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Medicine

Virtual Reality Surgical Navigation System for Holmium Laser Enucleation of the Prostate

Abstract. Holmium Laser Enucleation of the Prostate (HoLEP) is an endoscopic transurethral surgical technique for Benign Prostatic Hyperplasia (BPH) treatment that carries significant benefits compared with the traditional TransUrethral Resection of the Prostate (TURP). In HoLEP procedure the portion of the prostate with hyperplasia (adenoma) is cut under endoscopic view. Only a few experts in the world perform HoLEP, since the adenoma borders are not clearly visible in the 2D endoscopic images and consequently the clinicians have difficulties to orientate the laser.

Virtual reality navigators demonstrated their potentialities in many fields of surgery to show hidden structures to direct vision and to restore surgeon's orientation.

3D trans-rectal ultrasound (US) probe allows acquiring volumetric information containing prostate and adenoma borders, which can be segmented and represented in a virtual environment. To coherently and real-time render the surgical instrument in respect to the patient anatomy, we can employ a tracking system. A crucial aspect of each navigation system regards the virtual scene ergonomics.

We designed and implemented a pilot surgical navigation system to support the surgeons to accomplish the HoLEP, showing them the cutting plane and the outlines of adenoma and the prostatic capsule in respect of the surgical tool.

Under supervision of an expert urologist we studied and tested the optimal way to realize an anthropomorphous US phantom. Furthermore our virtual reality surgical navigator provides various visualization modalities studied on the basis of clinical requirements.

On the basis of our results it will be possible to perform in-vitro trails to evaluate the usability of our solution to precisely enucleate the adenoma along its borders.

Keywords: HoLEP • Virtual Reality • Navigation system • Benign Prostatic Hyperplasia

1 Introduction

Trans-Urethral Resection of the Prostate (TURP) is considered the first choice for the removal of obstructing Benign Prostatic Hyperplasia (BPH). Although TURP has been the gold standard for almost fifty years [1] until now the morbidity is still about 15% [2-3]. Even though TURP procedure evolved in order to reduce its morbidity [4], a solution to decrease patient dissatisfaction and collateral damages is missing [5]. Ideally, to reduce patient's morbidity, an adenoma complete and one shot enucleation is better than the traditional slice-by-slice TURP resection. To perform this kind of intervention the Holmium Laser Enucleation of the Prostate (HoLEP) procedure was developed. The holmium laser is a pulsed solid-state laser, with a wavelength of 2140 nm strongly absorbed by water, making it ideal for safe use in aqueous environment. An end-firing bare laser fiber is inserted through the urethral channel. It delivers the laser energy to the prostatic tissue. The laser simultaneously cuts and coagulates blood vessels and its effect is circumscribed with a penetration of approximately 0.2 mm and very little thermal spread [6-7].

Although HoLEP potential benefits, this procedure is performed only by a few experts in the world, since the adenoma borders are not clearly visible in the 2D endoscopic images and consequently the clinicians have difficulties to orientate the laser. These difficulties determine the risk to partially remove the adenoma and consequently the need of reintervention. The best performed HoLEP procedure is to cut as big as possible the adenoma without injuring the patient's prostate healthy tissue.

Virtual reality navigators demonstrated their potentialities in many fields of surgery to identify hidden structures to direct vision and to restore surgeon's orientation.

In this paper we propose a navigation system that shows three dimensional (3D) models of prostate, adenoma, urethral channel and medical instruments in a virtual reality scene.

 
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