Page 12 - Read Online

Pecoraro et al. Mini-invasive Surg 2024;8:25 https://dx.doi.org/10.20517/2574-1225.2023.134 Page 5 of 12

Knoedler et al. also observed that 3D-printed physical models enhanced students’ ability to correctly assign
[20]
the R, N, and L components of the nephrometry score . Accurately identifying the tumor’s location is
crucial for minimizing both postoperative and major complications during partial nephrectomy.

Finally, several studies [8,20,23] have explored how 3D imaging models benefit urologists in presurgical
planning, training and learning curves. Porpiglia et al. highlighted that 3D imaging provides a “hyper-
[9]
accurate” view, offering a clearer understanding of surgical complexity compared to 2D images . A recent
study showed the usability and users’ perception of this platform during a urology congress. Surgeons and
[18]
attendees had the opportunity to test the new ICON3DTM platform and to fill out the Health Information
Technology Usability Evaluation Scale (Health-ITUES) and the User-Experience Questionnaire (UEQ)
questionnaire. The platform was helpful both for presurgical and surgical planning for the 43.4% and the
39.6% of the attendees.

Table 3 summarizes 3D application, training and competency framework for 3DVM use.

RENAL PEDICLE MANAGEMENT
Selective and superselective clamping
During the preoperative planning phase, the surgeon can explore various approaches to the hilum and
determine the optimal clamping strategy to balance the risk of hypoxic damage with the potential for
bleeding from the resection bed. Indeed, three-dimensional visualization of the pedicle enables the surgeon
to more frequently use selective clamping or clampless NSS instead of global clamping. This approach, as
[23]
highlighted in a recent systematic review by Piramide et al., significantly reduces global ischemia by 80% .
Indeed, 3DVM can reproduce not only the main renal artery and segmental branches, but also the
interlobar vessels with specific attention to the feeding tumor artery. This can support a selective clamping
approach, as initially demonstrated by Porpiglia et al. . Additionally, the 3D group exhibited lower blood
[15]
loss (mean difference of 23.1 mL, 95%CI: 31.8-14.4; P < 0.01). Finally, the same review indicated that the risk
of incorrect selective clamping was reduced by approximately 10% in the ICG AR group compared to ICG
guidance alone [12,13] .

These encouraging results have pushed forward the research in this field.

Perfusion areas: the rainbow kidney
The latest generation of 3D kidney models can be enhanced with mathematical models that predict which
regions of the renal parenchyma are supplied by each arterial branch, allowing for the individualization of
specific perfusion areas. Specifically, each branch of the renal artery is considered as a set of seed points in a
Voronoi diagram instead of using the endpoints of arteries [24,25] . The 3D reconstructions can then be divided
by perfusion region and displayed in different colors , as a “rainbow kidney”. This means that, based on
[25]
3DVM perfusion areas, it is possible to balance the rate of renal tissue spared from ischemia and the
feasibility of selective or superselective clamping. For example, the surgeon can put a bulldog clamp only on
the segmental tumor feeding arteries or on the prepyelic or the retropyelic branch of the main renal
[25]
artery .
RESECTION AND RECONSTRUCTIVE TECHNIQUE
Intraoperative real-time superimposition of 3D models over the real anatomy
Intraoperatively, the resection plane follows the lesion marked on the renal parenchyma surface under a 3D
AR guidance overlay, allowing the surgeon to spare vascular or draining structure.