EUROPEAN UROLOGY OPEN SCIENCE 46 (2022) 96–98 available at www.sciencedirect.com journal homepage: www.eu-openscience.europeanurology.com Opinion: Open Science The Metaverse in Urology: Ready for Prime Time. The ESUT, ERUS, EULIS, and ESU Perspective Enrico Checcucci a,b,*, Giovanni Enrico Cacciamani b,c,d, Daniele Amparore e, Ali Gozen f, Christian Seitz g, Alberto Breda h, Evangelos Liatsikos i, Francesco Porpiglia e a Department of Surgery, Candiolo Cancer Institute FPO-IRCCS, Candiolo, Italy; b Young Academic Urologist-Urotechnology Working Party, European Association of Urology, Arnhame, The Netherlands; c Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, USC Institute of Urology, Los Angeles, CA, USA; d Artificial Intelligence Center, USC Institute of Urology, Los Angeles, CA, USA; e Department of Oncology, Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy; f Urology Department, SLK Kliniken, Heidelberg University Teaching Hospital, Heilbronn, Germany; g Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; h Department of Urology, Fundacion Puigvert, Universitat Autonoma de Barcelona, Barcelona, Spain; i Department of Urology, University of Patras, Patras, Greece In the past two decades we have faced a groundbreaking works, characterized by low latency and higher data trans- technological revolution thanks to the spread of multiple mission speeds in comparison to previous network new technologies and tools that offer a previously unseen generations [2]. A few centers have started to explore poten- range of opportunities. Health care systems have been tial applications. The ability to manage a huge amount of heavily impacted by digital transformation, further pushed data allows storage of more complex information for consul- by COVID-19 pandemic restrictions and social distancing tation, such as full three-dimensional (3D) images. Further- that inevitably led to an increase in digital literacy for both more, surgical interventions can be rehearsed with a virtual patients and physicians thanks to wider adoption of digital simulator requiring real-time access to a vast amount of infrastructure and a new awareness of the potential of these data. relatively new technologies. The new opportunities in In term of intraoperative applications, some experiences health care systems result from the application of various with real-time transmission of biopsy images have been digital innovations, such as telemedicine, 5G wireless net- reported. ‘‘Real time’’ telepathology can be performed in works, and artificial intelligence (AI) with machine learning the same hospital and anywhere else, allowing expert con- and deep learning. sultation for complex or undefined cases [3]. Remote sur- A significant increase in the diffusion of telehealth has gery (or telesurgery) represents the maximum utilization been achieved in recent years, including urology [1]. of 5G connection technology, in which the aim is to over- Patients can be evaluated remotely not only during the come the issue of physical distance, allowing experienced decision-making process but also during follow-up after surgeons to perform high-quality procedures for complex an intervention. Specifically developed platforms allow col- cases virtually anywhere in the world. Some pioneering lection of clinical data and visualization and sharing of med- experiences have been reported from 2018, and Li et al. ical images to create an accurate digital medical chart for [4] recently presented their experience with 29 radical every patient (eg, Maia Connected Care). Furthermore, with robotic nephrectomies performed remotely, merging the new devices (eg, Tytocare) it is possible to record patients’ potential of robotics and 5G connectivity. vital signs, such as heart or pulmonary sounds and blood Another exciting field exploiting 5G capability is the con- pressure, remotely, opening the door to a new form of mon- tinuous evolution of the performance of head-mounted dis- itored discharge that can potentially reduce hospital stays play systems in terms of hardware and software. A without affecting patient safety. pioneering study used 3D virtual models of patients’ organs Broader use of internet infrastructure in medicine has stored on a cloud platform (ICON3D; Medics3D) for real- been possible thanks to the introduction of 5G wireless net- time surgical navigation in a mixed reality setting during * Corresponding author. Department of Surgery, Candiolo Cancer Institute FPO-IRCCS, Strada Provinciale 142, km 3.95, 10060 Candiolo, Turin, Italy. E-mail address: checcu.e@hotmail.it (E. Checcucci). https://doi.org/10.1016/j.euros.2022.10.011 2666-1683/Ó 2022 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). EUROPEAN UROLOGY OPEN SCIENCE 46 (2022) 96–98 97 applied to any input; big data, radiology with radiomics, and pathology are the major fields in which developments are ongoing. However, AI is limited by the quality and quan- tity of data provided for the training phase, which represents the greatest challenge to further development and imple- mentation. Focusing on surgery, can we expect autonomous AI-driven surgical robots in the next few years? Automated surgery could be possible in the distant future, but, as reported by Heller et al. [9], AI is currently able to execute small automated surgical steps in urological procedures. ‘‘Man + machine’’ cooperation would be desirable to, at least in part, relieve burdens on health care systems, reduce burn- out, enhance patient satisfaction, and improve the way in which we exert ‘‘human’’ intelligence to improve patients’ lives [10]. As highlighted above, all these technologies are strictly correlated and deeply integrated and present a synergistic effect, allowing each technology to maximize its potential. Therefore, the concept of the internet of medical things (IoMT), defined as the translation of real objects on the inter- net, allowing perception, transmission, and intelligent pro- Fig. 1 – Integration of extended reality and artificial intelligence (AI) in a 5G cessing in multiple settings, seems to perfectly fit this environment brings physicians into the metaverse, where three-dimen- scenario [11] and opens the door to a metaverse in urology. sional models, holograms, augmented reality images, radiomics, and Access to the IoMT, thanks to virtual reality (VR) and AR genomics can improve health care, thanks to information sharing boosted by these new technologies. glasses, will allow everyone to use avatars for interaction in the digital world [11]. The technologies required (5G, VR/ AR, AI) are mature for establishing a metaverse in urology. percutaneous kidney puncture [5]. The availability of high- Virtual and real environments can be merged to improve definition 3D models [6] can facilitate further improvements the quality of our care (Fig. 1): in the precision of surgical procedures thanks to augmented reality (AR) real-time navigation, especially in robotics [7]. (1) A 5G network can store and share a vast amount of A further step is the introduction of AI for more sophisti- data and patient information, even computationally cated hybrid interactions between digital and natural envi- heavy items such as 3D models and streaming video. ronments, achieving so-called ‘‘extended reality’’ [8]. AI is (2) AI can allow extraction of more information from trained to ‘‘learn’’ from a given example to replicate the same patient data, including history, medical images with characteristics in unseen settings. This concept can be radiomics, and genomic analyses. Fig. 2 – With the advent of the metaverse, multidisciplinary team discussion can be conducted in a virtual environment using physician avatars and consultation regarding a patient’s digital images. 98 EUROPEAN UROLOGY OPEN SCIENCE 46 (2022) 96–98 (3) Extended reality permits navigation in a virtual envi- Acknowledgments: We would like to thank Dr. Andrea Bellin for his con- ronment, allowing physicians to explore and directly tribution to this manuscript. interact with all of a patient’s digital data. References Therefore, even though the metaverse is virtual, the [1] Novara G, Checcucci E, Crestani A, et al. Telehealth in urology: a impact will be real. systematic review of the literature. How much can telemedicine be We can hypothesize a multidisciplinary team discussion useful during and after the COVID-19 Pandemic? Eur Urol (MTD) planned in a virtual environment with digital avatars 2020;78:786–811. https://doi.org/10.1016/j.eururo.2020.06.025. 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