(UroToday.com) The potential benefits and limitations of using preoperative three-dimensional virtual models (3DVMs) in renal cancer surgery were critically examined in this edition of "Crossfire: Controversies in Urology." Dr. Ahmed Ghazi, advocating for the use of 3DVMs, emphasized their superiority over traditional 2D CT scans in providing surgeons with a more intuitive understanding of patient anatomy. This enhancement reportedly boosts surgeons’ confidence and precision during operations. Supporting this claim, Dr. Ghazi referenced a meta-analysis by Piramide et al., which noted that 3D-guided surgeries often employ more refined surgical techniques, such as selective clamping and pure enucleations, while also minimizing violations of the perinephric fat capsule (PCS)1.
A pivotal advantage of 3DVMs, as discussed by Dr. Ghazi, is their role in preserving renal parenchyma, thereby optimizing postoperative kidney function. Citing research by Amparore et al., Dr. Ghazi highlighted a significant reduction in renal function loss when surgeries were guided by 3D models compared to traditional methods2. This preservation is crucial for maintaining the patient's quality of life post-surgery.
Dr. Ghazi also introduced the next frontier of 3D modeling—3D-hydrogel modeling and augmented reality—proposing these as tools for preoperative surgical rehearsals and real-time surgical guidance, respectively. These technologies represent a leap from virtual to physical applications, potentially reducing intraoperative risks and postoperative recovery times.
Countering Dr. Ghazi's arguments, Dr. Alberto Martini raised concerns about the actual efficacy of 3DVMs in improving clinical outcomes. He pointed out that, according to the same studies cited by the proponents, 3DVMs did not significantly affect many critical surgical metrics, such as ischemia times, overall complications, and surgical margins1. This suggests that while 3DVMs may enhance certain surgical processes, they do not universally translate to better patient outcomes.
Dr. Martini also discussed the logistical challenges and ethical implications of widespread 3DVM adoption. He underscored the time and resource-intensive nature of creating and utilizing 3D models, questioning whether these investments yield proportional benefits. Additionally, he highlighted potential liabilities, especially concerning inaccuracies in model rendering that could lead to surgical errors.
In defense of 3DVMs, Dr. Ketan Badani referred to an international validation study showing significant improvements in operative metrics such as reduced operative times and hospital stays when surgeries were guided by 3DVMs3.
Additionally, Dr. Badani cited unpublished data, in which 3DVMs were shown to be superior in assessing the PADUA and RENAL nephrometry scores and relative risk categories (NS/NC), often reducing the rate of renal masses surgical complexity, and therefore potentially increasing the indication to nephron-sparing approaches while being more accurate in identifying those cases more likely to develop postoperative complications. He also noted the intangible benefits of 3D models, such as enhanced educational opportunities and operational efficiencies within the surgical team.
Dr. Ariel Shalhav voiced skepticism about the prevailing enthusiasm for 3DVMs, criticizing the quality and robustness of existing studies. He argued that traditional imaging combined with skilled surgical judgment remains the gold standard, cautioning against over-reliance on technology that may not yet be ready for widespread clinical adoption.
In his closing remarks, Dr. Brian Schuch reflected on the ongoing debate by emphasizing the necessity for more rigorous and controlled studies to evaluate the true impact of 3DVMs. He advocated for a balanced approach to innovation in surgical practices, stressing the importance of integrating new technologies only when they have been conclusively proven to add clinical value.
This debate highlights a critical junction in surgical oncology: the need to balance technological advancements with empirical evidence and practical considerations. As the field of urology continues to evolve, the contributions from such discussions are invaluable in guiding future research and clinical practices.
Presented by: Brian Schuch, MD, UCLA, Los Angeles, CA
Expert Panel:
- Ahmed Ghazi, MD, MHPE, Johns Hopkins University, Baltimore, MD
- Alberto Martini, MD, UT MD Anderson Cancer Center, Houston, TX
- Ketan Badani, MD, Mount Sinai, New York, NY
- Arieh Shalhav, MD, University of Chicago, Chicago, IL
Written by: Brandon Camp, MS3, University of California Irvine School of Medicine, @brando_camp on X (formerly Twitter) during the 2024 American Urological Association (AUA) Annual Meeting, San Antonio, TX, Fri, May 3 – Mon, May 6, 2024.
References:
- Piramide F, Kowalewski KF, Cacciamani G, et al. Three-dimensional Model-assisted Minimally Invasive Partial Nephrectomy: A Systematic Review with Meta-analysis of Comparative Studies. Eur Urol Oncol. 2022;5(6):640-650. doi:10.1016/j.euo.2022.09.003.
- Amparore D, Pecoraro A, Checcucci E, et al. Three-dimensional Virtual Models' Assistance During Minimally Invasive Partial Nephrectomy Minimizes the Impairment of Kidney Function. Eur Urol Oncol. 2022;5(1):104-108. doi:10.1016/j.euo.2021.04.001.
- Amparore D, Piramide F, Piani A, et al. 3D virtual models improve the accuracy of nephrometric scores in predicting surgical complexity during robotic partial nephrectomy: Results of a collaborative ERUS validation study. European Urology. 2023;83;S1198-S1199. doi:10.1016/s0302-2838(23)00888-6.