Efficiency of robot-assisted stereotactic neurosurgeries
The evolution of stereotactic neurosurgery: from neuronavigation to robots
Stereotactic neurosurgery dates as far back as the early 1900s when two pioneering neurosurgeons, Horsley and Clark, became the first to use a 3D cartesian coordinate system to guide electrodes to targets1. Despite its longstanding history, vast advances in stereotactic neurosurgery have only occurred in recent decades. This has been enabled by the evolution of computational technology and advanced medical imaging techniques, providing safer and more precise surgical procedures.
A key step forward in stereotactic neurosurgery has been the development of neuronavigation systems in the 1990s. These are image-guided and computer-assisted platforms that fuse patient images with a 3D coordinate system to plan the safest trajectories for surgical equipment. Neuronavigation systems can more accurately target lesions while avoiding important vascular structures in the brain.
More recently, the integration of robotics, like the Renishaw neuromate® stereotactic robot, has taken stereotactic neurosurgery one step further. These sophisticated platforms serve as a testament to how far medical technology has advanced in the last 100 years.
Robotic-assisted stereotactic neurosurgery has seen widespread adoption across hospitals and institutions worldwide. It has become a cornerstone for functional and stereotactic neurosurgical procedures. These include stereoelectroencephalography (SEEG), deep brain stimulation (DBS), tumour resection, biopsies, and endoscopies 2-5.
The benefits of robotic-assisted stereotactic neurosurgery
Robotic-assisted platforms typically require computational surgical planning software. These use images of the patient's brain to plan the safest trajectories to reach the target. A robotic arm is then used to automatically guide surgical instruments along these planned trajectories, and make any necessary adjustments.
By automating trajectory guidance and adjustment, robotic-assisted stereotactic neurosurgery can reduce the neurosurgeon's fatigue. It also minimises the risk of human error and improves precision and safety, compared to neuronavigational systems.
Another major potential benefit of robotic systems is the improved efficiency of stereotactic neurosurgery. This can be achieved through the integration of surgical planning software, intraoperative imaging and robotic-assisted instrument positioning. As a result, robotic-assisted stereotactic neurosurgery benefits both neurosurgeons and patients because of reduced operating times and the increased number of surgical procedures that can be conducted. This helps to optimise the efficiency and productivity of healthcare systems, which is more important than ever.
Are robotic systems really more efficient?
Robotic systems are used across a wide range of stereotactic neurosurgical procedures. However, most of the literature comparing the efficiency of neuronavigation and robotic systems has focused on SEEG procedures. SEEG typically involves the implantation of 7-16 electrodes into the cerebrum, and is commonly used to locate regions in the brain responsible for epileptic seizures.
To date, thousands of robotic-assisted SEEG procedures have been conducted worldwide. The adoption of robotic systems for SEEG is expected to increase further as the benefits that robotic systems can offer this procedure are recognised more widely around the globe. As of 2020, the Japanese health insurance system recommends the use robotic-assisted SEEG when seven or more electrodes are to be implanted, avoiding the burden of manual electrode placement6.
Efficiency of robotic-assisted and neuronavigation-based SEEG
Research comparing the efficiency of robotic-assisted and neuronavigation-based SEEG includes a 2022 study that was conducted at Osaka City University Hospital, Japan. This study found that robotic technology drastically sped up the electrode implantation process, with patients undergoing robotic-assisted SEEG having an electrode implantation time of 32 - 38.9 minutes, compared to 51.6 - 88.5 minutes in patients undergoing neuronavigation-based SEEG6. However, with a small total sample population of six patients, this study didn't demonstrate a significant reduction in operative time for robotic-assisted SEEG.
A larger UK-based study published in 2021 investigated 32 patients in a single-blind randomised control trial, finding that robotic-assisted SEEG reduced the mean electrode insertion time by approximately 30%. The study also found that the reduced electrode implantation time led to a significantly shorter operative time, helping to improve the efficiency of SEEG procedures7.
This has been supported by a recent study conducted by neurosurgeons at Stanford University, USA, where the mean operative time of robot-assisted SEEG was found to be on average 47.9 minutes shorter than neuronavigation-based SEEG8.
Other stereotactic procedures
So far, there has been limited comparison of the efficiency of robotic-assisted and neuronavigation-based systems for procedures other than SEEG. However, for tumour biopsies, a preclinical study conducted on over 160 cadaver brains showed that robotic platforms could offer a 30% reduction in instrument positioning time9.
DBS Parkinson's disease
Additionally, research has shown that DBS procedures for the treatment of Parkinson's disease may also be more efficient using robotic systems. A trial at Stanford University, studying a total of 40 patients, found that robotic-assisted DBS had a significantly shorter total case time (including total operative time and anaesthesia) compared to neuronavigation-based DBS10. As the use of robotic-assisted stereotactic neurosurgery continues to expand, the evidence of its efficiency across various procedures, including biopsies and DBS, is expected to increase further.
The growing adoption of robotic systems offering improved efficiency could have wide-reaching benefits in stereotactic neurosurgery. With prolonged operative times linked to an increased risk of patient complications, such as bleeding and infection11, robotic-assisted procedures could improve recovery rates and reduce surgical risks. In addition to the patient's decreased trauma, reduced operative times will undoubtedly benefit healthcare systems, allowing for more procedures to be conducted per day.
What does this mean in terms of costs?
If robotic-assisted stereotactic neurosurgery is faster than neuronavigation, could this mean a reduction in the costs? Unfortunately, this doesnt have a simple answer. The associated expenses of robotic-assisted stereotactic neurosurgery depend on several factors, including the upfront cost of the robotic system, resources used, operating room costs per hour, and the length of inpatient stay.
Moreover, the upfront cost of purchasing and installing robotic systems can be high. This could potentially be offset by the increased efficiency of robotic systems. However, long-term cost analysis that compares robotic and neuronavigation systems in stereotactic neurosurgery is needed to confirm which is more cost-effective in the long run.
Is the future of stereotactic neurosurgery robotic?
There is growing evidence to show that robotic systems can offer faster stereotactic neurosurgery, particularly for SEEG procedures that require multiple instrument trajectories. The implementation of these systems holds the promise of improving the efficiency of neurosurgery departments.
As such, the increased adoption of robotic-assisted stereotactic neurosurgery, such as Renishaw's neuromate, could transform healthcare systems, by reducing long patient waiting times and easing the pressure of burdening workloads.
References
1. P. H. Schurr and W. R. Merrington, The HorsleyClarke stereotaxic apparatus, Journal of British Surgery, vol. 65, p. 3336, 1978.
2. Faria, W. Erlhagen, M. Rito, E. De Momi, G. Ferrigno and E. Bicho, Review of robotic technology for stereotactic neurosurgery, IEEE reviews in biomedical engineering, vol. 8, p. 125137, 2015.
3. Fayed, R. D. Smit, S. Vinjamuri, K. Kang, A. Sathe, A. Sharan and C. Wu, "Robot-Assisted Minimally Invasive Asleep Single-Stage Deep Brain Stimulation Surgery: Operative Technique and Systematic Review.," Operative neurosurgery (Hagerstown, Md.), vol. 26, no. 4, pp. 363-371, April 2024.
4. J. Marcus, V. N. Vakharia, S. Ourselin, J. Duncan, M. Tisdall and K. Aquilina, "Robot-assisted stereotactic brain biopsy: systematic review and bibliometric analysis.," Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, vol. 34, no. 7, pp. 1299-1309, July 2018.
5. D. N. Vasconcellos, T. Almeida, A. Mller Fiedler, H. Fountain, G. Santos Piedade, B. A. Monaco, J. Jagid and J. G. Cordeiro, "Robotic-Assisted Stereoelectroencephalography: A Systematic Review and Meta-Analysis of Safety, Outcomes, and Precision in Refractory Epilepsy Patients.," Cureus, vol. 15, no. 10, p. e47675, October 2023.
6. Kojima, T. Uda, T. Kawashima, S. Koh, M. Hattori, Y. Mito, N. Kunihiro, S. Ikeda, R. Umaba and T. Goto, Primary experiences with robot-assisted navigation-based frameless stereo-electroencephalography: higher accuracy than neuronavigation-guided manual adjustment, Neurologia medico-chirurgica, vol. 62, p. 361368, 2022.
7. N. Vakharia, R. Rodionov, A. Miserocchi, A. W. McEvoy, A. OKeeffe, A. Granados, S. Shapoori, R. Sparks, S. Ourselin and J. S. Duncan, Comparison of robotic and manual implantation of intracerebral electrodes: a single-centre, single-blinded, randomised controlled trial, Scientific Reports, vol. 11, p. 17127, 2021.
8. H. Kim, A. Y. Feng, A. L. Ho, J. J. Parker, K. K. Kumar, K. S. Chen, G. A. Grant, J. M. Henderson and C. H. Halpern, Robot-assisted versus manual navigated stereoelectroencephalography in adult medically-refractory epilepsy patients, Epilepsy research, vol. 159, p. 106253, 2020.
9. Minchev, G. Kronreif, M. Martnez-Moreno, C. Dorfer, A. Micko, A. Mert, B. Kiesel, G. Widhalm, E. Knosp and S. Wolfsberger, A novel miniature robotic guidance device for stereotactic neurosurgical interventions: preliminary experience with the iSYS1 robot, Journal of neurosurgery, vol. 126, p. 985996, 2017.
10. L. Ho, A. V. Pendharkar, R. Brewster, D. L. Martinez, R. A. Jaffe, L. W. Xu, K. J. Miller and C. H. Halpern, Frameless robot-assisted deep brain stimulation surgery: an initial experience, Operative Neurosurgery, vol. 17, p. 424431, 2019.
11. Cheng, J. W. Clymer, B. Po-Han Chen, B. Sadeghirad, N. C. Ferko, C. G. Cameron and P. Hinoul, "Prolonged operative duration is associated with complications: a systematic review and meta-analysis," Journal of Surgical Research, vol. 229, p. 134144, 2018.
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