Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review

Effects of the home-based exercise program with an augmented reality system on balance in patients with stroke: a randomized controlled trial

PURPOSE

To investigate the therapeutic potentials of the home-based exercise program (HEP) with an augmented reality (AR) system to improve balance in patients with stroke.

METHODS

Sixty-eight patients with stroke were recruited in this randomized controlled study with blind observer. Patients in the smart-rehab group underwent HEP with an AR system for four weeks, whereas patients in the control group underwent the written and pictorial HEP. Assessments of balance and fear of falling were performed three times: at baseline (T0), immediately (T1), and four weeks (T2) after cessation of HEP.

RESULTS

The change in balance from T0 to T1 was significantly higher in the smart-rehab group than in the control group (p < 0.017). The change in fear of falling from T0 to T1 and T2 was significantly higher in the smart-rehab group than in the control group, respectively (p < 0.017). One participant with vertebral artery dissection in the smart-rehab group discontinued participation due to a transient ischemic attack which resolved during the study period.

CONCLUSIONS

The results of this study suggest that the HEP with the AR system might be effective to improve balance in patients with stroke. However, more careful precautions for the HEP using the AR system are also required. Implications for rehabilitationBalance was modestly improved in both home-based exercise programs, slightly more in AR home exercise group.AR home-based program was significantly better in reducing fear of falling compared to the control group.No falls were recorded, however, safety for patients with arterial dissection needs to be carefully considered due to the possibility of adverse effects.

Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review

BACKGROUND

The conventional way of treating burn victims with mainstream pain control modalities is costly and has many negative side effects. In this study, the authors aim to present the findings from the major clinical trials on three nonpharmacologic interventions-hypnosis, virtual/augmented reality, and yoga-as supplements to conventional pain regimens for burn management.

METHODS

A computerized literature search was conducted of the PubMed and ClinicalTrials.gov databases in April of 2020. The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research.

RESULTS

The search yielded 254 articles from 1955 to 2020. Fifty-eight studies met the authors' inclusion criteria. Yoga reduced cognitive and somatic anxiety in burn survivors, and improved body image. Virtual reality is effective in pain reduction in both the pediatric and the adult burn population, and in faster burn wound reepithelialization. Hypnosis has similar results regarding reducing pain quality and anxiety in burn patients undergoing burn wound care and dressing changes but was not found to significantly accelerate the healing process.

CONCLUSIONS

Nonpharmacologic interventions are not a substitute for conventional analgesics; however, they could help patients have better control over their pain, greater self-esteem, and less postburn traumatic experiences. Burn care centers should consider nonpharmacologic interventions to improve patient satisfaction and their participation in the treatment and rehabilitation process.

Thermal Ablation of Liver Tumors Guided by Augmented Reality: An Initial Clinical Experience

Background: Over the last two decades, augmented reality (AR) has been used as a visualization tool in many medical fields in order to increase precision, limit the radiation dose, and decrease the variability among operators. Here, we report the first in vivo study of a novel AR system for the guidance of percutaneous interventional oncology procedures. Methods: Eight patients with 15 liver tumors (0.7−3.0 cm, mean 1.56 + 0.55) underwent percutaneous thermal ablations using AR guidance (i.e., the Endosight system). Prior to the intervention, the patients were evaluated with US and CT. The targeted nodules were segmented and three-dimensionally (3D) reconstructed from CT images, and the probe trajectory to the target was defined. The procedures were guided solely by AR, with the position of the probe tip was subsequently confirmed by conventional imaging. The primary endpoints were the targeting accuracy, the system setup time, and targeting time (i.e., from the target visualization to the correct needle insertion). The technical success was also evaluated and validated by co-registration software. Upon completion, the operators were assessed for cybersickness or other symptoms related to the use of AR. Results: Rapid system setup and procedural targeting times were noted (mean 14.3 min; 12.0−17.2 min; 4.3 min, 3.2−5.7 min, mean, respectively). The high targeting accuracy (3.4 mm; 2.6−4.2 mm, mean) was accompanied by technical success in all 15 lesions (i.e., the complete ablation of the tumor and 13/15 lesions with a >90% 5-mm periablational margin). No intra/periprocedural complications or operator cybersickness were observed. Conclusions: AR guidance is highly accurate, and allows for the confident performance of percutaneous thermal ablations.

Percutaneous Kidney Puncture with Three-dimensional Mixed-reality Hologram Guidance: From Preoperative Planning to Intraoperative Navigation

BACKGROUND

Despite technical and technological innovations, percutaneous puncture still represents the most challenging step when performing percutaneous nephrolithotomy. This maneuver is characterized by the steepest learning curve and a risk of injuring surrounding organs and kidney damage.

OBJECTIVE

To evaluate the feasibility of three-dimensional mixed reality (3D MR) holograms in establishing the access point and guiding the needle during percutaneous kidney puncture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective study included ten patients who underwent 3D MR endoscopic combined intrarenal surgery (ECIRS) for kidney stones from July 2019 to January 2020. A retrospective series of patients who underwent a standard procedure were selected for matched pair analysis.

SURGICAL PROCEDURE

For patients who underwent 3D MR ECIRS, holograms were overlapped on the real anatomy to guide the surgeon during percutaneous puncture. In the standard group, the procedures were only guided by ultrasound and fluoroscopy.

MEASUREMENTS

Differences in preoperative and postoperative patient characteristics between the groups were tested using a χ² test and a Kruskal-Wallis test for categorical and continuous variables, respectively. Results are reported as the median and interquartile range for continuous variables and as the frequency and percentage for categorical variables.

RESULTS AND LIMITATIONS

Ten patients underwent 3D MR ECIRS. In all cases, the inferior calyx was punctured correctly, as planned using the overlapping hologram. The median puncture and radiation exposure times were 27 min and 120 s, respectively. No intraoperative or major postoperative complications occurred. Matched pair analysis with the standard ECIRS group revealed a significantly shorter radiation exposure time for the 3D MR group (p < 0.001) even though the puncture time was longer in comparison to the standard group (p < 0.001). Finally, use of 3D MR led to a higher success rate for renal puncture at the first attempt (100% vs 50%; p = 0.032). The main limitations of the study are the small sample size and manual overlapping of the rigid hologram models.

CONCLUSIONS

Our experience demonstrates that 3D MR guidance for renal puncture is feasible and safe. The procedure proved to be effective, with the inferior calyx correctly punctured in all cases, and was associated with a low intraoperative radiation exposure time because of the MR guidance.

PATIENT SUMMARY

Three-dimensional virtual models visualized as holograms and intraoperatively overlapped on the patient's real anatomy seem to be a valid new tool for guiding puncture of the kidney through the skin for minimally invasive treatment.

Augmented reality technology in image-guided therapy: State-of-the-art review

Image-guided therapies have been on the rise in recent years as they can achieve higher accuracy and are less invasive than traditional methods. By combining augmented reality technology with image-guided therapy, more organs, and tissues can be observed by surgeons to improve surgical accuracy. In this review, 233 publications (dated from 2015 to 2020) on the design and application of augmented reality-based systems for image-guided therapy, including both research prototypes and commercial products, were considered for review. Based on their functions and applications. Sixteen studies were selected. The engineering specifications and applications were analyzed and summarized for each study. Finally, future directions and existing challenges in the field were summarized and discussed.

Automatically Addressing System for Ultrasound-Guided Renal Biopsy Training Based on Augmented Reality

Chronic kidney disease has become one of the diseases with the highest morbidity and mortality in kidney diseases, and there are still some problems in surgery. During the operation, the surgeon can only operate on two-dimensional ultrasound images and cannot determine the spatial position relationship between the lesion and the medical puncture needle in real-time. The average number of punctures per patient will reach 3 to 4, Increasing the incidence of complications after a puncture. This article starts with ultrasound-guided renal biopsy navigation training, optimizes puncture path planning, and puncture training assistance. The augmented reality technology, combined with renal puncture surgery training was studied. This paper develops a prototype ultrasound-guided renal biopsy surgery training system, which improves the accuracy and reliability of the system training. The system is compared with the VR training system. The results show that the augmented reality training platform is more suitable as a surgical training platform. Because it takes a short time and has a good training effect.

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.

Laparoscopic augmented reality registration for oncological resection site repair

PURPOSE

Resection site repair during laparoscopic oncological surgery (e.g. laparoscopic partial nephrectomy) poses some unique challenges and opportunities for augmented reality (AR) navigation support. This work introduces an AR registration workflow that addresses the time pressure that is present during resection site repair.

METHODS

We propose a two-step registration process: the AR content is registered as accurately as possible prior to the tumour resection (the primary registration). This accurate registration is used to apply artificial fiducials to the physical organ and the virtual model. After the resection, these fiducials can be used for rapid re-registration (the secondary registration). We tested this pipeline in a simulated-use study with [Formula: see text] participants. We compared the registration accuracy and speed for our method and for landmark-based registration as a reference.

RESULTS

Acquisition of and, thereby, registration with the artificial fiducials were significantly faster than the initial use of anatomical landmarks. Our method also had a trend to be more accurate in cases in which the primary registration was successful. The accuracy loss between the elaborate primary registration and the rapid secondary registration could be quantified with a mean target registration error increase of 2.35 mm.

CONCLUSION

This work introduces a registration pipeline for AR navigation support during laparoscopic resection site repair and provides a successful proof-of-concept evaluation thereof. Our results indicate that the concept is better suited than landmark-based registration during this phase, but further work is required to demonstrate clinical suitability and applicability.

A Scoping Review on Virtual Reality-Based Industrial Training

The fourth industrial revolution has forced most companies to technologically evolve, applying new digital tools, so that their workers can have the necessary skills to face changing work environments. This article presents a scoping review of the literature on virtual reality-based training systems. The methodology consisted of four steps, which pose research questions, document search, paper selection, and data extraction. From a total of 350 peer-reviewed database articles, such as SpringerLink, IEEEXplore, MDPI, Scopus, and ACM, 44 were eventually chosen, mostly using the virtual reality haptic glasses and controls from Oculus Rift and HTC VIVE. It was concluded that, among the advantages of using this digital tool in the industry, is the commitment, speed, measurability, preservation of the integrity of the workers, customization, and cost reduction. Even though several research gaps were found, virtual reality is presented as a present and future alternative for the efficient training of human resources in the industrial field.

Augmented and Mixed Reality: Technologies for Enhancing the Future of IR

Augmented and mixed reality are emerging interactive and display technologies. These technologies are able to merge virtual objects, in either 2 or 3 dimensions, with the real world. Image guidance is the cornerstone of interventional radiology. With augmented or mixed reality, medical imaging can be more readily accessible or displayed in actual 3-dimensional space during procedures to enhance guidance, at times when this information is most needed. In this review, the current state of these technologies is addressed followed by a fundamental overview of their inner workings and challenges with 3-dimensional visualization. Finally, current and potential future applications in interventional radiology are highlighted.

Three-dimensional Augmented Reality Robot-assisted Partial Nephrectomy in Case of Complex Tumours (PADUA ≥10): A New Intraoperative Tool Overcoming the Ultrasound Guidance

BACKGROUND

Despite technical improvements introduced with robotic surgery, management of complex tumours (PADUA score ≥10) is still a matter of debate within the field of transperitoneal robot-assisted partial nephrectomy (RAPN).

OBJECTIVE

To evaluate the accuracy of our three-dimensional (3D) static and elastic augmented reality (AR) systems based on hyperaccuracy models (HA3D) in identifying tumours and intrarenal structures during transperitoneal RAPN (AR-RAPN), compared with standard ultrasound (US).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted, including 91 patients who underwent RAPN for complex renal tumours, 48 with 3D AR guidance and 43 with 2D US guidance, from July 2017 to May 2019.

SURGICAL PROCEDURE

In patients who underwent 3D AR-RAPN, virtual image overlapping guided the surgeon during resection and suture phases. In the 2D US group, interventions were driven by US only.

MEASUREMENTS

Patient characteristics were tested using the Fisher's exact test for categorical variables and the Mann-Whitney test for continuous ones. Intraoperative, postoperative, and surgical outcomes were collected. All results for continuous variables were expressed as medians (range), and frequencies and proportions were reported as percentages.

RESULTS AND LIMITATIONS

The use of 3D AR guidance makes it possible to correctly identify the lesion and intraparenchymal structures with a more accurate 3D perception of the location and the nature of the different structures relative to the standard 2D US guidance. This translates to a lower rate of global ischaemia (45.8% in the 3D group vs 69.7% in the US group; p = 0.03), higher rate of enucleation (62.5% vs 37.5% in the 3D and US groups, respectively; p = 0.02), and lower rate of collecting system violation (10.4% vs 45.5%; p = 0.003). Postoperatively, 3D AR guidance use correlates to a low risk of surgery-related complications in 3D AR groups and a lower drop in estimated renal plasma flow at renal scan at 3 mo of follow-up (-12.38 in the 3D group vs -18.14 in the US group; p = 0.01). The main limitations of this study are short follow-up time and small sample size.

CONCLUSIONS

HA3D models that overlap in vivo anatomy during AR-RAPN for complex tumours can be useful for identifying the lesion and intraparenchymal structures that are difficult to visualise with US only. This translates to a potential improvement in the quality of the resection phase and a reduction in postoperative complications, with better functional recovery.

PATIENT SUMMARY

Based on our findings, three-dimensional augmented reality robot-assisted partial nephrectomy seems to help surgeons in the management of complex renal tumours, with potential early postoperative benefits.

How well do software assistants for minimally invasive partial nephrectomy meet surgeon information needs? A cognitive task analysis and literature review study

INTRODUCTION

Intraoperative software assistance is gaining increasing importance in laparoscopic and robot-assisted surgery. Within the user-centred development process of such systems, the first question to be asked is: What information does the surgeon need and when does he or she need it? In this article, we present an approach to investigate these surgeon information needs for minimally invasive partial nephrectomy and compare these needs to the relevant surgical computer assistance literature.

MATERIALS AND METHODS

First, we conducted a literature-based hierarchical task analysis of the surgical procedure. This task analysis was taken as a basis for a qualitative in-depth interview study with nine experienced surgical urologists. The study employed a cognitive task analysis method to elicit surgeons' information needs during minimally invasive partial nephrectomy. Finally, a systematic literature search was conducted to review proposed software assistance solutions for minimally invasive partial nephrectomy. The review focused on what information the solutions present to the surgeon and what phase of the surgery they aim to support.

RESULTS

The task analysis yielded a workflow description for minimally invasive partial nephrectomy. During the subsequent interview study, we identified three challenging phases of the procedure, which may particularly benefit from software assistance. These phases are I. Hilar and vascular management, II. Tumour excision, and III. Repair of the renal defects. Between these phases, 25 individual challenges were found which define the surgeon information needs. The literature review identified 34 relevant publications, all of which aim to support the surgeon in hilar and vascular management (phase I) or tumour excision (phase II).

CONCLUSION

The work presented in this article identified unmet surgeon information needs in minimally invasive partial nephrectomy. Namely, our results suggest that future solutions should address the repair of renal defects (phase III) or put more focus on the renal collecting system as a critical anatomical structure.