Hybrid Surgical Guidance in Urologic Robotic Oncological Surgery

Urologic oncological surgery increasingly makes use of robotic systems to realize precise and minimally invasive resections, convent to shorter hospital stays and faster recovery times. The dexterity gains enabled through procedures such as robot-assisted (RA) prostatectomy have helped realize significant advancements in recent years. Complementing these effects via the used of hybrid tracers that illuminate surgical targets, i.e., cancerous tissue, has helped advance the surgical decision making via enhanced visualization. A well-known example is Indocyanine green (ICG)-Technetium-99m (99mTc)-nanocolloid, a hybrid extension of the radiopharmaceutical 99mTc-nanocolloid. These hybrid tracers provide a direct link between preoperative imaging roadmaps and intraoperative target identification, and improve efficiency, accuracy, and confidence of the urologist in procedures such as sentinel lymph node biopsy (SLNB). Receptor-targeted hybrid tracer analogues, for e.g., prostate specific membrane antigen (PSMA), are also being explored as an extension of the ongoing efforts that use radiotracers such as 99mTc-PSMA-I&S. Together, these efforts jointly pave the way for novel techniques in intraoperative lesion localization in other urological malignancies. This narrative review discusses the potential use of hybrid tracers in robotic oncological urology, including different imaging techniques and their applications for tumor localization for prostate, bladder, and kidney cancer.