Clinical evaluation of a robotic system for precise CT-guided percutaneous procedures

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.

Review of robotic systems for thoracoabdominal puncture interventional surgery

Cancer, with high morbidity and high mortality, is one of the major burdens threatening human health globally. Intervention procedures via percutaneous puncture have been widely used by physicians due to its minimally invasive surgical approach. However, traditional manual puncture intervention depends on personal experience and faces challenges in terms of precisely puncture, learning-curve, safety and efficacy. The development of puncture interventional surgery robotic (PISR) systems could alleviate the aforementioned problems to a certain extent. This paper attempts to review the current status and prospective of PISR systems for thoracic and abdominal application. In this review, the key technologies related to the robotics, including spatial registration, positioning navigation, puncture guidance feedback, respiratory motion compensation, and motion control, are discussed in detail.

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.

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.

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.

Image-Guided Ablation of Renal Masses: Challenges to Produce High-Quality Evidence and Future Directions

Image-guided ablation (IGA) is a rapidly developing field in interventional oncology. There is some evidence suggesting IGA's non-inferiority compared with partial or radical nephrectomy for the treatment of small renal masses (SRM). However, these are mostly limited to retrospective cohort studies. This review article outlines the evidence comparing IGA to partial nephrectomy by collating the different survival measures and evaluates the challenges of producing clinical trials and high-quality evidence. The main challenges are due to the heterogeneity of SRM, patient selection bias, unstandardized endpoint and outcomes, and the lack of global practice standards. Despite the evidence thus far demonstrating that IGA stands as a non-inferior treatment modality for SRMs, exhibiting favorable short- and long-term outcomes, further robust research is needed to integrate ablation techniques into routine clinical practice with a multidisciplinary approach. There is emerging evidence that suggests randomized controlled trial in SRMs is possible, and technologies such as histotripsy as well as artificial intelligence are used in IGA.

Review of robotic surgery platforms and end effectors

In the last 50 years, the number of companies producing automated devices for surgical operations has grown extensively. The population started to be more confident about the technology capabilities. The first patents related to surgical robotics are expiring and this knowledge is becoming a common base for the development of future surgical robotics. The review describes some of the most popular companies manufacturing surgical robots. The list of the company does not pretend to be exhaustive but wishes to give an overview of the sector. Due to space constraints, only a limited selction of companies is reported. Most of the companies described are born in America or Europe. Advantages and limitations of each product firm are described. A special focus is given to the end effectors; their shape and dexterity are crucial for the positive outcome of the surgical operations. New robots are developed every year, and existing robots are allowed to perform a wider range of procedures. Robotic technologies improve the abilities of surgeons in the domains of urology, gynecology, neurology, spine surgery, orthopedic reconstruction (knee, shoulder), hair restoration, oral surgery, thoracic surgery, laparoscopic surgery, and endoscopy.

Robotic systems in interventional oncology: a narrative review of the current status

Interventional oncology offers minimally invasive treatments for malignant tumors for curative and palliative purposes based on the percutaneous insertion of needles or catheters into the target location under image guidance. Robotic systems have been gaining increasing attention as tools that provide potential advantages for image-guided interventions. Among the robotic systems developed for intervention, those relevant to the oncology field are mainly those for guiding or driving the needles in non-vascular interventional procedures such as biopsy and tumor ablation. Needle-guiding robots support planning the needle path and align the needle robotically according to the planned trajectory, which is combined with subsequent manual needle insertion by the physician through the needle guide. Needle-driving robots can advance the needle robotically after determining its orientation. Although a wide variety of robotic systems have been developed, only a limited number of these systems have reached the clinical phase or commercialization thus far. The results of previous studies suggest that such interventional robots have the potential to increase the accuracy of needle placement, facilitate out-of-plane needle insertion, decrease the learning curve, and reduce radiation exposure. On the other hand, increased complexity and costs may be a concern when using robotic systems compared with conventional manual procedures. Further data should be collected to comprehensively assess the value of robotic systems in interventional oncology.

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.

Feasibility and Safety of Percutaneous CT-Guided Bone Biopsies in Patients with Cancer Using a Patient-Mounted Robotic System: A Retrospective Analysis of 40 Consecutive Biopsies

This retrospective study evaluated the feasibility and safety of percutaneous computed tomography (CT)-guided bone biopsies in patients with cancer using a patient-mounted robotic system with steering capabilities. The study included 39 patients (17 women, 22 men; median age, 65.5 years; interquartile range [IQR], 54.8-71.0 years). Forty biopsies were performed in the pelvis, spine, ribs, shoulder, femur, and sternum. The technical success rate was 100%, and the median trajectory length was 55.9 mm (IQR, 47.1-73.6 mm). Intermediate checkpoints were used in 8 biopsies. Median time from the first to final scan was 21 minutes (IQR, 17-37 minutes). The overall procedure time was 30 minutes (IQR, 24-36 minutes). The median dose length product and effective dose were 536.6 mGy⋅cm (IQR, 396.2-837.7 mGy∗cm) and 7.1 mSv (IQR, 4.7-10.8 mSv), respectively. No adverse events occurred. The diagnostic yield for cancer was 72.5%. Percutaneous robotic-assisted bone biopsies demonstrated high technical success, adequate diagnostic yield, and favorable safety profile.

Petre E, Marinelli B, Sarkar D, Barral M, H Cornelis F. Percutaneous liver interventions with robotic systems: a systematic review of available clinical solutions

OBJECTIVE

Robotic-guided interventions are emerging techniques that are gradually becoming a common tool for performing biopsies and tumor ablations in liver. This systematic review aims to evaluate their advancements, challenges, and outcomes.

METHODS

A systematic review was conducted using the PubMed database to identify relevant articles published between January 2000 and February 2023. Inclusion criteria focused on studies that assessed robotic systems for percutaneous liver biopsies and tumor ablations. Data extraction was performed to collect information on study characteristics; robotic systems; components and software; imaging modality; degree of freedom; and needle insertion methods. The outcome measures analyzed were procedure time, radiation dose, and accuracy.

RESULTS

10 studies met the inclusion criteria. The robotic devices used included MAXIO, EPIONE, ROBIO-EX, AcuBot, and ACE robotic systems. The data set consisted of 429 percutaneous thermal ablations and 57 biopsies, both robot-guided. On average, the mean deviation of probes was reduced by 30% (from 1.6 vs 3.3 mm to 2.4 vs 3.9 mm (p < 0.001)), and 40% (p < 0.05) fewer readjustments were required during the robotic-assisted interventions. Moreover, robotic systems contributed to a reduction in operating time, ranging from 15% (18.3 vs 21.7 min, p < 0.001) to 25% (63.5 vs 87.4 min, p < 0.001). Finally, the radiation dose delivered to both the patient and the operator was decreased by an average of 50% (p < 0.05) compared to manual procedures.

ADVANCES IN KNOWLEDGE

Robotic systems could provide precise navigation and guidance during liver biopsies and percutaneous ablations.

Hepatic Arteriography and C-Arm CT-Guided Ablation (HepACAGA) to Improve Tumor Visualization, Navigation and Margin Confirmation in Percutaneous Liver Tumor Ablation

PURPOSE

We present a technique that combines Hepatic Arteriography with C-arm CT-Guided Ablation (HepACAGA) to improve tumor visualization, navigation and margin confirmation for percutaneous ablation of liver tumors.

MATERIALS AND METHODS

All consecutive patients scheduled for HepACAGA between April 20th, 2021, and November 2nd, 2021, were included in this retrospective, cohort study. HepACAGA was performed in an angiography-suite under general anesthesia. The hepatic artery was catheterized for selective contrast injection. C-arm CT and guidance software were then used to visualize the tumor and the microwave antenna was inserted during apnea. Pre- and post-ablation C-arm CTs were performed and ablation margins assessed. Technical success, antenna placement deviation, number of repositions, tumor recurrence, and safety were evaluated. Technical success was defined as a tumor that was ablated according to the HepACAGA technique.

RESULTS

A total of 21 patients (28 tumors) were included. The main tumor type was colorectal cancer liver metastases (11/21, 52%), followed by hepatocellular carcinoma (7/21, 33%), neuroendocrine tumor metastases (1/21, 5%), and other tumor types (2/21, 10%). The technical success rate was 93% (26/28 tumors) with two small hypovascular lesions unable to be identified. A single microwave antenna was used in all patients. The median antenna placement deviation was 1 mm (range 0-6 mm). At a median follow-up time of 16 months (range 5-22 months), there was no tumor recurrence in any patient. Safety analysis showed a complication rate of 5% grade 2 and 5% grade 3.

CONCLUSION

HepACAGA was demonstrated to be a safe and effective percutaneous ablation technique, without any local tumor recurrence in this study.

Percutaneous Robotics in Interventional Radiology

The accuracy of the robotic device not only relies on a reproducible needle advancement, but also on the possibility to correct target movement at chosen checkpoints and to deviate from a linear to a nonlinear trajectory. We report our experience in using the robotic device for the insertion of trocar needles in CT guided procedures. The majority of procedures were targeted organ biopsies in the chest abdomen or pelvis. The accuracy of needle placement after target adjustments did not significantly differ from those patients where a linear trajectory could be used. The steering capabilities of the robot allow correction of target movement of the fly.

A systematic review of image-guided, surgical robot-assisted percutaneous puncture: Challenges and benefits

Percutaneous puncture is a common medical procedure that involves accessing an internal organ or tissue through the skin. Image guidance and surgical robots have been increasingly used to assist with percutaneous procedures, but the challenges and benefits of these technologies have not been thoroughly explored. The aims of this systematic review are to furnish an overview of the challenges and benefits of image-guided, surgical robot-assisted percutaneous puncture and to provide evidence on this approach. We searched several electronic databases for studies on image-guided, surgical robot-assisted percutaneous punctures published between January 2018 and December 2022. The final analysis refers to 53 studies in total. The results of this review suggest that image guidance and surgical robots can improve the accuracy and precision of percutaneous procedures, decrease radiation exposure to patients and medical personnel and lower the risk of complications. However, there are many challenges related to the use of these technologies, such as the integration of the robot and operating room, immature robotic perception, and deviation of needle insertion. In conclusion, image-guided, surgical robot-assisted percutaneous puncture offers many potential benefits, but further research is needed to fully understand the challenges and optimize the utilization of these technologies in clinical practice.

Evaluation of Accuracy and Performance of a Novel, Fully Gantry Integrated 3D Laser System for Computed Tomography Guided Needle Placement: A Phantom Study

The purpose of this phantom study was to compare the accuracy, speed and technical performance of CT guided needle placement using a conventional technique versus a novel, gantry integrated laser guidance system for both an expert and a novice. A total of 80 needle placements were performed in an abdominal phantom using conventional CT guidance and a laser guidance system. Analysis of pooled results of expert and novice showed a significant reduction of time (277 vs. 204 s, p = 0.001) and of the number of needle corrections (3.28 vs. 1.58, p < 0.001) required when using laser guidance versus conventional technique. No significant improvement in absolute (3.81 vs. 3.41 mm, p = 0.213) or angular deviation (2.85 vs. 2.18°, p = 0.079) was found. With either approach, the expert was significantly faster (conventional guidance: 207 s vs. 346 s, p < 0.001; laser guidance: 144 s vs. 264 s, p < 0.001) and required fewer needle corrections (conventional guidance: 4 vs. 3, p = 0.027; laser guidance: 2 vs. 1, p = 0.001) than the novice. The laser guidance system helped both the expert and the novice to perform CT guided interventions in a phantom faster and with fewer needle corrections compared to the conventional technique, while achieving similar accuracy.

Fully Integrated Laser Guidance for CT-Based Punctures: A Study in Phantoms and Patients

PURPOSE

To test the hypothesis of equal or even superior applicability and accuracy of a fully integrated, laser-based computed tomography (CT) navigation system compared with conventional CT guidance for percutaneous interventions.

MATERIALS AND METHODS

CT-guided punctures were first performed in phantoms. Four radiologists with different experience levels (2 residents (L.B., C.D.) and 2 board-certified radiologists (B.M., K.R.) performed 48 punctures using both conventional image-guided and laser-guided approaches. Subsequently, 12 punctures were performed in patients during a clinical pilot trial. Phantom targets required an in-plane or a single-/double-angulated, out-of-plane approach. Planning and intervention time, control scan number, radiation exposure, and accuracy of needle placement (measured by deviation of the needle tip to the designated target) were assessed for each guidance technique and compared (Mann-Whitney U test and t test). Patient interventions were additionally analyzed for applicability in a clinical setting.

RESULTS

The application of laser guidance software in the phantom study and in 12 human patients in a clinical setting was both technically and clinically feasible in all cases. The mean planning time (P = .009), intervention time (P = .005), control scan number (P < .001), and radiation exposure (P = .013) significantly decreased for laser-navigated punctures compared with those for conventional CT guidance and especially in punctures with out-of-plane-trajectories. The accuracy significantly increased for laser-guided interventions compared with that for conventional CT (P < .001).

CONCLUSIONS

Interventional radiologists with differing levels of experience performed faster and more accurate punctures for out-of-plane trajectories in the phantom models, using a new, fully integrated, laser-guided CT software and demonstrated excellent clinical and technical success in initial clinical experiments.

Robotics in Interventional Radiology: Review of Current and Future Applications

This review is a brief overview of the current status and the potential role of robotics in interventional radiology. Literature published in the last decades, with an emphasis on the last 5 years, was reviewed and the technical developments in robotics and navigational systems using CT-, MR- and US-image guidance were analyzed. Potential benefits and disadvantages of their current and future use were evaluated. The role of fusion imaging modalities and artificial intelligence was analyzed in both percutaneous and endovascular procedures. A few hundred articles describing results of single or several systems were included in our analysis.

A Novel Laser Angle Selection System for Computed Tomography-Guided Percutaneous Transthoracic Needle Biopsies

Purpose: To evaluate a novel laser angle selection system (LASS) for improving the efficiency of a computed tomography (CT)–guided percutaneous transthoracic needle biopsy (PTNB). Methods: Thirty-eight patients referred for CT-guided PTNB were randomly separated into a LASS-assisted puncture group (18 patients) or conventional freehand control group (20 patients). The puncture time, number of control CT scans, and patients’ radiation dose were compared for each group. Results: The lesion size, target-to-pleural distance, planned puncture depth, and angle of the two groups were not significantly different. LASS-assisted PTNB significantly reduced the number of control scans (1.7 ± 0.8 vs 3.5 ± 1.5, P < .001) and the mean operation time (12.0 ± 4.3 min vs 28.8 ± 13.3 min, P < .001) compared with the conventional method. The corresponding room time (27.1 ± 6.6 min vs 44.1 ± 14.4 min, P < .001) and total radiation dose (7.9 ± 1.0 mSv vs 10.1 ± 1.7 mSv, P < .001) of each procedure also decreased significantly. Fifty-six percent (10/18) of the operations hit the target on the first needle pass when using LASS compared with 10% (2/20) using the conventional method. Conclusions: Compared with a conventional method, this novel laser angle simulator improves puncture efficiency with fewer needle readjustments and reduces patient radiation dose.

Interventional oncology of liver tumors: how it all started and where are we now

Liver was the very first organ for which interventional procedures were applied for the local treatment of primary and secondary malignancies. In this paper, the history of Interventional Oncology of liver, from the very beginning to the current situation, is summarized, including both percutaneous and intravascular procedures, and together with the evolution of the techniques for image guidance. The main ongoing developments, such as new techniques, combined interventional treatments and association of local interventions with new drugs are briefly described, too.

Robotic Tissue Sampling for Safe Post-Mortem Biopsy in Infectious Corpses

In pathology and legal medicine, the histopathological and microbiological analysis of tissue samples from infected deceased is a valuable information for developing treatment strategies during a pandemic such as COVID-19. However, a conventional autopsy carries the risk of disease transmission and may be rejected by relatives. We propose minimally invasive biopsy with robot assistance under CT guidance to minimize the risk of disease transmission during tissue sampling and to improve accuracy. A flexible robotic system for biopsy sampling is presented, which is applied to human corpses placed inside protective body bags. An automatic planning and decision system estimates optimal insertion point. Heat maps projected onto the segmented skin visualize the distance and angle of insertions and estimate the minimum cost of a puncture while avoiding bone collisions. Further, we test multiple insertion paths concerning feasibility and collisions. A custom end effector is designed for inserting needles and extracting tissue samples under robotic guidance. Our robotic post-mortem biopsy (RPMB) system is evaluated in a study during the COVID-19 pandemic on 20 corpses and 10 tissue targets, 5 of them being infected with SARS-CoV-2. The mean planning time including robot path planning is 5.72±167s. Mean needle placement accuracy is 7.19± 422mm.

Image-Guided Robotics for Standardized and Automated Biopsy and Ablation

Image-guided robotics for biopsy and ablation aims to minimize procedure times, reduce needle manipulations, radiation, and complications, and enable treatment of larger and more complex tumors, while facilitating standardization for more uniform and improved outcomes. Robotic navigation of needles enables standardized and uniform procedures which enhance reproducibility via real-time precision feedback, while avoiding radiation exposure to the operator. Robots can be integrated with computed tomography (CT), cone beam CT, magnetic resonance imaging, and ultrasound and through various techniques, including stereotaxy, table-mounted, floor-mounted, and patient-mounted robots. The history, challenges, solutions, and questions facing the field of interventional radiology (IR) and interventional oncology are reviewed, to enable responsible clinical adoption and value definition via ergonomics, workflows, business models, and outcome data. IR-integrated robotics is ready for broader adoption. The robots are coming!