Current Use of Three-dimensional Model Technology in Urology: A Road Map for Personalised Surgical Planning

The role of hyperaccuracy CT three-dimensional reconstruction technology in partial nephrectomy for completely endophytic renal cell carcinoma: A retrospective propensity-matched cohort study

BACKGROUND

To compare the clinicopathological, perioperative, functional, and oncological outcomes of completely endophytic renal cell carcinoma (RCC) patients who underwent partial nephrectomy (PN) with or without preoperative hyperaccuracy CT three-dimensional (HACT3D) reconstruction.

METHODS

A retrospective cohort study was conducted on 154 completely endophytic RCC patients treated with PN at our medical center from January 2018 to December 2023. Patients were divided into two groups based on whether they received preoperative HACT3D reconstruction. To control for selection bias, we implemented 1:1 propensity score matching based on baseline characteristics.

RESULTS

In the original cohort, 47 patients in the HACT3D group had higher RENAL scores (P = 0.014) and PADUA scores (P = 0.012). After matching, each group contained 47 RCC patients with no significant baseline differences (P > 0.05). In the matched cohort, patients in the HACT3D group had significantly shorter warm ischemia time (WIT) (22.3 vs. 26.7 min, p < 0.001), shorter total length of hospital stay (LOS) (10.0 vs. 11.6 days, p = 0.012), shorter postoperative LOS (5.8 vs. 7.3 days, p = 0.003), and higher trifecta achievement rate (83.0 % vs. 36.2 %, p < 0.001). Among functional variables, patients in the HACT3D group exhibited a smaller increase in postoperative serum creatinine (SCR) (7.5 vs. 16.5 μmol/L, p = 0.012), and a smaller decrease in postoperative estimated Glomerular Filtration Rate (eGFR) (-6.9 vs. -14.1 mL/min/1.73 m2, p = 0.011). No significant differences were found in pathological outcomes and prognosis between the two groups (p > 0.05).

CONCLUSIONS

For completely endophytic RCC patients, HACT3D reconstruction can assist clinicians in performing precise parameter measurements, designing personalized surgical approaches, and providing intraoperative image guidance.

A novel preoperative evaluation technique for partial nephrectomy: three-dimensional extended renal tumor plane

OBJECTIVE

To develop a three-dimensional (3D) image based extended tumor plane technique for robotic-assisted partial nephrectomy (RAPN).

METHODS

We prospectively enrolled patients with a local renal tumor for RAPN between March 2019 and Mar 2022. 3D virtual model was reconstructed based on the computed tomography urography. The tumor plane was extended equidistantly (10 mm) to form a virtual plane. According to the relationship between the extended plane and the collection system, patients are divided into those with no collecting system involvement, renal medulla involvement, and renal calyx involvement. The primary endpoint was trifecta achievement, which was defined as warm ischemic time ≤ 25 min, negative surgical margins, and no major perioperative complications.

RESULTS

This study enrolled a total of 215 patients. The median preoperative aspects and dimensions used for an anatomical (PADUA) score was 9 (6-15). The average warm ischemic time was 21.64 ± 9.35 min. Postoperative complications occurred in 26 (12.1%) patients, of whom 14 (6.5%) classified as major complication. The number of cases with trifecta failure was 1 (5.3%) in the no involvement group, 28 (20.6%) in the renal medullary involvement group, and 24 (40.0%) in the renal calyx involvement group (p < 0.001). Logistic regression indicated that renal calyx involvement was a risk factor for trifecta failure (OR = 2.639, 95% confidence interval [1.268-5.492], p = 0.009).

CONCLUSIONS

The extended tumor plane based on three-dimensional images can is useful for the evaluation of RAPN. Determining whether the extended plane involves the collecting system, particularly the renal calyx, may impact the achievement of trifecta.

Integrating 3D technology with the Sampaio classification for enhanced percutaneous nephrolithotomy in complex renal calculi treatment

Background

To investigate the safety and efficacy of percutaneous nephrolithotomy (PCNL) in the treatment of complicated renal calculi by integrating three-dimensional (3D) computed tomography (CT) reconstruction with the Sampaio classification of the renal collecting system.

Methods

Sixty-four consecutive patients with complex kidney calculi who underwent PCNL between January 2019 and October 2023 were retrospectively analyzed and divided into experimental group (3D printing) and control group (CT imaging) according to their willingness to pay for 3D imaging. Both groups underwent preoperative CT urography. The Digital Imaging and Communications (DICOM) in Medicine data of the experimental group from CT imaging were used for 3D reconstruction and model printing. Then, the Sampaio classification system was used to design the puncture channel and develop a surgical strategy.

Results

The 3D-printed models of the experimental group successfully displayed the Sampaio classification system. There was no significant difference in the baseline parameters between the groups. Compared with the control group, the experimental group exhibited significant improvements in the puncture time, number of puncture needles, number of puncture channels, target calyx consistency, number of first puncture channels, and stone clearance. There were no significant differences in the total operative time, decrease in the hemoglobin level, length of hospital stay, and postoperative complications between the groups.

Conclusions

Integration of 3D technology with the Sampaio classification of the renal collecting system can enhance the preoperative evaluation and planning of percutaneous renal access. This approach allows a more precise method of PCNL for treating complex renal calculi.

Extrarenal Visceral Arteries Injuries during Left Radical Nephrectomy: A 50-Year Continuing Problem

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.

Hyper accuracy three-dimensional virtual anatomical rainbow model facilitates surgical planning and safe selective clamping during robot-assisted partial nephrectomy

Objective

To highlight the role of hyper accuracy three-dimensional (3D) reconstruction in facilitating surgical planning and guiding selective clamping during robot-assisted partial nephrectomy (RAPN).

Methods

A transperitoneal RAPN was performed in a 62-year-old male patient presenting with a 4 cm right anterior interpolar renal mass (R.E.N.A.L nephrometry score 7A). An abnormal vasculature was observed, with a single renal vein and two right renal arteries originating superiorly to the vein and anterior, when dividing in their segmental branches. According to the hyper accuracy 3D (HA3D®) rainbow model (MEDICS Srl, Turin, Italy), one branch belonging to one of the segmental arteries was feeding the tumor. This allowed for an accurate prediction of the area vascularized by each arterial branch. The 3D model was included in the intraoperative console view during the whole procedure, using the TilePro feature. A step-by-step explanation of the procedure is provided in the video attached to the present article.

Results

The operative time was 90 min with a warm ischemia time on selective clamping of 13 min. Estimated blood loss was 180 mL. No intraoperative complication was encountered and no drain was placed at the end of the procedure. The patient was discharged on postoperative Day 2, without any early postoperative complications. The final pathology report showed a pathological tumor stage 1 clear cell renal cell carcinoma with negative surgical margins.

Conclusion

The present study and the attached video illustrate the value of 3D rainbow model during the planning and execution of a RAPN with selective clamping. It shows how the surgeon can rely on this model to be more efficient by avoiding unnecessary surgical steps, and to safely adopt a "selective" clamping strategy that can translate in minimal functional impact.

Recent Advances in Robotic Surgery for Urologic Tumors

This review discusses recent advances in robotic surgery for urologic tumors, focusing on three key areas: robotic systems, assistive technologies, and artificial intelligence. The Da Vinci SP system has enhanced the minimally invasive nature of robotic surgeries, while the Senhance system offers advantages such as tactile feedback and eye-tracking capabilities. Technologies like 3D reconstruction combined with augmented reality and fluorescence imaging aid surgeons in precisely identifying the anatomical relationships between tumors and surrounding structures, improving surgical efficiency and outcomes. Additionally, the development of artificial intelligence lays the groundwork for automated robotics. As these technologies continue to evolve, we are entering an era of minimally invasive, precise, and intelligent robotic surgery.

Robotic kidney transplantation

Kidney transplantation is the best treatment option for patients with end-stage renal disease owing to improved survival and quality of life compared with dialysis. The surgical approach to kidney transplantation has been somewhat stagnant in the past 50 years, with the open approach being the only available option. In this scenario, evidence of reduced surgery-related morbidity after the introduction of robotics into several surgical fields has induced surgeons to consider robot-assisted kidney transplantation (RAKT) as an alternative approach to these fragile and immunocompromised patients. Since 2014, when the RAKT technique was standardized thanks to the pioneering collaboration between the Vattikuti Urology Institute and the Medanta hospital (Vattikuti Urology Institute-Medanta), several centres worldwide implemented RAKT programmes, providing interesting results regarding the safety and feasibility of this procedure. However, RAKT is still considered an alternative procedure to be offered mainly in the living donor setting, owing to various possible drawbacks such as prolonged rewarming time, demanding learning curve, and difficulties in carrying out this procedure in challenging scenarios (such as patients with obesity, severe atherosclerosis of the iliac vessels, deceased donor setting, or paediatric recipients). Nevertheless, the refinement of robotic platforms through the implementation of novel technologies as well as the encouraging results from multicentre collaborations under the umbrella of the European Association of Urology Robotic Urology Section are currently expanding the boundaries of RAKT, making this surgical procedure a real alternative to the open approach.

Intraoperative image-guidance during robotic surgery: is there clinical evidence of enhanced patient outcomes?

BACKGROUND

To date, the benefit of image guidance during robot-assisted surgery (IGS) is an object of debate. The current study aims to address the quality of the contemporary body of literature concerning IGS in robotic surgery throughout different surgical specialties.

METHODS

A systematic review of all English-language articles on IGS, from January 2013 to March 2023, was conducted using PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases. Comparative studies that tested performance of IGS vs control were included for the quantitative synthesis, which addressed outcomes analyzed in at least three studies: operative time, length of stay, blood loss, surgical margins, complications, number of nodal retrievals, metastatic nodes, ischemia time, and renal function loss. Bias-corrected ratio of means (ROM) and bias-corrected odds ratio (OR) compared continuous and dichotomous variables, respectively. Subgroup analyses according to guidance type (i.e., 3D virtual reality vs ultrasound vs near-infrared fluoresce) were performed.

RESULTS

Twenty-nine studies, based on 11 surgical procedures of three specialties (general surgery, gynecology, urology), were included in the quantitative synthesis. IGS was associated with 12% reduction in length of stay (ROM 0.88; p = 0.03) and 13% reduction in blood loss (ROM 0.87; p = 0.03) but did not affect operative time (ROM 1.00; p = 0.9), or complications (OR 0.93; p = 0.4). IGS was associated with an estimated 44% increase in mean number of removed nodes (ROM 1.44; p < 0.001), and a significantly higher rate of metastatic nodal disease (OR 1.82; p < 0.001), as well as a significantly lower rate of positive surgical margins (OR 0.62; p < 0.001). In nephron sparing surgery, IGS significantly decreased renal function loss (ROM 0.37; p = 0.002).

CONCLUSIONS

Robot-assisted surgery benefits from image guidance, especially in terms of pathologic outcomes, namely higher detection of metastatic nodes and lower surgical margins. Moreover, IGS enhances renal function preservation and lowers surgical blood loss.

Selective Clamping for Robot-Assisted Surgical Procedures

Partial nephrectomy, the gold standard treatment for renal tumors, is performed with clamping of the renal arteries, in order to interrupt the blood flowing towards the tumor. However, the temporary interruption of arterial flow may lead to ischemia of the renal parenchyma. Thus, the interruption of the flow should be as short as possible and the clamping should be localized to the arteries flowing towards the tumor only, by implementing the so-called selective clamping. In this paper, we propose a system to automatically provide to the surgeon the optimal clamping points, according to our methods, which allow to minimize the ischemia percentage, thus preserving the health of the remaining renal parenchyma. Moreover, we exploit the algorithm as a planner for a robotic system that, starting from the clamping points automatically computed, emulates the clamping procedure. The overall architecture is validated on different patient's anatomies and using a robotic setup.

Effects of PCNL under the guidance of hologram technology on stress response and renal injury factors in patients with complex kidney stones

Background

To investigate the effect of percutaneous nephrolithotomy (PCNL) guided by holographic image technology on stress response and renal injury factors in patients with complex renal calculi.

Methods

A retrospective analysis was conducted on the clinical data of 70 patients admitted to our hospital between August 2022 and June 2023 who had complex kidney stones. The patients were divided into two groups, namely, group A and group B, based on whether they received guidance from preoperative holographic imaging technology. Group A consisted of forty patients who underwent PCNL after undergoing renal CT examination prior to surgery, while Group B included thirty patients who underwent PCNL guided by holographic imaging technology. Various indexes, including operative factors, stress response, inflammatory response, renal injury factors, renal function, complication rate, and the rate of achieving complete stone clearance in a single procedure, were compared between the two groups.

Results

In group B, the puncture time and operation time of the target calyces were shorter compared to group A, additionally, the intraoperative blood loss in group B was lower than that in group A (P<0.05). 24 h after surgery, group B exhibited higher levels of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) compared to group A, additionally, the level of malondialdehyde (MDA) in group B was lower than that in group A (P<0.05). 24 h after surgery, group B exhibited lower levels of tumor necrosis factor a (TNF-a), interleukin-6 (IL-6), IL-1, and hypersensitive C-reactive protein (hs-CRP) compared to group A (P<0.05). Furthermore, group B showed lower levels of neutrophil gelatinase-associated lipid carrier protein (NGAL), inducible protein-8-like molecule 2 (TIPE2), and b2-microglobulin (b2-MG) than group A at the 7-day mark (P<0.05). 24 h after the operation, There was no statistically significant difference observed in the levels of SCr, BUN, between group A and group B group (P > 0.05); however, exhibited lower levels of CysC compared to group A (P < 0.05). Additionally, there were no significant differences in postoperative complications between group B and group A (P>0.05). Furthermore, one month after surgery, the one-time stone clearance rate in group B was significantly higher than that in group A (P<0.05).

Conclusions

PCNL under the guidance of hologram technology can shorten the time of puncture target calyce and operation, reduce the amount of intraoperative blood loss, effectively reduce the postoperative stress reaction and inflammatory reaction of patients, reduce the level of renal injury factors, improve renal function, and increase the one-time stone clearance rate.

Automatic 3D Augmented-Reality Robot-Assisted Partial Nephrectomy Using Machine Learning: Our Pioneer Experience

The aim of "Precision Surgery" is to reduce the impact of surgeries on patients' global health. In this context, over the last years, the use of three-dimensional virtual models (3DVMs) of organs has allowed for intraoperative guidance, showing hidden anatomical targets, thus limiting healthy-tissue dissections and subsequent damage during an operation. In order to provide an automatic 3DVM overlapping in the surgical field, we developed and tested a new software, called "ikidney", based on convolutional neural networks (CNNs). From January 2022 to April 2023, patients affected by organ-confined renal masses amenable to RAPN were enrolled. A bioengineer, a software developer, and a surgeon collaborated to create hyper-accurate 3D models for automatic 3D AR-guided RAPN, using CNNs. For each patient, demographic and clinical data were collected. A total of 13 patients were included in the present study. The average anchoring time was 11 (6-13) s. Unintended 3D-model automatic co-registration temporary failures happened in a static setting in one patient, while this happened in one patient in a dynamic setting. There was one failure; in this single case, an ultrasound drop-in probe was used to detect the neoplasm, and the surgery was performed under ultrasound guidance instead of AR guidance. No major intraoperative nor postoperative complications (i.e., Clavien Dindo > 2) were recorded. The employment of AI has unveiled several new scenarios in clinical practice, thanks to its ability to perform specific tasks autonomously. We employed CNNs for an automatic 3DVM overlapping during RAPN, thus improving the accuracy of the superimposition process.

Application of 3D printing technology in tumor diagnosis and treatment

3D printing technology is an increasing approach consisting of material manufacturing through the selective incremental delamination of materials to form a 3D structure to produce products. This technology has different advantages, including low cost, short time, diversification, and high precision. Widely adopted additive manufacturing technologies enable the creation of diagnostic tools and expand treatment options. Coupled with its rapid deployment, 3D printing is endowed with high customizability that enables users to build prototypes in shorts amounts of time which translates into faster adoption in the medical field. This review mainly summarizes the application of 3D printing technology in the diagnosis and treatment of cancer, including the challenges and the prospects combined with other technologies applied to the medical field.

3D Model Artificial Intelligence-Guided Automatic Augmented Reality Images during Robotic Partial Nephrectomy

More than ever, precision surgery is making its way into modern surgery for functional organ preservation. This is possible mainly due to the increasing number of technologies available, including 3D models, virtual reality, augmented reality, and artificial intelligence. Intraoperative surgical navigation represents an interesting application of these technologies, allowing to understand in detail the surgical anatomy, planning a patient-tailored approach. Automatic superimposition comes into this context to optimally perform surgery as accurately as possible. Through a dedicated software (the first version) called iKidney, it is possible to superimpose the images using 3D models and live endoscopic images during partial nephrectomy, targeting the renal mass only. The patient is 31 years old with a 28 mm totally endophytic right-sided renal mass, with a PADUA score of 9. Thanks to the automatic superimposition and selective clamping, an enucleoresection of the renal mass alone was performed with no major postoperative complication (i.e., Clavien-Dindo < 2). iKidney-guided partial nephrectomy is safe, feasible, and yields excellent results in terms of organ preservation and functional outcomes. Further validation studies are needed to improve the prototype software, particularly to improve the rotational axes and avoid human help. Furthermore, it is important to reduce the costs associated with these technologies to increase its use in smaller hospitals.

Three-Dimensional Customized Imaging Reconstruction for Urological Surgery: Diffusion and Role in Real-Life Practice from an International Survey

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

The First Entirely 3D-Printed Training Model for Robot-assisted Kidney Transplantation: The RAKT Box

Background

Robot-assisted kidney transplantation (RAKT) is increasingly performed at selected referral institutions worldwide. However, simulation and proficiency-based progression training frameworks for RAKT are still lacking, making acquisition of the RAKT-specific skill set a critical unmet need for future RAKT surgeons.

Objective

To develop and test the RAKT Box, the first entirely 3D-printed, perfused, hyperaccuracy simulator for vascular anastomoses during RAKT.

Design setting and participants

The project was developed in a stepwise fashion by a multidisciplinary team including urologists and bioengineers via an iterative process over a 3-yr period (November 2019-November 2022) using an established methodology. The essential and time-sensitive steps of RAKT were selected by a team of RAKT experts and simulated using the RAKT Box according to the principles of the Vattituki-Medanta technique. The RAKT Box was tested in the operating theatre by an expert RAKT surgeon and independently by four trainees with heterogeneous expertise in robotic surgery and kidney transplantation.

Surgical procedure

Simulation of RAKT.

Measurements

Video recordings of the trainees' performance of vascular anastomoses using the RAKT Box were evaluated blind by a senior surgeon according to the Global Evaluative Assessment of Robotic Skills (GEARS) and Assessment of Robotic Console Skills (ARCS) tools.

Results and limitations

All participants successfully completed the training session, confirming the technical reliability of the RAKT Box simulator. Tangible differences were observed among the trainees in both anastomosis time and performance metrics. Key limitations of the RAKT Box include lack of simulation of the ureterovesical anastomosis and the need for a robotic platform, specific training instruments, and disposable 3D-printed vessels.

Conclusions

The RAKT Box is a reliable educational tool to train novice surgeons in the key steps of RAKT and may represent the first step toward the definition of a structured surgical curriculum in RAKT.

Patient summary

We describe the first entirely 3D-printed simulator that allows surgeons to test the key steps of robot-assisted kidney transplantation (RAKT) in a training environment before performing the procedure in patients. The simulator, called the RAKT Box, has been successfully tested by an expert surgeon and four trainees. The results confirm its reliability and potential as an educational tool for training of future RAKT surgeons.

Three-dimensional virtual models assistance predicts higher rates of "successful" minimally invasive partial nephrectomy: an Institutional analysis across the available trifecta definitions

PURPOSE

3D virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. Five different Trifecta definitions have been proposed to optimize the framing of "success" in the PN field. Our aim is to analyze if the use of 3DVMs could impact the success rate of minimally invasive PN (mi-PN), according to the currently available definitions of Trifecta.

MATERIALS AND METHODS

At our Institution 250 cT1-2N0M0 renal masses patients treated with mi-PN were prospectively enrolled. Inclusion criteria were the availability of contrast-enhanced CT, baseline and postoperative serum creatinine, and eGFR. These patients were then compared with a control group of 710 patients who underwent mi-PN with the same renal function assessments, but without 3DVMs. Multivariable logistic regression (MLR) models were used to predict the trifecta achievement according to the different trifecta definitions.

RESULTS

Among the definitions, Trifecta rates ranged between 70.8% to 97.4% in the 3DVM group vs. 56.8% to 92.8% in the control group (all p values < 0.05). 3DVMs showed better postoperative outcomes in terms of ΔeGFR, ( - 16.6% vs.  - 2.7%, p = 0.03), postoperative complications (15%, vs 22.9%, p = 0.002) and major complications (Clavien Dindo > 3, 2.8% vs 5.6%, p = 0.03). At MLR 3DVMs assistance independently predicted higher rates of successful PN across all the available definitions of Trifecta (OR: 2.7 p < 0.001, OR:2.0 p = 0.0008, OR:2.8 p = 0.02, OR 2.0 p = 0.003).

CONCLUSIONS

The 3DVMs availability was found to be the constant predictive factor of successful PN, with a twofold higher probability of achieving Trifecta regardless of the different definitions available in Literature.

New Generation of 3D Virtual Models with Perfusional Zones: Perioperative Assistance for the Best Pedicle Management during Robotic Partial Nephrectomy

Selective clamping during robot-assisted partial nephrectomy (RAPN) may reduce ischemia-related functional impairment. The intraoperative use of 3D-virtual models (3DVMs) can improve surgical planning, resulting in a greater success rate for selective clamping. Our goal is to introduce a new generation of 3DVMs, which consider the perfusion volumes of the kidney. Patients listed for RAPN from 2021 to 2022 were recruited. A selective clamping strategy was designed and intraoperatively performed based on the specifically generated 3DVMs. The effectiveness of selective clamping was evaluated using near-infrared-fluorescence imaging (NIRF) and 3DVM. Perfusion areas extensions were compared, and relevant preoperative characteristics were analyzed. In 61 of 80 (76.25%) cases, selective clamping was performed. The concordance between the 3DVM areas and the NIRF-enhanced areas was verified (k = 0.91). According to the distribution of perfused areas crossing the tumor, there were one, two, three, four, and five crossing areas, with relative perfusion rates of 13.75%, 35%, 32.5%, 13.75%, and 5%, respectively. Lesion diameter and mesorenal location were the only factors related to a higher number (>3) of perfusion volumes crossing the lesion. The implementation of mathematical algorithms to 3DVMs allows for precise estimation of the perfusion zone of each arterial branch feeding the organ, leading to the performance of safe and effective pedicle management planning.

Health Information Technology Usability Evaluation Scale (Health-ITUES) and User-Experience Questionnaire (UEQ) for 3D Intraoperative Cognitive Navigation (ICON3DTM) System for Urological Procedures

Backgound and objectives: In recent years, the adoption of 3D models for surgical planning and intraoperative guidance has gained a wide diffusion. The aim of this study was to evaluate the surgeons' perception and usability of ICON3D^TM platform for robotic and laparoscopic urological surgical procedures. Materials and Methods: During the 10th edition of the Techno-Urology Meeting, surgeons and attendees had the opportunity to test the new ICON3D^TM platform. The capability of the user to manipulate the model with hands/mouse, the software usability, the quality of the 3D model's reproduction, and the quality of its use during the surgery were evaluated with the Health Information Technology Usability Evaluation Scale (Health-ITUES) and the User-Experience Questionnaire (UEQ). Results: Fifty-three participants responded to the questionnaires. Based on the answers to the Health-ITUES questionnaire, ICON3D^TM resulted to have a positive additional value in presurgical/surgical planning with 43.4% and 39.6% of responders that rated 4 (agree) and 5 (strongly agree), respectively. Regarding the UEQ questionnaire, both mouse and infrared hand-tracking system resulted to be easy to use for 99% of the responders, while the software resulted to be easy to use for 93.4% of the responders. Conclusions: In conclusion, ICON3D^TM has been widely appreciated by urologists thanks to its various applications, from preoperative planning to its support for intraoperative decision-making in both robot-assisted and laparoscopic settings.

Three-dimensional Model-assisted Minimally Invasive Partial Nephrectomy: A Systematic Review with Meta-analysis of Comparative Studies

CONTEXT

Use of three-dimensional (3D) guidance for nephron-sparing surgery (NSS) has increased in popularity, especially for laparoscopic and robotic approaches. Different 3D visualization modalities have been developed as promising new tools for surgical planning and intraoperative navigation.

OBJECTIVES

To summarize and evaluate the impact of 3D models on minimally invasive NSS in terms of perioperative, functional, and oncological outcomes.

EVIDENCE ACQUISITION

A systematic literature search was conducted in December 2021 using the Medline (PubMed), Embase (Ovid), Scopus, and Web of Science databases. The protocol was registered on PROSPERO (CRD42022300948). The search strategy used the PICOS (Population, Intervention, Comparison, Outcome, Study design) criteria and article selection was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Meta-analysis was performed using the Mantel-Haenszel method for binary outcomes, with results summarized as the odds ratio (OR), and the inverse variance method for continuous data, with results reported as the mean difference (MD). All effect estimates are reported with the 95% confidence interval (CI) and p ≤ 0.05 was considered statistically significant. All analyses were performed using R software and the meta package.

EVIDENCE SYNTHESIS

The initial electronic search identified 450 papers, of which 17 met the inclusion criteria and were included in the analysis. Use of 3D technology led to a significant reduction in the global ischemia rate (OR 0.22, 95% CI 0.07-0.76; p = 0.02) and facilitated more frequent enucleation (OR 2.54, 95% CI 1.36-4.74; p < 0.01) and less frequent opening of the collecting system (OR 0.36, 95% CI 0.15-0.89; p = 0.03) and was associated with less blood loss (MD 23.1 ml, 95% CI 31.8-14.4; p < 0.01). 3D guidance for NSS was associated with a significant reduction in the transfusion rate (OR 0.20, 95% CI 0.07-0.56; p < 0.01). There were no significant differences in rates of conversion to radical nephrectomy, minor and major complications, change in glomerular filtration rate, or surgical margins (all p > 0.05).

CONCLUSIONS

3D guidance for NSS is associated with lower rates of detriment and surgical injury to the kidney. Specifically, a lower amount of nontumor renal parenchyma is exposed to ischemia or sacrificed during resection, and opening of the collecting system is less frequent. However, use of 3D technology does not lead to significant improvements in oncological or functional outcomes.

PATIENT SUMMARY

We reviewed the use of three-dimensional tools for minimally invasive surgery for partial removal of the kidney in patients with kidney cancer. The evidence suggests that these tools have benefits during surgery, but do not lead to significant improvements in cancer control or functional outcomes for patients.

Systematic Review of Comparative Studies of 3D Models for Preoperative Planning in Minimally Invasive Partial Nephrectomy

Background: The employment of 3-dimensional (3D) virtual models of the organs and tumors, obtained from conventional 2-dimensional (2D) imaging (i.e. computed tomography scan and magnetic resonance imaging) have already demonstrated an outstanding potential in urology, especially in renal surgery. Objectives: The aim of this systematic review is to provide an updated focus on the results obtained from the preoperative employment of 3D virtual imaging reconstructions in nephron sparing oncological surgery. Methods: A systematic literature search was conducted in April 2022 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Results: The initial electronic search identified 471 papers, of which 13 ultimately met the inclusion criteria and were included in the review. 11 studies reported outcomes of virtual models, 2 studies focused on printed 3D models. In these studies, the application of 3D models for preoperative planning has been reported to increase the selective clamping rate and reducing the opening of collecting system, blood loss and loss of renal function. Conclusions: 3D virtual models seem to provide some surgical benefits for preoperative planning especially for complex renal masses. In the next future the continuous evolution of this technology may further increase its field of application and its potential clinical benefit.

NeuroSAFE in radical prostatectomy increases the rate of nerve-sparing surgery without affecting oncological outcome

OBJECTIVES

To investigate the impact of intra-operative neurovascular structure-adjacent frozen-section examination (NeuroSAFE) on the rate of nerve-sparing surgery (NSS) and oncological outcome in a large radical prostatectomy (RP) cohort.

PATIENTS AND METHODS

Between January 2016 and December 2020, 1756 prostate cancer patients underwent robot-assisted RP, of whom 959 (55%) underwent this with NeuroSAFE and 797 (45%) without (control cohort). In cases where NeuroSAFE showed tumour in the margin, a secondary resection was performed. The effect of NeuroSAFE on NSS and positive surgical margin (PSM) status was analysed using logistic regression. Cox regression was used to identify predictors of biochemical recurrence-free survival (BCRFS).

RESULTS AND LIMITATIONS

Patients in the NeuroSAFE cohort had a higher tumour grade (P < 0.001) and clinical stage (P < 0.001) than those in the control cohort. NeuroSAFE enabled more frequent NSS for both pT2 (93% vs 76%; P < 0.001) and pT3 disease (83% vs 55%; P < 0.001). In adjusted analysis, NeuroSAFE resulted in more frequent unilateral (odds ratio [OR] 3.90, 95% confidence interval (CI) 2.90-5.30; P < 0.001) and bilateral (OR 5.22, 95% CI 3.90-6.98; P < 0.001) NSS. While the PSM rate decreased from 51% to 42% in patients with pT3 stage disease (P = 0.031), NeuroSAFE was not an independent predictor of PSM status (OR 0.85, 95% CI 0.68-1.06; P = 0.2) in the entire cohort. Patients who underwent NeuroSAFE had better BCRFS compared to the control cohort (hazard ratio 0.62, 95% CI 0.45-0.84; P = 0.002). This study is limited by its comparison with a historical cohort and lack of functional outcomes.

CONCLUSIONS

NeuroSAFE enables more unilateral and bilateral NSS without negatively affecting surgical margin status and biochemical recurrence. This validation study provides a comprehensive overview of the implementation, evaluation and intra-operative decision making associated with NeuroSAFE in clinical practice.

Clinical experience of using virtual 3D modelling for pre and intraoperative guidance during robotic-assisted partial nephrectomy

Objective:

Surgical planning for robotic-assisted partial nephrectomy is widely performed using two-dimensional computed tomography images. It is unclear to what extent two-dimensional images fully simulate surgical anatomy and case complexity. To overcome these limitations, software has been developed to reconstruct three-dimensional models from computed tomography data. We present the results of a feasibility study, to explore the role and practicality of virtual three-dimensional modelling (by Innersight Labs) in the context of surgical utility for preoperative and intraoperative use, as well as improving patient involvement.

Methods:

A prospective study was conducted on patients undergoing robotic-assisted partial nephrectomy at our high volume kidney cancer centre. Approval from a research ethics committee was obtained. Patient demographics and tumour characteristics were collected. Surgical outcome measures were recorded. The value of the three-dimensional model to the surgeon and patient was assessed using a survey. The prospective cohort was compared against a retrospective cohort and cases were individually matched using RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines) scores.

Results:

This study included 22 patients. Three-dimensional modelling was found to be safe for this prospective cohort and resulted in good surgical outcome measures. The mean (standard deviation) console time was 158.6 (35) min and warm ischaemia time was 17.3 (6.3) min. The median (interquartile range) estimated blood loss was 125 (50–237.5) ml. Two procedures were converted to radical nephrectomy due to the risk of positive margins during resection. The median (interquartile range) length of stay was 2 (2–3) days. No postoperative complications were noted and all patients had negative surgical margins. Patients reported improved understanding of their procedure using the three-dimensional model.

Conclusion:

This study shows the potential benefit of three-dimensional modelling technology with positive uptake from surgeons and patients. Benefits are improved perception of vascular anatomy and resection approach, and procedure understanding by patients. A randomised controlled trial is needed to evaluate the technology further.

Level of evidence:

2b

A pilot study investigating the feasibility of using a fully automatic software to assess the RENAL and PADUA score

PURPOSE

Image-based morphometric scoring systems such as the RENAL and PADUA scores are useful to evaluate the complexity of partial nephrectomy for renal cell carcinoma (RCC). The main aim of this study was to develop a new imaging software to enable an automatic detection and a 3D visualization of RCC from CT angiography (CTA) and to address the feasibility to use it to evaluate the features of the RENAL and the PADUA scores.

METHODS

A training dataset of 210 patients CTA-scans manually segmented was used to train a deep learning algorithm to develop the automatic detection and 3D-visualization of RCC. A trained operator blindly assessed the RENAL and PADUA scores on a testing dataset of 41 CTA from patients with RCC using a commercialized semi-automatic software (ground truth) and the new automatic software. Concordance between the two methods was evaluated.

RESULTS

The median PADUA score was 9 (7-11) and the renal score was 8 (5.5-9). The automatic software enabled to automatically detect the tumoral kidney and provided a 3D-visualization in all cases, with a computational time less than 20 seconds. Concordances for staging the anatomical features of the RENAL scores were respectively: 87.8% for radius, 85.4% for exophytic rate, 82.9% for location to the polar lines and 92.7% for the antero-posterior location. For the PADUA scores, concordances were 90.2% for tumor size, 85.4% for exophytic rate, 87.8% for polar location and 100% for renal rim.

CONCLUSION

By enabling an automatic 3D-visualization of tumoral kidney, this software could help to calculate morphometric scores, save time and improve reproducibility for clinicians.

LEVEL OF EVIDENCE: 4

Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery—First Pilot Study

When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.

Anatomical Engineering and 3D Printing for Surgery and Medical Devices: International Review and Future Exponential Innovations

Three-dimensional printing (3DP) has recently gained importance in the medical industry, especially in surgical specialties. It uses different techniques and materials based on patients' needs, which allows bioprofessionals to design and develop unique pieces using medical imaging provided by computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, the Department of Biology and Medicine and the Department of Physics and Engineering, at the Bioastronautics and Space Mechatronics Research Group, have managed and supervised an international cooperation study, in order to present a general review of the innovative surgical applications, focused on anatomical systems, such as the nervous and craniofacial system, cardiovascular system, digestive system, genitourinary system, and musculoskeletal system. Finally, the integration with augmented, mixed, virtual reality is analyzed to show the advantages of personalized treatments, taking into account the improvements for preoperative, intraoperative planning, and medical training. Also, this article explores the creation of devices and tools for space surgery to get better outcomes under changing gravity conditions.

Effect of a three-dimensional (3D) printed kidney model on patient understanding of the percutaneous nephrolithotomy procedure: a preliminary study

Three-dimensional (3D) printed anatomical models can provide cognitive anatomical information. We aimed to study the effect of a 3D printed kidney model on patient understanding of kidney anatomy and the percutaneous nephrolithotomy (PCNL) procedure as well as the overall patient satisfaction with the model. Seven patients who underwent PCNL were enrolled in the study. Personalized 3D printed kidney models were constructed based on the patients' computed tomography images. Patients completed two questionnaires regarding their understanding and satisfaction with the use of the 3D printed kidney model before and after using the model during informed consent. The mean age of the study population was 58.0 years. Comparison of patient understanding and satisfaction between the two questionnaires showed a general trend toward better understanding and improved satisfaction with use of 3D printed kidney models. Statistically significant results were seen for understanding of kidney anatomy, stone size, procedure, and satisfaction (p values 0.046, 0.025, 0.046, and 0.046, respectively). Five of the seven patients (71.4%) answered that the model was very useful. However, none of the patients answered that the cost was appropriate. In the current study, patients showed improved understanding of the kidney anatomy and the PCNL procedure and higher satisfaction with using the 3D printed kidney model during informed consent. With further studies using larger patient numbers and decreased production cost, using 3D printed kidney models has the potential to be a useful adjunct for patient understanding during PCNL.

Open and Laparoscopic Partial Nephrectomy: Comparison and Validation of Preoperative Scoring Systems, Including PADUA, RENAL, ABC Nephrometric Scores and Perinephric Fat Evaluation with Mayo Adhesive Probability Score

Purpose

To evaluate potential associations between 4 nephrometric scoring systems, namely the PADUA (preoperative aspects and dimensions used for anatomical classification), RENAL (radius endophytic/exophytic nearness anterior posterior location), ABC (arterial-based complexity), and MAP (Mayo adhesive probability) scores and their individual components, with surgical and oncological outcomes of patients undergoing a partial nephrectomy.

Materials and Methods

A consecutive, monocentric cohort of partial nephrectomy patients was retrospectively analyzed. PADUA, RENAL, ABC and MAP nephrometry scores were determined from preoperative axial images. Unadjusted and adjusted associations between overall scores, individual components, surgical approach, complications and oncological outcomes were determined using univariate and multivariate logistic regressions.

Results

A total of 189 partial nephrectomies were performed in 181 patients, via an open or a laparoscopic approach. Among scoring systems, only the MAP classification, which assesses adherent perinephric fat, was associated with severe surgical complications as well as with operative time (p<0.05). Among all components of the PADUA and RENAL scores, only proximity of the tumor to the collecting system was associated with overall surgical complication rates, while the diameter of the tumor influenced the operative time (p<0.05). The ABC score was not relevant. Male gender, antiplatelet therapy, and a laparoscopic approach were associated with higher overall surgical complication rates (p<0.05). The number of oncologic recurrences during follow-up was too low to run statistical analyses.

Conclusion

Nephrometry scores could be simplified to predict surgical complications after partial nephrectomy. In this framework, adherent perinephric fat seemed to be strongly associated with an increased risk of surgical complications.

Robot-assisted partial nephrectomy with 3D preoperative surgical planning: video presentation of the florentine experience

Purpose:

Three-dimensional (3D) virtual models have recently gained consideration in the partial nephrectomy (PN) field as useful tools since they may potentially improve preoperative surgical planning and thus contributing to maximizing postoperative outcomes (1-5).

The aim of the present study was to describe our first experience with 3D virtual models as preoperative guidance for robot-assisted PN.

Materials and methods:

Data of patients with renal mass amenable to robotic PN were prospectively collected at our Institution from January to April 2020. Using a dedicated web-based platform, abdominal CT-scan images were processed by M3DICS (Turin, Italy) and used to obtain 3D virtual models. 2D CT images and 3D models were separately assessed by two different highly experienced urologists to assess the PADUA score and risk category and to forecast the surgical strategy of the single cases, accordingly.

Results:

Overall, 30 patients were included in the study. Median tumor size was 4.3cm (range 1.3-11). Interestingly, 8 (26.4%) cases had their PADUA score downgraded when switching from 2D CT-scan to 3D virtual model assessment and 4 (13.4%) cases had also lowered their PADUA risk category. Moreover, preoperative off-clamp, selective clamping strategy and enucleation resection strategy increased from CT-scan to 3D evaluation.

Conclusion:

3D virtual models are promising tools as they showed to offer a reliable assessment of surgical planning. However, the advantages offered by the 3D reconstruction appeared to be more evident as the complexity of the mass raises. These tools may ultimately increase tumor's selection for PN, particularly in highly complex renal masses.

Disclosure of potential conflicts of interest: The authors declare they do not have conflict of interests.

Informed consent: Informed consent was obtained from all individual participants included in the study. All the procedures were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

[Three dimensional nephrometry system for partial nephrectomy: Our initial exploration]

OBJECTIVE

To construct a preoperative evaluation system for partial nephrectomy using CT three-dimensional visualization technology and to explore its practical value.

METHODS

The clinical data of the patients who underwent partial nephrectomy for renal tumors in Department of Urology, Peking University First Hospital were collected retrospectively. At the same time, the homogenized standard data of patients who underwent partial nephrectomy for renal tumors were collected in 16 clinical centers in China. The CT three-dimensional visualization system was applied (IPS system, Yorktal) to evaluate tumor anatomy, blood supply, perirenal fat and other information. The parameters were summarized to build a three-dimensional nephrometry system, on the basis of which virtual surgery design and intraoperative navigation were completed.

RESULTS

A three-dimensional visualization image was established based on the enhanced CT urography. The nephrometry system included the longest diameter and volume of the tumor, proportion volume of tumor invading the parenchyma, maximum depth of the tumor invading the parenchyma, contact surface area, flatness of the tumor surface, renal segment where the tumor was located, vascular variation, and perirenal fat. The average two-dimensional diameter of the tumor was (2.78±1.43) cm, the average three-dimensional maximum diameter was (3.09±1.35) cm, and the average postoperative pathological size was (3.01±1.38) cm. The maximum tumor diameter in the three-dimensional image was significantly related to the prolonged renal artery clamping time and intra-operative blood loss (r=0.502, P=0.020; r=0.403, P=0.046). The three-dimensional and pathological tumor volume were (25.7±48.4) cm³ and (33.0±36.4) cm³, respectively (P=0.229). The tumor volume was significantly related to the intraoperative blood loss (r=0.660, P < 0.001). The proportion volume of the tumor invading into renal parenchyma was significantly related to the prolongation of renal artery clamping and the occurrence of postoperative complications (r=0.410, P=0.041; r=0.587, P=0.005). The tumor contact surface area and the presence of vascular variation did not show correlation with the perioperative data and postoperative complications. While the preoperative evaluation was completed, the reconstructed three-dimensional image could be zoomed, rotated, combined display, color adjustment, transparency, and simulated cutting on the Touch Viewer system. The process generally consisted of showing or hiding the tissue, adjusting the transparency of the interested area, rotating and zooming the image to match the position of the surgical patient. Together, these functions met the requirements of preoperative virtual surgery plan and intraoperative auxiliary navigation.

CONCLUSION

Three-dimensional images can provide a more intuitive anatomical structure. The CT three-dimensional visua-lization system clearly displays tumor anatomical parameters, blood supply and perirenal fat. The three-dimensional nephrometry system for renal tumors can help predict the difficulty of partial nephrectomy and perioperative complications. Importing the reconstructed three-dimensional visualization image into the specified program or robot operating system can complete virtual surgery and intraoperative navigation, helping the surgeon to better grasp the surgical process. The indexes included in the nephrometry system and the score weights of each index need to be confirmed and perfected by multi-center study with large samples.

Mixed reality applications in urology: Requirements and future potential

Background

Mixed reality (MR), the computer-supported augmentation of a real environment with virtual elements, becomes ever more relevant in the medical domain, especially in urology, ranging from education and training over surgeries. We aimed to review existing MR technologies and their applications in urology.

Methods

A non-systematic review of current literature was performed using the PubMed-Medline database using the medical subject headings (MeSH) term “mixed reality”, combined with one of the following terms: “virtual reality”, “augmented reality”, ‘’urology’’ and “augmented virtuality”. The relevant studies were utilized.

Results

MR applications such as MR guided systems, immersive VR headsets, AR models, MR-simulated ureteroscopy and smart glasses have enormous potential in education, training and surgical interventions of urology. Medical students, urology residents and inexperienced urologists can gain experience thanks to MR technologies. MR applications are also used in patient education before interventions.

Conclusions

For surgical support, the achievable accuracy is often not sufficient. The main challenges are the non-rigid nature of the genitourinary organs, intraoperative data acquisition, online and multimodal registration and calibration of devices. However, the progress made in recent years is tremendous in all respects and the gap is constantly shrinking.

∙

MR, including AV and AR, is an intriguing technology with tremendous potential in urology field.

∙The main challenges lie in intraoperative data acquisition, online and multimodal registration and calibration of devices and data, appropriate display hardware, as well as cooperative devices and tools in the operation theatres.

∙Medical experts should feel encouraged to experience MR solutions and to communicate their specific needs and effects they aim at.

Three-dimensional virtual planning for nodule resection in solid organs: A systematic review and meta-analysis

OBJECTIVES

To systematically review the effects of 3D-imaging virtual planning for nodule resection in the following solid organs: lung, liver, and kidney.

METHODS

MEDLINE, EMBASE, and Cochrane Library were searched through September 31, 2020 to include randomized and non-randomized controlled studies that compared outcomes of surgical resection of lung, liver, or kidney nodule resection with and without 3D virtual planning with computed tomography. From each article, the mean operation time (OT), mean estimated blood loss (EBL), mean postoperative hospital stay (POHS), and the number of postoperative events (POE) were extracted. The effect size (ES) of 3D virtual planning vs. non-3D planning was extracted from each study to calculate the pooled measurements for continuous variables (OT, EBL, POHS). Data were pooled using a random-effects model.

RESULTS

The literature search yielded 2397 studies and 10 met the inclusion criteria with a total of 897 patients. There was a significant difference in OT between groups with a moderate ES favoring the 3D group (ES,-0.56; 95%CI: 0.91,-0.29; I² = 83.1%; p < .001). Regarding EBL, there was a significant difference between 3D and non-3D with a small ES favoring IGS (ES,-0.18; 95%CI: 0.33,-0.02; I² = 22.5%; p = .0236). There was no difference between the 3D and non-3D groups for both POHS (POHS ES,-0.15; 95%CI: 0.39,0.10; I² = 37.0%; p = .174) and POE (POE odds ratio (OR),0.80; 95%CI:0.54,1.19; I² = 0.0%; p = .0.973).

CONCLUSIONS

3D-imaging planning for surgical resection of lung, kidney, and liver nodules could reduce OT and EBL with no effects on immediate POHS and POE. Improvements in these perioperative variables could improve medium and long-term postoperative clinical outcomes.

Three-dimensional Virtual Models' Assistance During Minimally Invasive Partial Nephrectomy Minimizes the Impairment of Kidney Function

Three-dimensional virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. This report aims to analyze their impact on renal function preservation after minimally invasive PN. A total of 100 patients treated with minimally invasive PN with contrast-enhanced computed tomography from which a 3DVM was obtained, and having undergone baseline and 3rd month postoperative renal scans were prospectively enrolled and compared with a control group of 251 patients without 3DVMs. Weighted differential of pre- and postoperative renal scan-based effective renal plasmatic flow (b-WD ERPF) was calculated, according to the availability of 3DVMs and PADUA risk category. Multivariable logistic regression (MLR) models predicting a significant loss of renal function (LORF; ERPF drop >20%) were performed, overall and according to PADUA risk categories. The b-WD ERPF of the 3DVM group showed significantly lower LORF (-10%) than that of the control group (-19.6%, p =  0.02). In MLR, the availability of a 3DVM was found to be the only protective factor against a significant LORF (odds ratio [OR] = 0.3, p =  0.002). Moreover, after stratification as per tumor surgical complexity, this protective role was observed in both PADUA 8-9 and ≥10 category risk patients (OR = 0.3, p =  0.03 and OR = 0.1, p =  0.01). PATIENT SUMMARY: The drop in operated kidney function was significantly lower in surgeries assisted by three-dimensional virtual models (3VDMs), indicating that the availability of a 3VDM is the only protective factor against a significant functional damage.

Three-dimensional Reconstruction of Renal Vascular Tumor Anatomy to facilitate accurate preoperative planning of partial nephrectomy

Objectives

To evaluate the role of three-dimensional (3D) reconstruction tumors and vessels of the kidneys in aiding the preoperative planning of partial nephrectomy.

Materials and methods

Patients with renal tumors to be treated with partial nephrectomy were included. Each patient underwent a preoperative computed tomography (CT) survey, and the reconstruction of each patient's 3D arteriography and 3D surface-rendered tumor was performed based on the CT images for preoperative surgical planning.

Results

A total of 6 patients, three with tumors of the right kidney and three with tumors of the left kidney, were enrolled in the study. The patients' mean age was 49.33 ± 4.03 years (range: 45-57 years), and their mean tumor size was 4.4 ± 1.84 cm (range: 2.2-6.8 cm). Four underwent robot-assisted laparoscopic partial nephrectomies, one underwent a traditional laparoscopic partial nephrectomy, and one underwent a radical nephrectomy through laparotomy. Their average postoperative hospital stay was 6.7 days (range: 3-10 days). No intraoperative or postoperative complications were noted. The renal function was preserved in all the patients, and none of the patients exhibited evidence of local recurrence during more than 6 years of follow-up.

Conclusions

3D arteriography fused with 3D surface-rendered tumor image navigation facilitates precise preoperative planning.

Real-time navigation by three-dimensional virtual reconstruction models in robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: our initial experience

Background

The aim of this study was to evaluate the effectiveness and safety of real-time surgical navigation by three-dimensional (3D) virtual reconstruction models in robot-assisted laparoscopic pyeloplasty (RALP).

Methods

Between November 2018 and January 2020, 38 patients with ureteropelvic junction obstruction (UPJO) who underwent RALP were retrospectively enrolled. The operations were assisted in real time by 3D models in 16 patients, while 22 patients underwent surgery without navigation. Based on whether patients had a prior intervention history, crossing vessels or congenital deformities, we further divided them into the “complicated UPJO” cohort and the “regular UPJO” cohort for subgroup analysis. The demographic characteristics, intraoperative parameters, perioperative data and follow-up data were recorded and compared between the groups.

Results

All of the procedures were successfully performed without open or laparoscopic conversion. The mean dissection time to the UPJ was shorter in the navigation group than in the non-navigation group, both in the whole cohort (15.3 vs. 24.8 min, P=0.011) and in the complicated cohort (15.4 vs. 27.5 min, P=0.004), while there was no significant difference in the regular cohort. The overall operative time and estimated blood loss in the navigation group tended to be less, although the difference was not statistically significant. No difference in anastomosis time, postoperative hospital stay or complications was noted between the two groups in either cohort. At a mean follow-up of 11.2 months, the overall success rate was 94.7% (36/38), and there was no significant difference between the two groups.

Conclusions

Real-time navigation by 3D virtual reconstruction models might be helpful to improve surgical efficiency and safety of RALP by facilitating the dissection around the UPJ, especially for cases of complicated UPJO. However, the prospective study with larger sample size is further needed to confirm the results.

3D reconstruction of Wilms' tumor and kidneys in children: Variability, usefulness and constraints

INTRODUCTION

Wilms' tumor (WT) is the most common type of malignant kidney tumor in children. Three-dimensional reconstructions can be performed pre-operatively to help surgeons in the planning phase.

OBJECTIVES

The main objective of this study was to determine the variability of WT segmentation and 3D reconstruction. The secondary objectives were to assess the usefulness of these 3D reconstructions in the surgical planning phase and in the selection of patients for nephron-sparing surgery (NSS).

METHODS

14 scans from 12 patients were manually or semi-automatically segmented by 2 teams using 3D Slicer software. Inter-individual variability of 3D reconstructions was measured based on the Dice index. The utility of 3D reconstructions for the surgical planning was evaluated by 4 pediatric surgeons using a 5-point Likert scale. The possibility of undertaking NSS was evaluated according to the criteria defined in the Umbrella SIOP-RTSG 2016 protocol.

RESULTS

Segmentation of the WT, healthy kidney, pathological kidney, arterial and venous vascularization could be performed for all of the patients in this study. Urinary cavities segmentation could only be performed for 5 out of 14 scans that had a delayed acquisition phase. The mean time required to carry out these segmentations was 8.6 h [3-15 h]. The mean Dice index for all of the scans was good (mean: 0.87; range [0.83-0.91]). Considering each anatomical structure, the Dice index was very good for the WT (mean: 0.95; range [0.91-0.97]) and the healthy kidney (mean: 0.95; range [0.93-0.96]), good for the pathological kidney (mean: 0.87; range [0.69-0.96]) and arterial vascularization (mean: 0.84; range [0.74-0.91]). The Dice index was lower than 0.8 for venous vascularization only (mean: 0.77; range [0.58-0.86]). All the surgeons who were interviewed agreed that the 3D reconstructions were realistic representations and useful for the surgical planning phase. The images reconstructed in 3D allowed most of the criteria defined by the Umbrella SIOP-RTSG 2016 protocol to be evaluated regarding the selection of patients who could benefit from NSS.

CONCLUSION

The inter-individual variability of 3D reconstructions of WT is acceptable. Three-dimensional representation appears to assist surgeons with the surgical planning phase by allowing them to better anticipate the operative risks. 3D reconstructions can also be an additional tool to better select patients for NSS. However, the manual or semi-automatic method used is very time-consuming, making it difficult for a routinely use. Developing techniques to automate this segmentation process, therefore, appears to be essential if surgeons and radiologists are to use it in daily practice.

Multi-institutional Retrospective Validation and Comparison of the Simplified PADUA REnal Nephrometry System for the Prediction of Surgical Success of Robot-assisted Partial Nephrectomy

BACKGROUND

The use of a nephron-sparing surgery for the treatment of localized renal masses is being pushed to more challenging cases. However, this procedure is not devoid of risks, and the Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classifications are commonly employed in the prediction of complications. Recently, the Simplified PADUA REnal (SPARE) scoring system has been proposed with the aim to provide a more simple system, to improve its reproducibility to predict postoperative risks.

OBJECTIVE

We aim to retrospectively validate and compare the proposed new SPARE system in a multi-institutional population.

DESIGN, SETTING, AND PARTICIPANTS

The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to robot-assisted partial nephrectomy (RAPN) between 2010 and 2016 at three tertiary care referral centers. Of these patients, 536 presented complete demographic and clinical data.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Renal masses were classified according to the SPARE, RENAL, and PADUA nephrometry scores, and surgical success was defined according to the margin, ischemia, and complication scores.

RESULTS AND LIMITATIONS

Of 536 patients, 340 were male; the median age was 61 (53-69) yr and preoperative tumor size was 30 (22-43) mm. The margin, ischemia, and complication score was achieved in 399 of cases (74.4%). All three nephrometry scores were significant predictors of surgical outcomes both in univariate and in adjusted multivariate logistic regression model analysis. In accuracy analysis, the area under the curve (AUC) of the SPARE scoring system (0.73) was significantly higher than those of the PADUA (0.65) and RENAL (0.68) nephrometry scores in predicting surgical success.

CONCLUSIONS

The SPARE score appears to be a promising and reliable score for the prediction of surgical outcomes of RAPN, showing a higher accuracy relative to the traditional PADUA and RENAL nephrometry scores. Further, prospective studies are warranted before its introduction in clinical practice.

PATIENT SUMMARY

The Simplified PADUA REnal (SPARE) score is a reproducible and simple nephrometry score, offering better predictive capabilities of surgical success and complications.

Patient Counseling Through the Pelvicalyceal-shaped Labyrinth: In Search of an Easy Understanding of the Upcoming Stone Removal: A Pilot Study

OBJECTIVE

To investigate the impact of a mobile application (app) displaying a visualization of the internal anatomy of the pelvicalyceal systemPCS and of kidney stones on patient understanding of their affected kidney anatomy and their upcoming percutaneous nephrolithotripsy (PCNL).

MATERIALS AND METHODS

One-hundred patients who required PCNL were included in this study, and all patients were nonrandomly distributed into 2 groups: counseled using only 3D-reconstructed computed tomography (CT) images (group 1) or using only the "InsKid" app (group 2). Patient data were obtained from CT scans as Digital Imaging and Communications in Medicine format and converted into stereolithography (STL) format. All patients completed the questionnaire after counseling, and the results were compared between groups.

RESULTS

Patients from group 2 better understood the anatomy of their affected kidney by 53%; awareness regarding their stone location was better by 32%; the steps of planned surgery, as well as possible complications, were more transparent for patients using the app by 24% and 56%, respectively. The number of patients who were dissatisfied with the mobile counseling dropped by 70%. The average duration of consultation with the 3D reconstruction of CT images was 10.9 ± 0.6 min, while counseling using our program reliably led to a reduction in this duration (7.3 ± 0.5 min).

CONCLUSION

The InsKid app is a freely available, easy-to-use educational software that improves patient counseling without considerable financial expense or long waiting periods for use.

Role of 3D printing in surgical education for robotic urology procedures

During the past 5 years, the body of literature surrounding the utilization of three-dimensional (3D) printing in the field of urology has grown exponentially. Incentivized by work hour restrictions, patient safety initiatives, and inspired by technical advances in biomaterials and rapid printing strategies, this emerging, and fascinating area of research has begun to make headway into clinical practice. However, concerns about cost, limited understanding of the technical processes involved, and lack of its potential uses remain barriers to its widespread adoption. We examined existing published literature on how 3D printing technologies have been utilized in the field of Urology to enhance pre-operative planning, revitalize surgical training, and modernize patient education, with particular focus on, robotic surgery. To date, 3D-printed models have been used and studied most commonly in the preoperative planning for nephron-sparing surgeries during the treatment of renal masses, where the challenges of complex renal anatomy and benefits of reducing renal ischemic injury create the most intuitive value. Prostate models are the second most common, particularly in the planning of nerve-sparing procedures. Early studies have demonstrated sufficient realism and educational effectiveness. Subsequent studies demonstrated improved surgeon confidence, operative performance, and optimized patient outcomes including high levels of patient satisfaction. Realistic, accurate, and reasonably priced models can currently be generated within hours using standard desktop 3D printers. While primarily utilized as anatomic replicas of diseased organs that restore a sense of haptic feedback lost in robotic procedures, innovations in polymers, improvements in 3D printer host and modeling software, and upgrades in printer hardware allow this technology to serve as a comprehensive, interactive, simulation platform that can be a critical surgical decision making as well as an effective teaching tool. As Urologists continue to rapidly diversify and iterate upon this adaptive modality, the benefits in patient outcomes will likely outpace the diminishing drawbacks, and we may well see the next revolution in surgical education, robotic techniques, and personalized medicine concurrently.

Review of the effect of 3D medical printing and virtual reality on urology training with ‘MedTRain3DModsim’ Erasmus + European Union Project

Background/aim

It is necessary to incorporate novel training modalities in medical education, especially in surgical fields, because of the limitations of cadaveric training. Traditional medical education has many drawbacks, such as residency working hour restrictions, patient safety conflicts with the learning needs, and the lack of hands-on workshops. The MedTRain3DModsim Project aimed to produce 3-dimensional (3D) medical printed models, simulations, and innovative applications for every level of medical training using novel worldwide technologies. It was aimed herein to improve the interdisciplinary and transnational approaches, and accumulate existing experience for medical education, postgraduate studies, and specialty training.

Materials and methods

This project focused on models of solid organs and the urinary system, including the kidney, prostate, ureter, and liver. With 3D medical printing, it is possible to produce a body part from inert materials in just a few hours with the standardization of medical 3D modeling.

Results

The target groups of this project included medical students and residents, graduate students from engineering departments who needed medical education and surgical training, and medical researchers interested in health technology or clinical and surgical an atomy.

Conclusion

It was also intended to develop a novel imaging platform for education and training by reevaluating the existing data using new software and 3D modalities. Therefore, it was believed that our methodology could be implemented in all related medical fields.