Clinical application of 3D anatomical modeling software (IRISTM) during Robot-assisted Partial Nephrectomy for complex renal masses

Abstract

Introduction: IRISTM is an interactive 3-D anatomic modeling software allowing functional manipulation of anatomical models for the surgical planning of renal masses. The software represent converted DICOM files of CT images to 3D virtual anatomical models, viewed on an iOS device during preoperative surgical planning and the da Vinci surgical system TilePro input for intraoperative navigation. The objective of this video is to demonstrate the clinical (utility/application) usefulness of IRIS as a preoperative planning and intraoperative navigation tool in 2 patients with highly complex renal masses. Methods: The first case is a 73 year old male patient with a 2.7cm right, completely endophytic hilar renal mass. Nephrometry score was 10h. The second case was a 45 years old male presenting with a 7.8 by 7.6 cm left hilar posterior renal mass with a nephrometry score of 11p. Two other cases demonstrate the utility of IRIS technology for selective and super-selective arterial ischemia. Preoperative planning was completed utilizing axial imaging and IRIS on an iOS device and a surgical plan put forth. Intraoperative navigation was via the da Vinci surgical system TilePro input. Perioperative and intraoperative patient data was collected. Results: In the first case IRIS helped visualize the resection cavity exposing the surrounding vascular branches that maybe injured during resection, identifying the feeding vessels perfusing the tumor and realizing structures that are likely to get injured during suturing the base of the resection bed during the renoprraphy sutures. Estimated Blood loss (EBL) was 100cc, Warm ischemia time (WIT) 17 minutes, with minimal change in postoperative renal function. In the second partially case with an exophytic tumor, the transparency function allowed for identification of vital structures that would be encountered at the resection base. In this case a large portion of the PCS and a feeding branch of the renal artery, which was accurately localized by altering parenchyma transparency. EBL was 60cc, WIT 28 minutes and GFR was maintained postoperatively. Pathology was positive for clear cell carcinoma with negative margins. In the final tow cases IRIS helped the surgeon accurately identify and dissect the 2ry and 3ry arterial branches supplying the tumor for selective ischemia. Conclusion: IRIS technology with its interactive features offered valuable pre and intraoperative information not attainable by standard axial imaging in the robotic management of complex renal masses.