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| Three-dimensional automatic artificial intelligence driven augmented-reality selective biopsy during nerve-sparing robot-assisted radical prostatectomy: A feasibility and accuracy study |
Enrico Checcuccia ,*( ),Alberto Pianab,Gabriele Volpia,Pietro Piazzollac,Daniele Amparoreb,Sabrina De Cillisb,Federico Piramideb,Cecilia Gattib,Ilaria Sturad,Enrico Bollitoe,Federica Massae,Michele Di Diof,Cristian Fiorib,Francesco Porpigliab
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aDepartment of Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
bDepartment of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, To, Italy
cDepartment of Mechanical Engineering, Politecnico di Milano, Milan, Italy
dDepartment of Public Health and Pediatric Sciences, School of Medicine, University of Turin, Italy
eDepartment of Pathology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
fSS Annunziata Hospital, Department of Surgery, Division of Urology, Cosenza, Italy |
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Abstract Objective: To evaluate the accuracy of our new three-dimensional (3D) automatic augmented reality (AAR) system guided by artificial intelligence in the identification of tumour's location at the level of the preserved neurovascular bundle (NVB) at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy. Methods: In this prospective study, we enrolled patients with prostate cancer (clinical stages cT1c-3, cN0, and cM0) with a positive index lesion at target biopsy, suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging. Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital (Orbassano, Turin, Italy), from December 2020 to December 2021. At the end of extirpative phase, thanks to our new AAR artificial intelligence driven system, the virtual prostate 3D model allowed to identify the tumour's location at the level of the preserved NVB and to perform a selective excisional biopsy, sparing the remaining portion of the bundle. Perioperative and postoperative data were evaluated, especially focusing on the positive surgical margin (PSM) rates, potency, continence recovery, and biochemical recurrence. Results: Thirty-four patients were enrolled. In 15 (44.1%) cases, the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging (Wheeler grade L2) while in 19 (55.9%) cases extracapsular extension was detected (Wheeler grade L3). 3D AAR guided biopsies were negative in all pathological tumour stage 2 (pT2) patients while they revealed the presence of cancer in 14 cases in the pT3 cohort (14/16; 87.5%). PSM rates were 0% and 7.1% in the pathological stages pT2 and pT3 (<3 mm, Gleason score 3), respectively. Conclusion: With the proposed 3D AAR system, it is possible to correctly identify the lesion's location on the NVB in 87.5% of pT3 patients and perform a 3D-guided tailored nerve-sparing even in locally advanced diseases, without compromising the oncological safety in terms of PSM rates.
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Received: 24 January 2023
Available online: 20 October 2023
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Corresponding Authors:
*E-mail address: enrico.checcucci@ircc.it (E. Checcucci).
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Augmented reality system development strategy. AR, augmented reality; 3D, three-dimensional; RARP, robot-assisted radical prostatectomy; CNN, convolutional neural network; NN, neuronal network.
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Three-dimensional automatic augmented reality processing. According to the convolutional neuronal network method pipeline, the image (A) was segmented (B) and after the shape detection (C), the 3D model was projected over the two-dimensional image (D). 3D, three-dimensional.
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Three-dimensional automatic AR biopsy workflow. (A) Operative field after bilateral full nerve-sparing procedure; (B and C) The catheter was inserted into the prostatic lodge and the 3D model was automatically overlapped; (D) The lesion projection was left into the Tile-Pro screen; (E) The biopsy was performed; (F) The final result was a 3D tailored nerve-sparing procedure. AI, artificial intelligence; AR, augmented reality; 3D, three-dimensional; NVB, neurovascular bundle.
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| Patient characteristic | Value | | Age, year | 62 (60-69) | | BMI, kg/m2 | 24.9 (23.6-27.1) | | ASA score | 2 (2-3) | | PSA, ng/mL | 5.6 (4.1-9.2) | | Positive DRE | 8 (23.5) | | IIEF-5 score | 21 (12-24) | | Prostate volumea, mL | 40 (30.3-44.2) | | Lesion volume, mm | 9 (6-12) | | PIRADS score | | 3 | 2 (5.9) | | 4 | 21 (61.8) | | 5 | 11 (32.4) | | Radiological Wheeler | | L2 | 15 (44.1) | | L3 | 19 (55.9) | | Gleason score | 7 (7-8) |
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Preoperative variables (n=34).
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| Intra- and peri-operative variable | Value | | Operative time, min | 123 ± 31 | | Blood loss, mL | 235 ± 50 | | NS procedure | | Full NS | 10 (29.4) | | Partial NS | 24 (70.6) | | Intraoperative complications | 0 (0) | | Postoperative Clavien-Dindo Grades III-V complication | 0 (0) | | Catheterization time, day | 5 (4-7) | | Hospital stay, day | 6 (5-6) | | Urinary continence | | After catheter removal | 22 (64.7) | | 1 week after catheter removal | 25 (73.5) | | 1 month after surgery | 28 (82.4) | | 3 months after surgery | 29 (85.3) | | 6 months after surgery | 30 (88.2) | | 12 months after surgery | 32 (94.1) | | Potency rate | | 1 month after surgery | 13 (38.2) | | 3 months after surgery | 20 (58.8) | | 6 months after surgery | 24 (70.6) | | 12 months after surgery | 24 (70.6) | | Biochemical recurrence at 12th month | 0 (0) |
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Intra- and peri-operative findings (n=34).
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| Pathological data | Value | | Prostate volume, mL | 34.3 (27.2-38.7) | | Tumour volume, mL | 2.1 (1.5-2.8) | | Pathological tumour stage | | pT2 | 18 (52.9) | | pT3 | 16 (47.1) | | Gleason score | | 2-6 | 0 (0) | | 7 | 30 (88.2) | | 8-10 | 4 (11.8) |
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Pathological data (n=34).
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| cT stage | pT stage | Patient | NVB Bx+ | PSM | | cT2 (n=14) | ? pT2 | 11 (78.6) | 0 (0) | 0 (0) | | - Apical lesion | 4 (28.6) | 0 (0) | 0 (0) | | - Equatorial lesion | 3 (21.4) | 0 (0) | 0 (0) | | - Basal lesion | 4 (28.6) | 0 (0) | 0 (0) | | ? pT3 | 3 (21.4) | 3 (21.4) | 1 (7.1) | | - Apical lesion | 1 (7.1) | 1 (7.1) | 1 (7.1) | | - Equatorial lesion | 2 (14.3) | 2 (14.3) | 0 (0) | | - Basal lesion | 0 (0) | 0 (0) | 0 (0) | | cT3 (n=20) | ? pT2 | 7 (35.0) | 0 (0) | 0 (0) | | - Apical lesion | 1 (5.0) | 0 (0) | 0 (0) | | - Equatorial lesion | 6 (30.0) | 0 (0) | 0 (0) | | - Basal lesion | 0 (0) | 0 (0) | 0 (0) | | ? pT3 | 13 (65.0) | 11 (55.0) | 0 (0) | | - Apical lesion | 4 (20.0) | 3 (15.0) | 0 (0) | | - Equatorial lesion | 3 (15.0) | 3 (15.0) | 0 (0) | | - Basal lesion | 6 (30.0) | 5 (25.0) | 0 (0) |
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Three-dimensional automatic augmented reality biopsy findings (n=34).
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