V07-05: Hyper Accuracy 3D reconstruction is able to maximize the efficacy of selective clamping during Robot Assisted Partial Nephrectomy
In the “precision surgery”era, if renal ischemia is among the factors influencing renal damage it is theoretically intolerable that the removal of a renal tumor requires global ischemia. The key point is the detailed understanding of surgical anatomy. Fluorescence was introduced with the aim of guiding selective arterial clamping, but it is empirical with a high rate of failures. The development of a radiologic guidance technology seems to be the right way. Trying to give a contribution in this field, we began our experience with a novel software specifically designed for hyper-accuracy 3D reconstruction of the anatomical structures from CT-scan images.
CT-scan with angiography was performed with 1 mm slices according to a dedicated protocol. DICOM format images were processed by using dedicated software. 3D virtual model was created on the basis of high resolution CT scans. The reconstruction was focused on the renal vasculature. The virtual models were reviewed by navigation of a 3D-PDF file by bio-engineers and urologists together, to evaluate the accuracy. On the created virtual 3D model, renal pedicle management and subsequent ischemia were simulated. After the era of the “cognitive” isolation of the renal pedicle, the 3D virtual reconstructions were integrated inside the console. The augmented reality experience began.
21 cases were performed aided by this technology. The technology we used allowed a precise understanding of the tumor location and growth pattern with respect to the use of standard bidimensional CT scan. In the presented case, the isolated branches of the renal artery were clamped on the basis of the preoperative simulation of the ischemia performed on the virtual 3D model. Fluorescence guidance was used as a double check of the correct planning of the selective clamping. Fluorescence guidance proved the good choice of the renal arterial branches to be clamped, with the tumor and the tumor bed being devascularized. In the 90% of the cases, the management of the renal pedicle was performed as preoperatively planned.
With the presented hyper-accuracy 3D virtual navigation technique, the arterial vasculature was faithfully reproduced. The surgeon was able to simulate the selective ischemia caused by the different selective clampings possible. In all the performed cases, selective clamping was successful with tumor and the peritumoral area devascularized, thus avoiding the ischemia of the healthy renal remnant.