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Urol Clin N Am 31 (2004) 793–800

Robotics : a journey into the future Abhilash Pandya, PhD*, Gregory Auner, PhD Department of Electrical and Computer , Wayne State University, Engineering Building #3160, 5050 Anthony Wayne Drive, Detroit, MI 48201, USA

The authors predict that technology-assisted Even with enormous technologic gains, robotic medicine, and in particular, will have surgery is still in its infancy. Some major techno- a significant impact over the few decades. logic improvements are needed for this technology Robots will augment the surgeon’s motor perfor- to reach its ultimate potential, including better mance, diagnosis capability, and senses with visualization, tactile sensing, diagnostic sensing, haptics (feel), augmented reality (sight), and and miniaturization [27]. This article gives the ultrasound (sound). Robots already boost surgical authors’ vision of the future of robotic technology skills by filtering tremor and scaling motions, but with respect to robotic vision, fusion, and may be able to automate certain routine tasks to nano-/microrobot development and discusses the free the surgeon to focus on higher-level tasks. path to that future from the current state-of-the- With intelligent interfaces, the robotic system art for medical robots. could warn surgeons of incorrect trajectories or restrict the movements of the surgery away from Robotic vision (augmented reality and image dangerous or critical areas. The authors predict guidance) that the impact of robots will parallel that of imaging technology in medicine today. Many studies have compared and improved Robotic devices have been used in cardiac the surgical interface and improved the surgeon’s surgery [1–13], urology [14–16], fetal surgery performance [28–31]. One of the key problems of [17,18], pediatrics [19–22], neurosurgery [23,24], robotic surgery, however, is that surgeries can orthopedics [25,26], and many other medical become more difficult and take longer [32].In disciplines. As with imaging technology, robotics robotic surgery, the magnification and, therefore, will bring patient care and treatment a leap for- the size of the field-of-view changes with the ward. In several cases, it has started to happen proximity of the endoscope to the objects being already. In particular, the Vattikuti Urology In- viewed [33]. Because of the small incisions and stitute at Henry Ford Hospital in Detroit, Mich- camera view, the surgeon can no longer see inside igan is the first facility in the country to perform the patient directly. Visualization is critical for surgery routinely using a robotic system for the systems that use a robotic interface because the treatment of prostate cancer. With this robotic surgeon typically operates from a remote location laparoscopic procedure, the patient’s , blood and relies almost entirely on indirect, limited field- loss, and recovery time in the hospital and at of-view video of the surgery [27,33,34]. Direct home are reduced significantly compared with linkage of medical robotic systems to patient data traditional surgery. In addition, the procedure and the optimal visualization of those data for eliminates the need for large incisions [15]. the surgical team are important for successful operations. In their review article on medical robots, Cleary and Nguyen [27] state that if medical * Corresponding author. robots are to reach their full potential, they need E-mail address: [email protected] to be more integrated systems in which the robots (A. Pandya). are linked to the imaging modalities or directly to

0094-0143/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ucl.2004.06.013 794 A. Pandya, G. Auner / Urol Clin N Am 31 (2004) 793–800 the patient anatomy. They state further that robotic arms on the operating table to avoid robotics systems need to be developed in an collisions between arms during the procedure ‘‘Image-Compatible’’ way. Visual information and maximize the range of motion of the instru- from the patient site needs to be augmented to ments. A significant potential exists to affect allow greater situational awareness, accuracy, and medical robotics with the preoperative planning confidence. That is, these systems must operate and intraoperative visualization tools [37]. within the constraints of various image modalities Two types of visualization technology have such as CT and MRI. This link, they conjecture, is been used for real-time visualization in the essential if the potential advantages of robots are medical : augmented reality (AR) and to be realized in the medical domain. virtual reality (VR) [38,39]. These visualization In addition, surgical planning and information methods are well suited for robotic surgery. management for these robotic systems is essential Image guidance is an example of VR. In image- for successful operations [27]. Two main problems guidance surgery (IGS), the surgeon views a encountered in robotic surgery are nonoptimal computer-generated world of image data and port (incisions on the patient’s body for the three-dimensional models after registration. The robotic arms) placements and robotic-arm colli- registration ensures a one-to-one correspondence sions. Robotic-arm collisions often require man- to the end-effector of the robot and the image ual repositioning of the robotic arms on the coordinates. In contrast, the AR system gener- operating table that unnecessarily adds to the ates a composite view for the user that includes operative time. Incorrect port placement typically the live video view fused (registered) with either results in robotic-arm collisions, can damage precomputed data (eg, three-dimensional geome- robotic instruments, and also can make the try) or other registered sensed data [40].ARis operative site inaccessible. Improved accessibility a variation and extension of VR and represents to the operative site can enhance patient safety a middle ground between computer graphics in [35]. These problems can be avoided in the a completely synthetically generated world (as in preoperative stages given the appropriate visual- VR) and a normal camera view of the real world ization tools. Therefore, it is important that [41–45]. The current technique of image guidance a robust visualization system be built that is does not allow the surgeon to use real and linked to patient imaging data to offer the surgeon synthetic data simultaneously [46]. The surgeon tools for visualization, robotic system setup, and can detect anomalies using advanced imaging port placement [36]. and and can place his or her tools Computer modeling tools that help visualize accurately within surgical environments with the anatomic structures of the patient would aid robots. Nevertheless, the surgeon also needs his the surgeon greatly in the preoperative stage. or her own vision to detect other features that Visualization tools can help the surgeon determine may not be available from the sensor informa- optimal port-placement sites. In addition, these tion. This, the authors believe, is one advantage tools will help determine the placement of the of AR (Fig. 1) [47].

Fig. 1. Augmented reality and image-guided visualization. A. Pandya, G. Auner / Urol Clin N Am 31 (2004) 793–800 795

Robotic ultrasound volume. If this information is extracted, the physical parameters of each resolvable volume Imagine listening to tissue for abnormalities. element (ie, approximately 1 mm3) in the insoni- New technology using acoustic holography is fied volume then should enable diagnosis of the within reach for early diagnosis of diseases such nature of the material. In principle, it is possible as cancer because of significant advances in to distinguish small tumors from healthy tissues microsystem and signal analysis. Although holog- by this method. Preliminary images and phase raphy technology has existed for over 25 years, its information are shown in Fig. 2. application in the clinical/diagnostic arena did not come to fruition because of a lack of advanced microsystems and signal analysis technology. Robotic touch What has been missing is a conversion element that can record the ultrasound interference pat- Can the sense of hyper-touch and -temperature terns, reconstruct them with a real or synthesized be useful for a surgeon? Development of advanced ultrasound interference pattern, and finally re- force-sensing arrays can advance tactile augmen- construct them with real or synthesized ultra- tation on the robot. For example, new dual-mode sound frequency waves that could be transformed acoustic wave sensors that can switch between directly into a visible image. surface acoustic wave and surface transverse wave This is now possible using micropiezoelectric modes can sense pressure and viscosity in liquid, arrays equipped with chip reconstruction at high distinguish force caused by liquid or solid inter- spatial and temporal resolution. In addition to actions, and further distinguish between normal three-dimensional holography imaging, a vital and transverse forces (pinching pressure or sliding objective of the device is to recover the wave frictional forces). Because new wide-bandgap, envelope emerging from each pixel. Although the semiconductor-based acoustic sensor arrays have hologram requires freezing the waves in time long linear temperature coefficients, they can be superb enough to capture a stable interference pattern temperature sensors as well. Thus, tactile forces with adequate signal-to-noise (typically 10 micro- and sensory information on touch and tempera- seconds), the wave envelope contains an instanta- ture can mimic human tactile feeling but with neous integrated dynamic history of the scattering many orders of magnitude greater sensitivity and events along each ray path throughout the precision.

Fig. 2. Holographic image created from ultrasound signals. 796 A. Pandya, G. Auner / Urol Clin N Am 31 (2004) 793–800

Diagnostic sensors provides detailed information about the bimolec- ular composition of tissues that may be used to The authors believe sensing systems will benefit distinguish between normal and malignant tissues. robots most in the area of diagnostic sensing. Raman has been under investigation Sensors that can differentiate in real-time between during the last decade because of its potential various pathologic conditions, such as cancer, and application as a molecular-level tool for the normal tissue would be invaluable. One such diagnosis of cancer [48]. sensor is a micro-Raman probe, which may be Pathologic conditions involve changes in mo- able to be mounted on the end-effector of a robotic lecular composition of tissue as a result or cause device to provide pathologic evaluation. of disease. By measuring Raman-marker bands of Cancer treatment, whether with drugs, radia- , lipids, or , the relative ratios tion, or surgery, depends on distinguishing malig- and absolute concentration of each component nant from normal tissue. Visual inspection is can be determined and related to pathologic seldom adequate for this task. Biopsy with histo- changes. Raman spectroscopy could enable in logic evaluation is the criterion standard for vivo detection of these changes in a minimally making this determination. Final results usually invasive, nondestructive manner by using the require at least 12 to 24 hours, however, and even appropriate excitation laser wavelength and laser the more immediate frozen section generally power. The Raman spectral data obtained then requires at least 20 minutes from when the tissue could be used to guide further clinical action. The is removed until an answer is available. The importance of Raman spectroscopy in its process of evaluating all essential margins and potential in vivo application and direct, real-time surfaces can be time-consuming and prone to therapeutic intervention based on that informa- sampling errors. As the ability to treat cancer tion (Fig. 3). improves, the early detection of disease provides Micro-Raman probes can be built to be an even greater opportunity for intervention miniature systems specific to a particular pathol- resulting in a significant increase in survival. ogy. The authors envision that future robotic Raman spectroscopy is a vibrational spectro- system will have on-board sensor systems that scopic technique that originates from inelastic include diagnostics capability. These robots will scattering of light by vibrating molecules. This be able to work methodically and perhaps

Fig. 3. Integration of a micro-Raman sensor with a robotic system. A. Pandya, G. Auner / Urol Clin N Am 31 (2004) 793–800 797 autonomously to remove tissue that they deter- mine to be diseased.

Future micro- and nanorobots Autonomous robots need to be miniature. can be defined as structures and mechanism that extend below 100 nm in size. ‘‘In nature, nano-scale structures and mechanisms are ubiquitous,’’ Richard Feynman [49] states in his pioneering lecture on nanotechnology. ‘‘Nature transforms inexpensive, abundant and inanimate ingredients into self-repairing, self-aware crea- Fig. 4. Polymerase (nanomachine) used to duplicate tures that walk, wiggle, swim sniff, see think and DNA. even dream.’’ Feynman poses the question, ‘‘What could we humans do if we could assemble the basic ingredients of the material world with a glint research: (1) the solid-state engineering efforts to of nature’s virtuosity?’’ use DNA to build nanostructures from DNA DNA can be considered biologic nanosoft- molecules and (2) the efforts ware. For instance, ribosomes can be considered to describe the three-dimensional structure and large-scale molecular constructors/robots [50]. function of molecular . Enzymes are nature’s truly functional molecular- The authors try to give a greater understanding sized assemblers. Genetic are not creat- of the use of one of nature’s most important ing new tools per se, but adapting and improvising molecules, DNA, in the field of nanotechnology. from those nature has provided. Future genera- DNA in nature functions as an information tions of engineers, armed with molecular-engi- molecule [50]. It is a ‘‘computer program’’ that neering techniques, will have a real chance of dictates what molecular structures should be built, imitating and improving on nature. how the molecular machines should function, and One of the most amazing nanomachines found ultimately, how a living should behave. in nature is the DNA polymerase. When DNA is DNA’s amazing properties allow it to be used for replicated or copied, it has to be copied exactly, fabrication of nanostructures. This section focuses otherwise minor errors in the copying process lead on DNA and its potential use for nanotechnology. to major problems in the creation of the structures It also provides some ideas for the future imita- of the cells. DNA polymerase is an accurate tion of nature for building synthetic/organic . It creates an exact copy of DNA each nanomachinery. time, making less than one mistake in 1 billion Nature clearly has built functional nanoma- bases. DNA polymerase plays the central role chines. The key to Nature’s development is its in the processes of life. It carries the weighty special software: DNA. DNA’s biologic impor- responsibility of duplicating our genetic infor- tance lies in the specificity of the base pairing that mation. It is a sophisticated machine that holds the two strands of the together: has numerous regions, each responsible for vari- adenine pairs with thymine and guanine pairs with ous functions. For instance, one section of the cytosine. The structure that results from these ‘‘machine’’ is used for synthesis, another for proof- complementary interactions is a linear molecule; reading, and a third for removal of sequences that is, it is not branched. By designing appropri- (Fig. 4). ate sequences, however, it is possible in synthetic Nano- or microelectro mechanical systems are systems to produce branched DNA molecules. multidisciplinary fields. They involve solid-state DNA is well known for duplication and electrical engineers studying the electrical proper- storage of genetic information in biology. It also ties of nanostructures, mechanical engineers has been shown recently to be highly useful as an studying the physical properties of nanostruc- engineering material for construction of special- tures, and genetic engineers who have created purpose computers and micron-scale objects methods to study important nanomachines in with nanometer-scale feature resolution [51,52]. nature. This section focuses on two avenues of Properly designed synthetic DNA can be a 798 A. Pandya, G. Auner / Urol Clin N Am 31 (2004) 793–800 programmable glue that, through specific sensors with robots. Systems such as pressure hybridization of complementary sequences, will sensors, tactile sensors, and temperature sensors self-organize reliably to form desired structures no doubt will become more advanced and will and superstructures. Such engineered structures allow the surgeon to perform more delicate are inherently information-rich and are suitable surgeries. In addition, video sensing and imaging for use directly as computers or as templates sensors will become integrated into robot end- for imposing specific patterns on various other effectors, which will give an unprecedented view of materials. the human body in real-time. In , DNA can be used to create any Although robots have the potential to improve desired pattern in two or three dimensions and the precision and capabilities of physicians, the simultaneously to guide the assembly of a wide number of robots in clinical use is still small. First, variety of other materials into any desired pat- there needs to be a strong cooperation between terned structure. Given the diverse mechanical, engineers and clinicians. Engineers need to team chemical, catalytic, and electronic properties of with clinicians and biologic scientists to under- these specifically patterned materials, DNA self- stand their needs and build useful and simple assembly techniques hold great promise for bot- systems. Building is not enough, however; these tom-up nanofabrication in many applications in systems need to be tested by surgeons to ensure wide-ranging fields of technology as diverse as that the performance is affected positively and electronics, combinatorial chemistry, nanoro- that the patient’s outcome is enhanced. Clinical botics, and therapy. trials need to be well organized with results The structures and arrays described here are quantified. Only then will the medical community static structures. Can a nanomechanical device be accept these systems. produced from DNA? Seeman and LaBean The merging of sensors with robots is a logical [51,52] describe a minimal mechanical device step. Sensors of touch and temperature to enhance using the DNA molecule. This molecule’s struc- the surgeon’s haptic sense, imaging sensors to ture switches between two alternatives in response allow greater visualization, and sensors for diag- to an external signal. Seeman’s group has de- nostics can be more effective when used in veloped a two-state device predicated on the B to conjunction with robotic devices. Z transition of DNA. Conventional DNA, known In the realm of nanotechnology, the authors as B-DNA, is a right-handed molecule. There is believe that the future will meld two disciplines: another structure of DNA that is radically differ- nanotechnology and . Molecu- ent from B-DNA, however, known as Z-DNA19. lar biologists have seen and studied what is Z-DNA is a left-handed molecule. Seeman and possible in the nanotechnology world—they just LaBean produced a two-state mechanical device don’t know how to build these systems. Nano- (like a pincer) using a combination of B-DNA and technologist can work on these scales and are Z-DNA19. The two states are well defined struc- starting to understand how molecular machines turally and controllable. Although these steps are work, but some are unaware of what nature has significant, they are the first steps in the built already. Can DNA be synthesized in a labo- of nanorobotic devices. ratory so that it can carry out assembly instruc- The unique features of DNA allow it to be used tions for molecular building designed by as a building block to create other new, basic researchers? The robots or machines of this scale structures from which complex machines can be could be used to clean vessels, deliver drugs to built. DNA nanotechnology also can be combined specific locations, and seek out and destroy with carbon nanotubes to take advantage of the particular types of cells. self-organization properties of DNA. The authors In summary, a melding of engineers and conjecture that the future will yield controllable surgeons, a melding of sensors and robots, and nano- and microrobots that can be used for a melding of nanotechnologists with microbiolo- medical use for surveillance and perhaps treatment. gists are needed for this field to progress.

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