Real-time Augmented Reality Three-dimensional Guided Robotic Radical Prostatectomy: Preliminary Experience and Evaluation of the Impact on Surgical Planning

Augmented reality (AR) is a novel technology adopted in prostatic surgery.To evaluate the impact of a 3D model with AR (AR-3D model), to guide nerve sparing (NS) during robot-assisted radical prostatectomy (RARP), on surgical planning.Twenty-six consecutive patients with diagnosis of prostate cancer (PCa) and multiparametric magnetic resonance imaging (mpMRI) results available were scheduled for AR-3D NS RARP.Segmentation of mpMRI and creation of 3D virtual models were achieved. To develop AR guidance, the surgical DaVinci video stream was sent to an AR-dedicated personal computer, and the 3D virtual model was superimposed and manipulated in real time on the robotic console.The concordance of localisation of the index lesion between the 3D model and the pathological specimen was evaluated using a prostate map of 32 specific areas. A preliminary surgical plan to determinate the extent of the NS approach was recorded based on mpMRI. The final surgical plan was reassessed during surgery by implementation of the AR-3D model guidance.The positive surgical margin (PSM) rate was 15.4% in the overall patient population; three patients (11.5%) had PSMs at the level of the index lesion. AR-3D technology changed the NS surgical plan in 38.5% of men on patient-based and in 34.6% of sides on side-based analysis, resulting in overall appropriateness of 94.4%. The 3D model revealed 70%, 100%, and 92% of sensitivity, specificity, and accuracy, respectively, at the 32-area map analysis.AR-3D guided surgery is useful for improving the real-time identification of the index lesion and allows changing of the NS approach in approximately one out of three cases, with overall appropriateness of 94.4%.Augmented reality three-dimensional guided robot-assisted radical prostatectomy allows identification of the index prostate cancer during surgery, to tailor the surgical dissection to the index lesion and to change the extent of nerve-sparing dissection.