Pieter De Backer

Objectives: Our objective was to evaluate the feasibility, safety, and operational reliability of a standardized telesurgical robot‐assisted radical prostatectomy (RARP) programme performed between two Belgian institutions. Materials and Methods: This prospective pilot study included 20 patients undergoing RARP (10 telesurgical and 10 contemporaneous matched on‐site reference procedures) performed between two Belgian institutions, AZORG Hospital and Orsi Academy. The primary endpoint was intraoperative safety, assessed using the European Association of Urology intraoperative adverse incident classification. Secondary endpoints included perioperative outcomes; postoperative recovery; pathological, biochemical, and functional outcomes; and telesurgery‐specific technical parameters (network latency, system reliability, and surgeon‐reported usability and workload). Results: All telesurgical procedures were completed successfully without intraoperative adverse events or local takeover. Median operative time was 155 (interquartile range 140–180) min, and median estimated blood loss was 325 (interquartile range 200–400) mL. No major postoperative complications (Clavien–Dindo ≥3) occurred. Pathological, biochemical, and early functional outcomes following telesurgical RARP were within the range observed in the contemporaneous reference cohort. Mean network latency was 10.7 ± 5.3 ms, mean jitter was 4 ms, and packet loss remained below 0.05% throughout all procedures. One transient connection interruption occurred, without clinical consequences, and all procedures were completed successfully. Surgeon‐reported usability and workload scores were favourable. Conclusion: This prospective pilot study provides early clinical evidence that telesurgical RARP can be safely implemented under stable low‐latency conditions. These findings support the clinical applicability of telesurgery, providing a framework for larger‐scale evaluations.

Article: The data dividend: how AI turns robotic surgery into measurable value. Insight from EAU-YAU Urotechnology and Digital Health Working Group - Minerva Urology and Nephrology 2026 April;78(2):161-3 - Minerva Medica - Journals

Objective: We evaluate the performance and relevance of MRI to detect csPC in men with normal PSA. Methods: Out of our database of patients referred for prostate MRI, we selected men with PSA < 4 ng/mL for whom histopathology or at least 2 years of clinical follow-up data were available as standard of reference. Subgroup analyses were performed for the patients with PSA < 3 ng/mL, <2 ng/mL, and 2–3.9 ng/mL. The reasons for prostate MRI referral despite their normal PSA level were retrieved by exploring the patients’ files. The prostate MRIs were reported according to the Prostate Imaging and Reporting Data System (PI-RADS), and the overall assessment score was registered. For evaluation of the performance, PI-RADS ≥ 3 was set as a threshold for a positive exam. The patients without PC or only International Society of Urological Pathology (ISUP) grade group 1 PC (Gleason 3+3) were considered as one category having no csPC. The performance of prostate MRI was separately evaluated for detection of ISUP ≥ 2 and for ISUP ≥ 3 csPC. Results: A total of 148 men were included, with PSA ranging from 0.42 to 3.99 ng/mL (median 2.95, IQR 1.68–3.50) and age ranging from 36 to 84 years (median 58, IQR 52–66). A total of 74 men (50.0%) had a PSA level < 3 ng/mL, 42 (28.4%) had a PSA level < 2 ng/mL, and 106 (71.6%) had a PSA level of 2–3.9 ng/mL. They were referred for prostate MRI for a wide variety, and usually a combination of, reasons, such as younger age (<60 years in 55.4%, N = 82; <50 years in 17.6%, N = 26), abnormal digital rectal examination in 31.8% of cases (N = 47), suspicious PSA dynamics in 29.7% (N = 44), positive familial history in 27.0% (N = 40), clinical signs of prostatitis in 18.2% (N = 27), suspicious findings on Transrectal Ultrasound (TRUS) in 16.9% (N = 25), hematospermia in 7.4% (N = 11), hematuria in 4.1% (N = 6), incidental hot spot in the prostate on Fluoro-Deoxy-Glucose (FDG) Positron Emission Tomography (PET)–Computed Tomography (CT) in 4.1% (N = 6), lymphadenopathies on CT in 2.7% (N = 4), or severe patient anxiety in 3.4% (N = 5). Overall, ISUP ≥ 2 PC was present in 18.9% (N = 28) of cases, and MRI detected this with a sensitivity of 92.9%, a specificity of 66.7%, and a positive predictive value of 39.4%. ISUP ≥ 3 PC was present in 9.5% (N = 14) of cases, and prostate MRI detected this with a sensitivity of 100%, a specificity of 61.2%, and a positive predictive value of 21.2%. In patients with PSA < 2 ng/mL (N = 42), no csPC was found, but MRI generated false positives in 33.3%. Conclusions: Performing prostate MRI in men with normal PSA (<4 ng/mL) seems useful if there are other reasons that increase the clinical suspicion of csPC. In about one-fifth of these patients, csPC is present and MRI has high sensitivity for its detection. Prostate MRI has, however, low positive predictive value in this patient group, and clinicians should be aware of the risk of false-positive MRI. Below a PSA level of 2 ng/mL, no csPC was found and prostate MRI generated only false positives, suggesting limited value in this subgroup.

Objectives To investigate the influence of different tumor diameter measurement methods on the clinical T-staging of renal masses and compare this with the pathological T-staging. Methods Four two-dimensional (2D) and two three-dimensional (3D) measurement methods (2D axial, 2D perpendicular, 2D oblique, 2D ellipsoid*, 3D diameter* and 3D volume* (*newly proposed methods)) were used to calculate the tumor diameter in 173 patient cases. 3D models of the tumors were segmented on the preoperative computed tomography (CT) scans. PyRadiomics was used to automatically analyze the 3D models for the six different measurement methods. Paired t-tests were performed to compare the tumor diameter over the different methods. Operation time (OT) and estimated blood loss (EBL) were compared between the T1a and T1b tumors for all methods using unpaired t-tests. Results Maximal tumor diameter results depend on the measurement method. The 3D diameter method gave the highest value, on average 16.9% larger than the pathological diameter. The 3D volume method distinguished best between T1a and T1b with regard to OT and EBL, followed by the 2D axial method. The biggest limitations are the small number of large tumors included and the single-observer measurements. Conclusion The renal tumor diameter measured on imaging is influenced by the measurement technique and is larger than the pathological diameter. The newly proposed 3D volume method distinguishes surgical complexity best between T1a and T1b. However, when no 3D model is available, the simple diameter measurement on the axial plane could be sufficient.

Introduction: Minimally invasive treatments (MITs) have emerged as viable treatment options for carefully selected patients with localized disease. Their major advantage is that MITs enable the preservation of nearby healthy prostate tissue and critical structures such as the urethral sphincter and neurovascular bundles without compromising oncologic outcomes. The aim of the current review is to describe the impact of different MITs for prostate cancer (PCa) on urinary continence. Materials and Methods: A systematic literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Inclusion criteria were as follows: all clinical trials conducted and related to the urinary outcomes (UO) of PCa MITs. Exclusion criteria were as follows: any reviews, articles, conference abstracts, articles whose subject fell outside the scope of this review, or any articles published more than 5 years ago. Results: In the course of the last 5 years, a total of 114 articles on MITs of PCa have been published. Among them, only 36 dealt with the UO for MITs. Brachytherapy, cryoablation, and high-intensity focused ultrasound (HIFU) seem to be the most widely used technologies, whereas irreversible electroporation, focal brachytherapy, focal cryoablation, and multi-parametric magnetic resonance imaging-ultrasound-guided (mpMRI-US-guided) HIFU seem to be the safest techniques in terms of UO. Conclusion: The use of MITs for treating PCa is a fast-growing option that can help preserve functional parameters and urinary continence close to their normal levels. It should be noted that although there are currently limited data available on all MITs for the treatment of PCa, the ones that have been extensively studied have shown promising results.

Purpose: Automated surgical phase recognition (SPR) uses artificial intelligence (AI) to segment the surgical workflow into its key events, functioning as a building block for efficient video review, surgical education as well as skill assessment. Previous research has focused on short and linear surgical procedures and has not explored if temporal context influences experts’ ability to better classify surgical phases. This research addresses these gaps, focusing on robot-assisted partial nephrectomy (RAPN) as a highly nonlinear procedure. Methods: Urologists of varying expertise were grouped and tasked to indicate the surgical phase for RAPN on both single frames and video snippets using a custom-made web platform. Participants reported their confidence levels and the visual landmarks used in their decision-making. AI architectures without and with temporal context as trained and benchmarked on the Cholec80 data set were subsequently trained on this RAPN data set. Results: Video snippets and presence of specific visual landmarks improved phase classification accuracy across all groups. Surgeons displayed high confidence in their classifications and outperformed novices, who struggled discriminating phases. The performance of the AI models is comparable to the surgeons in the survey, with improvements when temporal context was incorporated in both cases. Conclusion: SPR is an inherently complex task for expert surgeons and computer vision, where both perform equally well when given the same context. Performance increases when temporal information is provided. Surgical tools and organs form the key landmarks for human interpretation and are expected to shape the future of automated SPR.

Purpose: Automated Surgical Phase Recognition (SPR) uses Artificial Intelligence (AI) to segment the surgical workflow into its key events, functioning as a building block for efficient video review, surgical education as well as skill assessment. Previous research has focused on short and linear surgical procedures and has not explored if temporal context influences experts' ability to better classify surgical phases. This research addresses these gaps, focusing on Robot-Assisted Partial Nephrectomy (RAPN) as a highly non-linear procedure. Methods: Urologists of varying expertise were grouped and tasked to indicate the surgical phase for RAPN on both single frames and video snippets using a custom-made web platform. Participants reported their confidence levels and the visual landmarks used in their decision-making. AI architectures without and with temporal context as trained and benchmarked on the Cholec80 dataset were subsequently trained on this RAPN dataset. Results: Video snippets and presence of specific visual landmarks improved phase classification accuracy across all groups. Surgeons displayed high confidence in their classifications and outperformed novices, who struggled discriminating phases. The performance of the AI models is comparable to the surgeons in the survey, with improvements when temporal context was incorporated in both cases. Conclusion: SPR is an inherently complex task for expert surgeons and computer vision, where both perform equally well when given the same context. Performance increases when temporal information is provided. Surgical tools and organs form the key landmarks for human interpretation and are expected to shape the future of automated SPR.

Purpose In this trial we explore potential indications of an intra-operative mobile PET/CT camera. The tested device is designed to acquire high quality images of resected tissue specimens from patients who were administered a PET-tracer, shortly before resection. Besides clinical experiences, we will also comment on the practical aspects of the implementation of a safe workflow for intra-operative PET/CT-imaging. Methods This investigator driven study involved a 12-month evaluation of the AURA 10 PET/CT camera (XEOS Medical, Belgium). Depending on the tumour type, [¹⁸F]FDG, [18F]JK-PSMA-7, [^18F]PSMA-1007 or [¹⁸F]Choline was injected intravenously 60–90 min prior to the removal of the tumour. The tissue was scanned in the mobile PET/CT-device and 12 min later the surgeon could review the images. Specimen PET/CT-images were confronted with pathology findings. Dose rates were monitored around the patient throughout the procedure. Results The technique was tested in 32 surgeries for thyroid carcinomas (n = 5), transitional cell carcinomas (n = 2,) renal cell carcinoma (n = 1), prostate cancer (n = 5), breast carcinoma (n = 7), skin cancer (n = 3), nodal or bone biopsy for oncology work up (n = 6) and parathyroid adenoma (n = 3). Normalized to an injected activity of 1 MBq/kg the estimated median absorbed doses per procedure were 15.6 µSv (range 0,7-140,8) and 14,1 µSv (0,5–46,2) for respectively the surgeons and instrumenting nurses. Conclusion The overall experience of intra-operative PET/CT-imaging of surgical specimens was promising in our hospital, with particular added value in case of (para)thyroid, urological surgeries, and oncological work-ups. High quality images were obtained with low activity of tracers, enabling a safe implementation. Trial registration number (Belgium) BUN: B0172022000009 (NCT retrospectively submitted).