Mobile eHealth apps are becoming increasingly important tools in healthcare management, capable of providing education and support at any time. There is little knowledge about surgical patients' appreciation and use of these apps. The objective of this study was to develop and evaluate a user-friendly medical app (PIA; Patient Information Assistant) for providing individual patient information before and after inpatient urological surgery. Twenty-two patients aged 35 to 75 years were provided with timely information, push notifications, and personalized agendas (e.g., date of presentation, time of surgery, time of doctor's consultation, imaging appointment) via the PIA app. Of the 22 patients, 19 evaluated the PIA app in terms of usage and usability, benefits, and potential for improvement. Of the study participants, 95% did not need any assistance to use the app, 74% confirmed that the PIA app made them feel better informed and more satisfied with their hospital stay, and 89% stated that they would like to re-use the PIA app and support the general use of medical apps in healthcare. Thus, we created an innovative digital health information tool, allowing targeted support for doctor-nurse-patient communication and offering great potential for patient support before and after surgery. Our study revealed that use of an app during the surgical hospital stay is readily accepted and benefits patients by acting as an additional informative tool.

Background Although digital and data-based technologies are widespread in various industries in the context of Industry 4.0, the use of smart connected devices in health care is still in its infancy. Innovative solutions for the medical environment are affected by difficult access to medical device data and high barriers to market entry because of proprietary systems. Objective In the proof-of-concept project OP 4.1, we show the business viability of connecting and augmenting medical devices and data through software add-ons by giving companies a technical and commercial platform for the development, implementation, distribution, and billing of innovative software solutions. Methods The creation of a central platform prototype requires the collaboration of several independent market contenders, including medical users, software developers, medical device manufacturers, and platform providers. A dedicated consortium of clinical and scientific partners as well as industry partners was set up. Results We demonstrate the successful development of the prototype of a user-centric, open, and extensible platform for the intelligent support of processes starting with the operating room. By connecting heterogeneous data sources and medical devices from different manufacturers and making them accessible for software developers and medical users, the cloud-based platform OP 4.1 enables the augmentation of medical devices and procedures through software-based solutions. The platform also allows for the demand-oriented billing of apps and medical devices, thus permitting software-based solutions to fast-track their economic development and become commercially successful. Conclusions The technology and business platform OP 4.1 creates a multisided market for the successful development, implementation, distribution, and billing of new software solutions in the operating room and in the health care sector in general. Consequently, software-based medical innovation can be translated into clinical routine quickly, efficiently, and cost-effectively, optimizing the treatment of patients through smartly assisted procedures.

Augmented reality (AR) systems are currently being explored by a broad spectrum of industries, mainly for improving point-of-care access to data and images. Especially in surgery and especially for timely decisions in emergency cases, a fast and comprehensive access to images at the patient bedside is mandatory. Currently, imaging data are accessed at a distance from the patient both in time and space, i.e., at a specific workstation. Mobile technology and 3-dimensional (3D) visualization of radiological imaging data promise to overcome these restrictions by making bedside AR feasible.

Surgical navigation, image guided surgery or computer assisted surgery describe more or less the same idea of computing und presenting pre- and intraoperative data from any source in real time to help surgeons doing their work better or easier. Among acoustic and visual presentation methods augmented reality is most spread and seems to be most accepted among the users. Data sources are mainly imaging methods like 3D-ultrasound, MRI, CT and others as well as optic, acoustic, magnetic or mechanic tracking methods. There are many published navigation systems for diagnostics and therapy in urology. Especially methods using screens like prostate biopsy or laparoscopy are ideal to integrate augmented reality. But also open surgery can profit by navigation. Mostly the systems are still under development and not jet applied by routine. After an introduction to the basic steps of surgical navigation which are preoperative imaging, intraoperative imaging and tracking four promising applications and their integration into daily practice are presented.

Introduction: Laparoscopic partial nephrectomy (LPN) remains challenging in endophytic and complex kidney tumors as the clear understanding of tumor location and spreading depends on a precise analysis of available imaging. The purpose of this study was to investigate navigated kidney surgery using intraoperative cone-beam computed tomography (CBCT) images in conjunction with a previously proposed method for augmented reality (AR) guidance for safe LPN. Materials and Methods: The concept proposed is based on using an intraoperative CBCT scan for (1) marker-based AR guidance for fast and reliable tumor access and (2) enhancement of real-time fluoroscopy images for accurate tumor resection. Workflow and accuracy of the system were assessed using a porcine kidney model. Ten patients with complex or endophytic tumor localization and R.E.N.A.L. Nephrometry Score of at least nine scheduled for LPN were included in this study. Patients received an intraoperative CBCT after marker placement. Defining the resection line was assisted by AR. In addition, fluoroscopy imaging for depth perception was used for assistance during dissection. Feasibility and performance were assessed by histopathological results, peri- and postoperative data. Results: Surgery was performed successfully and negative margins were found in all cases. Segmental branches of the renal artery shifted as much as 10mm in the vertical and 11mm in the sagittal axis intraoperatively compared to preoperative imaging. Fluoroscopy to intraoperative computed tomography image fusion enabled enhanced depth perception during dissection in all cases. Radiation dose area product was 4.8mGym(2). Conclusions: The application of the navigation system is feasible and allows for safe and direct access to complex or endophytic renal masses. Radiation limits the application to selected indications.

Laparoskopische Interventionen erfordern die präzise Navigation von chirurgischen Instrumenten unter Berücksichtigung von Risikostrukturen. Obwohl zahlreiche Konzepte zur Einblendung von anatomischen Details auf Basis intraoperativer Registrierungsmethoden existieren, scheitert die klinische Translation bislang an fehlender Robustheit und aufwendiger Integration in den klinischen Arbeitsablauf. In diesem Beitrag präsentieren wir einen neuartigen Ansatz zur robusten intraoperativen Datenfusion basierend auf fluoreszierenden Markern. In einer in vitro Pilotstudie zeigen wir, dass sich die neuen Marker im Gegensatz zu herkömmlichen Nadelmarkern auch in der Gegenwart von Rauch, Blut oder Gewebestücken im Sichtfeld der laparoskopischen Kamera lokalisieren und tracken lassen. So wird eine robuste Registrierung von 3D-Bilddaten mit der aktuellen Patientenanatomie ermöglicht. Durch die einfache Integrierbarkeit in den medizinischen Arbeitsablauf ist das Potential des neuen Ansatzes hoch.

PURPOSETo show the benefit of three-dimensional (3D) reconstructions of preoperative imaging for surgical performance.METHODSA laparoscopic training environment with 15 hidden lymph nodes was designed. Three of them were marked with radiographic contrast agent and were only distinguishable from unmarked nodes via CT imaging. Thirty-six surgeons were divided into two groups. To group 1 the unprocessed CT data were shown. Group 2 was additionally shown a 3D reconstruction of the anatomy. Time of studying the imaging was recorded. All surgeons had to find the three target lymph nodes laparoscopically. Time to fulfill this task and errors was measured. Afterward, the 3D reconstruction was also shown to group 1. Then, all participants completed a questionnaire. Furthermore, 3D reconstructions were used in 15 clinical cases of partial nephrectomy or lymphadenectomy, and surgeons' opinion was evaluated with an additional questionnaire. The imaging and 3D reconstructions were available on a mobile device.RESULTSThe time of studying the imaging to gain confidence was significantly shorter with the 3D reconstruction. Laparoscopic intervention time was shortened and errors were reduced significantly within group 2. The clinical application of 3D reconstructions in difficult cases was believed to be helpful.CONCLUSIONS3D reconstructions of preoperative imaging lead to better surgical performance in a difficult laparoscopic training environment. Surgeons gain a 3D impression of patients' individual anatomy easier, faster, and more reliable. Providing 3D reconstructions previous to surgery should be routinely implemented for patients with complex anatomical situations.

PURPOSE:Laparoscopic interventions require the precise navigation of medical instruments through the patient's body, while taking critical structures into account. Although numerous concepts have been proposed for displaying subsurface anatomical detail using augmented reality, clinical translation of these methods has suffered from a lack of robustness as well as from cumbersome integration into the clinical workflow. The purpose of this study was to investigate the feasibility of a new approach to intra-operative registration based on fluorescent markers.METHODS:The proposed approach to augmented reality visualization relies on metabolizable fluorescent markers that are attached to the target organ to guide a 2D/3D intra-operative registration algorithm. In an ex vivo porcine study, marker tracking performance is evaluated in the presence of smoke, blood, and tissue in the field of view of the endoscope.RESULTS:In contrast to state-of-the-art needle-shaped fiducial markers, the fluorescent markers can be reliably tracked when occluded by smoke, blood or tissue. This makes the new 2D/3D intra-operative registration approach considerably more robust than state-of-the-art marker-based methods.CONCLUSION:As the concept can be smoothly integrated into the clinical workflow, its potential for application in clinical laparoscopy is high.

During autopsy, forensic pathologists today mostly rely on visible indication, tactile perception and experience to determine the cause of death. Although computed tomography (CT) data is often available for the bodies under examination, these data are rarely used due to the lack of radiological workstations in the pathological suite. The data may prevent the forensic pathologist from damaging evidence by allowing him to associate, for example, external wounds to internal injuries. To facilitate this, we propose a new multimodal approach for intuitive visualization of forensic data and evaluate its feasibility.

PURPOSE OF REVIEW:Use of virtual reality to navigate open and endoscopic surgery has significantly evolved during the last decade. Current status of seven most interesting projects inside the European Association of Urology section of uro-technology is summarized with review of literature.RECENT FINDINGS:Marker-based endoscopic tracking during laparoscopic radical prostatectomy using high-definition technology reduces positive margins. Marker-based endoscopic tracking during laparoscopic partial nephrectomy by mechanical overlay of three-dimensional-segmented virtual anatomy is helpful during planning of trocar placement and dissection of renal hilum. Marker-based, iPAD-assisted puncture of renal collecting system shows more benefit for trainees with reduction of radiation exposure. Three-dimensional laser-assisted puncture of renal collecting system using Uro-Dyna-CT realized in an ex-vivo model enables minimal radiation time. Electromagnetic tracking for puncture of renal collecting system using a sensor at the tip of ureteral catheter worked in an in-vivo model of porcine ureter and kidney. Attitude tracking for ultrasound-guided puncture of renal tumours by accelerometer reduces the puncture error from 4.7 to 1.8 mm. Feasibility of electromagnetic and optical tracking with the da Vinci telemanipulator was shown in vitro as well as using in-vivo model of oesophagectomy. Target registration error was 11.2 mm because of soft-tissue deformation.SUMMARY:Intraoperative navigation is helpful during percutaneous puncture collecting system and biopsy of renal tumour using various tracking techniques. Early clinical studies demonstrate advantages of marker-based navigation during laparoscopic radical prostatectomy and partial nephrectomy. Combination of different tracking techniques may further improve this interesting addition to video-assisted surgery.

Methoden zur Oberflächenregistrierung sind häufig zentraler Bestandteil verschiedener Anwendungen basierend auf Tiefenbildkameras. Der Iterative Closest Point (ICP) Algorithmus wird oft für die rigide Feinregistrierung verwendet, bezieht jedoch a-priori Wissen über die für Tiefenbildkameras typischen anisotropen Messfehler nicht in die Transformationsberechnung mit ein. Eine kürzlich vorgestellte, als anisotroper ICP (A-ICP) bezeichnete Erweiterung des ICP kompensiert diese Probleme, konnte wegen der hohen Laufzeit bislang jedoch nicht für zeitkritische Anwendungen eingesetzt werden. In dieser Arbeit zeigen wir, dass man die Laufzeit des A-ICP mittels General Purpose Computation on Graphics Processing Unit (GPGPU)-Implementierung deutlich verringern kann. Eine in silico Studie auf öffentlich verfügbaren Daten lieferte abhängig von der Oberflächengröße einen Geschwindigkeitsgewinn um den Faktor 22 (1000 Punkte pro Oberfläche) bis 149 (50.000 Punkte pro Oberfläche) im Vergleich zur Central Processing Unit (CPU) Implementierung. Des Weiteren zeigen wir anhand einer Softwaredemonstration auf der BVM 2014, dass die GPU-basierte Variante des A-ICP für die Echtzeitvisualisierung im Kontext der mobilen erweiterten Realität geeignet ist.

Percutaneous nephrolithotomy (PCNL) is the most commonly used procedure to remove large stones from the human kidney. To improve the speed and safety of PCNL, researchers have been developing an intraoperative navigation system which employs a marker-based registration technique to superimpose CT images on the video stream of a tablet computer. In this paper, we present our work on the fusion of intraoperative X-ray and video aimed at improving the existing system. For the fusion, we used automatic marker-detection algorithms and then processed the data by using thin-plate spline transformation and landmark warping. The evaluation of the technique was performed by testing it on a silicone phantom. The results of the evaluation are very promising, showing a mean geometrical error of 0.9 mm. The aggregated runtime of our algorithms is 0.086 ms, which gives the fusion real-time capability. The fusion enables the detection of organ deformations by the surgeon. Possible future work could include the development of a registration framework to automatically detect organ deformations. Furthermore, algorithms for needle detection in fluoroscopic images would greatly improve intraoperative navigation. The location of the needle could then be superimposed on the tablet screen.

Ultraschall (US) als bildgebendes Verfahren in der Medizin ist nicht invasiv, schnell, vielerorts verfügbar, kommt ohne Strahlenbelastung aus und liefert kontinuierlich Daten in Echtzeit. Die Nutzung von US für computerassistierte Interventionen (CAI) stellt jedoch nicht nur extrem hohe Anforderungen an die Methoden zur Bildverarbeitung aufgrund der beschränkten Bildqualität, sondern bedeutet auch einen beträchtlichen Integrationsaufwand wenn die Daten in Echtzeit weiterverarbeitet werden sollen. Mit MITK-US stellen wir in dieser Arbeit ein neues Modul für das Open Source verfügbare Medical Imaging Interaction Toolkit (MITK) vor, welches die einheitliche Einbindung und Weiterverarbeitung von Echtzeitultraschalldaten ermöglicht und somit den Aufwand für die Integration von US in CAI Systeme verringert. Da die Verwendung von Echtzeitdaten insbesondere im Bereich der CAI zahlreiche neue Möglichkeiten bietet, erwarten wir einen hohen Nutzen dieses Moduls für künftige Projekte.

PURPOSE:The Medical Imaging Interaction Toolkit (MITK) has been available as open-source software for almost 10 years now. In this period the requirements of software systems in the medical image processing domain have become increasingly complex. The aim of this paper is to show how MITK evolved into a software system that is able to cover all steps of a clinical workflow including data retrieval, image analysis, diagnosis, treatment planning, intervention support, and treatment control.METHODS:MITK provides modularization and extensibility on different levels. In addition to the original toolkit, a module system, micro services for small, system-wide features, a service-oriented architecture based on the Open Services Gateway initiative (OSGi) standard, and an extensible and configurable application framework allow MITK to be used, extended and deployed as needed. A refined software process was implemented to deliver high-quality software, ease the fulfillment of regulatory requirements, and enable teamwork in mixed-competence teams.RESULTS:MITK has been applied by a worldwide community and integrated into a variety of solutions, either at the toolkit level or as an application framework with custom extensions. The MITK Workbench has been released as a highly extensible and customizable end-user application. Optional support for tool tracking, image-guided therapy, diffusion imaging as well as various external packages (e.g. CTK, DCMTK, OpenCV, SOFA, Python) is available. MITK has also been used in several FDA/CE-certified applications, which demonstrates the high-quality software and rigorous development process.CONCLUSIONS:MITK provides a versatile platform with a high degree of modularization and interoperability and is well suited to meet the challenging tasks of today's and tomorrow's clinically motivated research.

Percutaneous nephrolithotomy (PCNL) plays an integral role in treatment of renal stones. Creating percutaneous renal access is the most important and challenging step in the procedure. To facilitate this step, we evaluated our novel mobile augmented reality (AR) system for its feasibility of use for PCNL.

Electromagnetic tracking (EMT) systems are gaining increased attention in various fields of image-guided surgery. One of the main problems related to EMT systems is their vulnerability to distortion due to metallic objects. Several methods have been introduced to evaluate electromagnetic trackers, yet, the data acquisition has to be manually performed in a time consuming procedure, which often leads to a sparse volume coverage. The aim of this work is to present a fully automatic calibration system. It consists of a novel, parallel robotic arm and has the potential to collect a very large number of tracking data while scanning the entire tracking volume of a field generator. To prove the feasibility of our system, we evaluate two electromagnetic field generators (NDI Planar and Tabletop) in an ideal metal-free environment and in a clinical setup. Our proposed calibration robot successfully performed throughout the experiments and examined 1,000 positions in the tracking volume of each field generator (FG). According to the results both FGs are highly accurate in an ideal environment. However, in the examined clinical setup, the Planar FG is strongly distorted by metallic objects. Whereas the Tabletop FG provided very robust and accurate tracking, even if metallic objects where lying directly underneath the FG.