Percutaneous liver interventions with robotic systems: a systematic review of available clinical solutions

Robotic navigation-assisted percutaneous liver puncture: a pilot study

Background

Liver cancer is often diagnosed at an advanced stage, rendering many cases unresectable and necessitating minimally invasive treatments such as ablation, for which accurate puncture is essential. Manual techniques are limited by steep learning curves, frequent needle adjustments, and increased radiation exposure. Robotic navigation-assisted puncture (RNAP) offers improved precision, efficiency, and safety, but its efficacy compared to that of manual puncture (MP) remains unclear. This study aimed to assess the safety and efficacy of RNAP in the treatment of liver tumors.

Methods

From October 2023 to February 2024, 65 patients with liver tumors underwent percutaneous puncture procedures (ablation, iodine-125 implantation, and biopsy) at department of interventional radiology. They were divided into two groups: the RNAP group (n=29) and the MP group (n=36). Two techniques were compared in terms of technical success (TS), clinical success (CS), puncture scoring (PS), number of computed tomography (CT) scans, total procedure time (TPT), puncture time (PT), irradiation dose (ID), and puncture-related complications.

Results

There were significant differences between patients in the RNAP group and those in the MP group in terms of PS (3.02±0.68 vs. 2.24±0.73; P=0.01), PT (8.86±1.91 vs. 13.44±3.66 min; P=0.01), number of CT scans (7.03±2.30 vs. 11.58±4.25; P=0.01), and ID (160.76±40.60 vs. 230.06±86.46 mGy·cm; P=0.01); meanwhile, TS (100% vs. 100%; P>0.99), CS (91.50% vs. 91.40%; P=0.81), TPT (33.22±7.80 vs. 32.13±5.50 min; P=0.52), and complications (10.30% vs. 5.56%; P=0.47) showed no differences.

Conclusions

RNAP is a useful tool for performing puncture procedures on liver tumors, which can decrease PT, CT scan times, and ID.

Evaluation of navigation and robotic systems for percutaneous image-guided interventions: A novel metric for advanced imaging and artificial intelligence integration

PURPOSE

Navigation and robotic systems aim to improve the accuracy and efficiency of percutaneous image-guided interventions, but the evaluation of their autonomy and integration of advanced imaging and artificial intelligence (AI) is lacking. The purpose of this study was to evaluate the level of automation and integration of advanced imaging and artificial intelligence in navigation and robotic systems for percutaneous image-guided interventions, using established and novel metrics to categorize and compare their capabilities.

MATERIALS AND METHODS

Following PRISMA guidelines, a systematic review was conducted to identify studies on clinically validated navigation and robotic systems published between 2000 and May 2024. The PubMed, Embase, Cochrane Library, and Web of Science databases were searched. Data on navigation devices were extracted and analyzed. The levels of autonomy in surgical robotics (LASR) classification system (from 1 to 5) was used to analyze automation. A novel taxonomy, the Levels of Integration of Advanced Imaging and AI (LIAI2) classification system, was created to categorize the integration of imaging technologies and AI (from 1 to 5). These two scores were combined into an aggregate score (from 1 to 10) to reflect the autonomy in percutaneous image-guided intervention.

RESULTS

The review included 20 studies assessing two navigation systems and eight robotic devices. The median LASR score was 1 (Q1, Q3: 1, 1), the median LIAI2 score was 2 (Q1, Q3: 2, 3), and the median aggregate score was 3 (Q1, Q3: 3, 4). Only one robotic system (10 % of those reviewed) achieved the highest LASR qualification in the literature, a level 2/5. Four systems (40 %) shared the highest rating for LIAI2, which was a score of 3/5. Four systems (40 %) achieved the highest aggregate scores of 4/10.

CONCLUSION

None of the navigation and robotic systems achieved full autonomy for percutaneous image-guided intervention. The LASR and LIAI2 scales can guide innovation by identifying areas for further development and integration.

In Vivo Safety and Feasibility of a CT-Guided Robotic Device for Percutaneous Needle Placement in Bone

PURPOSE

To evaluate the feasibility and accuracy of a robotic device used clinically in soft tissues (abdomen and lung), modified in design and workflow, to perform needle insertions in percutaneous skeletal procedures.

MATERIALS AND METHODS

The primary objective was safety (severe adverse events) of robotic-assisted insertion in this new application. Secondary objectives were feasibility (placement technical success), performance (rate of acceptable insertions), accuracy (lateral deviation), number of intermediate computed tomography (CT) scans, and tolerance (minor/moderate adverse events). Robotic-assisted insertions were performed by 6 interventional radiologists on 3 male pigs under general anesthesia. Needle trajectory was planned on the device software, and then needles were inserted with robotic guidance to reach the cortical bone. Intermediate CT was then performed to verify needle direction; if needed, the trajectory was modified, and robotic-assisted modified insertion into the target was performed. As many intermediate CT scans and trajectory modifications as needed by the operator were allowed.

RESULTS

Twenty-eight needles were inserted (10 in the spine and 18 in the pelvis). No adverse event was reported. Technical success rate was 96.4% (27/28). One insertion was not feasible after several robotic attempts. The placement success rate was 100% (27/27). After the planned intermediate CT scan, 13 (48.1%) of 27 trajectories did not require any modification, and 11 (40.7%) of 27 trajectories required a single modification. One needle was removed and replaced to achieve correct placement. Placement accuracy was similar for spinal and pelvic insertions, with a mean lateral deviation of 2.1 mm (SD ± 1.3).

CONCLUSIONS

Preclinical robotic-assisted needle insertions in bone were safe and feasible, with satisfactory accuracy. A multicenter in-human study is ongoing to evaluate feasibility and safety for percutaneous bone ablation and consolidation procedures.

Democratization in abdominal ablation therapies: The impact of percutaneous robotic assistance on accuracy-A systematic review

Advances in medical technology have revolutionized minimally invasive procedures. This study aims to determine the status of intra-abdominal ablation therapies, focusing on outcomes regarding technique improvement and benefits related to the learning curve. A systematic search in four databases was performed in March 2024 to identify relevant studies. Endpoints included targeting accuracy, organ efficacy, safety, outcomes and technical advantages regardless of physician experience. A total of 40 studies were included. The robotic technique demonstrated significantly higher accuracy (median 1.75 mm) compared to the freehand technique (median 4.50 mm) (p < 0.05). RFA and MWA were the most frequently used ablation techniques, reaching a rate of 52.5% and liver was the main target organ in 77.5% of the studies. Subgroup analysis showed a median tumor size of 2.30 cm, 1.40 mm for the readjustments and 3.30 mm for accuracy in the freehand technique. For robotic approach, the median tumor size was 1.95 cm, readjustments were 0.55 mm, and accuracy was 1.85 mm, and no statistical difference was identified. Severe adverse events were lower with the robotic approach, and improvement in the learning curve was observed among novice physicians. Robotic-assisted ablation techniques improve accuracy and efficacy compared to freehand techniques and are easier for novices to use. This technology allows novices to achieve similar outcomes to experts, contributing to the democratization of ablation techniques. Nevertheless, more clinical trials and standardized studies are necessary to validate these findings and enable the integration of robotic systems into routine practice.

Image-Guided Percutaneous Robotic Interventions for Lung

Interventional radiology (IR) has aided advances in the diagnosis and treatment of lung pathologies through procedures such as percutaneous biopsy, tumor ablation and drainage of intra-thoracic collections. The success and safety of these interventions largely depend on timely and accurate needle/device placement. Additionally, there is an inherent need to minimize radiation exposure during image-guided procedures. Robotic systems offer potential solutions to improve procedure time and accuracy, as well as reduce radiation dose. This article summarizes the existing data for clinically utilized robotic systems in the context of percutaneous lung intervention. Additionally, practical considerations are outlined when implementing robotic systems in clinical practice. Whilst robotic systems can be useful adjunctive tools, currently available systems require significant physician supervision and are therefore limited by a lack of true system autonomy.

Image Guided Percutaneous Robotic Interventions for Solid Organs

Robotic systems for minimally invasive procedures, particularly in interventional oncology, have advanced significantly, especially for percutaneous interventions guided by CT, Cone-beam CT, and MRI. These systems, which include needle-guiding and needle-driving robots, enhance the precision of procedures like biopsy and tumor ablation. Needle-guiding robots plan and align the needle, while needle-driving robots autonomously advance it, improving needle placement accuracy, enabling out-of-plane insertion, and reducing radiation exposure. These robotic systems offer key clinical benefits, such as stable needle guidance for challenging angulated approaches and better access to lesions in confined spaces, like CT or MRI gantries. They can guide the needle to the optimal region of a lesion without the need for a second contrast injection, improving both diagnosis and treatment. While many robotic systems have been developed, only a few have reached clinical use. Early studies show promising results, but concerns about increased complexity and cost remain. Further research and clinical trials are needed to fully evaluate their value, though we believe that robotic systems will play an increasingly important role in the future of image-guided interventions, particularly for challenging tumors.

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.

Percutaneous cryoablation in soft tissue tumor management: an educational review

BACKGROUND

Percutaneous cryoablation (PCA), having shown effectiveness in treating liver, lung, prostate, breast, and kidney tumors, is now gaining attention for the treatment of soft tissue tumors. PCA functions by freezing tissue, which induces ice crystal formation and cell death without damaging collagen structures. Technical considerations include the selection and handling of cryoprobes and cryogenic agents, procedural duration, and choice of image guidance for precision. This review aims to synthesize the mechanisms, applications, and technical aspects of PCA in the treatment of soft tissue tumors.

METHODS

Adhering to PRISMA 2020 guidelines, a review was conducted of studies published prior to March 2024 that investigated PCA of soft tissue tumors. The review focused on technical and procedural aspects of cryoablation, cryobiological principles, cellular and tissue responses to extreme cold, intra- and post-procedure physiological mechanisms during and post-procedure, and main clinical applications.

RESULTS

PCA is efficient in treating soft tissue tumors, including desmoid tumors, vascular malformations, and abdominal wall endometriosis. Several cryobiological mechanisms are involved, notably ice crystal formation, cellular dehydration, osmotic effects, and the inflammatory response, all of which contribute to its efficacy. Key technical aspects include the choice of cryoprobes, cryogenic agents (argon gas or liquid nitrogen), and the duration and control of freezing/thawing cycles. PCA also frequently outperformed traditional treatments like surgery and radiotherapy in terms of pain reduction, tumor size reduction, and patient outcomes. Moreover, its nerve sideration properties make it effective under local anesthesia.

CONCLUSION

Demonstrating substantial pain reduction, tumor size decrease, and high technical success rates, PCA offers a promising and minimally invasive alternative for soft tissue tumor treatment.

CRITICAL RELEVANCE STATEMENT

Percutaneous cryoablation provides a minimally invasive, precise alternative for soft tissue tumor management, advancing clinical radiology by offering effective treatment with reduced patient risk and enhanced outcomes through image-guided procedures.

KEY POINTS

Percutaneous cryoablation (PCA) offers a promising, minimally invasive alternative for managing soft tissue tumors. PCA employs image-guided techniques to accurately target and treat tumors, ensuring high precision and control. PCA preserves structures like collagen, reduces pain, decreases tumor size, and generally enhances patient outcomes.

Percutaneous Lung Biopsies With Robotic Systems: A Systematic Review of Available Clinical Solutions

Objectives: This systematic review aims to assess existing research concerning the use of robotic systems to execute percutaneous lung biopsy. Methods: A systematic review was performed and identified 4 studies involving robotic systems used for lung biopsy. Outcomes assessed were operation time, radiation dose to patients and operators, technical success rate, diagnostic yield, and complication rate. Results: One hundred and thirteen robot-guided percutaneous lung biopsies were included. Technical success and diagnostic yield were close to 100%, comparable to manual procedures. Technical accuracy, illustrated by needle positioning, showed less frequent needle adjustments in robotic guidance than in manual guidance (P < .001): 2.7 ± 2.6 (range 1-4) versus 6 ± 4 (range 2-12). Procedure time ranged from comparable to reduced by 35% on average (20.1 ± 11.3 minutes vs 31.4 ± 10.2 minutes, P = .001) compared to manual procedures. Patient irradiation ranged from comparable to reduced by an average of 40% (324 ± 114.5 mGy vs 541.2 ± 446.8 mGy, P = .001). There was no significant difference in reported complications between manual biopsy and biopsies that utilized robotic guidance. Conclusion: Robotic systems demonstrate promising results for percutaneous lung biopsy. These devices provide adequate accuracy in probe placement and could both reduce procedural duration and mitigate radiation exposure to patients and practitioners. However, this review underscores the need for larger, controlled trials to validate and extend these findings.

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.

Image-Guided Liver Biopsy: Perspectives from Interventional Radiology

Liver biopsy is a crucial aspect of interventional radiology and plays a significant role in the management of hepatobiliary diseases. Radiologists commonly perform two major image-guided liver biopsy techniques: percutaneous and transjugular approaches. It is essential for radiologists to understand the role of liver biopsy in diagnosing and treating hepatobiliary conditions, the procedural details involved, and how to manage potential complications. This article reviews the indications, contraindications, techniques, and efficacy of image-guided liver biopsy, with a focus on both percutaneous and transjugular methods.

The role of artificial intelligence and image processing in the diagnosis, treatment, and prognosis of liver cancer: a narrative-review

Artificial intelligence (AI) and image processing are revolutionising the diagnosis and management of liver cancer. Recent advancements showcase AI's ability to analyse medical imaging data, like computed tomography scans and magnetic resonance imaging, accurately detecting and classifying liver cancer lesions for early intervention. Predictive models aid prognosis estimation and recurrence pattern identification, facilitating personalised treatment planning. Image processing techniques enhance data analysis by precise segmentation of liver structures, fusion of information from multiple modalities, and feature extraction for informed decision-making. Despite progress, challenges persist, including the need for standardised datasets and regulatory considerations.

Interventional Oncology: 2024 Update

Interventional Oncology (IO) stands at the forefront of transformative cancer care, leveraging advanced imaging technologies and innovative interventions. This narrative review explores recent developments within IO, highlighting its potential impact facilitated by artificial intelligence (AI), personalized medicine and imaging innovations. The integration of AI in IO holds promise for accelerating tumour detection and characterization, guiding treatment strategies and refining predictive models. Imaging modalities, including functional MRI, PET and cone beam CT are reshaping imaging and precision. Navigation, fusion imaging, augmented reality and robotics have the potential to revolutionize procedural guidance and offer unparalleled accuracy. New developments are observed in embolization and ablative therapies. The pivotal role of genomics in treatment planning, targeted therapies and biomarkers for treatment response prediction underscore the personalization of IO. Quality of life assessment, minimizing side effects and long-term survivorship care emphasize patient-centred outcomes after IO treatment. The evolving landscape of IO training programs, simulation technologies and workforce competence ensures the field's adaptability. Despite barriers to adoption, synergy between interventional radiologists' proficiency and technological advancements hold promise in cancer care.

Micro-robotic percutaneous targeting of type II endoleaks in the angio-suite

PURPOSE

Endovascular aneurysm repair has emerged as the standard therapy for abdominal aortic aneurysms. In 9-30% of cases, retrograde filling of the aneurysm sac through patent branch arteries may result in persistence of blood flow outside the graft and within the aneurysm sac. This condition is called an endoleak type II, which may be treated by catheter-based embolization in case of continued sac enlargement. If an endovascular access is not possible, percutaneous targeting of the perfused nidus remains the only option. However, this can be very challenging due to the difficult access and deep puncture with risk of organ perforation and bleeding. Innovative targeting techniques such as robotics may provide a promising option for safe and successful targeting.

METHODS

In nine consecutive patients, percutaneous embolization of type II endoleaks was performed using a table-mounted micro-robotic targeting platform. The needle path from the skin entry to the perfused nidus was planned based on the C-arm CT image data in the angio-suite. Entry point and path angle were aligned using the joystick-operated micro-robotic system under fluoroscopic control, and the coaxial needle was introduced until the target point within the perfused nidus was reached.

RESULTS

All punctures were successful, and there were no puncture-related complications. The pre-operative C-arm CT was executed in 11-15 s, and pathway planning required 2-3 min. The robotic setup and sterile draping were performed in 1-2 min, and the alignment to the surgical plan took no longer than 30 s.

CONCLUSION

Due to the small size, the micro-robotic platform seamlessly integrated into the routine clinical workflow in the angio-suite. It offered significant benefits to the planning and safe execution of double-angulated deeply localized targets, such as type II endoleaks.

Robotic-assisted CT-guided percutaneous thermal ablation of abdominal tumors: An analysis of 41 patients

PURPOSE

Robotic assistance is rapidly evolving and may help physicians optimize needle guidance during percutaneous interventions. The purpose of the study was to report feasibility, safety, accuracy, immediate clinical success and short-term local tumor control after robotic-assisted computed tomography (CT)-guided thermal ablation of abdominal tumors.

MATERIALS AND METHODS

Forty-one patients who underwent percutaneous thermal ablation of abdominal tumors using robotic-assisted CT-guided were included. All ablations were performed with robotic assistance, using an optically-monitored robotic system with a needle guide sent to preplanned trajectories defined on three-dimensional-volumetric CT acquisitions with respiration monitoring. Endpoints were technical success, safety, distance from needle tip to planned trajectory and number of needle adjustments, and complete ablation rate.

RESULTS

Forty-one patients (31 men; mean age, 66.7 ± 9.9 [standard deviation (SD)] years [age range: 41-84 years]) were treated for 48 abdominal tumors, with 79 planned needles. Lesions treated were located in the liver (23/41; 56%), kidney (14/41;34%), adrenal gland (3/41; 7%) or retroperitoneum (1/41; 2%). Technical success was achieved in 39/41 (95%) patients, and 76/79 (96%) needle insertions. The mean lateral distance between the needle tip and planned trajectory was 3.2 ± 4.5 (SD) mm (range: 0-20 mm) before adjustments, and the mean three-dimensional distance was 1.6 ± 2.6 (SD) mm (range: 0-13 mm) after 29 manual depth adjustments (29/78; 37%) and 33 lateral adjustments (33/78; 42%). Two (2/79; 3%) needles required complete manual reinsertion. One grade 3 complication was reported in one patient (1/41; 2%). The overall clinical success rate was 100%. The 3-month local tumor control rate (progression free survival) was 95% (38/41).

CONCLUSION

These results provide further evidence on the use of robotic-assisted needle insertion regarding feasibility, safety, and accuracy, resulting in effective percutaneous thermal ablation of abdominal tumors.

Comparison of a Patient-Mounted Needle-Driving Robotic System versus Single-Rotation CT Fluoroscopy to Perform CT-Guided Percutaneous Lung Biopsies

PURPOSE

To compare the effectiveness of percutaneous lung biopsy using a patient-mounted needle-driving robotic system with that using a manual insertion of needles under computed tomography (CT) fluoroscopy guidance.

MATERIALS AND METHODS

In this institutional review board approved study, the cohort consisted of a series of patients who underwent lung biopsies following the intention-to-treat protocol from September 2022 to September 2023 using robot (n = 15) or manual insertion under single-rotation CT fluoroscopy (n = 66). Patient and procedure characteristics were recorded as well as outcomes.

RESULTS

Although age, body mass index, and skin-to-target distance were not statistically different, target size varied (median, 8 mm [interquartile range, 6.5-9.5 mm] for robot vs 12 mm [8-18 mm] for single-rotation CT fluoroscopy; P = .001). No statistical differences were observed in technical success (86.7% [13/15] vs 89.4% [59/66], P = .673), Grade 3 adverse event (AE) (6.7% [1/15] vs 12.1% [8/66], P = .298), procedural time (28 minutes [22-32 minutes] vs 19 minutes [14.3-30.5 minutes], P = .086), and patient radiation dose (3.9 mSv [3.2-5.6 mSv] vs 4.6 mSv [3.3-7.5 mSv], P = .398). In robot-assisted cases, the median angle out of gantry plane was 10° (6.5°-16°), although it was null (0°-5°) for single-rotation CT fluoroscopy (P = .001).

CONCLUSIONS

Robot-assisted and single-rotation CT fluoroscopy-guided percutaneous lung biopsies were similar in terms of technical success, diagnostic yield, procedural time, AEs, and radiation dose, although robot allowed for out-of-gantry plane navigation along the needle axis.