Feasibility and Accuracy of Robot-Assisted, Stereotactic Biopsy Using 3-Dimensional Intraoperative Imaging and Frameless Registration Tool

Launching Stealth AutoGuideTM robot for stereotactic biopsy procedures in a neurosurgical centre: learning curve and workflow optimization

Background

Accurate histological analysis is crucial for confirming intracerebral neoplasia due to the diverse array of potential diagnoses presented by imaging. In the realm of biopsy techniques, the use of robot-based systems is on the rise, primarily owing to their heightened targeting accuracy. The objective of this study was to elucidate the practicality, learning curve and workflow associated with robot-guided biopsies upon their introduction to a neurosurgical centre.

Materials and methods

In March 2022, the neurosurgical department at our institution adopted the Medtronic Stealth AutoGuide™ cranial robotic guidance platform, a miniaturized robotic guidance device designed for stereotactic procedures. Four experienced neurosurgeons underwent training with the Stealth AutoGuide™ system, after which 51 consecutive biopsies were performed. The evaluation encompassed entry and target accuracy, preoperative setup time, time required for the biopsy procedure, and overall operating time. Statistical analysis was conducted to identify any differences between the initial 26 and subsequent sets of 25 patients, with the aim of identifying changes in workflow.

Results

The study included all patients necessitating a diagnostic biopsy for intracerebral tumours, with only one patient excluded due to the inaccessibility of the intended target point caused by tumour calcification. Notably, there were no significant differences between the first 25 and last 26 patients in the median time from incision to the first biopsy (overall: 11.5 min, IQR 9.03-15.0), the procedure time (overall: 30.0 min, IQR 23.5-46.5), median accuracy at entry (overall: 2.05 mm, IQR 0.8-3.8), or target point (overall: 2.2 mm (IQR 1.6-3.7). However, a significant reduction in robot setup time was observed between the two groups, median 2.69 min versus 1.17 min, respectively (p ≤ 0.001).

Conclusion

The deployment of the robotic biopsy system, Stealth AutoGuide™, showed high feasibility, steep learning curve due to uncomplicated technical handling using our standardized operative workflow. Therefore, even in prone position a high diagnostic yield was achieved. Overall, the Stealth AutoGuide™ system facilitated biopsies in traditionally challenging regions with concise procedure time and surgeon-independent high accuracy.

Accuracy of frameless robot-assisted stereoelectroencephalography depth electrode implantation using the neurolocate registration system in paediatric patients

BACKGROUND

We assessed the accuracy and performed a directional analysis of robot-assisted implantation of stereoelectroencephalography (SEEG) depth electrodes in children using the frameless neurolocate 3D registration module.

METHODS

Thirteen children with epilepsy undergoing stereotactic robot-assisted insertion of SEEG electrodes were included. Six children were operated on with standard frame-based registration while 7 with the use of the frameless neurolocate registration module. Accuracy and directional analysis of orthogonal and oblique electrodes were assessed by calculating the absolute error, the radial error, the angle error, and the Euclidean distance.

RESULTS

Of 172 electrodes 89 were implanted in the 6 standard frame-based mode patients and 83 in the 7 neurolocate patients. The overall mean age was 12.2 ± 4.4 years (range 2-17). The mean number of electrodes in each patient was 13.2 ± 2.04 (range 9-17). The median radial error of electrode placement in the neurolocate patients (1.08 mm, [IQR: 1.26]) was significantly less when compared with standard frame-based mode patients (1.49 mm, [IQR 1.25)]; p = 0.04). The same applies to the median angle error which was in the neurolocate group 1.61° [IQR: 1.46] and in the standard frame-based group 2.16° [IQR: 2.09]; p = 0.019. Directional analysis of electrode trajectories in the neurolocate group showed that in the x-axis the median absolute error of orthogonal electrodes (0.4 mm, [IQR: 0.475]) was less when compared with oblique electrodes (0.7 mm, [IQR: 1.2]; p = 0.007). In the standard frame-based mode group in the y-axis, the median absolute error of orthogonal electrodes (0.7 mm, [IQR: 1.3]) was less compared with oblique electrodes (1.25 mm, [IQR: 1.6]; p = 0.03).

CONCLUSION

In paediatric patients, robot-assisted SEEG depth electrode implantation with the non-invasive and easy-to-use frameless neurolocate registration module is a consistent and accurate procedure.

Intentional Insertion of Air to Predict the Diagnostic Accuracy of Stereotactic Biopsy and a Uniform Grading System for Reporting

BACKGROUND AND OBJECTIVES

Stereotactic biopsies are a relatively safe and reliable way of tissue diagnosis and characterization of eloquent area lesions/neoplasm. However, predicting the accuracy of the site of biopsy with the desired/planned site is not always possible. We describe a technique to identify the precise location of the biopsy site in the post-operative computed tomography (CT) scan using the injection of a low volume of air into the biopsy cannula.

METHODS

Hundred consecutive biopsies were performed in 80 adults/20 children (59 males/41 females, median age 51 years) over 3 years, consisting of 75 frameless and 25 frame-based stereotactic biopsies. After the biopsy specimens had been collected, a small volume of air (median 1 cc) was injected into the site. Post-operative CT was done within 4 hours of the biopsy to see the site of the air bubble, and the same was correlated with the histopathological accuracy.

RESULTS

Intra-cranial air in the selected target was present in 95 patients (Grade 1 and 2), while the air was seen in the track (Grade 3) in 3% and at an unrelated site (Grade 4) in 2% of cases. Both Grade 4 biopsies were negative on histopathology (diagnostic yield = 98%). Two negative biopsies were reported, which were both predicted with the Grade 4 biopsy. The grading allowed uniform reporting across series and eliminated the chance of upgrading/downgrading the report due to wrong site sampling within the lesion/neoplasm.

CONCLUSION

The air-injection manoeuvre proposed for use in stereotactic biopsies of intra-cranial mass lesions is a safe and reliable technique that allows the exact biopsy site to be located without any related complications.

Safety and efficacy of frameless stereotactic robot-assisted intraparenchymal brain lesion biopsies versus image-guided biopsies: a bicentric comparative study

PURPOSE

User-friendly robotic assistance and image-guided tools have been developed in the past decades for intraparenchymal brain lesion biopsy. These two methods are gradually becoming well accepted and are performed at the discretion of the neurosurgical teams. However, only a few data comparing their effectiveness and safety are available.

METHODS

Population-based parallel cohorts were followed from two French university hospitals with different surgical methods and defined geographical catchment regions (September 2019 to September 2022). In center A, frameless robot-assisted stereotactic intraparenchymal brain lesion biopsies were performed, while image-guided intraparenchymal brain lesion biopsies were performed in center B. Pre-and postoperative clinical, radiological, and histomolecular features were retrospectively collected and compared.

RESULTS

Two hundred fifty patients were included: 131 frameless robot-assisted stereotactic intraparenchymal brain lesion biopsies in center A and 119 image-guided biopsies in center B. The clinical, radiological, and histomolecular features were comparable between the two groups. The diagnostic yield (96.2% and 95.8% respectively; p = 1.000) and the overall postoperative complications rates (13% and 14%, respectively; p = 0.880) did not differ between the two groups. The mean duration of the surgical procedure was longer in the robot-assisted group (61.9 ± 25.3 min, range 23-150) than in the image-guided group (47.4 ± 11.8 min, range 25-81, p < 0.001). In the subgroup of patients with anticoagulant and/or antiplatelet therapy administered preoperatively, the intracerebral hemorrhage > 10 mm on postoperative CT scan was higher in the image-guided group (36.8%) than in the robot-assisted group (5%, p < 0.001).

CONCLUSION

In our bicentric comparative study, robot-assisted stereotactic and image-guided biopsies have two main differences (shorter time but more frequent postoperative hematoma for image-guided biopsies); however, both techniques are demonstrated to be safe and efficient.

Clinical experiences and learning curves from robot-assisted neurosurgical biopsies with Stealth Autoguide™

Background

Biopsies of intracranial lesions are a cornerstone in the diagnosis of unresectable tumors to guide neurooncological treatment; however, the procedure is also associated with risks. The results from the cranial robot guidance system Stealth Autoguide™ were studied after introduction at a neurosurgical department. Primary aims include the presentation of clinical and radiological data, accuracy of radiological diagnosis, learning curves of the new technology, diagnostic yield, and precision. The secondary aim was to study complications.

Methods

Retrospective data inclusion was performed on patients ≥ 18 years undergoing biopsy with Stealth Autoguide™ due to suspected brain tumors in the first 3 years after the introduction of the technique. Data regarding clinical characteristics, intraoperative variables, pathological diagnosis, and complications were recorded. Analyses of learning curves were performed.

Results

A total of 79 procedures were performed on 78 patients with a mean age of 62 years (SD 12.7, range 23-82), 30.8% were female. Tumors were often multifocal (63.3%) and supratentorial (89.9%). The diagnostic yield was 87.3%. The first-hand radiological diagnosis was correct in 62.0%. A slight decrease in operation time was observed, although not significant. The surgeon contributed to 12% of the variability.

Conclusions

Robot-assisted biopsies with Stealth Autoguide™ seem to be comparable, with regards to complications, to frame-based and other frameless neurosurgical biopsies. Learning curves demonstrated no statistical differences in time of surgery and only 12% surgeon-related variation (ie, variation caused by the change of performing surgeon), suggesting a successful implementation of this technical adjunct.

Robot-assisted endoscopic third ventriculostomy under intraoperative CT imaging guidance

BACKGROUND

The robot-assisted neurosurgical procedures have recently benefited of the evolution of intraoperative imaging, including mobile CT unit available in the operating room. This facilitated use paved the way to perform more neurosurgical procedures under robotic assistance. Endoscopic third ventriculocisternostomy requires both a safe transcortical trajectory and a smooth manipulation.

METHOD

We describe our technique of robot-assisted endoscopic third ventriculocisternostomy combining robotic assistance and intraoperative CT imaging.

CONCLUSION

Robot-assisted endoscopic third ventriculocisternostomy using modern intraoperative neuroimaging can be easily implemented and prevented erroneous trajectory and abrupt endoscopic movements, reducing surgically induced brain damages.

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

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