Archie Hughes-Hallett, mrcs
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The current and future use of imaging in urological robotic surgery: A survey of the European Association of Robotic Urological Surgeons Archie Hughes-Hallett, MRCS1, Erik K Mayer, PhD1, Philip Pratt, PhD2, Alex Mottrie, PhD3,4, Ara Darzi, FRS1,2, Justin Vale, MS1, Department of Surgery and Cancer, Imperial College London The Hamlyn Centre for Robotic Surgery, Imperial College London Department of Urology, OLV Clinic, Aalst, Belgium O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium Corresponding Author Erik Mayer, Department of Surgery and Cancer, Imperial College London, St Marys Hospital Campus, London, W2 1NY 07984195642 e.mayer@imperial.ac.uk
Word count manuscript text: 2,142 5 figures and 2 tables
Introduction Since Röntgen first utilised x-rays to image the carpal bones of the human hand in 1895, medical imaging has evolved and is now able to provide a detailed representation of a patient’s intracorporeal anatomy, with recent advances now allowing for 3-dimensional (3D) reconstructions. The visualisation of anatomy in 3D has been shown to improve the ability to localize structures when compared to 2D with no change in the amount of cognitive loading [1]. This has allowed imaging to move from a largely diagnostic tool to one that can be used for both diagnosis and operative planning.
A web based survey instrument was designed and sent out, as part of a larger survey, to members of the EAU Robotic Urology Section (ERUS). Only independently practising robotic surgeons performing RALP, RAPN and/or robotic cystectomy were included in the analysis, those surgeons exclusively performing other procedures were excluded. Respondents were offered no incentives to reply. All data collected was anonymous. Survey design and administration The questionnaire was created using the LimeSurvey platform (www.limesurvey.com) and hosted on their website. All responses (both complete and incomplete) were included in the analysis. The questionnaire was dynamic with the questions displayed tailored to the respondents’ previous answers. When computing fractions or percentages the denominator was the number of respondents to answer the question, this number is variable due to the dynamic nature of the questionnaire. Survey Content Demographics All respondents to the survey were asked in what country they practised and what robotic urological procedures they performed, in addition to what procedures they performed surgeons were asked specify the number of cases they had undertaken for each procedure. Current Imaging Practice Procedure-specific questions in this group were displayed according to the operations the respondent performed. A summary of the questions can be seen in appendix 1. Procedure non-specific questions were also asked. Participants were asked whether they routinely used the Tile Pro™ function of the da Vinci console (Intuitive Surgical, Sunnyvale, USA) and whether they routinely viewed imaging intraoperatively. Augmented Reality Prior to answering questions in this section, participants were invited to watch a video demonstrating an augmented reality platform during Robot-Assisted Partial Nephrectomy (RAPN), performed by our group at Imperial College London. A still from this video can be seen in figure 1. They were then asked whether they felt augmented reality would be of use as a navigation or training tool in robotic surgery. Once again, in this section, procedure-specific questions were displayed according to the operations the respondent performed. Only those respondents who felt augmented reality would be of use as a navigation tool were asked procedure-specific questions. Questions were asked to establish where in these procedures they felt an augmented reality environment would be of use. Results Demographics Of the 239 respondents completing the survey 117 were independently practising robotic surgeons and were therefore eligible for analysis. The majority of the surgeons had both trained (210/239, 87.9%) and worked in Europe (215/239, 90.0%). The median number of cases undertaken by those surgeons reporting their case volume was: 120 (6 - 2000), 9 (1 – 120) and 30 (1 – 270), for RALP, Robot assisted cystectomy and RAPN respectively. Contemporary use of imaging in robotic surgery When enquiring about the use of imaging for surgical planning, the majority of surgeons (57%, 65/115) routinely viewed preoperative imaging intraoperatively with only 9% (13/137) routinely capitalising on the TilePro™ function in the console to display these images, when assessing the use of TilePro™ amongst surgeons who performed RAPN 13.8% (9/65) reported using the technology routinely. When assessing the imaging modalities that are available to a surgeon in theatre the majority of surgeons performing RALP (74%, 78/106)) reported using MRI with an additional 37% (39/106) reporting the use of CT for preoperative staging and/or planning. For surgeons performing RAPN and robot-assisted cystectomy there was more of a consensus with 97% (68/70) and 95% (54/57) of surgeons, respectively, using CT for routine preoperative imaging (table 1). Those surgeons performing RAPN were found to have the most diversity in the way they viewed preoperative images in theatre, routinely viewing images in sagittal, coronal and axial slices (table 2). The majority of these surgeons also viewed the images as 3D reconstructions (54%, 38/70). The majority of surgeons used ultrasound intraoperatively in RAPN (51%, 35/69) with a further 25% (17/69) reporting they would use it if they had access to a ‘drop-in’ ultrasound probe (figure 3). Desire for augmented reality In all 87% of respondents envisaged a role for augmented reality as a navigation tool in robotic surgery and 82% (88/107) felt that there was an additional role for the technology as a training tool. The greatest desire for augmented reality was amongst those surgeons performing RAPN with 86% (54/63) feeling the technology would be of use. The largest group of surgeons felt it would be useful in identifying tumour location, with significant numbers also feeling it would be efficacious in tumour resection (figure 4). When enquiring about the potential for augmented reality in Robot-Assisted Laparoscopic Prostatectomy (RALP), 79% (20/96) of respondents felt it would be of use during the procedure, with the largest group feeling it would be helpful for nerve sparing 65% (62/96) (Figure 2). The picture in cystectomy was similar with 74% (37/50) of surgeons believing augmented reality would be of use, with both nerve sparing and apical dissection highlighted as specific examples (40%, 20/50) (Figure 5). The majority also felt that it would be useful for lymph node dissection in both RALP and robot assisted cystectomy (55% (52/95) and 64% (32/50) respectively). Discussion The results from this study suggest that the contemporary robotic surgeon views imaging as an important adjunct to operative practice. The way these images are being viewed is changing; although the majority of surgeons continue to view images as two-dimensional (2D) slices a significant minority have started to capitalise on 3D reconstructions to give them an improved appreciation of the patient’s anatomy. This study has highlighted surgeons’ willingness to take the next step in the utilisation of imaging in operative planning, augmented reality, with 87% feeling it has a role to play in robotic surgery. Although there appears to be a considerable desire for augmented reality, the technology itself is still in its infancy with the limited evidence demonstrating clinical application reporting only qualitative results [3,11–13]. There are a number of significant issues that need to be overcome before augmented reality can be adopted in routine clinical practice. The first of these is registration (the process by which two images are positioned in the same coordinate system such that the locations of corresponding points align [14]). This process has been performed both manually and using automated algorithms with varying degrees of accuracy [2,15]. The second issue pertains to the use of static preoperative imaging in a dynamic operative environment; in order for the preoperative imaging to be accurately registered it must be deformable. This problem remains as yet unresolved. Live intraoperative imaging circumvents the problems of tissue deformation and in RAPN 51% of surgeons reported already using intraoperative ultrasound to aid in tumour resection. Cheung and colleagues [9] have published an ex-vivo study highlighting the potential for intraoperative ultrasound in augmented reality partial nephrectomy. They report the overlaying of ultrasound onto the operative scene to improve the surgeon’s appreciation of the subsurface tumour anatomy, this improvement in anatomical appreciation resulted in improved resection quality over conventional ultrasound guided resection [9]. Building on this work the first in vivo use of overlaid ultrasound in RAPN has recently been reported [10]. Although good subjective feedback was received from the operating surgeon, the study was limited to a single case demonstrating feasibility and as such was not able to show an outcome benefit to the technology [10]. RAPN also appears to be the area in which augmented reality would be most readily adopted with 86% of surgeons claiming they see a use for the technology during the procedure. Within this operation there are two obvious steps to augmentation, anatomical identification (in particular vessel identification to facilitate both routine ‘full clamping’ and for the identification of secondary and tertiary vessels for ‘selective clamping’ [16]) and tumour resection. These two phases have different requirements from an augmented reality platform; the first phase of identification requires a gross overview of the anatomy without the need for high levels of registration accuracy. Tumour resection, however, necessitates almost sub-millimetre accuracy in registration and needs the system to account for the dynamic intraoperative environment. The step of anatomical identification is amenable to the use of non-deformable 3D reconstructions of preoperative imaging while that of image-guided tumour resection is perhaps better suited to augmentation with live imaging such as ultrasound [2,9,17]. For RALP and robot-assisted cystectomy the steps in which surgeons felt augmented reality would be of assistance were those of neurovascular bundle preservation and apical dissection. The relative, perceived, efficacy of augmented reality in these steps correlate with previous examinations of augmented reality in RALP [18,19]. Although surgeon preference for utilising AR while undertaking robotic prostatectomy has been demonstrated, Thompson et al. failed to demonstrate an improvement in oncological outcomes in those patients undergoing AR RALP [19]. Both nerve sparing and apical dissection require a high level of registration accuracy and a necessity for either live imaging or the deformation of preoperative imaging to match the operative scene; achieving this level of registration accuracy is made more difficult by the mobilisation of the prostate gland during the operation [18]. These problems are equally applicable to robot-assisted cystectomy. Although guidance systems have been proposed in the literature for RALP [3,4,13,18,20], none have achieved the level of accuracy required to provide assistance during nerve sparing. Additionally, there are still imaging challenges that need to be overcome. Although multiparametric MRI has been shown to improve decision making in opting for a nerve sparing approach to RALP [21] the imaging is not yet able to reliably discern the exact location of the neurovascular bundle. This said significant advances are being made with novel imaging modalities on the horizon that may allow for imaging of the neurovascular bundle in the near future [22]. Limitations The number of operations included represents a significant limitation of the study, had different index procedures been chosen different results may have been seen. This being said the index procedures selected were chosen as they represent the vast majority of uro-oncological robotic surgical practice, largely mitigating for this shortfall. Although the available ex-vivo evidence suggests that introducing augmented reality operating environments into surgical practice would help to improve outcomes [9,23] the in-vivo experience to date is limited to small volume case series reporting feasibility [2,3,15]. To date no study has demonstrated an in-vivo outcome advantage to augmented reality guidance. In addition to this limitation augmented reality has been demonstrated to increased rates of inattention blindness amongst surgeons suggesting there is a trade of between increasing visual information and the surgeon’s ability to appreciate unexpected operative events [23]. Conclusions This survey depicts the contemporary robotic surgeon to be comfortable with the use of imaging to aid in intraoperative planning; furthermore it highlights a significant interest amongst the urological community in augmented reality operating platforms. Short to medium term development of augmented reality systems in robotic urology surgery would be best performed using RAPN as the index procedure. Not only was this the operation where surgeons saw the greatest potential benefits, but it may also be the operation where it is most easily achievable by capitalising on the respective benefits of technologies the surgeons are already using; preoperative CT for anatomical identification and intraoperative ultrasound for tumour resection. Conflicts of Interest None of the authors have any conflicts of interest to declare References 1. Foo J-L, Martinez-Escobar M, Juhnke B, Cassidy K, Hisley K, Lobe T, Winer E. Evaluating mental workload of two-dimensional and three-dimensional visualization for anatomical structure localization. J Laparoendosc Adv Surg Tech A. 2013;23(1):65–70. 2. Hughes-Hallett A, Mayer EK, Marcus HJ, Cundy TP, Pratt PJ, Darzi AW, Vale J. Augmented Reality Partial Nephrectomy: Examining the Current Status and Future Perspectives. Urology; 2014;83(2):266–73. 3. Sridhar AN, Hughes-Hallett A, Mayer EK, Pratt PJ, Edwards PJ, Yang G-Z, Darzi AW, Vale J. Image-guided robotic interventions for prostate cancer. Nat Rev Urol. 2013;10(8):452–62. 4. Cohen D, Mayer E, Chen D, Anstee A, Vale J, Yang G-Z, Darzi A, Edwards P “Eddie.” Augmented reality image guidance in minimally invasive prostatectomy. Lect Notes Comput Sci. 2010;6367:101–10. 5. Simpfendorfer T, Baumhauer M, Muller M, Gutt CN, Meinzer HP, Rassweiler JJ, Guven S, Teber D. Augmented reality visualization during laparoscopic radical prostatectomy. J Endourol. 2011;25(12):1841–5. 6. 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Augmented reality visualization during laparoscopic radical prostatectomy. J Endourol. 2011;25(12):1841–5. 21. Panebianco V, Salciccia S, Cattarino S, Minisola F, Gentilucci A, Alfarone A, Ricciuti GP, Marcantonio A, Lisi D, Gentile V, Passariello R, Sciarra A. Use of Multiparametric MR with Neurovascular Bundle Evaluation to Optimize the Oncological and Functional Management of Patients Considered for Nerve-Sparing Radical Prostatectomy. J Sex Med. 2012;9(8):2157–66. 22. Rai S, Srivastava A, Sooriakumaran P, Tewari A. Advances in imaging the neurovascular bundle. Curr Opin Urol. 2012;22(2):88–96. 23. Dixon BJ, Daly MJ, Chan H, Vescan AD, Witterick IJ, Irish JC. Surgeons blinded by enhanced navigation: the effect of augmented reality on attention. Surg Endosc. 2013;27(2):454–61. Tables
Figure Legends Figure 1 – A still taken from a video of augmented reality robot assisted partial nephrectomy performed. Here the tumour has been painted into the operative view allowing the surgeon to appreciate the relationship of the tumour to the surface of the kidney. Figure 2 – Chart demonstrating responses to the question - In robotic prostatectomy which parts of the operation do you feel augmented reality image overlay would be of assistance? Figure 3 - Chart demonstrating responses to the question - Do you use intraoperative ultrasound for robotic partial nephrectomy? Figure 4 - Chart demonstrating responses to the question – In robotic partial nephrectomy which parts of the operation do you feel augmented reality image overlay would be of assistance? Figure 5 - Chart demonstrating responses to the question – In robotic cystectomy which parts of the operation do you feel augmented reality overlay technology would be of assistance? Directory: bitstream -> 10044 bitstream -> Present state of the area 10044 -> A new Method to Determine Dispersive Surface Energy Site Distributions by Inverse Gas Chromatography 10044 -> A case study of japanese language teaching 10044 -> Palaeomagnetic evidence for the persistence or recurrence of geomagnetic main field anomalies in the South Atlantic 10044 -> Blair W. McPhee, a, b, c 10044 -> Inattention blindness in surgery 10044 -> Intraoperative ultrasound overlay in robot assisted partial nephrectomy 10044 -> Micronutrient supplementation augments anti-mycobacterial immune responses in tst reactive household contacts 10044 -> 100 mg/dL, and in Patients Already 10044 -> Guidelines for the Use and Interpretation of Assays for Monitoring Autophagy 2 Download 73.64 Kb. Share with your friends:
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