Image-Guided Robotics for Standardized and Automated Biopsy and Ablation

Fusion Technologies for Image-Guided Robotic Interventions

An image guided robot only becomes fully useful with integrated software leveraging image fusion. Image fusion is the process of registering and superimposing imaging data in the same coordinate space and can be helpful to image-guided robotic interventions. Effective percutaneous robotic procedures can utilize real-time image guidance and navigation which are powered by fusion technologies. By integrating information from multiple imaging modalities, fusion technologies provide insights into anatomic features and procedural targets that may not be apparent through traditional positional tracking or single-modality imaging. Current robots available for interventions highlight different approaches to utilizing real-time fusion and procedure planning. As robotics become increasingly integrated into interventional radiology clinical practice, the continued innovation and adoption of fusion-based approaches will enable more seamless use of this technology, offering the potential for improved safety, standardization, and clinical efficacy. This review explores key techniques in image fusion and highlights the integration of fusion and robotics towards the goal of optimized and automated interventional procedures.

Image Guided Percutaneous Robotic Interventions for Solid Organs

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

Components of Robotic Systems in Image-Guided Percutaneous Interventions

The field of interventional radiology is facing a growing demand for percutaneous procedures targeting smaller and more complex lesions. Percutaneous medical robots have proven to increase efficiency and accuracy and can address these issues. This review is intended to provide an overview of the functionality and components of these robotic systems for operators learning to use them. We begin by discussing the functions of robots in percutaneous interventions and how they operate. After this discussion, greater focus is then placed on the technical components of robots which help achieve these functions.

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

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

Perioperative, functional and oncologic outcomes of percutaneous ablation versus minimally invasive partial nephrectomy for clinical T1 renal tumors: outcomes from a pooled analysis

The objective of this study was to perform a comprehensive pooled analysis aimed at comparing the efficacy and safety of percutaneous ablation (PCA) versus minimally invasive partial nephrectomy (MIPN), including robotic and laparoscopic approaches, in patients diagnosed with cT1 renal tumors. We conducted a comprehensive search across four major electronic databases: PubMed, Embase, Web of Science, and the Cochrane Library, targeting studies published in English up to April 2024. The primary outcomes evaluated in this analysis included perioperative outcomes, functional outcomes, and oncological outcomes. A total of 2449 patients across 17 studies were included in the analysis. PCA demonstrated superior outcomes compared to MIPN in terms of shorter hospital stays (WMD: - 2.13 days; 95% Confidence Interval [CI]: - 3.29, - 0.97; p = 0.0003), reduced operative times (WMD: - 109.99 min; 95% CI: - 141.40, - 78.59; p < 0.00001), and lower overall complication rates (OR: 0.54; 95% CI: 0.40, 0.74; p = 0.0001). However, PCA was associated with a higher rate of local recurrence when compared to MIPN (OR: 3.81; 95% CI: 2.45, 5.92; p < 0.00001). Additionally, no significant differences were observed in major complications, estimated glomerular filtration rate decline, creatinine variation, overall survival, recurrence-free survival, and disease-free survival between the two treatment modalities. PCA presents a notable disadvantage regarding local recurrence rates in comparison to MIPN. However, PCA offers several advantages over MIPN, including shorter durations of hospital stay, reduced operative times, and lower complication rates, while achieving similar outcomes in other oncologic metrics.

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.

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.

Percutaneous tumor ablation versus image guided robotic-assisted partial nephrectomy for cT1b renal cell carcinoma: a comparative matched-pair analysis (UroCCR 80)

BACKGROUND

Partial nephrectomy (PN) is the gold standard treatment for cT1b renal tumors. Percutaneous guided thermal ablation (TA) has proven oncologic efficacy with low morbidity for the treatment of small renal masses (<3 cm). Recently, 3D image-guided robot-assisted PN (3D-IGRAPN) has been described, and decreased perioperative morbidity compared to standard RAPN has been reported. Our objective was to compare two minimally invasive image-guided nephron-sparing procedures (TA vs. 3D-IGRAPN) for the treatment of cT1b renal cell carcinomas (4.1-7 cm).

METHODS

Patients treated with TA and 3D-IGRAPN for cT1b renal cell carcinoma, prospectively included in the UroCCR database (NCT03293563), were pair-matched for tumor size, pathology, and RENAL score. The primary endpoint was the local recurrence rate between the two groups. Secondary endpoints included metastatic evolution, perioperative complications, decrease in renal function, and length of hospitalization.

RESULTS

A total of 198 patients were included and matched into two groups of 72 patients. The local recurrence rate was significantly higher in the TA group than that in the 3D-IGRAPN group (4.2% vs. 15.2%, P=0.04). Metastatic evolution and perioperative outcomes such as major complications, eGFR decrease, and length of hospitalization did not differ significantly between the two groups.

CONCLUSIONS

3D-IGRAPN resulted in a significantly lower local recurrence rate and comparable rates of complications and metastatic evolution compared with thermal ablation.

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.