Augmented Reality to Guide Selective Clamping and Tumor Dissection During Robot-assisted Partial Nephrectomy: A Preliminary Experience

Clinical Practice Points•Three-dimensional (D) models can be used as additional preoperative tools to improve the understanding of size, location, depth a renal mass and vascular anatomy before robot-assisted partial nephrectomy (RAPN).•During RAPN, augmented reality (AR) technology with overlapping 3D inside robotic console, facilitate fast accurate anatomic identification vasculature tumor in real-time manner.•The 3D-guided approach AR during RAPN allows surgeon perform selective super-selective clamping higher proportion cases compared conventional planning based on 2D imaging.•The effective intraoperative management hilum guided by guidance was performed preoperatively planned 86.7% patients.•Three-D were more than standard imaging evaluate surgical complexity masses according nephrometry scores.•The use for surgery is useful knowledge adoption safe outcomes. •Three-dimensional Robot-assisted (RAPN) has been increasingly adopted treatment T1 lead perioperative outcomes.1Ljungberg B. 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We prospectively enrolled 15 consecutive diagnoses mass, scheduled at our institution between December 2018 June 2019. One single experienced (R.S.) all cases. Participants signed written informed consent document. study approved Institutional Ethics Committee (IRB approval 3386/2018). scored PADUA22Laverdière R.E.N.A.L.24Kutikov Uzzo R.G. R.E.N.A.L. score: comprehensive standardized quantitating location depth.J 2009; 182: 844-853Crossref (1410) score imaging. Then, PADUA scores25Schiavina Novara borghesi al.PADUA scores correlate analysis Vattikuti Global Quality Initiative Robotic Urologic Surgery (GQI-RUS) database.BJU Int. (accessed October 7, 2020)https://doi.org/10.1111/bju.13628Crossref (53) each lesion re-assessed separate section, using virtual model. define (namely, no clamping, non-selective, [first branch], [second tertiary branch] clamping) recorded basing reviewing surgery. To obviate bias inaccurate imaging, surgery, underwent high-quality chest abdominal contrast-enhanced computed tomography (CT) (slice thickness, 1.25 × 2.5 mm; interval, 0.8 2.0 mm) angiography protocol. Intravenous non-ionic contrast material (Iomeprol 350 mg/mL, Iomeron; Bracco Imaging srl, Milan, Italy) injected flow 3 mL/s. delay scanning determined basis typical (25-30 seconds), parenchymal (80-100 delayed (5-10 minutes) phases. All reconstructions CT scans, carried out Laboratory Bioengineering DIMES Department University Bologna. Multiple series levels anatomical structure interest (healthy parenchyma, lesion, tree, veins, collecting system) image segmentation process. Segmentation (ie, labeling slice) achieved D2P software (‘DICOM PRINT’; Systems Inc, Rock Hill, SC), modular package designed convert DICOM patient into models, CE-certified purpose planning.15Bianchi Manual refinement overall obtained automatic/semi-automatic output 2 4 hours. segmented arising multiple then combined 1 file alignment common regions, such healthy (Figure 1). also obtain converting triangulated surface mesh file, creation methods (contour gridbase). For case, viewed operation dedicated personal computer (PC) operating room. ad-hoc hardware setup 2) haves implemented order develop technique DaVinci stream sent frame grabber (USB3HD, Startech, London, Ontario, Canada) connected AR-dedicated PC (equipped Intel i7 CPU, 8 GB RAM, NVIDIA GeForce 840M card), previously described prostatic surgery.26Schiavina Lodi al.Real-time radical prostatectomy: preliminary experience evaluation planning.Eur Focus. 2020 Aug 31; (S2405-4569(20)30217-0. (12) received view (MeshMixer, Autodesk San Rafael, CA) overlapped (vMIX, StudioCoast Pty Ltd, Robina, Queensland, Australia). end, biomedical engineer employed 6 degrees freedom mouse (SpaceMouse, Connexion, Munich, Germany) manipulating achieve, agreement surgeon, best Da Vinci stream. resulting constituted aligned superimposed actual provided (AR-3D stream) sent, real-time, second monitor quality control and, same time, imported console TilePro. Xi Surgical System (Intuitive Sunnyvale, 4-arm configuration integrated Firefly fluorescence-imaging mode, described.3Bianchi intervention, tumor’s localization AR-3D stream, manually oriented through assistant engineer. plan, 10 mg indocyanine green vessels clamped assess if adequate achieved. If not adequate, non-selective clamp performed. After resection, always inner renorrhaphy outer renorrhaphy, sliding clip described.27Volpe Garrou al.Perioperative elective tumours high complexity.BJU 2014; 114: 903-909Crossref mean deviation continuous variables. Frequencies proportions categorical Correlations PADUA23Ficarra Secco al.Preoperative aspects dimensions (PADUA) who candidates nephron-sparing surgery.Eur 56: 786-793Abstract (631) evaluated without calculated Pearson correlation coefficient. Preoperative model, 3D-AR McNemar test. A P-value < .05 considered significant. statistical tests SPSS 23.0 Windows. Overall, 9 (60%) (40%) tumors stage, respectively (see Supplemental Table online version). revision reconstructions, reassessed (53%) cases, (all P ? .04) version>). follows: (20%), artery (66.7%), (6.7%), (6.7%) modified (13.3%), (53.3%), (26.7%) (P = .03) (Table clampless, selective, 7 (46.7%), (20%) patients, respectively. AR-guidance 13 (86.7%) 2). median warm (considering approach) minutes (IQR, 6-12 minutes). ± SD estimated 140 190 mL. No positive margins observed, major (Clavien ? 3) postoperative complication observed.Table 1Intended Level Arterial Clamping Planned Based Conventional Model Evaluation Effective Approach With AR-assisted Compared Intended (McNeamar Test)Pre-surgical Plan ImagingPre-surgical ModelP ValuePre-surgical ModelIntraoperative RealityP ValueLevel n (%) clamping3 (20)1 (6.7).031 (6.7)2 (13.3).4 Main artery10 (66.7)2 (13.3)2 (13.3)3 (20) (first branch)1 (6.7)8 (53.3)8 (53.3)7 (46.7) Super-selective (second-third (6.7)4 (26.7)4 (26.7)3 (20)Abbreviations: reality; D dimensional. Open table tab 2Intraoperative, Perioperative, Pathologic CharacteristicsOverall, (%)WIT, min 02 (13.3) 1-1913 (86.7) ?200 (0) Median (IQR)9 (6-12)Intraoperative No2 Yes13 (86.7)Intraoperative ICG No5 (33.3) Yes10 (66.7)Operative (IQR)135 (113-177)Time Mean SD9 7Time suturing, SD12 9EBL, mL SD140 190Intraoperative complications No13 Yes2 (13.3)Conversion RN No15 (100) Yes0 (0)Postoperative grade complications12 (80) Clavien 1-22 31 (6.7)Positive (0)Length stay, d (IQR)5 (4-6)Pathologic diameter, cm SD3.6 2.0Pathology Benign2 Clear carcinoma9 (60) Papillary carcinoma2 Chromophobe carcinoma1 (6.7) Other malignancies1 (6.7)Pathologic stage pT1a9 pT1b5 pT3a1 (6.7)Follow-up mos SD4 2Postoperative serum creatinine last follow-up, mg/dL SD0.85 0.18Abbreviations: EBL loss; green; IQR interquartile range; nephrectomy; deviation; WIT time. Abbreviations: Several points remarkable. First, study, observed significant difference reassessment (80% vs. 13.4%) .03). Accordingly, al15Bianchi significantly referred PN individuals (57.1% 13.3%; .01). Moreover, found differences .4). patients. changed clampless exophytic pattern patient, fibrotic tissue increased Our results consistent those al.14Porpiglia Second, console; thus, it surgeons temporarily stop intervention device. Third, reconstruction, .04), better comprehension anatomy, reported.28Porpiglia tumours: tool accuracy scores.BJU 24: 945-954Crossref Fourth, implementation feasible represent Video Finally, 3D-planned proved safe, margins. (13.3%) minor 1-2) only observed: urinary linkage ureteral stenting. revealed suspected involvement detected scan. void limitations. restricted number included limits results. despite being reproduce variability findings related lack precisely defining consistency tissues, patient’s position table, manipulation tissues organs. group did allow modifying approach. limitations consist possible registration inaccuracy, translating poor navigation precision manual external adjustments field.15Bianchi size shape kidney may vary both because surgeon’s organ tissues.29Altamar H.O. Ong R.E. Glisson C.L. al.Kidney deformation intraprocedural registration: elements image-guided surgery.J 511-517Crossref (34) Indeed, displayed moved adjusted field AR, potential reducing tracking lengthening further efforts automatic content (3D model) expected improvement artificial intelligence technology. approaches.