Debating the utility of 3D pre-op models in renal surgery
Is a clearer picture worth the additional cost and time?
Can the latest generation of three-dimensional pre-op models improve surgical outcomes for kidney cancer surgery? Or are they an alluring technology that exhausts time and increases cost with little or no improvement in patient outcomes?
Brian Shuch, MD
“We are pushing the envelope with partial nephrectomy, taking on more and more challenging surgeries to try to spare patients the associated harms of chronic kidney disease,” said Brian Shuch, MD, director of the Kidney Cancer Program and the Alvin & Carrie Meinhardt Endowed Chair in Kidney Cancer Research at the University of California in Los Angeles. “As we are tackling larger, deeper tumors, we have the potential for getting into important structures like the collecting system, renal vein sinuses and the ureter. There are existing technologies that turn a two-dimensional CT or MRI image into a 3D model that could be visualized prior to surgery and/or used intraoperatively, even within the robotic console.”
Dr. Shuch will moderate a Crossfire Debate, “Controversies in Urology: Pre-Op 3D Models Help Improve Surgical Outcomes in Renal Cancer Surgery,” 2:20-2:50 p.m. today in the Stars at Night Ballroom. He will present a patient with early-onset kidney cancer with multifocal and bilateral appearance including one tumor that appears to be highly invasive.
3D pre-op models promise to give the surgeon a better idea of patient-specific anatomy with the goal of improving operative parameters, including quicker operations, less blood loss and less entry into the urinary collecting system. The goal is to improve the rate of complete resection with negative margins and improve the ability to save a kidney with a successful partial nephrectomy.
“These models are not cheap,” Dr. Shuch said. “The majority of users will rely on a third party to develop them, something that is not reimbursed. These are also time consuming because we need to extract images from the institution, export deidentified images to the third party, then obtain and visualize the model, often with special software, and perhaps connect with the robotic console for real-time visualization. The question is whether they are really that useful.”
Similar 3D models may have clearer benefits to other types of surgery such as a complex segmental resection for lung cancer, where a lobectomy would not be ideal, Dr. Shuch noted. The surgeon may never clearly visualize a tumor buried deep in the lung tissue, which makes an accurate 3D pre-op model invaluable for performing a tissue-sparing segmental resection.
“However, for kidney cancer surgery, we are not operating blind,” he pointed out. “For a partial nephrectomy, it ultimately comes down to the surgeon visualizing the normal/tumor tissue interface and using intraoperative ultrasound for real-time planning to give the surgeon a clearer road map of the ideal tissue planes.
“Our goal is a better understanding of how some of our expert surgeons use 3D models to perhaps improve their operations,” Dr. Shuch added. “There are questions as to how and when these models may be useful and how surgeons might integrate this novel visualization approach into their practice, either for all patients or maybe for the most challenging cases they face in clinic. While there have been studies, the jury is still out on whether it is worth the additional cost and time to use this technology to improve patient outcomes. There are challenges with assessing impact, and randomization has limitations because operative metrics are greatly impacted by surgeon behavior.”
