants and the operated patients were asked to fill a questionnaire about their opinion expressed in Likert scale (1-10) about the use and application of the 3D printed models.

RESULTS

18 patients were enrolled, including 8 undergoing robot-assisted radical prostatectomy and 10 undergoing minimally invasive partial nephrectomy. For each patient, a virtual 3D printed model was created. The attendants rated the utility of printed models in surgical planning, anatomical representation and the role of technology in surgical training as 8/10, 10/10 and 9/10, respectively. All patients reported favorable feedbacks (from 9 to 10/10) about the use of the technology during the case discussion with the surgeon.

CONCLUSIONS

In our experience, 3D printing technology has been perceived as a useful tool for the purpose of surgical planning, physician education/training and patient counseling. Further researches are expected to increase the level of evidence.