Patient-specific, touch-based registration during robotic, image-guided partial nephrectomy.

Image-guidance during partial nephrectomy enables navigation within the operative field alongside a 3-dimensional roadmap of renal anatomy generated from patient-specific imaging. Once a process is performed by the human mind, the technology will allow standardization of the task for the benefit of all patients undergoing robot-assisted partial nephrectomy. Any surgeon will be able to visualize the kidney and key subsurface landmarks in real-time within a 3-dimensional simulation, with the goals of improving operative efficiency, decreasing surgical complications, and improving oncologic outcomes. For similar purposes, image-guidance has already been adopted as a standard of care in other surgical fields; we are now at the brink of this in urology. This review summarizes touch-based approaches to image-guidance during partial nephrectomy, as the technology begins to enter in vivo human evaluation. The processes of segmentation, localization, registration, and re-registration are all described with seamless integration into the da Vinci surgical system; this will facilitate clinical adoption sooner.

Mechatronic Design of a Two-Arm Concentric Tube Robot System for Rigid Neuroendoscopy.

Open surgical approaches are still often employed in neurosurgery, despite the availability of neuroendoscopic approaches that reduce invasiveness. The challenge of maneuvering instruments at the tip of the endoscope makes neuroendoscopy demanding for the physician. The only way to aim tools passed through endoscope ports is to tilt the entire endoscope; but, tilting compresses brain tissue through which the endoscope passes and can damage it. Concentric tube robots can provide necessary dexterity without endoscope tilting, while passing through existing ports in the endoscope and carrying surgical tools in their inner lumen. In this paper we describe the mechatronic design of a new concentric tube robot that can deploy two concentric tube manipulators through a standard neuroendoscope. The robot uses a compact differential drive and features embedded motor control electronics and redundant position sensors for safety. In addition to the mechatronic design of this system, this paper contributes experimental validation in the context of colloid cyst removal, comparing our new robotic system to standard manual endoscopy in a brain phantom. The robotic approach essentially eliminated endoscope tilt during the procedure (17.09° for the manual approach vs. 1.16° for the robotic system). The robotic system also enables a single surgeon to perform the procedure - typically in a manual approach one surgeon aims the endoscope and another operates the tools delivered through its ports.

Renal cell cancer histological subtype distribution differs by race and sex.

OBJECTIVES: To examine racial differences in the distribution of histological subtypes of renal cell carcinoma (RCC) and associations with established RCC risk factors by subtype. MATERIALS AND METHODS: Tumours from 1532 consecutive patients with RCC who underwent nephrectomy at Vanderbilt University Medical Center (1998-2012) were classified as clear-cell, papillary, chromophobe and other subtypes. In pairwise comparisons, we used multivariate logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between race, sex, age, end-stage renal disease (ESRD) and body mass index at diagnosis according to histological subtype. RESULTS: The RCC subtype distribution was significantly different in black people from that in white people (P < 0.001), with a substantially higher proportion of patients with papillary RCC among black people than white people (35.7 vs 13.8%). In multivariate analyses, compared with clear-cell RCC, people with papillary RCC were significantly more likely to be black (OR 4.15; 95% CI 2.64-6.52) and less likely to be female (OR 0.60; 95% CI 0.43-0.83). People with chromophobe RCC were significantly more likely to be female (OR 2.32; 95% CI 1.44-3.74). Both people with papillary RCC (OR 6.26; 95% CI 2.75-14.24) and those with chromophobe RCC (OR 7.07; 95% CI 2.13-23.46) were strongly and significantly more likely to have ESRD, compared with those with clear-cell RCC. CONCLUSION: We observed marked racial differences in the proportional subtype distribution of RCCs diagnosed at a large tertiary care academic centre. To our knowledge, no previous study has examined racial differences in the distribution of RCC histologies while adjusting for ESRD, which was the factor most strongly associated with papillary and chromophobe RCC compared with clear-cell RCC.

Applications of spectroscopy in diagnosis, staging, and treatment of urologic malignancies.

PURPOSE OF REVIEW: To review the scientific literature on clinical applications of spectroscopy within urologic oncology. Specifically, we address the role of spectroscopy as a novel intraoperative or intraprocedural modality for the management of urothelial carcinoma, renal cell carcinoma, and prostate adenocarcinoma. RECENT FINDINGS: Recent studies have demonstrated that spectroscopy models, suitable for translation to in-vivo clinical use, can differentiate between benign parenchyma and malignant tissue for urothelial carcinoma, renal cell carcinoma, and prostate adenocarcinoma. Recent work has also established spectroscopy as a feasible modality to detect biologically aggressive high-risk disease and classify natural biomarkers. SUMMARY: Spectroscopy has the ability to objectively diagnose and stage malignancies in real time without tissue or cellular disruption. In the future, additional in-vivo studies will be needed to demonstrate that current models remain robust under physiological conditions.

Hand-held transendoscopic robotic manipulators: A transurethral laser prostate surgery case study.

Natural orifice endoscopic surgery can enable incisionless approaches, but a major challenge is the lack of small and dexterous instrumentation. Surgical robots have the potential to meet this need yet often disrupt the clinical workflow. Hand-held robots that combine thin manipulators and endoscopes have the potential to address this by integrating seamlessly into the clinical workflow and enhancing dexterity. As a case study illustrating the potential of this approach, we describe a hand-held robotic system that passes two concentric tube manipulators through a 5 mm port in a rigid endoscope for transurethral laser prostate surgery. This system is intended to catalyze the use of a clinically superior, yet rarely attempted, procedure for benign prostatic hyperplasia. This paper describes system design and experiments to evaluate the surgeon's functional workspace and accuracy using the robot. Phantom and cadaver experiments demonstrate successful completion of the target procedure via prostate lobe resection.

Future robotic platforms in urologic surgery: recent developments.

PURPOSE OF REVIEW: To review recent developments at Vanderbilt University of new robotic technologies and platforms designed for minimally invasive urologic surgery and their design rationale and potential roles in advancing current urologic surgical practice. RECENT FINDINGS: Emerging robotic platforms are being developed to improve performance of a wider variety of urologic interventions beyond the standard minimally invasive robotic urologic surgeries conducted currently with the da Vinci platform. These newer platforms are designed to incorporate significant advantages of robotics to improve the safety and outcomes of transurethral bladder surgery and surveillance, further decrease the invasiveness of interventions by advancing LESS surgery, and to allow for previously impossible needle access and ablation delivery. SUMMARY: Three new robotic surgical technologies that have been developed at Vanderbilt University are reviewed, including a robotic transurethral system to enhance bladder surveillance and transurethral bladder tumor, a purpose-specific robotic system for LESS, and a needle-sized robot that can be used as either a steerable needle or small surgeon-controlled micro-laparoscopic manipulator.

Are 3D Image Guidance Systems Ready for Use? A Comparative Analysis of 3D Image Guidance Implementations in Minimally Invasive Partial Nephrectomy.

Introduction: Three-dimensional image-guided surgical (3D-IGS) systems for minimally invasive partial nephrectomy (MIPN) can potentially improve the efficiency and accuracy of intraoperative anatomical localization and tumor resection. This review seeks to analyze the current state of research regarding 3D-IGS, including the evaluation of clinical outcomes, system functionality, and qualitative insights regarding 3D-IGS's impact on surgical procedures. Methods: We have systematically reviewed the clinical literature pertaining to 3D-IGS deployed for MIPN. For inclusion, studies must produce a patient-specific 3D anatomical model from two-dimensional imaging. Data extracted from the studies include clinical results, registration (alignment of the 3D model to the surgical scene) method used, limitations, and data types reported. A subset of studies was qualitatively analyzed through an inductive coding approach to identify major themes and subthemes across the studies. Results: Twenty-five studies were included in the review. Eight (32%) studies reported clinical results that point to 3D-IGS improving multiple surgical outcomes. Manual registration was the most utilized (48%). Soft tissue deformation was the most cited limitation among the included studies. Many studies reported qualitative statements regarding surgeon accuracy improvement, but quantitative surgeon accuracy data were not reported. During the qualitative analysis, six major themes emerged across the nine applicable studies. They are as follows: 3D-IGS is necessary, 3D-IGS improved surgical outcomes, researcher/surgeon confidence in 3D-IGS system, enhanced surgeon ability/accuracy, anatomical explanation for qualitative assessment, and claims without data or reference to support. Conclusions: Currently, clinical outcomes are the main source of quantitative data available to point to 3D-IGS's efficacy. However, the literature qualitatively suggests the benefit of accurate 3D-IGS for robotic partial nephrectomy.

A Safe Framework for Quantitative In Vivo Human Evaluation of Image Guidance.

Goal: We present a new framework for in vivo image guidance evaluation and provide a case study on robotic partial nephrectomy. Methods: This framework (called the "bystander protocol") involves two surgeons, one who solely performs the therapeutic process without image guidance, and another who solely periodically collects data to evaluate image guidance. This isolates the evaluation from the therapy, so that in-development image guidance systems can be tested without risk of negatively impacting the standard of care. We provide a case study applying this protocol in clinical cases during robotic partial nephrectomy surgery. Results: The bystander protocol was performed successfully in 6 patient cases. We find average lesion centroid localization error with our IGS system to be 6.5 mm in vivo compared to our prior result of 3.0 mm in phantoms. Conclusions: The bystander protocol is a safe, effective method for testing in-development image guidance systems in human subjects.

Follow-up for Clinically Localized Renal Neoplasms: AUA Guideline.

PURPOSE: The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy. MATERIALS AND METHODS: A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included. RESULTS: Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of postoperative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathological tumor stage. CONCLUSIONS: Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical examination, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long-term follow-up data are collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed.

Salvage robotic assisted laparoscopic radical prostatectomy: a single institution, 5-year experience.

PURPOSE: Salvage robotic assisted laparoscopic prostatectomy is a treatment option for certain patients with recurrent prostate cancer after primary therapy. Data regarding patient selection, complication rates and cancer outcomes are scarce. We report the largest, single institution series to date, to our knowledge, of salvage robotic assisted laparoscopic prostatectomy. MATERIALS AND METHODS: We reviewed our database of 4,234 patients treated with robotic assisted laparoscopic prostatectomy at Vanderbilt University and identified 34 men who had surgery after the failure of prior definitive ablative therapy. Each patient had biopsy proven recurrent prostate cancer and no evidence of metastases. The primary outcome measure was biochemical failure. RESULTS: Median time from primary therapy to salvage robotic assisted laparoscopic prostatectomy was 48.5 months with a median preoperative prostate specific antigen of 3.86 ng/ml. Most patients had Gleason scores of 7 or greater on preoperative biopsy, although 12 (35%) had Gleason 8 or greater disease. After a median followup of 16 months 18% of patients had biochemical failure. The positive margin rate was 26%, of which 33% had biochemical failure after surgery. On univariable analysis there was a significant association between prostate specific antigen doubling time and biochemical failure (HR 0.77, 95% CI 0.60-0.99, p = 0.049) as well as between Gleason score at original diagnosis and biochemical failure (HR 3.49, 95% CI 1.18-10.3, p = 0.023). There were 2 Clavien II-III complications, namely a pulmonary embolism and a rectal laceration. Postoperatively 39% of patients had excellent continence. CONCLUSIONS: Salvage robotic assisted laparoscopic prostatectomy is safe, with many favorable outcomes compared to open salvage radical prostatectomy series. Advantages include superior visualization of the posterior prostatic plane, modest blood loss, low complication rates and short length of stay.

Fine tilt tuning of a laparoscopic camera by local magnetic actuation: two-port nephrectomy experience on human cadavers.

BACKGROUND: The magnetic surgical camera is an emerging technology having the potential to improve visualization without taking up port site space. However, tilting the point of view downward/upward can be done only by constantly applying a pressure on the abdomen. This study aims to test the hypothesis that the novel concept of local magnetic actuation (LMA) is able to increase the tilt range available for a magnetic camera without the need for deforming the abdominal wall. The hypothesis that 2-port laparoscopic nephrectomy in fresh tissue human cadavers could be performed by using the LMA camera is also tested. METHODS: First, the 2 cameras were separately inserted, anchored, and moved inside the inflated abdomen. Tilting angles were quantified by image analysis while intra-abdominal pressure changes were monitored. Then, 5 two-port nephrectomies were performed by using the LMA camera while collecting quantitative outcomes. RESULTS: The magnetic camera required a constant pressure on the magnetic handle to achieve an average ±20° tilt from the horizontal position, with an average of 7 mm Hg loss of intra-abdominal pressure. The LMA camera allowed for 75° of tilt from the horizontal position with a resolution of ±1°, without any need to deform the abdomen. All the nephrectomies were completed successfully within an average time of 11 minutes. CONCLUSION: LMA is an effective strategy to provide magnetic cameras with wide-range and high-resolution vertical motion without the need to deform the abdominal wall.

Unified Robot and Inertial Sensor Self-Calibration.

Robots and inertial measurement units (IMUs) are typically calibrated independently. IMUs are placed in purpose-built, expensive automated test rigs. Robot poses are typically measured using highly accurate (and thus expensive) tracking systems. In this paper, we present a quick, easy, and inexpensive new approach to calibrate both simultaneously, simply by attaching the IMU anywhere on the robot's end effector and moving the robot continuously through space. Our approach provides a fast and inexpensive alternative to both robot and IMU calibration, without any external measurement systems. We accomplish this using continuous-time batch estimation, providing statistically optimal solutions. Under Gaussian assumptions, we show that this becomes a nonlinear least squares problem and analyze the structure of the associated Jacobian. Our methods are validated both numerically and experimentally and compared to standard individual robot and IMU calibration methods.

Carbon Dioxide Pyelography: A Convenient and Safe Alternative to Both Room Air and Iodinated Contrast Pyelography During Endourologic Procedures.

Introduction/Background: There are increasing reports of serious complications related to the air pyelography technique, which raise concerns about the safety of room air (RA) injection into the renal collecting system. Carbon dioxide (CO2) is much more soluble in blood than nitrogen and oxygen and thus considerably less likely to cause gas emboli. Iodinated contrast medium (ICM) is expensive, and supplies may not be as reliable as previously assumed. CO2 pyelography (CO2-P) techniques using standard fluoroscopy and digital subtraction fluoroscopy (CO2 digital subtraction pyelography [CO2-DSP]) are described. Materials and Methods: During the endourologic stone cases, 15 to 20 mL of CO2 gas was typically injected into the renal pelvis through a catheter or sheath. Imaging was usually obtained with endovascular CO2 digital subtraction angiography settings using either a traditional fluoroscopy system (TFS) or robotic arm multiplanar fluoroscopy system (RMPFS) (Artis Zeego Care+Clear®; Siemens). Results: CO2-P was performed in 22 endoscopic stone treatment cases between March 2021 and August 2022, primarily using digital subtraction settings in 20 cases. CO2-DSP overall provided higher quality images of the renal pelvis and collecting system than CO2-P, but with a relatively higher radiation dose. Following a quality intervention, fluoroscopy doses for CO2-DSP cases were decreased by 81% overall. The use of CO2-P avoided fluoroscopic or intraoperative CT (ICT) artifacts seen with intraluminal ICM. Conclusions: CO2-P allows the urologist to obtain imaging of the renal collecting system without ICM and with much lower risk of air embolism compared with RA pyelography. CO2 is a nearly cost-free alternative to ICM. Because CO2 is widely available and the technique is easy to perform, we propose that CO2-P should be favored over traditional air pyelography to improve patient safety.

National trends in the use of partial nephrectomy: a rising tide that has not lifted all boats.

PURPOSE: Treatment of organ confined renal masses with partial nephrectomy has durable oncologic outcomes comparable to radical nephrectomy. Partial nephrectomy is associated with lower risk of chronic kidney disease and in some series with better overall survival. We report a contemporary analysis on national trends of partial nephrectomy use to determine partial nephrectomy use over time, and whether nontumor related factors such as structural attributes of the treating institution or patient characteristics are associated with the underuse of partial nephrectomy. MATERIALS AND METHODS: We performed an analysis of the NIS (National Inpatient Sample), which contains 20% of all United States inpatient hospitalizations. We included patients who underwent radical or partial nephrectomy for a renal mass between 2002 and 2008. Survey weights were applied to obtain national estimates of nephrectomy use and to evaluate nonclinical predictors of partial nephrectomy. RESULTS: A total of 46,396 patients were included in the study for a weighted sample of 226,493. There was an increase in partial nephrectomy use from 15.3% in 2002 to 24.7% in 2008 (p <0.001). On multivariate analysis hospital attributes (urban teaching status, nephrectomy volume, geographic region) and patient socioeconomic status (higher income ZIP code and private/HMO payer) were independent predictors of partial nephrectomy use. CONCLUSIONS: Since 2002 the national use of partial nephrectomy for the management of renal masses has increased. However, the adoption of partial nephrectomy at smaller, rural and nonacademic hospitals lags behind that of larger hospitals, urban/teaching hospitals and higher volume centers. A lower rate of partial nephrectomy use among patients without private insurance and those living in lower income ZIP code areas highlights the underuse of partial nephrectomy as a quality of care concern.

Recovery of urinary function after radical prostatectomy: identification of trajectory cluster groups.

PURPOSE: Post-prostatectomy urinary incontinence can impact health related quality of life in men treated with radical prostatectomy for prostate cancer. Currently no consensus exists on which patients are at risk for impaired health related quality of life secondary to post-prostatectomy urinary incontinence. Using trajectory clustering analysis we identified predictors of post-prostatectomy urinary incontinence recovery in unique patient groups. MATERIALS AND METHODS: In a 5-year period health related quality of life was evaluated in patients treated with radical prostatectomy using UCLA-PCI preoperatively, and 3, 6 and 12 months postoperatively. We used a novel cluster modeling technique to identify unique group trajectories of urinary function recovery with time. RESULTS: Group based modeling of UCLA-PCI urinary function scores identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. The 73 group 1 patients had a significant postoperative decrease with only 33.4% of optimum function at 12 months. The 258 group 2 patients had moderately decreased urinary function at 3 months with improvement to 76.8% of optimum function at 12 months. The 89 group 3 patients had high scores throughout. Group 1 patients tended to be older (p=0.001), have major depression (p=0.008) and lower extremity circulatory disease (p=0.004), be a past or a current smoker (p=0.004) and have more comorbidities (p<0.001) than those in groups 2 and 3. On multivariate analysis age and the number of comorbidities significantly predicted inclusion in the poor function group. CONCLUSIONS: A novel modeling approach identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. Patient age and the number of comorbidities predicted worse outcome. These findings have implications for preoperative patient counseling and early intervention for post-prostatectomy urinary incontinence.

Tumour size, tumour complexity, and surgical approach are associated with nephrectomy type in small renal cortical tumours treated electively.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although the benefits of nephron-sparing renal cortical tumour treatments are now widely accepted and have robust data supporting their oncological efficacy, safety, and positive effect on medium- and long-term renal function, the decision to perform partial nephrectomy (PN) remains a complex interaction between several competing factors. Various patient factors, e.g. comorbid conditions, age, body habitus, patient preference, etc. may effect this decision. Then there are the preferences of the surgeon him- or herself, including faculty with different operative techniques and surgical approaches, which may lead to one treatment decision over another. Finally, the anatomy of the tumour itself, i.e. the complexity of the tumour within the kidney and anatomical relationships within the organ, is intuitively critical to a surgeon's assessment of resectability. There is very little published data indicating which of the multitude of clinical variables have the greatest impact on the decision to perform PN. Most previous investigations into the subject have focused on either imperative or relative indications for PN (i.e. solitary kidney, bilateral renal masses, and multifocal tumours) or have used maximal tumour diameter (i.e. tumour size) alone in their assessment of the clinical variables associated with PN use. OBJECTIVE: To identify preoperative variables associated with choice of partial nephrectomy (PN) vs radical nephrectomy (RN). PATIENTS AND METHODS: Between January 2004 and June 2008, 203 patients were treated for clinical T1a renal cortical tumours. Of these, 154 (75.8%) had all data available and form the analytic cohort. Patients were categorized into two groups, PN and RN, based on preoperative treatment plan. Patient-, procedure-, and tumour-related variables, together with tumour complexity (based on the R.E.N.A.L Nephrometry Score [RENAL-NS]) were evaluated for their association with planned PN vs RN. RESULTS: PN was planned in 120/154 patients (77.9%). Minimally invasive surgical approaches were planned in 66/154 cases overall (42.9%) and in 40/120 PN cases (33.3%). On univariate analysis, lower American Society of Anesthesiologists (ASA) score, planned open approach, smaller tumour size, left-sided tumour, and lower RENAL-NS were associated with planned PN. On multivariate analysis three factors remained independently associated with PN: tumour size (each 1 cm decrease in tumour size odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2-4.0, P= 0.011), tumour complexity quantified by RENAL-NS (each 1 point decrease OR 2.4, 95% CI 1.5-3.7, P < 0.001), and planned open surgical approach (OR 7.3, 95% CI 2.2-25, P= 0.001). CONCLUSIONS: The decision to perform elective PN is based primarily on tumour anatomical features but is also associated with surgical approach. The RENAL-NS accurately predicts nephrectomy type in clinical T1a renal cortical tumours.

ABO blood group is a predictor of survival in patients undergoing surgery for renal cell carcinoma.

UNLABELLED: What's known on the subject? and What does the study add? Some evidence suggests that ABO blood type may be a risk factor for cancer incidence and prognosis. For example, a large study recently discovered an increased incidence of pancreatic cancer in patients with non-O blood type; however, it is not known whether blood group correlates with outcomes in patients with RCC. We found a significant and independent association between ABO blood group and overall survival in patients undergoing surgery for locoregional RCC. Specifically, we identified non-O blood type as a predictor of mortality. OBJECTIVE: • To determine whether ABO blood group is associated with survival after nephrectomy or partial nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS: • We conducted a retrospective cohort study of 900 patients who underwent surgery for locoregional RCC between 1997 and 2008 at a single institution. • Covariates included age, gender, race, American Society of Anesthesiology Physical Status, preoperative anaemia and hypoalbuminemia, tumour characteristics, lymph node status, procedure performed, transfusion status and ABO blood group. • Primary outcomes were overall (OS) and disease-specific survival (DSS). • Univariable survival analyses were performed using the Kaplan-Meier and log-rank methods. Multivariable analysis was performed using a Cox proportional hazards model. RESULTS: • The 3-year OS estimate was 75% (95%CI 70-79%) for O blood group and 68% (95% CI 63-73%) for non-O blood group (P= 0.072). The 3-year DSS was 81% (95% CI 76-85%) for O blood group and 76% (95%CI 71-80%) for non-O blood group (P= 0.053). • In the multivariable analysis for OS, non-O blood type was significantly associated with decreased OS (HR 1.68, 95%CI 1.18-2.39; P= 0.004) but not DSS (HR 1.53, 95%CI 0.97-2.41; P= 0.065). CONCLUSION: • These data suggest that ABO blood group is independently associated with OS in patients undergoing surgery for locoregional RCC. ABO blood group has not been previously recognized as a predictor of survival in RCC.

Image-guided robotic surgery: update on research and potential applications in urologic surgery.

PURPOSE OF REVIEW: New methods of imaging and image-guidance technology have the potential to provide surgeons with spatially accurate three-dimensional information about the location and anatomical relationships of critical subsurface structures and instrument position updated and displayed during the performance of surgery. Robotic platforms and technology in various forms continues to revolutionize surgery and will soon incorporate image guidance. RECENT RESEARCH: Image-guided surgery (IGS) for abdominal and urologic interventions presents complex engineering and surgical challenges along with potential benefits to surgeons and patients. Key concepts such as registration, localization, accuracy, and targeting error are necessary for surgeons to understand and utilize the potential of IGS. Standard robotic surgeries, such as partial nephrectomy and radical prostatectomy may soon incorporate IGS. SUMMARY: Research continues to explore the potential for combining image guidance and robotics to augment and improve a variety of surgical interventions.

Single cell analysis of cribriform prostate cancer reveals cell intrinsic and tumor microenvironmental pathways of aggressive disease.

Cribriform prostate cancer, found in both invasive cribriform carcinoma (ICC) and intraductal carcinoma (IDC), is an aggressive histological subtype that is associated with progression to lethal disease. To delineate the molecular and cellular underpinnings of ICC/IDC aggressiveness, this study examines paired ICC/IDC and benign prostate surgical samples by single-cell RNA-sequencing, TCR sequencing, and histology. ICC/IDC cancer cells express genes associated with metastasis and targets with potential for therapeutic intervention. Pathway analyses and ligand/receptor status model cellular interactions among ICC/IDC and the tumor microenvironment (TME) including JAG1/NOTCH. The ICC/IDC TME is hallmarked by increased angiogenesis and immunosuppressive fibroblasts (CTHRC1+ASPN+FAP+ENG+) along with fewer T cells, elevated T cell dysfunction, and increased C1QB+TREM2+APOE+-M2 macrophages. These findings support that cancer cell intrinsic pathways and a complex immunosuppressive TME contribute to the aggressive phenotype of ICC/IDC. These data highlight potential therapeutic opportunities to restore immune signaling in patients with ICC/IDC that may afford better outcomes.