Robotics in Interventional Radiology: Review of Current and Future Applications

Paranoid About Androids: A Review of Robotics in Radiology

In tandem with the ever-increasing global population, the demand for diagnostic radiology service provision is on the rise and at a disproportionate rate compared to the number of radiologists available to practice. The current "revolution in robotics" promises to alleviate personnel shortages in many sectors of industry, including medicine. Despite negative depictions of robots in popular culture, their multiple potential benefits cannot be overlooked, in particular when it comes to health service provision. The type of robots used for interventional procedures are largely robotic-assistance devices, such as the Da Vinci surgical robot. Advances have also been made with regards to robots for image-guided percutaneous needle placement, which have demonstrated superior accuracy compared to manual methods. It is likely that artificial intelligence will come to play a key role in the field of robotics and will result in an increase in the levels of robotic autonomy attainable. However, this concept is not without ethical and legal considerations, most notably who is responsible should an error occur; the physician, the robot manufacturer, software engineers, or the robot itself? Efforts have been made to legislate in order to protect against the potentially harmful effects of unexplainable "black-box" decision outputs of artificial intelligence systems. In order to be accepted by patients, studies have shown that the perceived level of trustworthiness and predictability of robots is crucial. Ultimately, effective, widespread implementation of medical robotic systems will be contingent on developers remaining cognizant of factors that increase human acceptance, as well as ensuring compliance with regulations.

AI and Interventional Radiology: A Narrative Review of Reviews on Opportunities, Challenges, and Future Directions

The integration of artificial intelligence in interventional radiology is an emerging field with transformative potential, aiming to make a great contribution to the health domain. This overview of reviews seeks to identify prevailing themes, opportunities, challenges, and recommendations related to the process of integration. Utilizing a standardized checklist and quality control procedures, this review examines recent advancements in, and future implications of, this domain. In total, 27 review studies were selected through the systematic process. Based on the overview, the integration of artificial intelligence (AI) in interventional radiology (IR) presents significant opportunities to enhance precision, efficiency, and personalization of procedures. AI automates tasks like catheter manipulation and needle placement, improving accuracy and reducing variability. It also integrates multiple imaging modalities, optimizing treatment planning and outcomes. AI aids intra-procedural guidance with advanced needle tracking and real-time image fusion. Robotics and automation in IR are advancing, though full autonomy in AI-guided systems has not been achieved. Despite these advancements, the integration of AI in IR is complex, involving imaging systems, robotics, and other technologies. This complexity requires a comprehensive certification and integration process. The role of regulatory bodies, scientific societies, and clinicians is essential to address these challenges. Standardized guidelines, clinician education, and careful AI assessment are necessary for safe integration. The future of AI in IR depends on developing standardized guidelines for medical devices and AI applications. Collaboration between certifying bodies, scientific societies, and legislative entities, as seen in the EU AI Act, will be crucial to tackling AI-specific challenges. Focusing on transparency, data governance, human oversight, and post-market monitoring will ensure AI integration in IR proceeds with safeguards, benefiting patient outcomes and advancing the field.

Legal Implication in Utilizing Automated Robots: A Written Informed Consent Form Proposal

BACKGROUND

Robotic systems enhance physicians' capabilities by replicating hand movements in real-time, ensuring precise control and a quick return to conventional procedures if patient safety is compromised. Physicians performing robot-assisted procedures bear ultimate responsibility, sharing potential liability with manufacturers for malfunctions.

METHODS

This study, conducted by a transdisciplinary team of interventional radiologists and a legal expert, evaluates the integration of robotic systems in interventional radiology through a comprehensive literature review, addressing potential legal contingencies.

RESULTS

This paper aims to define liability in this context and examines how workflows and doctor-patient relationships might be reshaped: patients must be informed about treatment options, including details about robot-assisted procedures and associated risks.

CONCLUSIONS

These systems could significantly impact interventional radiology practice. A dedicated informed consent process is necessary to ensure clear communication and protect the decision-making process and patient-centred care; thereby, an informed consent is proposed to comprehensively address these needs.

IR-GPT: AI Foundation Models to Optimize Interventional Radiology

Foundation artificial intelligence (AI) models are capable of complex tasks that involve text, medical images, and many other types of data, but have not yet been customized for procedural medicine. This report reviews prior work in deep learning related to interventional radiology (IR), identifying barriers to generalization and deployment at scale. Moreover, this report outlines the potential design of an "IR-GPT" foundation model to provide a unified platform for AI in IR, including data collection, annotation, and training methods-while also contextualizing challenges and highlighting potential downstream applications.

Improving Pre- and Post-IR Procedure Experience: What the Anesthesiologists Can Offer

Anesthesia in interventional radiology (IR) is a dynamic and constantly evolving medical field, shaped by technological advances and clinical challenges specific to this discipline. IR has experienced significant expansion, becoming an essential modality for the treatment of various pathologies, ranging from vascular diseases to oncological interventions. This development has paved the way for an expanded range of procedures, sometimes involving fragile patients or those with comorbidities, presenting anesthesiologists with new patient management strategies. Technological advancements in interventional imaging demand increased precision in the planning and administration of anesthesia. Optimization of intubation techniques, airway management, and adjustment of pharmacological protocols become imperative to ensure patient safety and comfort. Individualization of anesthesia protocols becomes a necessity, requiring close collaboration between interventional radiologists and anesthesiologists to define optimal, case-specific strategies. These protocols must consider the duration of procedures, patient positioning, the potentially painful nature of the intervention, as well as the patient's physiological status and ability to tolerate general anesthesia. Anesthesia conditions should be discussed between interventional radiologists and anesthesiologist-intensivists, addressing the need for muscle relaxation, the possibility of performing the procedure under sedation/hypnosis, and the prediction of postoperative pain, aiming to provide the patient with the best possible care. This article aims to contribute to the enhancement of knowledge in IR anesthesia by providing a solid foundation for innovative and secure anesthetic practices in the specific context of interventional radiology.

The Evolution of Vascular Interventional Radiology and Endovascular Surgery: An Overview of Recent Advances

Vascular interventional radiology (VIR) and endovascular surgery (EVS) are dynamic and rapidly evolving fields in modern medicine [...].

Smart goggles augmented reality CT-US fusion compared to conventional fusion navigation for percutaneous needle insertion

PURPOSE

Targeting accuracy determines outcomes for percutaneous needle interventions. Augmented reality (AR) in IR may improve procedural guidance and facilitate access to complex locations. This study aimed to evaluate percutaneous needle placement accuracy using a goggle-based AR system compared to an ultrasound (US)-based fusion navigation system.

METHODS

Six interventional radiologists performed 24 independent needle placements in an anthropomorphic phantom (CIRS 057A) in four needle guidance cohorts (n = 6 each): (1) US-based fusion, (2) goggle-based AR with stereoscopically projected anatomy (AR-overlay), (3) goggle AR without the projection (AR-plain), and (4) CT-guided freehand. US-based fusion included US/CT registration with electromagnetic (EM) needle, transducer, and patient tracking. For AR-overlay, US, EM-tracked needle, stereoscopic anatomical structures and targets were superimposed over the phantom. Needle placement accuracy (distance from needle tip to target center), placement time (from skin puncture to final position), and procedure time (time to completion) were measured.

RESULTS

Mean needle placement accuracy using US-based fusion, AR-overlay, AR-plain, and freehand was 4.5 ± 1.7 mm, 7.0 ± 4.7 mm, 4.7 ± 1.7 mm, and 9.2 ± 5.8 mm, respectively. AR-plain demonstrated comparable accuracy to US-based fusion (p = 0.7) and AR-overlay (p = 0.06). Excluding two outliers, AR-overlay accuracy became 5.9 ± 2.6 mm. US-based fusion had the highest mean placement time (44.3 ± 27.7 s) compared to all navigation cohorts (p < 0.001). Longest procedure times were recorded with AR-overlay (34 ± 10.2 min) compared to AR-plain (22.7 ± 8.6 min, p = 0.09), US-based fusion (19.5 ± 5.6 min, p = 0.02), and freehand (14.8 ± 1.6 min, p = 0.002).

CONCLUSION

Goggle-based AR showed no difference in needle placement accuracy compared to the commercially available US-based fusion navigation platform. Differences in accuracy and procedure times were apparent with different display modes (with/without stereoscopic projections). The AR-based projection of the US and needle trajectory over the body may be a helpful tool to enhance visuospatial orientation. Thus, this study refines the potential role of AR for needle placements, which may serve as a catalyst for informed implementation of AR techniques in IR.

CT-Guided Transthoracic Core-Needle Biopsy of Pulmonary Nodules: Current Practices, Efficacy, and Safety Considerations

CT-guided transthoracic core-needle biopsy (CT-TTNB) is a minimally invasive procedure that plays a crucial role in diagnosing pulmonary nodules. With high diagnostic yield and low complication rates, CT-TTNB is favored over traditional surgical biopsies, providing accuracy in detecting both malignant and benign conditions. This literature review aims to present a comprehensive overview of CT-TTNB, focusing on its indications, procedural techniques, diagnostic yield, and safety considerations. Studies published between 2013 and 2024 were systematically reviewed from PubMed, Web of Science, Scopus, and Cochrane Library using the SANRA methodology. The results highlight that CT-TTNB has a diagnostic yield of 85-95% and sensitivity rates for detecting malignancies between 92 and 97%. Several factors, including nodule size, lesion depth, needle passes, and imaging techniques, influence diagnostic success. Complications such as pneumothorax and pulmonary hemorrhage were noted, with incidence rates varying from 12 to 45% for pneumothorax and 4 to 27% for hemorrhage. Preventative strategies and management algorithms are essential for minimizing and addressing these risks. In conclusion, CT-TTNB remains a reliable and effective method for diagnosing pulmonary nodules, particularly in peripheral lung lesions. Advancements such as PET/CT fusion imaging, AI-assisted biopsy planning, and robotic systems further enhance precision and safety. This review emphasizes the importance of careful patient selection and procedural planning to maximize outcomes while minimizing risks, ensuring that CT-TTNB continues to be an indispensable tool in pulmonary diagnostics.

Image-Guided Robotic Interventions for Musculoskeletal Disease

Image-guided robotic interventions have revolutionized the treatment of musculoskeletal (MSK) diseases, combining the precision of robotics with advanced imaging to improve procedural accuracy and patient outcomes. This review delves into the evolution, current applications, and future prospects of robotic systems in managing MSK disorders. Special attention is given to the integration of various imaging modalities, the clinical impact on patient care, and the ongoing challenges that need to be addressed to enhance the adoption and efficacy of these technologies.

Role of Robotics in Image-Guided Trans-Arterial Interventions

The integration of robotic systems in image-guided trans-arterial interventions has revolutionized the field of Interventional Radiology (IR), offering enhanced precision, safety, and efficiency. These advancements are particularly impactful for acute conditions such as stroke, pulmonary embolism, and STEMI, where timely intervention is critical. Robotic platforms like the CorPath GRX and Magellan allow for remote navigation and catheter-based interventions, making it possible to extend specialized services to remote and underserved areas. These systems reduce radiation exposure for operators and enable safer, more complex procedures such as neurovascular interventions, pulmonary embolism treatment, and trans-arterial chemoembolization. By allowing specialists to control procedures remotely, robotic systems can dramatically improve outcomes in regions lacking immediate access to expert care for acute diseases. However, challenges such as high costs, the need for robust telecommunication infrastructure, and the absence of tactile feedback still exist. Future innovations, including untethered micro-robots and MR-guided robotics, hold promise for addressing these limitations. As these technologies evolve, robotic systems are expected to play a vital role in improving access to life-saving interventions in remote areas, transforming how trans-arterial procedures for acute diseases are performed while reducing risks to both patients and operators.

The Transformative Impact of AI, Extended Reality, and Robotics in Interventional Radiology: Current Trends and Applications

Interventional Radiology is at the forefront of integrating advanced imaging techniques and minimally-invasive procedures to enhance patient care. The advent of Digital Health Technologies (DHTs), including artificial intelligence (AI), robotics, and extended reality (XR), is revolutionizing healthcare, particularly in IR due to its reliance on innovative technology and advanced imaging. Since 2016, the proportion of these DHT-related publications in IR has consistently increased. The proportion of AI-related studies published in IR was 69% higher than in surgery, XR-related studies were 94% higher, and robotics studies were 192% higher, indicating a more rapid growth rate in IR compared to surgery. This article explores the transformative impact of these technologies on IR, emphasizing their potential to enhance precision, efficiency, and patient outcomes. Despite the promising advancements, there is a lack of standardization and clinical consensus on the optimal use of DHTs in IR. The variability in IR procedures and imaging systems across hospitals complicates the standardization of workflows and comparison of studies. This underscores the importance of integrating DHTs as aids to IR practitioners rather than replacement, ensuring that these technologies enhance both clinical and procedural practice.

The Role and Future of Artificial Intelligence in Robotic Image-Guided Interventions

Artificial intelligence and robotics are transforming interventional radiology, driven by advancements in computer vision, robotics and procedural automation. Historically focused on diagnostics, AI now also enhances procedural capabilities in IR, enabling future robotic systems to handle complex tasks such as catheter manipulation or needle placement with increasing precision and reliability. Early robotic systems in IR demonstrated improved accuracy in both vascular and percutaneous interventions, though none were equipped with automatic decision-making. This review tends to show the potential in improving procedural outcomes with AI for robotics, though challenges remain. Techniques like reinforcement learning and haptic vision are under investigation to address several issues, training robots to adapt based on real-time feedback from the environment. As AI-driven robotics evolve, IR could shift towards a model where human expertise oversees the technology rather than performs the intervention itself.

Fluoroscopy and Cone Beam CT Guidance in Robotic Interventions

Developments in robotic interventions have greatly affected the field of interventional radiology (IR), particularly when combined with imaging modalities such as fluoroscopy and cone-beam computed tomography (CBCT). The aim of this review is to compare and evaluate the safety, precision, and clinical outcomes of fluoroscopy and CBCT-guided robotic interventions in IR. An extensive search of the literature on PubMed and Google Scholar databases was conducted up to November 2024. Searched terms included "robotic interventions," "fluoroscopy guidance," "cone-beam CT guidance," and "robotic surgery." Literature review showed improved patient outcomes in robotic-assisted procedures, with fewer complications and higher success rates especially in anatomically challenging cases. Fluoroscopy-guided robotic interventions provide real-time imaging, allowing for accurate interventions while CBCT-guided procedures offer enhanced 3D visualization, reducing radiation exposure while maintaining high diagnostic accuracy and shorter needle puncture times. Both fluoroscopy and CBCT-guided robotic interventions play a critical role in advancing interventional radiology and are expected to improve procedural outcomes in IR.

Remote-Controlled and Teleoperated Systems: Taking Robotic Image Guided Interventions to the Next Stage

Remote-controlled and teleoperated robotic systems mark transformative advancements in interventional radiology (IR), with the potential to enhance precision, reduce radiation exposure, and expand access to care. By integrating robotic devices with imaging guidance, these systems enable precise instrument placement and navigation, thereby improving the efficacy and safety of minimally invasive procedures. Remote-controlled and teleoperated robotic systems-operated by clinicians using control interfaces from within or adjacent to the procedure room-are being adopted for both percutaneous and endovascular interventions. In contrast, although their application is still experimental, teleoperation over long distances hold promise for extending IR services to medically underserved areas by enabling remote procedures. This review details the definitions and components of remote-controlled and teleoperated robotic systems in IR, examines their clinical applications in percutaneous and endovascular interventions, and discusses relevant challenges and future directions for their incorporation into IR practices.

Interventional Radiology Management of Bone Metastasis Pain: Strategies and Techniques

Osseous metastases are common in cancer patients, and pain is one of the most frequent associated symptoms. The management of cancer-related pain is still problematic worldwide with 40 to 50% of patients still being undertreated. A significant proportion of cancer patients will require discontinuation of traditional analgesic treatments such as opioids due to unsuccessful pain relief or severe unmanageable toxicity and may, therefore, benefit from alternative treatments. Over the last few decades, several interventional radiology (IR) minimally invasive treatment options have been introduced into the cancer pain management toolbox and can be proposed to cancer patients. This article reviews the main IR treatment options for painful bone metastases which include vertebral augmentation, percutaneous osteosynthesis, tumoral ablation, electrochemotherapy, intra-arterial therapies, and percutaneous neurolysis.

Contribution and advances of robotics in percutaneous oncological interventional radiology

The advent of robotic systems in interventional radiology marks a significant evolution in minimally invasive medical procedures, offering enhanced precision, safety, and efficiency. This review comprehensively analyzes the current state and applications of robotic system usage in interventional radiology, which can be particularly helpful for complex procedures and in challenging anatomical regions. Robotic systems can improve the accuracy of interventions like microwave ablation, radiofrequency ablation, and irreversible electroporation. Indeed, studies have shown a notable decrease of an average 30% in the mean deviation of probes, and a 40% lesser need for adjustments during interventions carried out with robotic assistance. Moreover, this review highlights a 35% reduction in radiation dose and a stable-to-30% reduction in operating time associated with robot-assisted procedures compared to manual methods. Additionally, the potential of robotic systems to standardize procedures and minimize complications is discussed, along with the challenges they pose, such as setup duration, organ movement, and a lack of tactile feedback. Despite these advancements, the field still grapples with a dearth of randomized controlled trials, which underscores the need for more robust evidence to validate the efficacy and safety of robotic system usage in interventional radiology.

Robot-Assisted 2D Fluoroscopic Needle Placement-A Phantom Study

RATIONALE AND OBJECTIVES

To evaluate the targeting accuracy of a novel robot-assisted guidance technique relying on one pair of 2D C-arm images.

MATERIAL AND METHODS

In total, 160 punctures were carried out semi-automatically by using a novel robotic device. The needle's paths were planned based on one pair of 2D fluoroscopic images from different angles. Conically shaped aluminum tips inside a gelatin-filled plexiglass phantom served as targets. The accuracy of the needle placement was assessed by taking control CTs and measuring the Euclidean distance (ED) and normal distance (ND) between the needle and the target point. In addition, the procedural time per needle placement was evaluated.

RESULTS

The accomplished mean NDs at the target for the 45°, 60°, 75° and 90° angles were 1.86 mm (SD ± 0.19), 2.68 mm (SD ± 0.18), 2.19 mm (SD ± 0.18) and 1.86 mm (SD ± 0.18), respectively. The corresponding mean EDs were 2.32 mm (SD ± 0.16), 2.68 mm (SD ± 0.18), 2.65 mm (SD ± 0.16) and 2.44 mm (SD ± 0.15). The mean duration of the total procedure, including image acquisition, trajectory planning and placement of four needles sequentially, was 12.7 min.

CONCLUSIONS

Robotic guidance based on two 2D fluoroscopy images allows for the precise placement of needle-like instruments at the first attempt without the need for using an invasive dynamic reference frame. This novel approach seems to be a valuable tool for the precise targeting of various anatomical structures that can be identified in fluoroscopic images.

Value of interventional radiology and their contributions to modern medical systems

Interventional radiology (IR) is a unique specialty that incorporates a diverse set of skills ranging from imaging, procedures, consultation, and patient management. Understanding how IR generates value to the healthcare system is important to review from various perspectives. IR specialists need to understand how to meet demands from various stakeholders to expand their practice improving patient care. Thus, this review discusses the domains of value contributed to medical systems and outlines the parameters of success. IR benefits five distinct parties: patients, practitioners, payers, employers, and innovators. Value to patients and providers is delivered through a wide set of diagnostic and therapeutic interventions. Payers and hospital systems financially benefit from the reduced cost in medical management secondary to fast patient recovery, outpatient procedures, fewer complications, and the prestige of offering diverse expertise for complex patients. Lastly, IR is a field of rapid innovation implementing new procedural technology and techniques. Overall, IR must actively advocate for further growth and influence in the medical field as their value continues to expand in multiple domains. Despite being a nascent specialty, IR has become indispensable to modern medical practice.

Puncture Accuracy of Robot-Assisted CT-Based Punctures in Interventional Radiology: An Ex Vivo Study

OBJECTIVES

The purpose of this study was to assess the performance of an optically tracked robot for computed-tomography (CT)-guided needle placements in a phantom study.

METHODS

In total, 240 needle punctures were carried out with the help of an optically tracked robotic device (Micromate) based on CT image datasets at three different slice thicknesses (1, 3, and 5 mm). Conically shaped targets inside a gelatin-filled plexiglass phantom were punctured. The target positioning error between the planned and actual needle trajectory was assessed by measuring the lateral positioning error (ND) between the target and the puncture needle and the Euclidean distance (ED) between the needle tip and target in control CTs.

RESULTS

The mean ND and ED for the thinnest CT slice thickness were 1.34 mm (SD ± 0.82) and 2.1 mm (SD ± 0.75), respectively. There was no significant impact of target depth on targeting accuracy for ND (p = 0.094) or ED (p = 0.187). The mean duration for the planning of one trajectory and for needle positioning were 42 s (SD ± 4) and 64 s (SD ± 7), respectively.

CONCLUSIONS

In this ex vivo study, the robotic targeting device yielded satisfactory accuracy results at CT slice thicknesses of 1 and 3 mm. This technology may be particularly useful in interventions where the accurate placement of needle-like instruments is required.

Innovations in Image-Guided Procedures: Unraveling Robot-Assisted Non-Hepatic Percutaneous Ablation

Interventional oncology is routinely tasked with the feat of tumor characterization or destruction, via image-guided biopsy and tumor ablation, which may pose difficulties due to challenging-to-reach structures, target complexity, and proximity to critical structures. Such procedures carry a risk-to-benefit ratio along with measurable radiation exposure. To streamline the complexity and inherent variability of these interventions, various systems, including table-, floor-, gantry-, and patient-mounted (semi-) automatic robotic aiming devices, have been developed to decrease human error and interoperator and intraoperator outcome variability. Their implementation in clinical practice holds promise for enhancing lesion targeting, increasing accuracy and technical success rates, reducing procedure duration and radiation exposure, enhancing standardization of the field, and ultimately improving patient outcomes. This narrative review collates evidence regarding robotic tools and their implementation in interventional oncology, focusing on clinical efficacy and safety for nonhepatic malignancies.

Performance Evaluation of a Miniature and Disposable Endovascular Robotic Device

PURPOSE

The LIBERTY® Robotic System is a miniature, single-use device designed to facilitate remote-controlled navigation to intravascular targets. We aim to evaluate the robot's performance to manipulate a range of microguidewires and microcatheters during percutaneous endovascular procedures.

MATERIALS AND METHODS

Six interventional radiologists performed selective robotic-assisted catheterization of eight pre-determined vascular targets in a pig model. The navigation time from the guiding catheter tip to the target vessel was recorded. Each physician with a clinical experience of 20 years completed a questionnaire to evaluate the ease of use, accuracy, and safety of the robotic operation.

RESULTS

Most of the physicians reached the vascular targets in less than one minute. There was no angiographic evidence of vascular injury such as artery laceration or contusion. All physicians reported consensus about the high performance of the robot.

CONCLUSION

The miniature disposable robot is effective at reaching a range of vessels in a porcine model. Physicians found the device intuitive and easy to operate remotely.

Chinese expert consensus on cone-beam CT-guided diagnosis, localization and treatment for pulmonary nodules

Cone-beam computed tomography (CBCT) system can provide real-time 3D images and fluoroscopy images of the region of interest during the operation. Some systems can even offer augmented fluoroscopy and puncture guidance. The use of CBCT for interventional pulmonary procedures has grown significantly in recent years, and numerous clinical studies have confirmed the technology's efficacy and safety in the diagnosis, localization, and treatment of pulmonary nodules. In order to optimize and standardize the technical specifications of CBCT and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Interventional Pulmonology of China Association for Promotion of Health Science and Technology.

Navigation and Robotics in Interventional Oncology: Current Status and Future Roadmap

Interventional oncology (IO) is the field of Interventional Radiology that provides minimally invasive procedures under imaging guidance for the diagnosis and treatment of malignant tumors. Sophisticated devices can be utilized to increase standardization, accuracy, outcomes, and "repeatability" in performing percutaneous Interventional Oncology techniques. These technologies can reduce variability, reduce human error, and outperform human hand-to-eye coordination and spatial relations, thus potentially normalizing an otherwise broad diversity of IO techniques, impacting simulation, training, navigation, outcomes, and performance, as well as verification of desired minimum ablation margin or other measures of successful procedures. Stereotactic navigation and robotic systems may yield specific advantages, such as the potential to reduce procedure duration and ionizing radiation exposure during the procedure and, at the same time, increase accuracy. Enhanced accuracy, in turn, is linked to improved outcomes in many clinical scenarios. The present review focuses on the current role of percutaneous navigation systems and robotics in diagnostic and therapeutic Interventional Oncology procedures. The currently available alternatives are presented, including their potential impact on clinical practice as reflected in the peer-reviewed medical literature. A review of such data may inform wiser investment of time and resources toward the most impactful IR/IO applications of robotics and navigation to both standardize and address unmet clinical needs.