OBJECTIVE:To chronicle the technical evolution of transurethral resection of bladder tumors (TURBT) from early endoscopy to contemporary robotic platforms, analyzing how interdisciplinary innovations addressed persistent challenges in visualization, hemostasis, and resection precision. METHODS:Historical analysis was conducted through examination of primary sources including historical peer-reviewed publications. The technological progression was evaluated across four distinct eras: the development of visualization tools from Bozzini's Lichtleiter to the Nitze-Leiter cystoscope; the integration of electrosurgical techniques beginning with Beer's spark-gap ablation through Bovie-McCarthy resectoscopes; advancements in energy and lasers; and the current digitalization phase featuring robotic platforms and AI detection systems. RESULTS:The historical review revealed significant milestones. Early cystoscopic techniques reduced reliance on open surgery, though hemostasis remained a challenge until the advent of electrosurgery. The late 20th century saw transformative improvements in safety through continuous irrigation systems and bipolar current, while laser technologies enabled more precise tissue resection. Contemporary robotic systems demonstrate enhanced technical capabilities. Artificial intelligence applications show particular promise in tumor detection. Throughout this evolution, the field has consistently balanced technological innovation with practical clinical implementation challenges. CONCLUSION:TURBT's 200-year evolution reflects a paradigm shift from radical excision to precision organ preservation. Modern technologies have addressed historical limitations of visualization and control. The advancement of these technologies has been a multidisciplinary effort, requiring the collaboration of scientists, engineers, and urologists. This team-based approach will be essential to balancing accessibility with precision in future advancements.

PURPOSE:Techniques that minimize dissection of neurovascular structures and the pelvic floor during radical prostatectomy improve perioperative outcomes and functional recovery. Previous groups have tried to reduce dissection by performing a transurethral prostatectomy. However, the vesicourethral anastomosis could not be reliably performed because of the limited instrumentation. We sought to address this with a concentric tube robot (CTR) system designed specifically for performing a transurethral vesicourethral anastomosis after transurethral prostatectomy, in a series of validated phantoms. MATERIALS AND METHODS:We have constructed a CTR system specifically for transurethral surgery. The robot features needle-sized robotic arms that pass through a rigid transurethral endoscope and are composed of telescoping, curved, elastic tubes. By axially rotating these tubes and telescopically extending them, our robot provides surgeons with two small arms that can bend and elongate at the tip of a standard-sized endoscope. This enables suturing within the small lumen of the urethra. We evaluated the CTR in performing the vesicourethral anastomosis in a series of validated phantoms, after transurethral radical prostatectomy was performed manually with a fiber laser. Anastomosis success was evaluated using a leak test. Additionally, we evaluated the surgical time of prostate resection and the suturing time of vesicourethral anastomosis. RESULTS:We performed transurethral radical prostatectomy and subsequent vesicourethral anastomosis in 11 phantoms. A successful anastomosis was performed in 10 out of 11 (91%) experiments. The median time of resection was 19 minutes (IQR: 18-21 minutes). The median suturing time was 103 minutes (IQR: 91-115 minutes). CONCLUSIONS:We demonstrated the use of a CTR system to perform a transurethral vesicourethral anastomosis in a series of experiments using validated phantoms. Our CTR overcomes the main barrier for providing a natural-orifice approach to radical prostatectomy by enabling intraluminal completion of the vesicourethral anastomosis.

Focal prostate treatment (aka “male lumpectomy”) has the potential to reduce invasiveness for prostate cancer patients. However, clinical deployment has been impeded by the difficulty of performing surgery through the urethra, which we hypothesize relates to both instrument dexterity and visualization limitations. To evaluate this hypothesis, in this paper we propose a system consisting of an endoscopic robot to enhance dexterity and an image-guidance display updated periodically during surgery based on MRI images. To evaluate the system, in this paper we compare four conditions: unaided manual resection using an endoscope, robot-aided surgery without image guidance, image guidance without the robot, and both robot and image guidance together. We find that while the robot and image guidance improve performance individually, the combination of the two provides the greatest improvement.

Traditional surgical robotic grasping end effectors do not scale down to needlescopic (3 mm and smaller) sizes well, and performance challenges are compounded when wrist degrees of freedom are included. Current wristed needlescopic grasper designs typically produce low grasp forces, making it challenging to retract tissue or firmly hold suture needles. In this paper, we propose a new design that achieves grasp forces at least six times higher than the repurposed flexible graspers used in prior concentric tube robotics research. Our new design exceeds even the grasp force of the much larger da Vinci Surgical System. We achieve this by combining a nitinol push-pull actuation tube with distal metal cam joints that amplify grasp force. The result is a tool with concentric-tube-type wrist joints capable of not only strong grasps, but also active jaw opening (e.g., for blunt dissection), that exceed the requirements of even larger-scale laparoscopic surgery. We validate our new grasper experimentally, comparing it against three commercially available graspers of the types previously attached to concentric tube robots, as well as to a da Vinci Surgical tool. We find that even at 3 mm diameter, our prototype surpasses the maximum grasp forces of an $\mathbf{8. 5 ~ m m}$ da Vinci tool, while providing more than 4 N of active opening force, and affording torsional stiffness many multiples higher than prior concentric tube end effectors. An additional useful feature of our design that is not present in prior grasper designs is the provision of an open central lumen useful for delivering tools such as laser fibers into the surgical field.

Concentric tube robots delivered through endoscopes have thus far been deployed approximately straight ahead of the endoscope's tip, which requires relatively low curvatures and strains, and a single fixed view angle. However, in tight spaces in the body (such as the interior of the uterus), it is often desirable to work close beside the endoscope tip, approximately perpendicular to the endoscope axis. Doing this requires two advancements: (1) a way to angle the camera, ideally without physically moving it, to prevent collisions with anatomy or other tools in the constrained space, and (2) the ability to reach points approximately perpendicular to the endoscope axis, that are close to its tip. We address the first challenge by integrating a variable view angle endoscope designed for arthroscopy. We address the second with highly curved concentric tube robots, designed to undergo higher strains than have previously been reported in the literature. We experimentally demonstrate working sideways from the endoscope tip with such a system by tracing the periphery of simulated uterine fibroids at multiple angles. We also demonstrate the use of electrosurgery to cut around the periphery of a simulated lesion made from animal tissues, while working in a direction approximately perpendicular to the endoscope axis.

We seek to enable transurethral focal resection of prostate tumors via enhanced robotic dexterity, combined with MRI image guidance. Our approach is designed to reduce invasiveness compared to traditional transabdominal radical prostatectomy, with the goal of reducing rates of impotence, incontinence, and other complications. MRI guidance is useful in focal resections since many prostate tumors look optically no different from the surrounding prostate, but can be seen in preoperative MRI images. To guide these procedures in a practical clinical setting, we envision using the new generation of low-field scanners emerging on the market, in conjunction with endoscope-deployed concentric tube robots. These scanners would provide periodic intraoperative imaging to which one would register the preoperative high-field images in which the tumor is visualized. In this paper, we conduct a feasibility study to explore whether our robot and image guidance system can help guide the resection of tumors that are invisible optically. In our experiments, surgeons used our robot with periodic highfield MRI image updates, to resect an optically invisible tumor in an anthropomorphic prostate phantom. We show how the availability of imaging information informed both the direction and depth with which surgeons chose to resect the tumor.

For transendoscopic concentric tube robots to have high accuracy with respect to endoscope-derived information, they must be calibrated with respect to the endoscope. We propose to accomplish this by defining rays from a monocular endoscope to a set of robot tip locations. Minimizing the error between the rays and tip positions provides a means of calibration. This is a first step toward enabling the robot to use endoscope-derived information in future applications that require accuracy, such as image guidance or automation.

Goal: We present a new framework for in vivo image guidance evaluation and provide a case study on robotic partial nephrectomy. Methods: This framework (called the “bystander protocol”) involves two surgeons, one who solely performs the therapeutic process without image guidance, and another who solely periodically collects data to evaluate image guidance. This isolates the evaluation from the therapy, so that in-development image guidance systems can be tested without risk of negatively impacting the standard of care. We provide a case study applying this protocol in clinical cases during robotic partial nephrectomy surgery. Results: The bystander protocol was performed successfully in 6 patient cases. We find average lesion centroid localization error with our IGS system to be 6.5 mm in vivo compared to our prior result of 3.0 mm in phantoms. Conclusions : The bystander protocol is a safe, effective method for testing in-development image guidance systems in human subjects.

As surgical robotics are made progressively smaller, and their actuation systems simplified, the opportunity arises to re-evaluate how we integrate them into operating room workflows. Over the past few years, several research groups have shown that robots can be made so small and light that they can become hand-held tools, in contrast to the prevailing commercial paradigm of surgical robots being large multi-arm floor-mounted systems that must be remotely teleoperated. This hand-held paradigm enables robots to fit much more seamlessly into existing clinical workflows, and as such, these new robots need to be paired with similarly compact user interfaces. It also gives rise to a new area of user interface research, exploring how the surgeon can simultaneously control the position and orientation of the overall system, while also simultaneously controlling small robotic manipulators that maneuver dexterously at the tip. In this paper, we compare an onboard user interface mounted directly to the robotic platform against the traditional offboard user interface positioned away from the robot. In the latter, the surgeon positions the robot, and a support arm holds it in place while the surgeon operates the manipulators using the offboard surgeon console. The surgeon can move back and forth between the robot and the console as often as desired. Three experiments were conducted, and results show that the onboard interface enables statistically significantly faster performance in a point-touching task performed in a virtual environment.

Introduction: Three-dimensional image-guided surgical (3D-IGS) systems for minimally invasive partial nephrectomy (MIPN) can potentially improve the efficiency and accuracy of intraoperative anatomical localization and tumor resection. This review seeks to analyze the current state of research regarding 3D-IGS, including the evaluation of clinical outcomes, system functionality, and qualitative insights regarding 3D-IGS's impact on surgical procedures. Methods: We have systematically reviewed the clinical literature pertaining to 3D-IGS deployed for MIPN. For inclusion, studies must produce a patient-specific 3D anatomical model from two-dimensional imaging. Data extracted from the studies include clinical results, registration (alignment of the 3D model to the surgical scene) method used, limitations, and data types reported. A subset of studies was qualitatively analyzed through an inductive coding approach to identify major themes and subthemes across the studies. Results: Twenty-five studies were included in the review. Eight (32%) studies reported clinical results that point to 3D-IGS improving multiple surgical outcomes. Manual registration was the most utilized (48%). Soft tissue deformation was the most cited limitation among the included studies. Many studies reported qualitative statements regarding surgeon accuracy improvement, but quantitative surgeon accuracy data were not reported. During the qualitative analysis, six major themes emerged across the nine applicable studies. They are as follows: 3D-IGS is necessary, 3D-IGS improved surgical outcomes, researcher/surgeon confidence in 3D-IGS system, enhanced surgeon ability/accuracy, anatomical explanation for qualitative assessment, and claims without data or reference to support. Conclusions: Currently, clinical outcomes are the main source of quantitative data available to point to 3D-IGS's efficacy. However, the literature qualitatively suggests the benefit of accurate 3D-IGS for robotic partial nephrectomy.

You have accessJournal of UrologyCME1 Apr 2023MP58-06 EVALUATION OF A TOUCH-BASED IMAGE GUIDANCE SYSTEM FOR ROBOTIC PARTIAL NEPHRECTOMY Shaan Setia, Piper Canon, James Ferguson, Nicholas Kavoussi, Robert Webster, and Duke Herrell Shaan SetiaShaan Setia More articles by this author , Piper CanonPiper Canon More articles by this author , James FergusonJames Ferguson More articles by this author , Nicholas KavoussiNicholas Kavoussi More articles by this author , Robert WebsterRobert Webster More articles by this author , and Duke HerrellDuke Herrell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Image-guidance during robotic partial nephrectomy (rPN) employs a 3D model of renal anatomy to allow for sub-surface identification of structures. Most image guidance surgery (IGS) systems involve manual registration, which is inaccurate and requires a separate individual to align the model intraoperatively. We sought to evaluate an automated, touch-based 3D IGS system and its accuracy compared to expert surgeons. METHODS: We identified patients with renal masses with planned rPN. Preop CT scans were used to generate virtual patient-specific 3D anatomical kidney models. Our IGS system was deployed during 6 rPNs by two primary surgeons. Registration was achieved by aligning a touch-based point cloud of the kidney surface tracing (using the robotic tool tip) to the models. The primary surgeon used the tool tip to estimate the location of the renal artery, vein, tumor centroid and intersection of the mass with parenchyma. After registration, a secondary surgeon (blinded to preop imaging) used the tool tip to record the location of these structures with the IGS system. The ground-truth, intraoperative locations of the target structures were recorded after dissection was complete. Target registration errors (TRE) with and without IGS were compared. RESULTS: Computed registration was performed successfully across 6 patients (mean axial diameter 3.0 cm, mean nephrometry score 6.5, Figure 1). After surface tracing, registration on average took 100 seconds. Median overall TRE for the secondary surgeon using the IGS compared to the primary surgeon was 9.8 vs 8.6 mm, respectively (p=0.25). TRE of localization was less for the lesion intersection with kidney (3.7 vs 2.2 mm, p=0.43) compared to the renal artery (14.1 vs 18.7 mm, p=0.61) and vein (14.4 vs 9.6 mm, p=0.06) (Figure 2). CONCLUSIONS: We report an automated, touch-based IGS system for rPN. The system is as accurate as an expert surgeon in target structure identification, though accuracy of registration for rigid structures was better than that of hilar vessels. Further improvements are needed to accurately model tissue deformation especially for hilar anatomy. Source of Funding: NIH R01-EB023717Software interface support from Intuitive © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e797 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shaan Setia More articles by this author Piper Canon More articles by this author James Ferguson More articles by this author Nicholas Kavoussi More articles by this author Robert Webster More articles by this author Duke Herrell More articles by this author Expand All Advertisement PDF downloadLoading ...

This conference presentation was prepared for SPIE Medical Imaging, 2023.

Introduction/Background: There are increasing reports of serious complications related to the air pyelography technique, which raise concerns about the safety of room air (RA) injection into the renal collecting system. Carbon dioxide (CO2) is much more soluble in blood than nitrogen and oxygen and thus considerably less likely to cause gas emboli. Iodinated contrast medium (ICM) is expensive, and supplies may not be as reliable as previously assumed. CO2 pyelography (CO2-P) techniques using standard fluoroscopy and digital subtraction fluoroscopy (CO2 digital subtraction pyelography [CO2-DSP]) are described. Materials and Methods: During the endourologic stone cases, 15 to 20 mL of CO2 gas was typically injected into the renal pelvis through a catheter or sheath. Imaging was usually obtained with endovascular CO2 digital subtraction angiography settings using either a traditional fluoroscopy system (TFS) or robotic arm multiplanar fluoroscopy system (RMPFS) (Artis Zeego Care+Clear((R)); Siemens). Results: CO2-P was performed in 22 endoscopic stone treatment cases between March 2021 and August 2022, primarily using digital subtraction settings in 20 cases. CO2-DSP overall provided higher quality images of the renal pelvis and collecting system than CO2-P, but with a relatively higher radiation dose. Following a quality intervention, fluoroscopy doses for CO2-DSP cases were decreased by 81% overall. The use of CO2-P avoided fluoroscopic or intraoperative CT (ICT) artifacts seen with intraluminal ICM. Conclusions: CO2-P allows the urologist to obtain imaging of the renal collecting system without ICM and with much lower risk of air embolism compared with RA pyelography. CO2 is a nearly cost-free alternative to ICM. Because CO2 is widely available and the technique is easy to perform, we propose that CO2-P should be favored over traditional air pyelography to improve patient safety.

Robots and inertial measurement units (IMUs) are typically calibrated independently. IMUs are placed in purpose-built, expensive automated test rigs. Robot poses are typically measured using highly accurate (and thus expensive) tracking systems. In this paper, we present a quick, easy, and inexpensive new approach to calibrate both simultaneously, simply by attaching the IMU anywhere on the robot's end effector and moving the robot continuously through space. Our approach provides a fast and inexpensive alternative to both robot and IMU calibration, without any external measurement systems. We accomplish this using continuous-time batch estimation, providing statistically optimal solutions. Under Gaussian assumptions, we show that this becomes a nonlinear least squares problem and analyze the structure of the associated Jacobian. Our methods are validated both numerically and experimentally and compared to standard individual robot and IMU calibration methods.

Using an image guidance system constructed over the past several years [1], [2] we have recently collected our first in vivo human pilot study data on the use of the da Vinci for image guided partial nephrectomy [3]. Others have also previously created da Vinci image guidance systems (IGS) for various organs, using a variety of approaches [4]. Our system uses touch-based registration, in which the da Vinci’s tool tips lightly trace over the tissue surface and collect a point cloud. This point cloud is then registered to segmented medical images. We provide the surgeon a picture-in-picture 3D Slicer display, in which animated da Vinci tools move exactly as the real tools do in the endoscope view (see [2] for illustrations of this). The purpose of this paper is to discuss recent in vivo experiences and how they are informing future research on robotic IGS systems, particularly the use of ultrasound.

Towards reducing the invasiveness of radical prostatectomy, we have designed a robotic system for performing it transurethrally. Suturing to attach the urethra to the bladder (i.e. anastomosis) after prostate removal is the most challenging part of the procedure, and has previously been demonstrated robotically only in synthetic phantoms. In this paper, we present initial experiments in biological tissues using ex vivo squid tissue embedded in an anthropomorphic phantom made using 3D printing and silicone casting. We successfully performed running sutures with our robotic system, fastening the urethra and the bladder to one another.

You have accessJournal of UrologyCME1 May 2022PD50-03 NO ASSOCIATION BETWEEN STATINS AND INCREASED NEPHROLITHIASIS RISK Wilson Sui, Christina J. Peterson, Naren Nimmagadda, Nicholas L. Kavoussi, Nicole L. Miller, S. Duke Herrell, and Ryan S. Hsi Wilson SuiWilson Sui More articles by this author , Christina J. PetersonChristina J. Peterson More articles by this author , Naren NimmagaddaNaren Nimmagadda More articles by this author , Nicholas L. KavoussiNicholas L. Kavoussi More articles by this author , Nicole L. MillerNicole L. Miller More articles by this author , S. Duke HerrellS. Duke Herrell More articles by this author , and Ryan S. HsiRyan S. Hsi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002621.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recently studies have shown inconclusive evidence for the association of statin intake and risk of nephrolithiasis in large cohort studies, while the impact of statin use on urinary chemistry factors related to stone risk are unknown. Therefore, we sought to examine the association between statin use and incident kidney stone risk and evaluate statin use on 24-hour urine analysis. METHODS: We performed a single center, retrospective study of patients with the diagnosis of hyperlipidemia (HLD) and without a history of kidney stones across the electronic health record (EHR). Medication information on statin use was extracted and then the occurrence of an incident kidney stone diagnosis or procedure was identified. Kaplan-Meier analysis was used to estimate risk of incident kidney stone diagnoses. Then, among patients with HLD and kidney stones undergoing 24-hour urine metabolic testing, we compared 24-hour urine parameters with and without concurrent statin use. RESULTS: We identified n=109,866 patients with HLD without prior medical therapy and without kidney stone history, of which 89,599 (81.6%) were exposed to statin over a median 6.5 years of follow-up. The statin exposed were more likely to have history of stroke, coronary artery disease, gout, hypertension, and diabetes. On survival analysis, statin use was not associated with improved stone-free survival (log rank p=0.84). Among patients with 24-hour urine profiles (n=539), those with statin exposure had higher mean BMI, were more often male, and more likely to have a history of hypertension or coronary artery disease. Comparing 24-hour urine parameters, the statin-exposed had higher mean calcium (234 vs 206.1 mg, p=0.02), but there were no other differences in other analytes observed. CONCLUSIONS: Contrary to prior studies, statin use does not appear to be associated with decreased risk of kidney stones. Additionally, there are no identifiable differences in urinary metabolites on 24-hour urine analysis that would suggest a benefit in reducing stone risk. Source of Funding: The project described was supported by CTSA award No. UL1 TR002243 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e836 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wilson Sui More articles by this author Christina J. Peterson More articles by this author Naren Nimmagadda More articles by this author Nicholas L. Kavoussi More articles by this author Nicole L. Miller More articles by this author S. Duke Herrell More articles by this author Ryan S. Hsi More articles by this author Expand All Advertisement PDF downloadLoading ...