Patient-specific 3D printed and augmented reality kidney and prostate cancer models: impact on patient education

Clinical validation of 3D virtual modelling for laparoscopic complete mesocolic excision with central vascular ligation for proximal colon cancer

INTRODUCTION

Laparoscopic Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) in colon cancer surgery has not been broadly adopted in part because of safety concerns. Pre-operative 3-D virtual modelling (3DVM) may help but needs validation.

METHODS

3DVM were routinely constructed from CT mesenteric angiograms (CTMA) using a commercial service (Visible Patient, Strasbourg, France) for consecutive patients during our CMECVL learning curve over three years. 3DVMs were independently checked versus CTMA and operative findings. CMECVL outcomes were compared versus other patients undergoing standard mesocolic excision (SME) surgery laparoscopically in the same hospital as control. Stakeholders were studied regarding 3DVM use and usefulness (including detail retention) versus CTMA and a physical 3D-printed model.

RESULTS

26 patients underwent 3DVM with intraoperative display during laparoscopic CMECVL within existing workflows. 3DVM accuracy was 96 % re arteriovenous variations at patient level versus CTMA/intraoperative findings including accessory middle colic artery identification in three patients. Twenty-two laparoscopic CMECVL with 3DVM cases were compared with 49 SME controls (age 69 ± 10 vs 70.9 ± 11 years, 55 % vs 53 % males). There were no intraoperative complications with CMECVL and similar 30-day postoperative morbidity (30 % vs 29 %), hospital stay (9 ± 3 vs 12 ± 13 days), 30-day readmission (6 % vs 4 %) and reoperation (0 % vs 4 %) rates. Intraoperative times were longer (215.7 ± 43.9 vs 156.9 ± 52.9 min, p=<0.01) but decreased significantly over time. 3DVM surveys (n = 98, 20 surgeons, 48 medical students, 30 patients/patient relatives) and comparative study revealed majority endorsement (90 %) and favour (87 %).

CONCLUSION

3DVM use was positively validated for laparoscopic CMECVL and valued by clinicians, students, and patients alike.

Advances in tumor microenvironment: Applications and challenges of 3D bioprinting

The tumor microenvironment (TME) assumes a pivotal role in the treatment of oncological diseases, given its intricate interplay of diverse cellular components and extracellular matrices. This dynamic ecosystem poses a serious challenge to traditional research methods in many ways, such as high research costs, inefficient translation, poor reproducibility, and low modeling success rates. These challenges require the search for more suitable research methods to accurately model the TME, and the emergence of 3D bioprinting technology is transformative and an important complement to these traditional methods to precisely control the distribution of cells, biomolecules, and matrix scaffolds within the TME. Leveraging digital design, the technology enables personalized studies with high precision, providing essential experimental flexibility. Serving as a critical bridge between in vitro and in vivo studies, 3D bioprinting facilitates the realistic 3D culturing of cancer cells. This comprehensive article delves into cutting-edge developments in 3D bioprinting, encompassing diverse methodologies, biomaterial choices, and various 3D tumor models. Exploration of current challenges, including limited biomaterial options, printing accuracy constraints, low reproducibility, and ethical considerations, contributes to a nuanced understanding. Despite these challenges, the technology holds immense potential for simulating tumor tissues, propelling personalized medicine, and constructing high-resolution organ models, marking a transformative trajectory in oncological research.

Virtual Reality as an Adjunct to Traditional Patient Counseling in Patients With Newly Diagnosed Localized Prostate Cancer

OBJECTIVE

To determine the utility of a virtual reality (VR) model constructed using patient-derived clinical imaging to improve patient understanding of localized prostate cancer (PCa) diagnosis and surgical plan.

METHODS

Patients undergoing robotic radical prostatectomy were selected and demographic data recorded. Patients completed a questionnaire to assess baseline knowledge of their diagnosis after consultation and shared-decision making with their surgeon. A trained non-clinical staff member then guided the patient through a VR experience to view patient-specific anatomy in a 3-dimensional space. Patients then completed the same questionnaire, followed by an additional post-VR questionnaire evaluating patient satisfaction. Questions 1-7 (patient understanding of prostate cancer and treatment plan) and 11-17 (patient opinion of VR) used a standard Likert scale and Questions 8-10 were multiple choice with 1 correct answer.

RESULTS

In total, 15 patients were included with an average age of 64.1 years. 6 of 7 questions showed an improvement after VR (P <.001). The percentage of correct responses on Questions 8-10 was higher after VR but not statistically significant (P >.13). Mean responses range from 4.3 to 4.8 (Likert scale, 1 through 5) for the post-VR questionnaire, with a mean total of 31.9 out of 35.

CONCLUSION

This small preliminary investigation of a novel technology to improve the patient experience showed potential as an adjunct to traditional patient counseling. However, due the small sample size and study design, further research is needed to determine the value VR adds to prostate cancer surgical counseling.

Intraoperative margin assessment with near real time pathology during partial gland ablation of prostate cancer: A feasibility study

BACKGROUND

In-field or in-margin recurrence after partial gland cryosurgical ablation (PGCA) of prostate cancer (PCa) remains a limitation of the paradigm. Stimulated Raman histology (SRH) is a novel microscopic technique allowing real time, label-free, high-resolution microscopic images of unprocessed, un-sectioned tissue which can be interpreted by humans or artificial intelligence (AI). We evaluated surgical team and AI interpretation of SRH for real-time pathologic feedback in the planning and treatment of PCa with PGCA.

METHODS

About 12 participants underwent prostate mapping biopsies during PGCA of their PCa between January and June 2022. Prostate biopsies were immediately scanned in a SRH microscope at 20 microns depth using 2 Raman shifts to create SRH images which were interpreted by the surgical team intraoperatively to guide PGCA, and retrospectively assessed by AI. The cores were then processed, hematoxylin and eosin stained as per normal pathologic protocols and used for ground truth pathologic assessment.

RESULTS

Surgical team interpretation of SRH intraoperatively revealed 98.1% accuracy, 100% sensitivity, 97.3% specificity for identification of PCa, while AI showed a 97.9% accuracy, 100% sensitivity and 97.5% specificity for identification of clinically significant PCa. 3 participants' PGCA treatments were modified after SRH visualized PCa adjacent to an expected MRI predicted tumor margin or at an untreated cryosurgical margin.

CONCLUSION

SRH allows for accurate rapid identification of PCa in PB by a surgical team interpretation or AI. PCa tumor mapping and margin assessment during PGCA appears to be feasible and accurate. Further studies evaluating impact on clinical outcomes are warranted.

Clinical applications of 3D printing in colorectal surgery: A systematic review

BACKGROUND

The utilization of three-dimensional printing has grown rapidly within the field of surgery over recent years. Within the subspecialty of colorectal surgery, the technology has been used to create personalized anatomical models for preoperative planning, models for surgical training, and occasionally customized implantable devices and surgical instruments. We aim to provide a systematic review of the current literature discussing clinical applications of three-dimensional printing in colorectal surgery.

METHODS

Full-text studies published in English which described the application of 3D printing in pre-surgical planning, advanced surgical planning, and patient education within the field of colorectal surgery were included. Exclusion criteria were duplicate articles, review papers, studies exclusively dealing with surgical training and/or education, studies which used only virtual models, and studies which described colorectal cancer only as it pertained to other organs.

RESULTS

Eighteen studies were included in this review. There were two randomized controlled trials, one retrospective outcomes study, five case reports/series, one animal model, and nine technical notes/feasibility studies. There were three studies on advanced surgical planning/device manufacturing, six on pre-surgical planning, two on pelvic anatomy modeling, eight on various types of anatomy modeling, and one on patient education.

CONCLUSIONS

While more studies with a higher level of evidence are needed, the findings of this review suggest many promising applications of three-dimensional printing within the field of colorectal surgery with the potential to improve patient outcomes and experiences.

Development of a flexible liver phantom for hepatocellular carcinoma treatment planning: a useful tool for training & education

PURPOSE

Hepatocellular carcinoma (HCC) is one of the most common types of liver cancer that could potentially be surrounded by healthy arteries or veins that a surgeon would have to avoid during treatment. A realistic 3D liver model is an unmet need for HCC preoperative planning.

METHODS

This paper presents a method to create a soft phantom model of the human liver with the help of a 3D-printed mold, silicone, ballistic gel, and a blender.

RESULTS

For silicone, the elastic modulus of seven different ratios of base silicone and silicone hardener are tested; while for ballistic gel, a model using 20% gelatin and 10% gelatin is created for the tumor and the rest of the liver, respectively. It is found that the silicone modulus of elasticity matches with the real liver modulus of elasticity. It is also found that the 10% gelatin part of the ballistic gel model is an excellent emulation of a healthy human liver.

CONCLUSION

The 3D flexible liver phantom made from a 10% gelatin-to-water mixture demonstrates decent fidelity to real liver tissue in terms of texture and elasticity. It holds significant potential for improving medical training, preoperative planning, and surgical research. We believe that continued development and validation of such models could further enhance their utility and impact in the field of hepatobiliary treatment planning and education.

3D Reconstruction and Virtual Reality Is an Acceptable and Feasible Method for Addressing Body Image in Bariatric Metabolic Surgery

BACKGROUND

Patients living with obesity continue to experience body image dissatisfaction following bariatric metabolic surgery. The underlying reasons are poorly understood but may be due to unmet expectations. Negative body image perception following metabolic surgery leads to poorer psychological and clinical outcomes. This study aims to establish the acceptability and feasibility of three-dimensional (3D) reconstruction and virtual reality (VR) as a method of providing psychological support to bariatric patients to improve body image satisfaction and interventional outcomes.

METHODS

Seven participants were recruited from the Imperial Weight Centre. 3D photographs were captured and processed to produce two 3D reconstructed images with 15% and 25% total weight loss. Participants were shown their images using VR and participated in peer group workshops.

RESULTS

Six participants were retained until the end of the study. Five out of six participants agreed the images provided them with a more accurate representation of their body changes and overall appearance following bariatric metabolic surgery. All participants strongly agreed with the group setting and felt VR facilitated discussions on body image. Overall, all participants felt that the use of VR and 3D reconstruction is beneficial in supporting patients to adjust to changes in their body image after bariatric metabolic surgery.

CONCLUSIONS

This is the first study to explore and demonstrate that 3D reconstruction and VR is an acceptable and feasible method providing patients with a realistic expectation of how their body will change following significant weight loss, potentially improving body image satisfaction after surgery, as well as psychological and interventional outcomes.

The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri

OBJECTIVES

To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging.

METHODS

3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models.

RESULTS

Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference.

CONCLUSIONS

Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

Role of patient specific 3D printed models in patient confidence, understanding and satisfaction of care in Singapore

Introduction

Patient specific 3D models have been widely used for pre-op planning and intra-op guidance in orthopaedic surgery. These models however are not often used in pre-operative doctor-patient communication. This study evaluates the roles of customized 3D models in improving patient understanding, confidence, and satisfaction of patient care when they were used during preoperative counselling.

Materials and methods

A prospective survey was conducted on 33 orthopaedic trauma patients who were required to rate on a scale of 1-5, the effectiveness of patient specific 3D models in: 1) improving patient's understanding and, 2) helping patients cope with the condition, 3) boosting patients' confidence in the treatment and 4) in the surgeon; and on a scale of 0-10, their overall satisfaction. Subgroup analysis was done to compare ratings of patients by age and by education levels.

Results

Over 90% patients rated agree or strongly agree on customised 3D models' effectiveness in improving understanding of injury and boosting confidence in treatments and surgeons. 87% patients agreed or strongly agreed that the models enhanced patient self-efficacy. No significant correlation was identified between age and patients' perceived effectiveness of customised 3D models in improving patient care. Ratings on four areas evaluated by pre-secondary and post-secondary groups were comparable. Post-secondary group had significantly higher satisfaction level than the pre-secondary group.

Conclusion

Customized 3D models help patients visualise complex pathology to facilitate patients' understanding of their condition and treatment, resulting in improved self-efficacy, confidence, and overall satisfaction. The use of patient specific 3D models in pre-operative counselling allows greater patient involvement therefore prompting patient-centred healthcare. Age does not influence patients' perceived effectiveness of customised 3D models in improving patient care. Patients with higher education level are likely to experience higher satisfaction level due to their willingness to take responsibility for their care.

3D printing: a useful tool for safe clinical practice in children with complex vasculature

BACKGROUND

3D printing has been used in different medical contexts, although it is underutilised in paediatrics. We present the first use of 3D printing in the management of three paediatric patients with complex renovascular disease.

METHODS

Patient-specific 3D models were produced from conventional 2D imaging and manufactured using 3D polyjet printing technology. All three patients had different underlying pathologies, but all underwent multiple endovascular interventions (renal artery balloon angioplasty) prior to 3D printing and subsequent vascular surgery. The models were verified by an expert radiologist and then presented to the multidisciplinary team to aid with surgical planning.

RESULTS

Following evaluation of the 3D-printed models, all patients underwent successful uni/bilateral renal auto-transplants and aortic bypass surgery. The 3D models allowed more detailed preoperative discussions and more focused planning of surgical approach, therefore enhancing safer surgical planning. It influenced clinical decision-making and shortened general anaesthetic time. The families and the patients reported that they had a significantly improved understanding of the patient's condition and had more confidence in understanding proposed surgical intervention, thereby contributing to obtaining good-quality informed consent.

CONCLUSION

3D printing has a great potential to improve both surgical safety and decision-making as well as patient understanding in the field of paediatrics and may be considered in wider surgical areas.

Holography-guided procedural planning for modifying Venus P-valve implantation technique in patients with left pulmonary artery stents: a case-series

Background

Venus P-valve™ (Venus Medtech, Hangzhou, China) is a self-expandable bioprosthetic valve that can be transcatheter-implanted in native right ventricular outflow tract (RVOT) patients. Valve implantation is technically challenging. Due to the implantation technique, left pulmonary artery (LPA) stents represent a relative contraindication to Venus P-valve. In this case series, we describe our experience in implanting Venus P-valve in patients with previous LPA stents and the use of holographic models to facilitate procedural planning.

Methods and results

From January to October 2023, 17 patients were scheduled for Venus P-Valve implantation. 16/17 (94%) patients were successfully implanted. 3/16 (18.7%) patients underwent Venus P-valve implantation with LPA stents. All patients underwent pre-operative CT scan. CT data set were employed to create three-dimensional (3D) holographic models (Artiness, Milan, Italy) of the entire heart, which were useful to plan valve implantation with a modified technique. Procedural success rate was 100%. No procedural complications occurred. All three patients presented good haemodynamic and angiographic results at discharge and follow-up visits.

Conclusion

This case-series underscores the feasibility of Venus P-valve implantation in patients with previous LPA stents. The use of holographic models facilitated procedural planning in these challenging anatomical scenarios.

Exploring methods of improving patient understanding and communication in a complex anal fistula clinic: results from a randomized controlled feasibility study

AIM

Patient understanding of disease can guide decision-making in the management of anal fistula. This prospective feasibility study aimed to assess the acceptability and methods of assessing the impact of viewing realistic models on patients with anal fistula.

METHODS

New referrals to a tertiary clinic participated in this single-centre, parallel-group randomized controlled study. Baseline characteristics, Decisional Conflict Scale and understanding of disease were assessed pre-consultation. Participants were randomized to a standard consultation, where disease and treatment options were explained using magnetic resonance images and drawn diagrams, or a similar consultation supplemented with an appropriate generic three-dimensional (3D) printed model. Understanding of disease and proposed surgery, Decisional Conflict Scale and ratings of visual aids were assessed post-consultation, along with 3D model feedback.

RESULTS

All 52 patients who were approached agreed to be randomized (25 standard, 27 3D consultation). Understanding of disease increased post-consultation in both groups. Post-consultation decisional conflict (0, no; 100, high decisional conflict) was low (median 27 post-standard vs. 24 post-3D consultation). Patients scored highly on measures assessing understanding of proposed surgery. 3D models were rated highly, with 96% of patients wanting to see them again in future consultations.

CONCLUSIONS

Three-dimensional printed fistula models are a welcome addition to outpatient consultations with results suggesting that understanding of surgery is improved. A future trial should be powered to detect whether 3D models result in a significant improvement in understanding beyond traditional methods of explanation and explore the conditions in which models have their maximal utility.

CLINICALTRIALS

GOV REGISTRATION ID

This study was registered on ClinicalTrials.gov (ID: NCT04069728). Registered on 23 August 2019.

A new training model using the self-healing properties of supramolecular hydrogels for endoscopic combined intrarenal surgery

The combination of hydronephrosis formation, ureteroscopic imaging, and ultrasound delineation has not been included in any non-biological training model of percutaneous nephrolithotomy or endoscopic combined intrarenal surgery. We aimed to develop a realistic kidney phantom using the self-healing properties of supramolecular hydrogels for percutaneous nephrolithotomy and endoscopic combined intrarenal surgery and evaluate its suitability as a training model.Expert and resident urologists performed ultrasound-guided renal pelvic punctures and flexible ureteroscopies for endoscopic combined intrarenal surgery using a training model. Subsequently, the training model was evaluated using a 17-item Likert scale questionnaire (range, 1-5 points). After being filled with carrageenan, the collecting system was inflated, and the relationship between the collecting system volume and collecting system pressure was determined. The durability of the model was verified by repeatedly inserting a 16-Fr access sheath. Five novices and seven urology experts performed the procedure. The mean questionnaire score was 4.25 (standard deviation, 0.37). The model was able to hold 50 mL of air, and the pressure in the collecting system ranged from 6 to 33 mmHg. Repeated punctures were possible even when a 16-Fr access sheath was inserted. Our new training model included the self-healing properties of supramolecular hydrogels, which are tough and flexible and can be evaluated using ultrasonography. According to the questionnaire score, the model was highly satisfactory and has potential as a new educational tool.

Virtual Reality for Patient Education about Hypertension: A Randomized Pilot Study

BACKGROUND

Hypertension challenges arise in part from poor adherence due to inadequate patient education. VR offers immersive learning to improve hypertension knowledge.

OBJECTIVE

To compare VR education with traditional verbal education to improve hypertension knowledge.

METHODS

In this randomised trial, 182 patients with hypertension were assigned to receive either traditional physician-led education (n = 88) or VR education (n = 94) with equivalent content. The VR group experienced a 3D video using Oculus Quest 2 headsets. Knowledge was assessed post-intervention using a 29-item questionnaire. The primary outcome was the objective score. Subjective satisfaction and responder characteristics were secondary outcomes.

RESULTS

Median objective scores were significantly higher for VR (14, IQR 3) versus traditional education (10, IQR 5), p < 0.001, indicating superior hypertension knowledge acquisition with VR. Subjective satisfaction was high in both groups. Participants were categorized into low (first quartile) and medium-high (second to fourth quartiles) responders based on their scores. Low responders had a significantly higher prevalence of older women than medium-high responders (57% vs. 40% female, p = 0.024; 68 vs. 65 years), p = 0.036).

CONCLUSIONS

VR outperforms traditional education. Tailoring to groups such as older women can optimise learning.

The Influence of Individualized Three-Dimensional Holographic Models on Patients' Knowledge Qualified for Intervention in the Treatment of Peripheral Arterial Disease (PAD)

We sought to determine the role of the patient-specific, three-dimensional (3D) holographic vascular model in patient medical knowledge and its influence on obtaining a more conscious informed consent process for percutaneous balloon angioplasty (PTA). Patients with peripheral arterial disease who had been scheduled for PTA were enrolled in the study. Information regarding the primary disease, planned procedure, and informed consent was recorded in typical fashion. Subsequently, the disease and procedure details were presented to the patient, showing the patients their individual model. A patient and medical supervisor equipped with mixed reality headsets could both simultaneously manipulate the hologram using gestures. The holographic 3D model had been created on a scale of 1:1 based on computed tomography scans. The patient's knowledge was tested by the completion of a questionnaire before and after the interaction in a mixed reality environment. Seventy-nine patients manipulated arterial holograms in mixed reality head-mounted devices. Before the 3D holographic artery model interaction, the mean ± standard deviation score of the knowledge test was 2.95 ± 1.21 points. After the presentation, the score had increased to 4.39 ± 0.82, with a statistically significant difference (p = 0.0000) between the two scores. Using a Likert scale from 1 to 5, the patients had scored the use of the 3D holographic model at 3.90 points regarding its usefulness in comprehending their medical condition; at 4.04 points regarding the evaluation of the holograms as helpful in understanding the course of surgery; and rated the model at 1.99 points in reducing procedure-related stress. Using a nominal scale (know or don't know), the patients had self-assessed their knowledge of the procedure before and after the 3D model presentation, with a score of 6.29 ± 2.01 and 8.39 ± 1.54, respectively. The study group tolerated the use of head-mounted devices. Only one patient had nausea and dizziness, while four patients experienced transient eye pain. The 3D holographic arterial model aided in the understanding of patients' knowledge regarding the disease and procedure, making the informed consent process more conscious. The holograms improved the patient's self-consciousness. Mixed reality headset-related complications were rare and within acceptable rates.

Assessment of Staphylococcus Aureus growth on biocompatible 3D printed materials

The customizability of 3D printing allows for the manufacturing of personalized medical devices such as laryngectomy tubes, but it is vital to establish the biocompatibility of printing materials to ensure that they are safe and durable. The goal of this study was to assess the presence of S. aureus biofilms on a variety of 3D printed materials (two surgical guide resins, a photopolymer, an elastomer, and a thermoplastic elastomer filament) as compared to standard, commercially available laryngectomy tubes.C-shaped discs (15 mm in height, 20 mm in diameter, and 3 mm in thickness) were printed with five different biocompatible 3D printing materials and S. aureus growth was compared to Shiley™ laryngectomy tubes made from polyvinyl chloride. Discs of each material were inoculated with S. aureus cultures and incubated overnight. All materials were then removed from solution, washed in phosphate-buffered saline to remove planktonic bacteria, and sonicated to detach biofilms. Some solution from each disc was plated and colony-forming units were manually counted the following day. The resulting data was analyzed using a Kruskal-Wallis and Wilcoxon Rank Sum test to determine pairwise significance between the laryngectomy tube material and the 3D printed materials.The Shiley™ tube grew a median of 320 colonies (IQR 140-520), one surgical guide resin grew a median of 640 colonies (IQR 356-920), the photopolymer grew a median of 340 colonies (IQR 95.5-739), the other surgical guide resin grew a median of 431 colonies (IQR 266.5-735), the thermoplastic elastomer filament grew a median of 188 colonies (IQR 113.5-335), and the elastomer grew a median of 478 colonies (IQR 271-630). Using the Wilcoxon Rank Sum test, manual quantification showed a significant difference between biofilm formation only between the Shiley™ tube and a surgical guide resin (p = 0.018).This preliminary study demonstrates that bacterial colonization was comparable among most 3D printed materials as compared to the conventionally manufactured device. Continuation of this work with increased replicates will be necessary to determine which 3D printing materials optimally resist biofilm formation.

Deep-Learning Models for Detection and Localization of Visible Clinically Significant Prostate Cancer on Multi-Parametric MRI

BACKGROUND

Deep learning for diagnosing clinically significant prostate cancer (csPCa) is feasible but needs further evaluation in patients with prostate-specific antigen (PSA) levels of 4-10 ng/mL.

PURPOSE

To explore diffusion-weighted imaging (DWI), alone and in combination with T2-weighted imaging (T2WI), for deep-learning-based models to detect and localize visible csPCa.

STUDY TYPE

Retrospective.

POPULATION

One thousand six hundred twenty-eight patients with systematic and cognitive-targeted biopsy-confirmation (1007 csPCa, 621 non-csPCa) were divided into model development (N = 1428) and hold-out test (N = 200) datasets.

FIELD STRENGTH/SEQUENCE

DWI with diffusion-weighted single-shot gradient echo planar imaging sequence and T2WI with T2-weighted fast spin echo sequence at 3.0-T and 1.5-T.

ASSESSMENT

The ground truth of csPCa was annotated by two radiologists in consensus. A diffusion model, DWI and apparent diffusion coefficient (ADC) as input, and a biparametric model (DWI, ADC, and T2WI as input) were trained based on U-Net. Three radiologists provided the PI-RADS (version 2.1) assessment. The performances were determined at the lesion, location, and the patient level.

STATISTICAL TESTS

The performance was evaluated using the areas under the ROC curves (AUCs), sensitivity, specificity, and accuracy. A P value <0.05 was considered statistically significant.

RESULTS

The lesion-level sensitivities of the diffusion model, the biparametric model, and the PI-RADS assessment were 89.0%, 85.3%, and 90.8% (P = 0.289-0.754). At the patient level, the diffusion model had significantly higher sensitivity than the biparametric model (96.0% vs. 90.0%), while there was no significant difference in specificity (77.0%. vs. 85.0%, P = 0.096). For location analysis, there were no significant differences in AUCs between the models (sextant-level, 0.895 vs. 0.893, P = 0.777; zone-level, 0.931 vs. 0.917, P = 0.282), and both models had significantly higher AUCs than the PI-RADS assessment (sextant-level, 0.734; zone-level, 0.863).

DATA CONCLUSION

The diffusion model achieved the best performance in detecting and localizing csPCa in patients with PSA levels of 4-10 ng/mL.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Artificial Intelligence in Surgical Training for Kidney Cancer: A Systematic Review of the Literature

The prevalence of renal cell carcinoma (RCC) is increasing due to advanced imaging techniques. Surgical resection is the standard treatment, involving complex radical and partial nephrectomy procedures that demand extensive training and planning. Furthermore, artificial intelligence (AI) can potentially aid the training process in the field of kidney cancer. This review explores how artificial intelligence (AI) can create a framework for kidney cancer surgery to address training difficulties. Following PRISMA 2020 criteria, an exhaustive search of PubMed and SCOPUS databases was conducted without any filters or restrictions. Inclusion criteria encompassed original English articles focusing on AI's role in kidney cancer surgical training. On the other hand, all non-original articles and articles published in any language other than English were excluded. Two independent reviewers assessed the articles, with a third party settling any disagreement. Study specifics, AI tools, methodologies, endpoints, and outcomes were extracted by the same authors. The Oxford Center for Evidence-Based Medicine's evidence levels were employed to assess the studies. Out of 468 identified records, 14 eligible studies were selected. Potential AI applications in kidney cancer surgical training include analyzing surgical workflow, annotating instruments, identifying tissues, and 3D reconstruction. AI is capable of appraising surgical skills, including the identification of procedural steps and instrument tracking. While AI and augmented reality (AR) enhance training, challenges persist in real-time tracking and registration. The utilization of AI-driven 3D reconstruction proves beneficial for intraoperative guidance and preoperative preparation. Artificial intelligence (AI) shows potential for advancing surgical training by providing unbiased evaluations, personalized feedback, and enhanced learning processes. Yet challenges such as consistent metric measurement, ethical concerns, and data privacy must be addressed. The integration of AI into kidney cancer surgical training offers solutions to training difficulties and a boost to surgical education. However, to fully harness its potential, additional studies are imperative.

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.

Understanding tumor localization in multiparametric MRI of the prostate-effectiveness of 3D printed models

Introduction

Understanding tumor localization in multiparametric MRI (mpMRI) of the prostate is challenging for urologists but of great importance in mpMRI-fused prostate biopsy or radical prostatectomy. The aim was to evaluate the effectiveness of 3D printed models of the prostate to help urologists to locate tumors.

Methods and Participants

20 urologists from University Medical Center Mainz (Germany) were asked to plot the location of a cancer suspicious lesion (PI-RADS ≥ 4) on a total of 30 mpMRI on a prostate sector diagram. The following 3 groups (as matched triplets) were divided into: mpMRI only, mpMRI with radiological report and mpMRI with 3D printed model (scaled 1:1). Statistical analysis was performed using one-way and two-way ANOVA (with bonferroni post-test).

Results

Overall, localization of the suspicious lesion was superior with the radiological report (median of max. 10 [IQR]: MRI 2 [IQR 1;5], MRI + report: 8 [6.3;9], MRI + 3D model 3 [1.3;5.8]; p < 0.001). Residents with <1 year of experience had a significantly higher detection rate using a 3D printed model [5 (5;5.8)] compared to mpMRI alone [1.5 (1;3.5)] (p < 0.05). Regarding the estimation of index lesion extension, the 3D model showed a significant benefit (mean percentage difference [95% CI]: MRI alone 234% [17.1;451.5], MRI + report 114% [78.5;149.6], MRI + 3D model 17% [-7.4;41.3] (p < 0.01).

Conclusion

Urologists still need the written radiological report for a sufficient understanding of tumor localization. The effectiveness of the 3D printed model regarding tumor localization is particularly evident in young residents (<1 year) and leads to a better overall assessment of the tumor extension.

Evaluating augmented reality e-typodont to improve a patient's dental implant health literacy

STATEMENT OF PROBLEM

Information regarding dental implants can be difficult to understand for participants. Improving patients' dental implant health literacy remains a challenging process.

PURPOSE

The purpose of this clinical study was to develop and evaluate patients' understanding of the implant treatment procedure, components, and sequences using traditional typodont and augmented reality (AR) applications (e-typodont), with the goal of improving their oral health literacy.

MATERIAL AND METHODS

Participants who had sought dental implant treatment at the group practice and implant clinic at the University of Illinois Chicago (UIC) College of Dentistry were invited to enroll in this study. Participants were asked to fill out the first questionnaire (Q1) assessing their understanding of implant treatment procedures, components, and sequences. The participants were randomly exposed to 1 of the 2 modes of delivering education, typodont or AR e-typodont. The participants were asked to complete the additional 2 questionnaires (Q2 and Q3), and the posttest questionnaire (Q1) to re-evaluate their understanding of the implant treatment procedure, components, and sequences. All data were entered and coded into a spreadsheet. Descriptive (mean) and statistical (Wilcoxon Signed Ranks and Mann-Whitney U test) analyses were used (α=.05).

RESULTS

Both interventions significantly increased participants' understanding of implant treatments (typodont: P=.004; e-typodont: P<.001), implant components (typodont: P=.003; e-typodont: P<.001), and implant treatment sequences (typodont: P=.001; e-typodont: P<.001). The e-typodont group significantly improved participants' understanding of implant treatments (P=.006), implant components (P=.023), and implant treatment sequences (P=.008) compared with the typodont group. Participants perceived the e-typodont mode of delivery to be significantly more interesting (P=.002), interactive (P=.008), educational (P=.002), user-friendly (P=.016), and "Wow" (P=.002) compared with the traditional typodont mode of delivery.

CONCLUSIONS

Both interventions improved participants' understanding of implant treatment procedures, components, and sequences. The e-typodont showed better improvement in participants' understanding of dental implants compared with the traditional typodont.

A Systematic Review of New Imaging Technologies for Robotic Prostatectomy: From Molecular Imaging to Augmented Reality

New imaging technologies play a pivotal role in the current management of patients with prostate cancer. Robotic assisted radical prostatectomy (RARP) is a standard of care for localized disease and through the already imaging-based console subject of research towards combinations of imaging technologies and RARP as well as their impact on surgical outcomes. Therefore, we aimed to provide a comprehensive analysis of the currently available literature for new imaging technologies for RARP. On 24 January 2023, we performed a systematic review of the current literature on Pubmed, Scopus and Web of Science according to the PRISMA guidelines and Oxford levels of evidence. A total of 46 studies were identified of which 19 studies focus on imaging of the primary tumor, 12 studies on the intraoperative tumor detection of lymph nodes and 15 studies on the training of surgeons. While the feasibility of combined approaches using new imaging technologies including MRI, PSMA-PET CT or intraoperatively applied radioactive and fluorescent dyes has been demonstrated, the prospective confirmation of improvements in surgical outcomes is currently ongoing.

Augmented reality-The way forward in patient education for intracranial aneurysms? A qualitative exploration of views, expectations and preferences of patients suffering from an unruptured intracranial aneurysm regarding augmented reality in patient education

Objectives: The goal of this project is to explore the views, expectations and preferences of patients with an unruptured intracranial aneurysm regarding the use of AR in patient education. Methods: To gain an in-depth understanding of the patients' perspective, a face-to-face interview study was conducted using an interview protocol with a predefined topic list. All interviews were audio-recorded and transcribed verbatim afterwards. Transcripts were analyzed using thematic content analyses. Coding was performed using Atlas.ti software. Results: Seventeen interviews were conducted. The views, expectations and preferences of patients regarding patient education with AR could be subdivided into 15 categories, which could be grouped into 4 general themes: 1) experiences with current patient education, 2) expectations of AR in patient education, 3) opportunities and limitations of AR, and 4) out-of-hospital use of an AR application. Patients' expectations were predominantly positive regarding improving patients' understanding of their medical situation and doctor-patient communication. Discusssion: This study suggests that patients with unruptured intracranial aneurysms are open to receive patient education regarding their disease with AR. Patients expect that AR models can help patients with intra-cranial aneurysms better understand their disease, treatment options and risks. Additionally, patients expect AR could improve doctor-patient communication.

Augmented Reality for Perioperative Anxiety in Patients Undergoing Surgery: A Randomized Clinical Trial

Importance

Both augmented reality (AR) and virtual reality (VR) have had increasing applications in medicine, including medical training, psychology, physical medicine, rehabilitation, and surgical specialties, such as neurosurgery and orthopedic surgery. There are little data on AR's effect on patients' anxiety and experiences.

Objective

To determine whether the use of an AR walkthrough effects patient perioperative anxiety.

Design, Setting, and Participants

This randomized clinical trial was conducted at an outpatient surgery center in 2021 to 2022. All patients undergoing elective orthopedic surgery with the senior author were randomized to the treatment or control group. Analyses were conducted per protocol. Data analysis was performed in November 2022.

Intervention

AR experience explaining to patients what to expect on their day of surgery and walking them through the surgery space. The control group received the standard educational packet.

Main Outcomes and Measures

The main outcome was change in State-Trait Anxiety Inventory (STAI) from the screening survey to the preoperative survey.

Results

A total of 140 patients were eligible, and 45 patients either declined or were excluded. Therefore, 95 patients (63 [66.3%] male; mean [SD] age, 38 [16] years) were recruited for the study and included in the final analysis; 46 patients received the AR intervention, and 49 patients received standard instructions. The AR group experienced a decrease in anxiety from the screening to preoperative survey (mean score change, -2.4 [95% CI, -4.6 to -0.3]), while the standard care group experienced an increase (mean score change, 2.6 [95% CI, 0.2 to 4.9]; P = .01). All patients postoperatively experienced a mean decrease in anxiety score compared with both the screening survey (mean change: AR, -5.4 [95% CI, -7.9 to -2.9]; standard care, -6.9 [95% CI, -11.5 to -2.2]; P = .32) and preoperative survey (mean change: AR, -8.0 [95% CI, -10.3 to -5.7]; standard care, -4.2 [95% CI, -8.6 to 0.2]; P = .19). Of 42 patients in the AR group who completed the postoperative follow-up survey, 30 (71.4%) agreed or strongly agreed that they enjoyed the experience, 29 (69.0%) agreed or strongly agreed that they would recommend the experience, and 28 (66.7%) agreed or strongly agreed that they would use the experience again. No differences were observed in postoperative pain levels or narcotic use.

Conclusions and Relevance

In this randomized clinical trial, the use of AR decreased preoperative anxiety compared with traditional perioperative education and handouts, but there was no significant effect on postoperative anxiety, pain levels, or narcotic use. These findings suggest that AR may serve as an effective means of decreasing preoperative patient anxiety.

Trial Registration

ClinicalTrials.gov Identifier: NCT04727697.

Technologic advances in robot-assisted nephron sparing surgery: a narrative review

BACKGROUND AND OBJECTIVE

Nephron sparing surgery (NSS) is the preferred management for clinical stage T1 (cT1) renal masses. In recent years, indications have expanded to larger and more complex renal tumors. In an effort to provide optimal patient outcomes, urologists strive to achieve the pentafecta when performing partial nephrectomy. This has led to the continuous technologic advancement and technique refinement including the use of augmented reality, ultrasound techniques, changes in surgical approach and reconstruction, uses of novel fluorescence marker guided imaging, and implementation of early recovery after surgery (ERAS) protocols. The aim of this narrative review is to provide an overview of the recent advances in pre-, intra-, and post-operative management and approaches to managing patients with renal masses undergoing NSS.

METHODS

We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010 to 2022 without limitation on study design. We included only full-text English articles published in peer-reviewed journals.

KEY CONTENT AND FINDINGS

Partial nephrectomy is currently prioritized for cT1a renal masses; however, indications have been expanding due to a greater understanding of anatomy and technologic advances. Recent studies have demonstrated that improvements in imaging techniques utilizing cross-sectional imaging with three-dimensional (3D) reconstruction, use of color doppler intraoperative ultrasound, and newer studies emerging using contrast enhanced ultrasound play important roles in certain subsets of patients. While indocyanine green administration is commonly used, novel fluorescence-guided imaging including folate receptor-targeting fluorescence molecules are being investigated to better delineate tumor-parenchyma margins. Augmented reality has a developing role in patient and surgical trainee education. While pre-and intra-operative imaging have shown to be promising, near infrared guided segmental and sub-segmental vessel clamping has yet to show significant benefit in patient outcomes. Studies regarding reconstructive techniques and replacement of reconstruction with sealing agents have a promising future. Finally, ERAS protocols have allowed earlier discharge of patients without increasing complications while improving cost burden.

CONCLUSIONS

Advances in NSS have ranged from pre-operative imaging techniques to ERAS protocols Further prospective investigations are required to determine the impact of novel imaging, in-vivo fluorescence biomarker use, and reconstructive techniques on achieving the pentafecta of NSS.

Virtual Reality and Augmented Reality in Plastic and Craniomaxillofacial Surgery: A Scoping Review

Virtual reality (VR) and augmented reality (AR) have evolved since their introduction to medicine in the 1990s. More powerful software, the miniaturization of hardware, and greater accessibility and affordability enabled novel applications of such virtual tools in surgical practice. This scoping review aims to conduct a comprehensive analysis of the literature by including all articles between 2018 and 2021 pertaining to VR and AR and their use by plastic and craniofacial surgeons in a clinician-as-user, patient-specific manner. From the initial 1637 articles, 10 were eligible for final review. These discussed a variety of clinical applications: perforator flaps reconstruction, mastectomy reconstruction, lymphovenous anastomosis, metopic craniosynostosis, dermal filler injection, auricular reconstruction, facial vascularized composite allotransplantation, and facial artery mapping. More than half (60%) involved VR/AR use intraoperatively with the remainder (40%) examining preoperative use. The hardware used predominantly comprised HoloLens (40%) and smartphones (40%). In total, 9/10 Studies utilized an AR platform. This review found consensus that VR/AR in plastic and craniomaxillofacial surgery has been used to enhance surgeons' knowledge of patient-specific anatomy and potentially facilitated decreased intraoperative time via preoperative planning. However, further outcome-focused research is required to better establish the usability of this technology in everyday practice.

The HoloLens in medicine: A systematic review and taxonomy

The HoloLens (Microsoft Corp., Redmond, WA), a head-worn, optically see-through augmented reality (AR) display, is the main player in the recent boost in medical AR research. In this systematic review, we provide a comprehensive overview of the usage of the first-generation HoloLens within the medical domain, from its release in March 2016, until the year of 2021. We identified 217 relevant publications through a systematic search of the PubMed, Scopus, IEEE Xplore and SpringerLink databases. We propose a new taxonomy including use case, technical methodology for registration and tracking, data sources, visualization as well as validation and evaluation, and analyze the retrieved publications accordingly. We find that the bulk of research focuses on supporting physicians during interventions, where the HoloLens is promising for procedures usually performed without image guidance. However, the consensus is that accuracy and reliability are still too low to replace conventional guidance systems. Medical students are the second most common target group, where AR-enhanced medical simulators emerge as a promising technology. While concerns about human-computer interactions, usability and perception are frequently mentioned, hardly any concepts to overcome these issues have been proposed. Instead, registration and tracking lie at the core of most reviewed publications, nevertheless only few of them propose innovative concepts in this direction. Finally, we find that the validation of HoloLens applications suffers from a lack of standardized and rigorous evaluation protocols. We hope that this review can advance medical AR research by identifying gaps in the current literature, to pave the way for novel, innovative directions and translation into the medical routine.

Prostate MRI for Improving Personalized Risk Prediction of Incontinence and Surgical Planning: The Role of Membranous Urethral Length Measurements and the Use of 3D Models

Prostate MRI has an important role in prostate cancer diagnosis and treatment, including detection, the targeting of prostate biopsies, staging and guiding radiotherapy and active surveillance. However, there are other ''less well-known'' applications which are being studied and frequently used in our highly specialized medical center. In this review, we focus on two research topics that lie within the expertise of this study group: (1) anatomical parameters predicting the risk of urinary incontinence after radical prostatectomy, allowing more personalized shared decision-making, with special emphasis on the membranous urethral length (MUL); (2) the use of three-dimensional models to help the surgical planning. These models may be used for training, patient counselling, personalized estimation of nerve sparing and extracapsular extension and may help to achieve negative surgical margins and undetectable postoperative PSA values.

"Mixed Reality" in patient education prior to abdominal aortic aneurysm repair

Background: To investigate the usability of Mixed-Reality (MR) during patient education in patients scheduled for abdominal aortic aneurysm (AAA) repair. Patients and methods: Consecutive patients scheduled for elective AAA repair were block-randomized in either the Mixed-Reality group (MR group) or the conventional group (control group). Patients of both groups were educated about open and endovascular repair of their respective AAA. The MR group was educated using a head-mounted display (HMD) demonstrating a three-dimensional virtual reconstruction of the respective patient's vascular anatomy. The control group was educated using a conventional two-dimensional monitor to display the patient's vasculature. Outcomes were informational gain as well as patient satisfaction with the educational process. (DRKS-ID: DRKS00025174). Results: 50 patients were included with 25 patients in either group. Both groups demonstrated improvements in scores in the Informational Gain Questionnaire (IGQ) when comparing pre- and post-education scores. (MR group: 6.5 points (±1.8) versus 7.9 points (±1.5); Control group: 6.2 points (±1.8) versus 7.6 points (±1.6); p<0.01) There was no significant difference between the MR group and the control group either in informational gain (MR group: 1.4±1.8; Control group: 1.4±1.8; p=0.5) nor in patient satisfaction scores (MR group: mean 18.3 of maximum 21 points (±3.7); Control group: mean 17 of 21 points (±3.6); p=0.1) Multiple regression revealed no correlation between the use of MR and informational gain or patient satisfaction. Usability of the system was rated high, and patients' subjective assessment of MR was positive. Conclusions: The use of MR in patient education of AAA patients scheduled for elective repair is feasible. While patients reported positively on the use of MR in education, similar levels of informational gain and patient satisfaction can be achieved with MR and conventional methods.

Helping Patients Understand Their Dizziness: Assessment of a Three-Dimensional Printed Vestibular Model

To assess the improvement in patient understanding with use of a three-dimensional printed vestibular model as a teaching tool and to evaluate the effects of educational approach on dizziness-related disabilities. Single center randomized controlled trial set in the Otolaryngology ambulatory care clinic located at a tertiary care, teaching institution in Shreveport, Louisiana. Patients with a current or suspected diagnosis of benign paroxysmal positional vertigo who met inclusion criteria were randomized to either the three-dimensional model group or the control group. Each group received the same education session about dizziness, with the three-dimensional model being used as a visual aid in the experimental group. The control group received only verbal education. Outcome measures included patient understanding of benign paroxysmal positional vertigo etiology, comfort level with symptom prevention, anxiety related to vertigo symptoms, and how likely the patient was to recommend the teaching session to another individual suffering from vertigo. Pre-session and post-session surveys were administered to all patients to assess outcome measures. Eight patients were enrolled in the experimental group, and eight patients were enrolled in the control group. On post-survey data, the experimental group reported increased understanding of symptom etiology (p = 0.0289), increased comfort level with preventing symptoms (p = 0.2999), a larger decrease in symptom related anxiety (p = 0.0453) and were more likely to recommend the education session (p = 0.2807) compared to the control group. Three-dimensional printed vestibular model demonstrates promise for patient education and reducing related anxiety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03325-5.

Pediatric Genitourinary 3D Modeling and Printing Using Multiphase Postcontrast Imaging Segmentation

OBJECTIVE

To describe the development and implementation of a process for creating accurate Pediatric genitourinary 3D modeling and printing with multiphase postcontrast imaging for surgical planning.

MATERIALS AND METHODS

Additive manufacturing and 3D model present opportunities to support clinical planning, this manuscript's specific process and considerations for creating pediatric genitourinary 3D modeling to support urology. The process for creating the 3D models and prints covers 3 key aspects from image acquisition, imaging review and selection, and segmentation and modification (as needed). Each step is outlined with the key roles and procedures.

RESULTS

The described case had digital and printed models prepared with references to the optimized imaging sequence for 3D modeling of Pediatric genitourinary. Case shared include complex genitourinary reconstruction and Kideny with Wilms tumors.

CONCLUSION

The processes described have become a standard of practice for complex kidney tumors and exstrophy planning. The team continues to work on ever-changing improvements to make the best possible models to support clinical and surgical planning.

The Role of Three-dimensional Model in Preoperative Communication Before Partial Nephrectomy and Postoperative Management

Objective

To investigate the role of the three-dimensional (3D) image reconstruction technique in preoperative communication before partial nephrectomy (PN) and postoperative follow-up.

Methods

A retrospective study was performed with 158 renal cancer patients treated with PN at our center from May 1, 2017 to April 30, 2019. 81 patients (group A) had preoperative communication using the 3D reconstruction technique, while 77 patients (group B) did not. The surgeon explained the anatomical structure, tumor characteristics, and surgical approach in detail to the two groups of patients. Each patient completed a questionnaire. The loss to follow-up rate over a 3-year period was counted for both groups, and non-cancer-related serious complications such as renal failure and cardio-cerebrovascular disease were observed. This research did not include patients who returned for follow-up care owing to associated complications such as postoperative chronic kidney disease. Comparisons between two groups were performed using the Mann-Whitney U test and chi-square test.

Results

All patients showed no statistically significant differences in basic clinical parameters, such as age, gender, body mass index, tumor size, and R.E.N.A.L. score (P ​> ​0.05). In group A, patients were significantly more likely to experience understanding of renal anatomy (P ​= ​0.001), characteristics of renal cell carcinoma (P ​= ​0.003), surgical approach (P ​= ​0.007), and relief of preoperative anxiety (P ​= ​0.013). The follow-up adherence at 3 years postoperatively in group A and group B was 21 cases and 10 cases, respectively (P ​= ​0.041). In addition, glomerular filtration rate < 60 ​mL/min/1.73 ​m² or serum creatinine > 186 ​μmol/L at 3 years after surgery occurred in 5 patients in group A and 13 in group B (P ​= ​0.034), and a systolic blood pressure rise greater than 20 ​mmHg occurred in 9 patients in group A and 18 in group B (P ​= ​0.041).

Conclusions

The use of 3D reconstruction techniques for preoperative communication can successfully improve patients' perception and comprehension of kidney tumors and PN, as well as help to prevent serious postoperative non-cancer-related complications.

Patient-Specific 3D-Printed Low-Cost Models in Medical Education and Clinical Practice

3D printing has been increasingly used for medical applications with studies reporting its value, ranging from medical education to pre-surgical planning and simulation, assisting doctor-patient communication or communication with clinicians, and the development of optimal computed tomography (CT) imaging protocols. This article presents our experience of utilising a 3D-printing facility to print a range of patient-specific low-cost models for medical applications. These models include personalized models in cardiovascular disease (from congenital heart disease to aortic aneurysm, aortic dissection and coronary artery disease) and tumours (lung cancer, pancreatic cancer and biliary disease) based on CT data. Furthermore, we designed and developed novel 3D-printed models, including a 3D-printed breast model for the simulation of breast cancer magnetic resonance imaging (MRI), and calcified coronary plaques for the simulation of extensive calcifications in the coronary arteries. Most of these 3D-printed models were scanned with CT (except for the breast model which was scanned using MRI) for investigation of their educational and clinical value, with promising results achieved. The models were confirmed to be highly accurate in replicating both anatomy and pathology in different body regions with affordable costs. Our experience of producing low-cost and affordable 3D-printed models highlights the feasibility of utilizing 3D-printing technology in medical education and clinical practice.

Impact of 3D printed models on quantitative surgical outcomes for patients undergoing robotic-assisted radical prostatectomy: a cohort study

BACKGROUND

Three-dimensional (3D) printed anatomic models can facilitate presurgical planning by providing surgeons with detailed knowledge of the exact location of pertinent anatomical structures. Although 3D printed anatomic models have been shown to be useful for pre-operative planning, few studies have demonstrated how these models can influence quantitative surgical metrics.

OBJECTIVE

To prospectively assess whether patient-specific 3D printed prostate cancer models can improve quantitative surgical metrics in patients undergoing robotic-assisted radical prostatectomy (RARP).

METHODS

Patients with MRI-visible prostate cancer (PI-RADS V2 ≥ 3) scheduled to undergo RARP were prospectively enrolled in our IRB approved study (n = 82). Quantitative surgical metrics included the rate of positive surgical margins (PSMs), operative times, and blood loss. A qualitative Likert scale survey to assess understanding of anatomy and confidence regarding surgical approach was also implemented.

RESULTS

The rate of PSMs was lower for the 3D printed model group (8.11%) compared to that with imaging only (28.6%), p = 0.128. The 3D printed model group had a 9-min reduction in operating time (213 ± 42 min vs. 222 ± 47 min) and a 5 mL reduction in average blood loss (227 ± 148 mL vs. 232 ± 114 mL). Surgeon anatomical understanding and confidence improved after reviewing the 3D printed models (3.60 ± 0.74 to 4.20 ± 0.56, p = 0.62 and 3.86 ± 0.53 to 4.20 ± 0.56, p = 0.22).

CONCLUSIONS

3D printed prostate cancer models can positively impact quantitative patient outcomes such as PSMs, operative times, and blood loss in patients undergoing RARP.

Development of a Survey Tool: Understanding the Patient Experience With Personalized 3D Models in Surgical Patient Education

BACKGROUND

Three-dimensional (3D) printing has been increasingly utilized in the healthcare sector for many applications including guiding surgical procedures, creating medical devices, and producing custom prosthetics. As personalized medicine becomes more accessible and desired, 3D printed models emerge as a potential tool in providing patient-specific education. These personalized 3D models are at the intersection of technological innovation and medical education. Our study group utilized a modified Delphi process to create a comprehensive survey tool assessing patient experience with personalized 3D models in preoperative education.

METHODS

A rigorous literature review was conducted of prior patient education survey tools in surgical cases across specialties involving personalized 3D printed models. Through categorization and mapping, a core study team reviewed individual questions, removed duplicates, and edited them into generalizable form. A modified Delphi process was then used to solicit feedback on question clarity and relevance from both 3D printing healthcare experts and patients to create a final survey.  Results: 173 survey questions from the literature were evaluated by the core study team, yielding 31 unique questions for further review. After multiple rounds of feedback, a final survey containing 18 questions was developed.  Conclusion: 3D printed models have the potential to be helpful tools in surgical patient education, and there exists a need to standardize the assessment of patient experience with these models. This survey provides a standardized, generalizable way to investigate the patient experience with personalized 3D-printed models.

Utility and Costs During the Initial Year of 3D Printing in an Academic Hospital

OBJECTIVE

There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital.

METHODS

All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs.

RESULTS

The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model).

DISCUSSION

Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research.

Automatic segmentation of human knee anatomy by a convolutional neural network applying a 3D MRI protocol

BACKGROUND

To study deep learning segmentation of knee anatomy with 13 anatomical classes by using a magnetic resonance (MR) protocol of four three-dimensional (3D) pulse sequences, and evaluate possible clinical usefulness.

METHODS

The sample selection involved 40 healthy right knee volumes from adult participants. Further, a recently injured single left knee with previous known ACL reconstruction was included as a test subject. The MR protocol consisted of the following 3D pulse sequences: T1 TSE, PD TSE, PD FS TSE, and Angio GE. The DenseVNet neural network was considered for these experiments. Five input combinations of sequences (i) T1, (ii) T1 and FS, (iii) PD and FS, (iv) T1, PD, and FS and (v) T1, PD, FS and Angio were trained using the deep learning algorithm. The Dice similarity coefficient (DSC), Jaccard index and Hausdorff were used to compare the performance of the networks.

RESULTS

Combining all sequences collectively performed significantly better than other alternatives. The following DSCs (±standard deviation) were obtained for the test dataset: Bone medulla 0.997 (±0.002), PCL 0.973 (±0.015), ACL 0.964 (±0.022), muscle 0.998 (±0.001), cartilage 0.966 (±0.018), bone cortex 0.980 (±0.010), arteries 0.943 (±0.038), collateral ligaments 0.919 (± 0.069), tendons 0.982 (±0.005), meniscus 0.955 (±0.032), adipose tissue 0.998 (±0.001), veins 0.980 (±0.010) and nerves 0.921 (±0.071). The deep learning network correctly identified the anterior cruciate ligament (ACL) tear of the left knee, thus indicating a future aid to orthopaedics.

CONCLUSIONS

The convolutional neural network proves highly capable of correctly labeling all anatomical structures of the knee joint when applied to 3D MR sequences. We have demonstrated that this deep learning model is capable of automatized segmentation that may give 3D models and discover pathology. Both useful for a preoperative evaluation.

The Effect of Digital Three-Dimensional Reality Models on Patient Counseling for Renal Masses

Background and Objectives

Patient counseling for treatment of renal masses is complex. It can be difficult for patients to understand their disease and make treatment decisions when being shown standard black-and-white, two-dimensional computed tomography scans or magnetic resonance images. In a telehealth setting, the patient-physician interaction can be even more challenging. We sought to determine the impact of using digital three-dimensional (3D) models during consultation visits for patients with renal masses.

Methods

Forty-seven patients participating in a consultation visit for renal masses, both in-person and virtual, were shown a digital 3D model comprised of their kidney, renal mass, and key adjacent structures as part of their counseling. Patients then completed a five-question survey to assess the impact of the 3D model on their visit, with a sixth question administered to telehealth patients.

Results

Thirty-five patients undergoing telehealth visits and 12 patients seen in-person were shown the digital 3D model and surveyed. Survey results were universally positive, with all Likert scores > 4.7 (1 - 5 scale). There were no differences between the telehealth and in-person groups. Patients noted the digital 3D model made telehealth visits as effective as in-person visits (average Likert score 4.94).

Conclusion

Counseling for patients with renal masses can be augmented with patient-specific digital 3D models, leading to increased provider loyalty, lower levels of patient anxiety, and better understanding and shared decision making.

3D printed patient-specific prostate cancer models to guide nerve-sparing robot-assisted radical prostatectomy: a systematic review

Precise knowledge of each patient's index cancer and surrounding anatomy is required for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). Complementary to this, 3D printing has proven its utility in improving the visualisation of complex anatomy. This is the first systematic review to critically assess the potential of 3D printed patient-specific prostate cancer models in improving visualisation and the practice of NS-RARP. A literature search of PubMed and OVID Medline databases was performed using the terms "3D Printing", "Robot Assisted Radical Prostatectomy" and related index terms as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eight articles were included; six were identified via database searches, to which a further two articles were located via a snowballing approach. Eight papers were identified for review. There were five prospective single centre studies, one case series, one technical report and one letter to the editor. Of these articles, five publications (62.5%) reported on the utility of 3D printed models for NS-RARP planning. Two publications (25%) utilised 3D printed prostate models for simulation and training, and two publications (25%) used the models for patient engagement. Despite the nascency of the field, 3D printed models are emerging in the uro-oncological literature as a useful tool in visualising complex anatomy. This has proven useful in NS-RARP for preoperative planning, simulation and patient engagement. However, best practice guidelines, the future regulatory landscape, and health economic considerations need to be addressed before this synergy of new technologies is ready for the mainstream.

Establishing a Point-of-Care Virtual Planning and 3D Printing Program

Virtual surgical planning (VSP) and three-dimensional (3D) printing have become a standard of care at our institution, transforming the surgical care of complex patients. Patient-specific, anatomic models and surgical guides are clinically used to improve multidisciplinary communication, presurgical planning, intraoperative guidance, and the patient informed consent. Recent innovations have allowed both VSP and 3D printing to become more accessible to various sized hospital systems. Insourcing such work has several advantages including quicker turnaround times and increased innovation through collaborative multidisciplinary teams. Centralizing 3D printing programs at the point-of-care provides a greater cost-efficient investment for institutions. The following article will detail capital equipment needs, institutional structure, operational personnel, and other considerations necessary in the establishment of a POC manufacturing program.

Utility of 3-dimensionally printed models for parent education in pediatric plagiocephaly

Objectives

Demonstrate the benefits of using 3D printed skull models when counseling families regarding disorders of the cranial vault (namely plagiocephaly and craniosynostosis), as traditional imaging review and discussion is often insufficient.

Methods

3D printed skull models of a patient with plagiocephaly were used during clinic appointments to aid in the counseling of parents. Surveys were distributed following the appointment to evaluate the utility of these models during the discussion.

Results

Fifty surveys were distributed (with a 98% response rate). 3D models were both empirically and anecdotally helpful for parents in understanding their child's diagnosis.

Conclusion

Advances in 3D printing technology and software have made producing models more accessible. Incorporating physical, disorder-specific models into our discussions has led to improvements in our ability to communicate with our patients and their families.

Innovation

Disorders of the cranial can be challenging to describe to the parents and guardians of affected children; using 3D printed models is a useful adjunct in patient-centered discussions. The subject response to the use of these emerging technologies in this setting suggests a major role for 3D models in patient education and counseling for cranial vault disorders.

3D printed model for triple negative inflammatory breast cancer

BACKGROUND

Access to imaging reports and review of the breast imaging directly with a patient with breast cancer helps improve the understanding of disease extent and severity. A 3D printed breast model can further enhance a patient's understanding and communication with the healthcare team resulting in improved patient comprehension and patient input with reduced treatment decision conflict. Furthermore, 3D printed models can facilitate training of residents and fellows involved in the diagnosis and treatment management of breast cancer.

CASE PRESENTATION

We present a 3D printed breast tumor model segmented from positron electron tomography/computed tomography and fabricated via desktop vat polymerization as proof of concept for treatment planning for a patient diagnosed with triple negative inflammatory breast carcinoma.

CONCLUSION

We illustrate benefits and indications for 3D printing in the management of breast cancer and specifically inflammatory breast cancer in this case. Fabrication and implementation of 3D printed models enhances patient's understanding and communication with the healthcare team regarding their condition, treatment options and anticipated outcomes. It provides personalized treatment planning by examining patient-specific pathology and the anatomic spatial relationships. Furthermore, 3D printed models facilitate medical education for trainees across disciplines involved in the patient's care.

Fully automated detection and localization of clinically significant prostate cancer on MR images using a cascaded convolutional neural network

Purpose

To develop a cascaded deep learning model trained with apparent diffusion coefficient (ADC) and T2-weighted imaging (T2WI) for fully automated detection and localization of clinically significant prostate cancer (csPCa).

Methods

This retrospective study included 347 consecutive patients (235 csPCa, 112 non-csPCa) with high-quality prostate MRI data, which were randomly selected for training, validation, and testing. The ground truth was obtained using manual csPCa lesion segmentation, according to pathological results. The proposed cascaded model based on Res-UNet takes prostate MR images (T2WI+ADC or only ADC) as inputs and automatically segments the whole prostate gland, the anatomic zones, and the csPCa region step by step. The performance of the models was evaluated and compared with PI-RADS (version 2.1) assessment using sensitivity, specificity, accuracy, and Dice similarity coefficient (DSC) in the held-out test set.

Results

In the test set, the per-lesion sensitivity of the biparametric (ADC + T2WI) model, ADC model, and PI-RADS assessment were 95.5% (84/88), 94.3% (83/88), and 94.3% (83/88) respectively (all p > 0.05). Additionally, the mean DSC based on the csPCa lesions were 0.64 ± 0.24 and 0.66 ± 0.23 for the biparametric model and ADC model, respectively. The sensitivity, specificity, and accuracy of the biparametric model were 95.6% (108/113), 91.5% (665/727), and 92.0% (773/840) based on sextant, and were 98.6% (68/69), 64.8% (46/71), and 81.4% (114/140) based on patients. The biparametric model had a similar performance to PI-RADS assessment (p > 0.05) and had higher specificity than the ADC model (86.8% [631/727], p< 0.001) based on sextant.

Conclusion

The cascaded deep learning model trained with ADC and T2WI achieves good performance for automated csPCa detection and localization.

Role of preoperative patient education among prostate cancer patients treated by radical prostatectomy

Introduction

Radical prostatectomy, as a prostate cancer treatment option, is associated with the presence of certain postoperative dysfunctions - physical, psychosocial, emotional and economic. However, regular and planned preoperative patient education can help and support physical and emotional well-being by reducing levels of anxiety, building feelings of being in control, and providing instruments for self-management by patients.

Material and methods

A literature search was conducted on the subject of educational interventions among cancer patients, focusing on men with prostate cancer undergoing radical prostatectomy.

Results

Preoperative patient education can affect key factors which have an impact on health-related quality of life such as levels of fear and anxiety, expectations and satisfaction in relation to treatment, postoperative activity, self-care management, and others.

Conclusions

Effective education of patients can lead to increased involvement in courses of treatment, which can in turn result in decreased postoperative complications and shorter recuperative periods. Patient education should be scheduled and organized using not only traditional methods but also modern technology, e.g. 3D printed models of organs or tumours.

Guide for starting or optimizing a 3D printing clinical service

Three-dimensional (3D) printing has applications in many fields and has gained substantial traction in medicine as a modality to transform two-dimensional scans into three-dimensional renderings. Patient-specific 3D printed models have direct patient care uses in surgical and procedural specialties, allowing for increased precision and accuracy in developing treatment plans and guiding surgeries. Medical applications include surgical planning, surgical guides, patient and trainee education, and implant fabrication. 3D printing workflow for a laboratory or clinical service that produces anatomic models and guides includes optimizing imaging acquisition and post-processing, segmenting the imaging, and printing the model. Quality assurance considerations include supervising medical imaging expert radiologists' guidance and self-implementing in-house quality control programs. The purpose of this review is to provide a workflow and guide for starting or optimizing laboratories and clinical services that 3D-print anatomic models or guides for clinical use.

Application of 3D Bioprinting in Urology

Tissue engineering is an emerging field to create functional tissue components and whole organs. The structural and functional defects caused by congenital malformation, trauma, inflammation or tumor are still the major clinical challenges facing modern urology, and the current treatment has not achieved the expected results. Recently, 3D bioprinting has gained attention for its ability to create highly specialized tissue models using biological materials, bridging the gap between artificially engineered and natural tissue structures. This paper reviews the research progress, application prospects and current challenges of 3D bioprinting in urology tissue engineering.

The role and effectiveness of augmented reality in patient education: A systematic review of the literature

OBJECTIVES

To provide an overview of the existing research concerning the use and effects of AR in patient education.

METHODS

Following PRISMA guidelines four electronic databases were systematically searched.

INCLUSION CRITERIA

empirical studies using any type of AR intervention in patient education across all medical specialties. Quality assessment of the retrieved literature was carried out.

RESULTS

Ten papers, comprising 788 patients, were identified and included (Randomized controlled trial (RCT)(n = 3), non-randomized controlled trial (n = 3), before-and-after study (n = 3), and qualitative survey (n = 1)). Retrieved literature showed itself to be highly heterogeneous. The studied population included patients suffering from a diverse spectrum of chronic diseases (e.g., prostate cancer, diabetes mellitus, multiple sclerosis, epilepsy). Quantitative results indicated that the use of AR had a positive effect on knowledge retention and patient satisfaction. Qualitative findings suggested that patients liked the technology and felt comfortable with its use for educational purposes. The quality of the retrieved results was shown to be moderate to low.

CONCLUSION

The limited evidence of this topic suggests the possible potential of AR in patient education.

PRACTICE IMPLICATION

More research, using high-quality study designs and more evidence-based interventions, is needed to fully appreciate the value of AR on patient education.

New imaging technologies for robotic kidney cancer surgery

Objective

Kidney cancers account for approximately 2% of all newly diagnosed cancer in 2020. Among the primary treatment options for kidney cancer, urologist may choose between radical or partial nephrectomy, or ablative therapies. Nowadays, robotic-assisted partial nephrectomy (RAPN) for the management of renal cancers has gained popularity, up to being considered the gold standard. However, RAPN is a challenging procedure with a steep learning curve.

Methods

In this narrative review, different imaging technologies used to guide and aid RAPN are discussed.

Results

Three-dimensional visualization technology has been extensively discussed in RAPN, showing its value in enhancing robotic-surgery training, patient counseling, surgical planning, and intraoperative guidance. Intraoperative imaging technologies such as intracorporeal ultrasound, near-infrared fluorescent imaging, and intraoperative pathological examination can also be used to improve the outcomes following RAPN. Finally, artificial intelligence may play a role in the field of RAPN soon.

Conclusion

RAPN is a complex surgery; however, many imaging technologies may play an important role in facilitating it.