3D virtual models and augmented reality for radical prostatectomy: a narrative review

Introduction

Increasingly popular as auxiliary tools in urology, three-dimensional (3D) virtual reconstructions of two-dimensional (2D) imaging have undergone progressive technological improvements, enabling the creation of ‘hyper-accurate’ 3D virtual models (3DVMs) that faithfully replicate individual anatomical details (Figure 1). This involves the semi-automatic segmentation of high-quality Digital Imaging and Communications in Medicine (DICOM) images by expert radiologists or bioengineers (1-3).

Figure 1 Prostate HA3DTM virtual model. HA3DTM, hyper-accuracy 3D; 3D, three-dimensional.

Various application methods have been identified, including virtual reality (VR), where the 3D reconstruction is presented in a fully virtual environment; mixed reality (MR), allowing users to observe the 3D model within their actual surroundings; augmented reality (AR), involving the overlay of virtual objects onto the real environment; and extended reality (XR), aiming to integrate VR, AR, and MR to establish a metaverse (4-6).

As a result, this technology enhances and personalizes the patient’s surgical reality, leading the surgeon to hyper-accuracy in understanding the instantaneous subjective surgical anatomy and improving surgical planning during preoperative assessment (7,8).

Moreover, 3D virtual reconstruction serves as effective tools for intraoperative navigation in both cognitive and AR settings, potentially impacting patient outcomes. Within the uro-oncologic field, the utility of this technology has been demonstrated in enhancing comprehension of vascular anatomy and tumor localization and directly influencing surgical strategy and postoperative outcomes (Figure 2) (9).

Figure 2 3DVM in prostate surgery. (A) Prostate 3DVM fruited for cognitive intraoperative navigation; (B) prostate 3DVM overlapped to in vivo endoscopic view via TilePro^TM to perform AR intraoperative navigation. 3DVM, three-dimensional virtual model; AR, augmented reality.

Prostate cancer (PCa) constitutes the most prevalent malignant tumor affecting men in the Western world. For individuals with a life expectancy of at least 10 years, radical prostatectomy (RP) emerges as a favorable therapeutic option (10). In light of these promising considerations, the potential significance of 3D reconstructions in the context of RP has garnered considerable attention within the realm of research.

While there are already reviews on the use of 3D models in robotic surgery, the aim of this study is to provide a comprehensive narrative review on the application of 3D reconstructions and AR in the context of RP, thus presenting an overview of the current state of this technological landscape (11). We present this article in accordance with the Narrative Review reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-24-31/rc).

Methods

A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database, and Embase were used as search engines for clinical trials, randomized controlled trials, review articles, and prospective and retrospective studies regarding the use of 3DVMs and AR for RP. The database research was conducted in January 2024.

The search strategy used the PICOS (Patients, Intervention, Comparison, Outcome, Study design) criteria (12):

P (patients): patients undergoing RP;

I (intervention): RP driven by 3D models and AR or VR;

C (comparator): standard urological surgical procedures;

O (outcome): perioperative, functional and oncological outcomes;

S (study design): comparative or single arm studies.

The review quality assessment was reported in Appendix 1 according to the Scale for the Assessment of Narrative Review Articles (SANRA) (13).

In our research strategy (Table 1), we included retrospective and prospective comparative studies, as well as single-arm studies, that reported on the utilization of 3DVMs and AR or VR for RP. Studies that were not written in English, non-original investigations (such as editorials, commentaries, abstracts, reviews, and book chapters), and studies involving experimental research on animals or cadavers were excluded.

Evidence synthesis

In the realm of urological oncology, the overarching goal is to strike a delicate balance between ensuring oncological safety and optimizing postoperative functional outcomes. Recent technological advancements, along with the standardization of advanced axial imaging, are turning the goal of balancing oncological safety and functional outcomes into a reality for the new generation of surgeons. The progress extends beyond viewing traditional 2D images, now enabling 3D rendering. This eliminates the requirement to examine 2D images in three spatial axes (axial, coronal, and sagittal) to create a 3D representation of the patient’s anatomy. Furthermore, recent studies have highlighted the ease with which physicians can utilize 3D virtual and printed models for interpreting complex anatomy and spatial relations (14).

This paradigm shift towards 3D visualization has witnessed widespread adoption, with applications ranging from preoperative planning to intraoperative consultations. Notably, the latter application has captivated the interest of the urological community, as evidenced by a substantial body of scientific literature published in recent years. Within this extensive literature, 16 investigations stand out, delineating experiences that encompass cognitive, virtual, mixed, and AR intraoperative surgical navigation during RP. The key findings from these investigations are concisely presented in Table 2. Subsequent sections provide a comprehensive summary of the experiences associated with 3D model guidance in the context of RP.

3D virtual cognitive procedures

In their groundbreaking study, Ukimura et al. (18) utilized a 3D end-fire transrectal ultrasound (TRUS) probe and Accuvix-V10 US machine for 3D data acquisition and biopsy trajectories during prostate biopsies. Magnetic resonance imaging (MRI)/TRUS elastic image-fusion guided biopsies were performed in cases with prebiopsy prostate MRI. A comprehensive 3D model, encompassing the prostate surface, cancer lesions, neurovascular bundles (NVBs), urethra, and color-coded biopsy trajectories, was reconstructed. During robot-assisted RP (RARP), the model facilitated navigation around biopsy-proven cancer lesions, providing valuable insights beyond robotic visualization. TilePro navigation images closely matched the robotic laparoscopic view. 3D surgical navigation improved intraoperative capabilities, enabling virtual models on the TilePro during surgery. Surgeon awareness of tumor location resulted in a 90% rate of negative surgical margins, aligning with the index lesion’s location in the software-generated 3D model on the final histology report. The 3D model accurately correlated the biopsy-proven cancer location with pathologic specimens, indicating potential extra prostate extension. Magnetic resonance (MR)-based 3D modeling demonstrated superior accuracy (82–90%) in estimating index lesion volume compared to TRUS-based modeling (48%).

In subsequent years, Mehralivand et al. (20) reported early experiences with MRI-based VR guidance in RARP. The 3D virtual reconstruction included the prostate and surrounding structures (urethra, seminal vesicles, NVBs, rectum, and bladder). During surgery, the 3D endoscopic view of the da Vinci system was recorded and overlaid on the 3D model using an automated alignment algorithm, aiding the surgeon in decision-making on NVB preservation. The VR method was successfully applied in all 10 planned surgeries without complications. Among patients with MRI findings suggestive of extraprostatic extension (ECE), only one had positive surgical margins (PSMs) and experienced biochemical recurrence (BCR) after 12 months. The remaining nine patients remained recurrence-free. All but one patient maintained continence (0–1 pads) post-surgery, with the exception having locally aggressive disease requiring a wide excision for optimal cancer control. This patient, despite a challenging pathology, remains recurrence-free at 12 months of follow-up.

In 2020, Samei et al. (23) introduced a novel VR system for guiding RARP. The system merged MRI images with real-time 3D TRUS images during surgery. Surgeons could dynamically adjust the visual perspective using the TRUS probe. Initial experiments on 12 patients yielded promising results, with a 1.4±0.3 mm registration error between TRUS and the da Vinci system. The system was successfully applied in 12 patients during surgery, demonstrating an average registration error of 1.4±0.3 mm and an average target registration error of 2.1±0.8 mm for the last 8 patients. The overall robot system to MRI mean registration error was consistently within 3.5 mm, aligning with laboratory studies.

In 2022, Martini et al. (27) assessed the impact of integrating 3D models from multiparametric MRI (mpMRI) into the robotic console to reduce PSMs. Using the Neurovascular Structure Adjacent Frozen Section Examination method, the study with 151 subjects reported a lower PSM rate of 11.3% compared to the 2018 cohort (22.5%). Notably, 35% of PSM cases were in areas not identified by mpMRI. Integrating 3D models during surgery substantially reduced both frozen (22.5% to 11.3%) and permanent section (13.1% to 6.6%) PSM rates, suggesting promise for improving PCa outcomes.

The latest study on 3DVMs, underscores their positive impact on PSM rates. In a cohort of 160 patients who underwent RARP with 3D model reconstruction from mpMRI (cognitive or augmented-reality approach), Checcucci et al. (29) described comparable results with a control group of 640 patients without 3D models. The 3D group exhibited a more conservative nerve sparing (NS) approach and lower PSM rates (25% vs. 35.1%, P=0.01), particularly in patients with ECE or pT3 tumors. A prospective study at our center from 01/2016 to 01/2020 confirmed the benefits, demonstrating that the availability of 3D models allows for modulating the NS approach, reducing PSM occurrence, especially in patients with ECE at mpMRI or pT3 PCa.

In conclusion, the use of 3DVMs enhances surgical navigation, reduces PSMs, and aids decision-making in prostate surgery. Integrating 3D models into the robotic console shows promise in improving overall PCa outcomes, offering better surgical precision and patient quality of life (31).

3D virtual and MR experiences

In 2006, Wagner et al. (15) compared the performance of robotic camera holders, EndoAssist, and Automated Endoscope System for Optimal Positioning (AESOP), in laparoscopic RP (LRP), collecting data from 20 procedures. Results revealed faster setup time for AESOP (2.0 vs. 5.3 minutes, P<0.001) and quicker dissection with EndoAssist (23 vs. 33 minutes, P<0.04) for specific steps. However, no significant differences were found in overall task efficiency. The study suggests that EndoAssist is comparably efficient to AESOP, emphasizing advantages like accurate response and surgeon control. Limitations include a larger profile, absence of a table-mounted design, and the need for pedal activation, prompting suggestions for further modifications to enhance efficiency and design.

Successively, Matsuoka et al. (16) published the first study on integrated image navigation using head-mounted displays (HMDs) in RP. Their preliminary experience of integrated image navigation utilizing the RoboSurgeon system for gasless single-port endoscopic RP included five patients. A robotically manipulated TRUS system integrated preoperative MRI images with real-time intraoperative images. The synchronized display on HMDs facilitated identification of correct dissection planes. The RoboSurgeon system setup took less than 10 minutes, and the integrated images provided sufficient resolution for clinical application throughout the procedure. The study suggests the feasibility and potential benefits of integrated image navigation in gasless single-port endoscopic RP, emphasizing its educational and didactic role in the surgical setting.

Another relevant experience was reported by Koga et al. (26) who introduced of a 3D-HMDs system in gasless single-port retroperitoneoscopic RP without CO₂ gas insufflation to facilitate the development of the “puboprostatic open-collar technique”. This innovative approach, leveraging high-resolution stereovision, enabled precise visualization of the apex and dorsal vein complex (DVC), contributing to reduced apical PSM rates. Notably, among 92 patients undergoing all three procedures, the overall and apical PSM rates were notably lower at 13.0% and 3.3%, respectively. Despite the absence of a control group in this study, the integrated 3D-HMD system played a pivotal role in advancing the anatomical apical dissection technique, showing promising results in terms of favorable outcomes in both apical surgical margins and continence recovery during 3D-RP.

Lastly, when the global coronavirus disease 2019 (COVID-19) pandemic necessitated innovative approaches to surgical training and education, Papalois et al. (28) developed a VR curriculum focusing on surgical anatomy and decision-making, particularly for RARP. Subject-matter experts identified critical decision points, anatomical landmarks, and intraoperative strategies. Content validity was ensured by an expert panel, and the curriculum was piloted with surgical science students. Results showed increased understanding and knowledge scores post-curriculum, supporting the feasibility and efficacy of virtual mentorship in surgical training. Additionally, embracing MR can play a pivotal role in educational and didactic contexts.

To recap, 3D technology improves surgical efficiency, as seen in robotic camera holder comparisons. Integrated image navigation via HMDs enhances identification of dissection planes, while 3D-HMD systems aid in anatomical precision, reducing PSM rates. VR curricula, especially during the pandemic, prove effective for surgical training, emphasizing decision-making. Embracing MR offers innovative educational approaches, providing valuable insights into intraoperative strategies.

3D and AR experiences

As previously explained, AR involves overlaying 3D reconstructions onto a real environment, such as the live view obtained during surgical endoscopy. Once a 3D model is generated, additional essential functionalities are required to execute an AR procedure. Initially, it is imperative to capture images of the surgical field, such as endoscopic images. The subsequent crucial step involves the concurrent tracking of movements of both the target organ and surgical tools. Subsequently, these images are integrated, providing the surgeon with the capability to observe an AR operative field.

One of the early AR experiences in RARP was documented in 2013. Thompson et al. (17) developed and evaluated an intraoperative navigation system that overlaid T2-weighted MRI images onto the surgical field. Following a preclinical assessment, this tool was utilized in 13 RARP procedures, and feedback from surgeons was systematically evaluated. Significant functional outcomes in terms of continence recovery were reported.

A further step was to evaluate the use of hyper-accuracy 3D (HA3DTM) (21) reconstruction based on mpMRI and superimposed imaging in AR-RARP. Patients with PCa undergoing RARP at our center were enrolled, diagnosed through target biopsy at the index lesion based on high-resolution mpMRI. The HA3DTM reconstruction created a 3DVM of the prostate and surrounding structures. AR technology was utilized during four standardized key steps in RARP, with variations in procedures based on the presence or absence of ECE at MRI. In group A (no ECE), the intraprostatic lesion was marked using virtual AR imaging, while in group B (with ECE), a metallic clip was placed at the suspicious ECE location on the NVB. Selective biopsies were taken, and the entire NVBs were removed for examination. Pathological confirmation of the index lesion and suspected ECE was achieved in all cases. The AR-guided selective biopsies confirmed ECE location, with a 73.3% positive rate for cancer. The dimensional comparison between mpMRI-based 3D VR and whole-mount specimens showed a mismatch of less than 3 mm in over 85% of cases.

In the assessment of this technology’s utility, six skilled robotic surgeons participated in testing the software during a live surgery involving AR-NS-RP (19). To gather expert opinions on the effectiveness of this technology in guiding intraoperative steps of AR-RARP, a face validity questionnaire was tailored. The median Likert scale value, derived from the evaluation of each surgery, was 9, with an interquartile range (IQR) of 9–10.

To enhance the refinement of 3D models and simulate tissue deformations during surgical procedures, particularly in the NS phase, the same research group introduced the 3D elastic model (22). These models employed non-linear parametric deformation along the two main axes to simulate organ deformations induced by instruments. The accuracy of this tool was assessed by placing a metal clip on the prostate at the location where the tumor was identified using the elastic model’s guidance in an AR setting. The tumor was correctly identified in all patients.

Schiavina et al. (25) aimed to evaluate the impact of an AR-3D model in guiding NS during RARP on surgical planning. Twenty-six consecutive patients diagnosed with PCa underwent AR-3D-NS-RARP. The AR-3D technology changed the NS surgical plan in approximately one out of three cases, resulting in an overall appropriateness of 94.4%. The PSM rate was 15.4%, with 11.5% having PSMs at the index lesion level. The 3D model demonstrated high sensitivity, specificity, and accuracy at the 32-area map analysis. In conclusion, AR-3D-guided surgery proves valuable for real-time identification of the index lesion, allowing modifications in the NS approach and achieving an overall appropriateness of 94.4%.

Since mpMRI serves as a valuable tool for guiding surgical planning in RARP, while intraoperative frozen section (IFS) aids in real-time surgical margin assessment, Bianchi et al. (24) explores a novel technique utilizing AR-3D models for IFS analysis during NS-RARP. A total of 20 consecutive PCa patients underwent NS-RARP with AR-3D-guided IFS directed towards the index lesion, forming the study group. The control group, consisting of 20 matched patients, underwent RARP with cognitive assessment of mpMRI. In the study group, an AR-3D model was superimposed onto the surgical field to guide dissection, and IFS tissue sampling was performed in the area where the index lesion was projected by AR-3D guidance. The study found comparable preoperative characteristics between the AR-3D and control groups. While overall PSM rates were similar, PSMs at the level of the index lesion were significantly lower in the AR-3D group (5%) compared to the control group (20%). The conclusion suggests that AR-3D guidance for IFS analysis may contribute to a reduction in PSMs at the index lesion during NS-RARP.

Recently, Checcucci et al. (30) assessed a novel 3D automatic AR (AAR) system’s accuracy in guiding NS-RARP thanks to the application of artificial intelligence (AI)-based convolutional neuronal networks. Focused on PCa patients with a positive index lesion and suspected capsular contact or ECE, the AAR system created a virtual 3D prostate model for precise tumor identification at the NVB. Selective biopsies spared the remaining NVB. Among 34 patients, 44.1% had lesions in contact with the capsule, and 55.9% had ECE. AAR-guided biopsies accurately identified tumors in 87.5% of pathological stage 3 cases, while all stage 2 cases had negative biopsies. PSM rates were 0% in stage 2 and 7.1% in stage 3. The study concluded that the 3D AAR system allows precise identification of lesion location in 87.5% of stage 3 patients, facilitating tailored NS in locally advanced cases without compromising oncological safety on PSM rates.

In summary, AR in RARP enhances surgical precision and aids in continence recovery. HA3DTM reconstruction proves effective for selective biopsies. Expert evaluations confirm the technology’s high effectiveness. AR-3D models influence NS, achieving overall appropriateness. AR-3D for IFS reduces PSM rates. A novel 3D AAR system, guided by AI, precisely identifies tumor locations, facilitating tailored NS without compromising oncological safety. These findings underscore AR’s role in lesion identification, modifying surgical approaches, and reducing PSM rates, marking a significant advance in precision-guided oncologic surgery (32).

Limits and future perspectives

Despite promising outcomes with 3DVM guidance during RP, limitations exist. Primarily, experiences are often limited to small cohorts without control groups, highlighting the need for extensive randomized controlled trials and comparative studies. To the best of our knowledge, only one prospective multicenter randomized study is ongoing, evaluating the benefit of AI-driven AR surgery vs. 2D the standard one (ISRCTN15750887). Preliminary data showed that selective excisional biopsies were positive in 43.75% (7/16) and 11.54% (3/26) of the cases in 3D and no-3D group (P=0.44); with a subsequent reduction of PSM rate (30.0% vs. 47.9% respectively; P=0.18) (33).

Secondly, proving scientific efficacy poses challenges, requiring standardization of the technological process from 2D image acquisition to 3D model utilization. It is hoped that forthcoming scientific endeavors will address this challenge through international guidelines involving medical engineers and surgeons. Thirdly, comparing results across studies is hindered by variations in methodological techniques for 3D model creation and AR. The absence of guidelines results in variability in quality and costs, crucial for influencing surgical strategy and perceived utility. The accuracy of these models is crucial, given its substantial impact on the surgeon’s surgical strategy and perception of the virtual models’ utility. Specifically for PCa and RARP, where the reliability of mpMRI in PCa identification and characterization has been well-established in the literature (30), high-quality reconstructions are necessary to ensure the adequacy of mpMRI-derived 3D models in identifying microscopic ECE (21,23).

Lastly, 3D VM and AR have been developed to enhance the accuracy and precision of minimally invasive oncologic surgery (34). Therefore, their application did not extend to open surgery, specifically in the case of RP. This is the reason why this review could only include studies related to LRP and RARP.

This technology is relatively new, continually evolving due to technological progress, making standardization challenging. While a common workflow for creating standardized 3DVMs has been published by an opinion leader group in the field (14), potential high variability in model quality persists due to different processes and software packages in use. Specific guidelines, defined 3D model reconstruction (tilt), are currently under development (35).

Finally, a major concern regarding the widespread adoption of 3D models, particularly in the AR setting, revolves around costs. The current state of the technology does not permit predictions about the sustainability of added costs, as standardization of all processes involved in creating and utilizing 3DVMs has not yet been achieved. In different domains, such as orthopedic and maxillofacial surgery, Ballard et al. (36) have illustrated the cost-saving benefits of medical 3D printing. This concept may extend to urological surgery as well. Particularly in NS-RARP, it could result in additional cost savings for the National Health Service, alleviating the financial burden associated with postoperative incontinence and erectile dysfunction (31). Indeed, the utilization of 3DVMs and AI has the potential to decrease operating time, as well as resulting from 3D printed models (37-39). Currently, there is no user-friendly and inexpensive software available on the market for creating 3D models for RARP. Unfortunately, this issue will persist until some form of standardization is established. Moreover, this area of research is dynamic, with the continuous introduction of new tools, making the assessment of financial expenses challenging.

Conclusions

The integration of 3DVMs and AR technologies in the context of RP, has shown promising advancements. These technologies offer valuable support in preoperative planning, intraoperative navigation, and real-time decision-making. The shift from traditional 2D imaging to comprehensive 3D rendering has significantly improved the visualization of complex anatomical structures as well as the tumor identification helping in modulating the NS approach and reducing PSM rate.

Despite the positive outcomes observed in various studies, certain limitations and challenges persist. Scientific validation, encompassing tangible improvements in clinical outcomes, remains a crucial aspect, necessitating the standardization of the entire technological process.

Moreover, variability in the techniques for creating 3DVMs and performing AR poses challenges in result comparison across different experiences. The technology’s evolving nature and associated costs raise concerns about its widespread adoption. Addressing these challenges through international guidelines, collaboration between medical engineers and surgeons, and further research will be instrumental in realizing the full potential of 3DVMs and AR in enhancing surgical precision and patient outcomes in urological oncology.

Acknowledgments

We would like to thank Dr. Andrea Bellin and Simona Barbuto for their support.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Davide Campobasso, Stefano Puliatti, and Stefania Ferretti) for the series “New Evidence and Advances in Surgical Treatment of Prostate Cancer” published in Chinese Clinical Oncology. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://cco.amegroups.com/article/view/10.21037/cco-24-31/rc

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-24-31/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-24-31/coif). The series “New Evidence and Advances in Surgical Treatment of Prostate Cancer” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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