Large kidney stones can be removed using the effective, less invasive percutaneous nephrolithotomy (PCNL) technique. Renal access creation is a vital but difficult phase in PCNL that involves connecting the skin on the back to the kidney. Severe complications from a poorly constructed renal access might include major bleeding, thoracis and bowel damage, renal pelvis perforation, and even sepsis.
The effective execution of this method requires years of training and practice. Fluoroscopic guidance and ultrasound (US) guidance with or without fluoroscopy are the two primary renal access techniques used during PCNL. Both methods give comparable postoperative results, but they both call for experience-based knowledge.
To close this skill gap, numerous cutting-edge techniques and technologies are being researched and applied in clinical settings. Others offer precise direct access while some provide greater imaging guidance.
However, for novices, the majority of skills are still difficult. This prompted a research group from Nagoya City University (NCU) Graduate School of Medical Sciences (Nephro-urology), led by Assistant Professors Kazumi Taguchi and Shuzo Hamamoto, as well as Chair and Professor Takahiro Yasui, to consider whether robotic systems with AI could provide better guidance than traditional US guidance.
They were particularly interested in determining whether the Automated Needle Targeting with X-ray (ANT-X) device, powered by artificial intelligence, provided good accuracy in percutaneous renal access along with automated needle trajectory. This device was created by the Singaporean medical start-up NDR Medical Technology.
The team compared its robotic-assisted fluoroscopic-guided (RAF) approach with US-guided PCNL in a randomized, single-blind, controlled experiment. The trial’s findings were made public online on May 13, 2022, and The Journal of Urology published them on June 13, 2022.
This was the first human study comparing RAF with conventional ultrasound guidance for renal access during PCNL, and the first clinical application of the ANT-X.
Kazumi Taguchi, Assistant Professor, Graduate School of Medical Sciences, Nagoya City University
Around January 2020 and May 2021, the experiment at NCU Hospital involved 71 patients—36 in the RAF group and 35 in the US group. Single puncture success was the study’s main finding; additional findings included the stone-free rate (SFR), complication rate, parameters assessed during renal access, and fluoroscopy duration.
In the US and RAF groups, the sole puncture rate of success was 34% and 50%, respectively. In comparison to the US group, the RAF group experienced an average of 1.82 times fewer needle punctures (2.51 times). A shift in surgeon was required in 14.3% of US-guided cases where the resident was also unable to acquire renal access due to procedural problems.
None of the RAF examples had this problem. Additionally, the RAF group’s median needle puncture time was noticeably shorter (5.5 minutes vs. 8.0 minutes). The other secondary endpoints did not differ significantly from one another. These findings showed that the mean number of needle punctures was decreased by 0.73 times when RAF guidance was used.
Reduced renal function and multiple renal accesses during PCNL are also known postoperative consequences. As a result, the ANT-low X’s needle puncture frequency and brief puncture length may provide patients with the best overall prognosis. While both the RAF and US groups had residents do the actual PCNL, only one inexperienced surgeon in the RAF group used ANT-X to construct the renal access.
This illustrates the simplicity and safety of the revolutionary robotic equipment, which might lessen the amount of training required of surgeons and enable more facilities to perform PCNL treatments.
Dr Taguchi summarizes the possible advantages of their RAF device saying, “The ANT-X simplifies a complex procedure, like PCNL, making it easier for more doctors to perform it and help a greater number of patients in the process.”
“Being an AI-powered robotic technology, this technique may pave the way for automating similar interventional surgeries that could shorten the procedure time, relieve the burden off of senior doctors, and perhaps reduce the occurrence of complications,” he added.
ANT-X and other comparable robotic-assisted platforms may be the destiny of percutaneous operations in urology and other medical specialties with such encouraging results.
Taguchi, K., et al. (2022) A randomized, single-blind clinical trial comparing robotic-assisted fluoroscopic-guided with ultrasound-guided renal access for percutaneous nephrolithotomy. Journal of Urology. doi.org/10.1097/JU.0000000000002749.