Improving pre-operative planning of robot assisted nephron sparing surgery using three-dimensional anatomical model

Introduction Despite the introduction of robot-assisted surgery in daily clinical practice, complex renal masses are still challenging even for expert surgeon. In this scenario 3D anatomical models and augmented reality represent valuable tools for the surgeon. Materials and methods We present a challenging case where PN was mandatory to preserve the overall renal function. The patient was 69 years old, with indwelling catheter for BPH and Parkinson disease. After a single episode of hematuria with negative cystoscopy, a cT1N0M0 renal cancer was diagnosed (38 mm maximum diameter). Pre-operative three-dimensional (3D) model was obtained. After multidisciplinary discussion robot-assisted partial nephrectomy was proposed. The surgery was planned according to the anatomical model. Results Before the procedure a 7Ch single loop ureteral stent was placed. The surgery was carried out in 220 minutes. Selective ischaemia was perfomed for 24 minutes. Estimated blood loss was 400cc. No post-operative complications were observed. Ureteral stent was removed 4 days after the surgery. Definitive histological examination described a pG2-3 T1a Nx R0 clear cell renal carcinoma. Conclusion In selected cases 3D model result to be a useful tool for the pre-operative planning of the surgery

Interactive virtual 3D image reconstruction to assist renal surgery in patients with fusion anomalies of the kidney

Objective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney. / Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans. / Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively. / Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach. / Oxford Centre for Evidence-Based Medicine Evidence Level: 4

Interactive virtual 3D models of renal cancer patient anatomies alter partial nephrectomy surgical planning decisions and increase surgeon confidence compared to volume-rendered images

PURPOSE: To determine whether the interactive visualisation of patient-specific virtual 3D models of the renal anatomy influences the pre-operative decision-making process of urological surgeons for complex renal cancer operations. METHODS: Five historic renal cancer patient pre-operative computed tomography (CT) datasets were retrospectively selected based on RENAL nephrectomy score and variety of anatomy. Interactive virtual 3D models were generated for each dataset using image segmentation software and were made available for online visualisation and manipulation. Consultant urologists were invited to participate in the survey which consisted of CT and volume-rendered images (VRI) for the control arm, and CT with segmentation overlay and the virtual 3D model for the intervention arm. A questionnaire regarding anatomical structures, surgical approach, and confidence was administered. RESULTS: Twenty-five participants were recruited (54% response rate), with 19/25 having > 5 years of renal surgery experience. The median anatomical clarity score increased from 3 for the control to 5 for the intervention arm. A change in planned surgical approach was reported in 19% of cases. Virtual 3D models increased surgeon confidence in the surgical decisions in 4/5 patient datasets. There was a statistically significant improvement in surgeon opinion of the potential utility for decision-making purposes of virtual 3D models as compared to VRI at the multidisciplinary team meeting, theatre planning, and intra-operative stages. CONCLUSION: The use of pre-operative interactive virtual 3D models for surgery planning influences surgical decision-making. Further studies are needed to investigate if the use of these models changes renal cancer surgery outcomes

Introducing new dimensions in pediatric oncologic surgery

In the Netherlands, approximately 30 children per year are diagnosed with kidney cancer. For most patients, the entire kidney along with the tumor is surgically removed (Total Nephrectomy, TN). For the other patients, the tumor is removed from the kidney (Nephron-Sparing Surgery, NSS). NSS is performed on children with bilateral tumors or children with specific overgrowth syndromes. NSS is only performed under very strict conditions in children who have a unilateral tumor and no overgrowth syndromes. This is because NSS is very challenging, and the tumor is not completely removed in 13.3% to 36.4% of the surgeries. Despite this, NSS is expected to have benefits compared to TN. For instance, the likelihood of chronic kidney disease later in life could be reduced. In this dissertation, we conducted research to make NSS more feasible for this specific patient group. First, we examined which patients in this group could be eligible for NSS surgically. There are oncological guidelines for this decision, but no surgical guidelines exist yet. Therefore, we conducted an international Delphi consensus study among experts in the field of NSS. The other part of our study focused on technical improvements in NSS. For this, we developed and implemented 3D technology in our surgical care. Using 3D models, a surgeon can prepare for an operation and gain a better understanding of the anatomical relationships of a patient's tumor. Additionally, we worked on surgical navigation using a holographic 3D model. The 3D model is projected holographically into a patient. This should make it easier to locate the tumor and improve the surgeon's depth perception. Following these two research directions, I looked at the impact of 3D models on surgical outcomes for patients who underwent NSS at the Princess Máxima Center. We observed a trend in decreased unexpected incomplete tumor removal in surgeries where the surgeon used a 3D model during preparation. In summary, we have taken steps to improve surgical decision-making and techniques for children with kidney tumors where nephron-sparing surgery could be possible