1151853 letter20232023 TAU0010.1177/17562872231151853Therapeutic Advances in UrologyE Checcucci, P Verri Therapeutic Advances in Urology Letter to the Editor The future of robotic surgery in urology: Ther Adv Urol 2023, Vol. 15: 1–4 from augmented reality to the advent of DOI: 10.1177/ https://doi.org/10.1177/17562872231151853 https://doi.org/10.1177/17562872231151853 17562872231151853 metaverse © The Author(s), 2023. Article reuse guidelines: sagepub.com/journals- permissions Enrico Checcucci , Paolo Verri , Daniele Amparore, Giovanni Enrico Cacciamani, Juan Gomez Rivas, Riccardo Autorino , Alex Mottrie, Alberto Breda and Francesco Porpiglia;On behalf of Young Academic Urologist (YAU) of the European Association of Urology (EAU), Research Group of the European Section of Urotechnology (ESUT) and EAU Robotic Urology Section (ERUS) Correspondence to: Enrico Checcucci Dear Editor, remote 3DVMs cognitive telementoring during Department of Surgery, Candiolo Cancer Institute, partial nephrectomy was preliminarily shown dur- FPO-IRCCS, Strada In the last years, following the concept of preci- ing the 9th edition of Techno-Urology-Meeting Provinciale 142, km 3,95, 10060 Turin, Italy. sion surgery1 different new technologies have (http://www.technourologymeeting.com)  from checcu.e@hotmail.it been introduced to tailor surgical interventions. Italy to Spain and Belgium: a 3DVM was shown Paolo Verri Division of Urology, inside the robotic console with the Tile-Pro and Department of Oncology, Among them, the application of 3D virtual mod- was maneuvered in real time remotely by an expert University of Turin, San Luigi Gonzaga Hospital, els (3DVMs) is one of the most attractive2 and, following the different phases of the intervention. Torino, Italy thanks to the integration of such models with Department of Urology, robotic platforms, augmented reality (AR) proce- In fact, the 3DVMs can be exploited in many dif- Fundació Puigvert, Autonomous University dures driven by the superimposition of the ferent settings such as patients counseling, pre- of Barcelona, Barcelona, 3DVMs can be performed. The creation of the surgical planning, and surgical training, displaying Spain 3DVMs is the first crucial step for this kind of images on a 2-dimensional (2D) flat screen or in Daniele Amparore Francesco Porpiglia image-guided surgery and a rigorous pathway a 3-dimensional (3D) virtual environment by Division of Urology, should be followed aimed to obtain high defini- using head-mounted display [mixed reality (MR) Department of Oncology, University of Turin, San tion models that strictly reproduce the surgical or virtual reality (VR) setting].9 The latter, which Luigi Gonzaga Hospital, anatomy and that can have a real benefit during allows to live the 3D experience integrated with Torino, Italy the surgical procedures3 (Table 1). reality (MR) or in a totally virtual environment Giovanni Enrico Cacciamani (VR), represents the origin of the concept of Catherine and Joseph Several experiences have already demonstrated metaverse, for which a clear definition is still lack- Aresty Department of Urology, Keck School of the potentialities of 3DVMs guidance in uro- ing. Generally, it usually refers to a totally alter- Medicine, USC Institute oncologic surgery.4 For prostate cancer, a selec- native virtual world or a union between a fictional of Urology, Los Angeles, CA, USA tive modulation of the nerve-sparing approach virtual world and the real one. So, it is correct to Juan Gomez Rivas can be carried out, reducing the positive surgical say that the metaverse can either represent an Department of Urology, Hospital Clinico San margins rate;5 likewise, for kidney cancer, the AR ‘enhanced’ world (i.e. MR) or, conversely, a Carlos, Madrid, Spain images can help during both the resection and totally different virtual world.10 Hence, the Riccardo Autorino suturing phases6 with promising, although under metaverse allows an opportunity to build infra- Department of Urology, Rush University Medical scrutiny, benefits on postoperative renal func- structure, through which other platforms like arti- Center, Chicago, IL, USA tion.7 More recently, this technology was also ficial intelligence (AI) and blockchain could Alex Mottrie applied during robotic kidney transplantation, improve different medical outcomes. Department of Urology, OLV Hospital, Aalst, solving the open issue of atheromatic plaques Belgium identification, expanding the indication of robotic Both doctors and patients can benefit from its ORSI Academy, Melle, approach in this field.8 potentialities starting from population health Belgium Alberto Breda management (i.e. cancer screening); however, Department of Urology, Furthermore, telementoring and telesurgery could herein we try to focus on robotic surgery only and Fundació Puigvert, Autonomous University be possible by using 3DVMs assistance, thanks to briefly give a snapshot of the two faces of the coin. of Barcelona, Barcelona, the potentialities of the 5G connections. The first Looking at the patients’ perspective, VR in the Spain journals.sagepub.com/home/tau 1 Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Therapeutic Advances in Urology Volume 15 Table 1. Clinical potential application of 3DVMs for prostate and kidney cancer surgery. 3DVMs applications for prostate cancer 3DVMs applications for kidney cancer Prostate landmarks identification Kidney landmarks identification Bladder neck identification Tumor identification (especially when endophytic) Tumor location during nerve-sparing phase Renal pedicle management Selective biopsy guidance at the level of preserved Management of intraparenchymal structures during neurovascular bundles at the end of extirpative demolitive and reconstructive phase phase 3DVMs, 3D virtual models. metaverse may allow to create avatars to interact the human anatomy and intraoperative move- with physicians, allowing consultations and per- ments of the surgeon. Furthermore, the integra- sonalized approaches, creating a new model of tion of AI in this environment can be used to help patient care. The patient’s avatar is called ‘digital with movement prediction for training/intraoper- twin’ and it represents the way by which the ative surgical steps. patient can ‘live’ in the metaverse setting. Preoperative counseling can also be carried out in Another interesting field of application is the pre- this virtual environment, where 3DVMs of the operative case discussion through multidiscipli- affected organ can be displayed and the surgical nary team discussion (MDT) which can take intervention can be discussed and explained. place in a virtual room using digital avatars, where Furthermore, also the preoperative anesthesio- the required specialists (e.g. oncologist, radiolo- logic assessment of pulmonary or cardiologic gist, pathologist, expert surgeon) have the chance abnormalities [i.e. obstructive sleep apnea (OSA) to share patient’s information (e.g. clinical data or other sleeping/breathing to detect lung capac- on cloud platforms, 3D models) overcoming ity with spirometry] can benefit from the intro- physical distances, building, when it is necessary, duction of such technologies. a ‘super-expert’ MDT maximizing the patient’s care.12 Finally, switching to an intraoperative set- Moreover, for postoperative care, surgeons may ting, as reported above, 3DVMs can allow to per- visit patients in a virtual metaverse-clinic, collect- form telementoring and telesurgery with 3D ing data using dedicated sensors and interacting Cognitive or AR guidance. using telemedicine devices and softwares devel- oped for patients’ monitoring,11 performing a However, not all that glitters is gold (Table 2).13 fully virtual physical examination, including The metaverse still needs to face some major observation, auscultation, and vital sign collec- issues such as data management, privacy, or tion. Finally, the creation of social platforms in cybersecurity, and these firm security parameters the metaverse could be used to improve social should be established first to the introduction of advocacy for different events such as prostate- metaverse in medicine. We must acknowledge specific antigen (PSA) prostate cancer screening that this new setting may open the doors to new or to improve patients’ recruitment for clinical types of risks, mainly related to personal data trials. stealing. From a surgical point of view, the first application Surely, the lack of accessibility (i.e. lack of that we can emphasize is training, which will be Internet connection) and disparities in care, espe- carried out in a totally virtual and immersive envi- cially if patients in certain countries cannot afford ronment. Students will be able to train intensively these newer technologies or do not have the band- in a simulated setting, overcoming the barriers of width/data storage to participate, can potentially elevated costs associated with training (e.g. represent an obstacle in the diffusion of such cadaver labs). To do so, surgical simulation technology and to further widen the gap between requires the employment of precise movement- the different health care systems in wealthy and tracking devices and software to reproduce both poor countries. Furthermore, another aspect that 2 journals.sagepub.com/home/tau E Checcucci, P Verri et al. Table 2. Advantages and disadvantages of metaverse application in robotic urology (adapted from Bhugaonkar et al.).11 Advantages Disadvantages Customization and modularity Expensive Integration with different non-medical professionalities Risk of dependency Three-dimensional environment Legal and safety issues Controlled and safe environment Loss of human empathy Multidisciplinary interaction Clinical and surgical benefit under scrutiny Surgical training, planning or navigation with increasing Still in an experimental stage safety of the patients should be considered is the absence of physical Alberto Breda: Data curation; Visualization. relationships, which may potentially hinder the Francesco Porpiglia: Conceptualization; Super­ patient–physician communication and the trans- vision; Validation. mission of empathy of the direct human contact. Acknowledgements In conclusion, even if the metaverse is still in an None. experimental stage, it may reserve great potenti- alities for both patients and robotic surgeons, Funding improving the quality of the health care system in The authors received no financial support for the terms of intervention and treatment, guarantee- research, authorship, and/or publication of this ing standardized surgical training, and helping article. the surgeons to maximize the quality of their surgery. Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, Declarations and/or publication of this article. Ethics approval and consent to participate Availability of data and materials Not applicable. Not applicable. Consent for publication Not applicable. ORCID iDs Enrico Checcucci https://orcid.org/0000-0001- Author contributions 7901-5608 Enrico Checcucci: Conceptualization; Writing Paolo Verri https://orcid.org/0000-0002-3662- – original draft. 6828 Riccardo Autorino https://orcid.org/0000- Paolo Verri: Data curation; Writing – review & 0001-7045-7725 editing. Daniele Amparore: Conceptualization; Writing – original draft. References Giovanni Enrico Cacciamani: Conceptuali­ 1. Autorino R, Porpiglia F, Dasgupta P, et al. zation; Formal analysis; Supervision; Visuali­zation. Precision surgery and genitourinary cancers. Eur Juan Gomez Rivas: Data curation; Investigation; J Surg Oncol 2017; 43: 893–908. Supervision. 2. Checcucci E, Amparore D, Fiori C, et al. 3D Riccardo Autorino: Formal analysis; Validation. imaging applications for robotic urologic surgery: an ESUT YAUWP review. World J Urol 2020; Alex Mottrie: Conceptualization; Visualization. 38: 869–881. journals.sagepub.com/home/tau 3 Therapeutic Advances in Urology Volume 15 3. Checcucci E, Piazza P, Micali S, et al. Three- 8. Piana A, Gallioli A, Amparore D, et al. Three- dimensional model reconstruction: the need for dimensional augmented reality-guided ­robotic- standardization to drive tailored surgery. Eur Urol assisted kidney transplantation: breaking the limit of 2022; 81: 129–131. atheromatic plaques. Eur Urol 2022; 82: 419–426. 4. Roberts S, Desai A, Checcucci E, et al. ‘Augmented 9. Amparore D, Pecoraro A, Checcucci E, et al. reality’ applications in urology: a systematic review. 3D imaging technologies in minimally invasive Minerva Urol Nephrol 2022; 74: 528–537. kidney and prostate cancer surgery: which is the urologists’ perception. Minerva Urol Nephrol 5. Checcucci E, Pecoraro A, Amparore D, et al. The 2022; 74: 178–185. impact of 3D models on positive surgical margins after robot-assisted radical prostatectomy. World 10. McWilliam A and Scarfe P. The metaverse and J Urol 2022; 40: 2221–2229. oncology. Clin Oncol (R Coll Radiol) 2023; 35: 12–14. 6. Piramide F, Kowalewski KF, Cacciamani G, et al. Three-dimensional model-assisted 11. Bhugaonkar K, Bhugaonkar R and Masne N. minimally invasive partial nephrectomy: The trend of metaverse and augmented & virtual a systematic review with meta-analysis of reality extending to the healthcare system. Cureus comparative studies. Eur Urol Oncol 2022; 5: 2022; 14: e29071. 640–650. 12. Checcucci E, Cacciamani GE, Amparore D, et al. The metaverse in urology: ready for prime time. 7. Amparore D, Pecoraro A, Checcucci E, et al. Eur Urol Open Sci 2022; 46: 96–98. Visit SAGE journals online Three-dimensional virtual models’ assistance journals.sagepub.com/ during minimally invasive partial nephrectomy 13. Petrigna L and Musumeci G. The metaverse: a home/tau minimizes the impairment of kidney function. Eur new challenge for the healthcare system: a scoping SAGE journals Urol Oncol 2022; 5: 104–108. review. J Funct Morphol Kinesiol 2022; 7: 63. 4 journals.sagepub.com/home/tau