New Technology and Techniques Intraoperative Optical Biopsy during Robotic Assisted Radical Prostatectomy Using Confocal Endomicroscopy Aristeo Lopez,* Dimitar V. Zlatev,* Kathleen E. Mach, Daniel Bui, Jen-Jane Liu, Robert V. Rouse, Theodore Harris, John T. Leppert and Joseph C. Liao†,‡ From the Department of Urology (AL, DVZ, KEM, DB, JJL, JTL, JCL) and Department of Pathology (RVR), Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto (AL, DVZ, KEM, DB, JJL, RVR, TH, JTL, JCL), California Purpose: Intraoperative optical biopsy technologies may aid in the identification Abbreviations of important anatomical landmarks and improve surgical outcomes of robotic and Acronyms assisted radical prostatectomy. We evaluate the feasibility of confocal laser ¼ CLE confocal laser endomicroscopy during robotic assisted radical prostatectomy. endomicroscopy Materials and Methods: A total of 21 patients with biopsy proven prostate cancer ECE ¼ extracapsular extension scheduled for robotic assisted radical prostatectomy were recruited. After FOV ¼ field of view intravenous administration of fluorescein 15 patients underwent in vivo intra- H&E ¼ hematoxylin and eosin operative confocal laser endomicroscopy of prostatic and periprostatic structures MPM ¼ multiphoton microscopy using a 2.6 or 0.85 mm imaging probe. Standard robotic instruments were used NVB ¼ neurovascular bundle to grasp and maneuver the confocal laser endomicroscopy probes for image OCT ¼ optical coherence acquisition. Confocal laser endomicroscopy imaging was performed ex vivo on tomography fresh prostate specimens from 20 patients. Confocal video sequences acquired in vivo and ex vivo were reviewed and analyzed, with additional image pro- RARP ¼ robotic assisted radical prostatectomy cessing using a mosaicing algorithm. Processed confocal images were compared with standard hematoxylin and eosin analysis of imaged regions. Accepted for publication November 2, 2015. Results: Confocal laser endomicroscopy was successfully integrated with robotic No direct or indirect commercial incentive surgery, including co-registration of confocal video sequences with white light associated with publishing this article. and probe handling with standard robotic instrumentation. Intraoperative To view the accompanying video, please see the online version of this article (Volume 195, confocal laser endomicroscopy imaging of the neurovascular bundle before and Number 4) at www.jurology.com. after nerve sparing dissection revealed characteristic features including dynamic The corresponding author certifies that, when vascular flow and intact axon fibers. Ex vivo confocal imaging of the prostatic applicable, a statement(s) has been included in the manuscript documenting institutional review parenchyma demonstrated normal prostate glands, stroma and prostatic board, ethics committee or ethical review board carcinoma. study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee Conclusions: We report the initial feasibility of optical biopsy of prostatic and approval; institutional animal care and use periprostatic tissue during robotic assisted radical prostatectomy. Image guid- committee approval; all human subjects provided ance and tissue interrogation using confocal laser endomicroscopy offer a new written informed consent with guarantees of confidentiality; IRB approved protocol number; intraoperative imaging method that has the potential to improve the functional animal approved project number. and oncologic outcomes of prostate cancer surgery. * Equal study contribution. † Correspondence: 300 Pasteur Dr., Room S-287, Stanford, California 94305-5118 (telephone: Key Words: prostatic neoplasms; prostatectomy; microscopy, confocal; 650-858-3916; FAX: 650-849-0319; e-mail: jliao@ erectile dysfunction; surgery, computer-assisted stanford.edu). ‡ Supported by U.S. National Institutes of Health Grant R01 CA160986. 1 CANCER control and recovery of urinary quality. Since Walsh’s initial descrip- and sexual function after radical pros- tion of anatomical radical prostatec- tatectomy are related to surgical tomytherehavebeeneffortstobetter 0022-5347/16/1954-1110/0 http://dx.doi.org/10.1016/j.juro.2015.10.182 THE JOURNAL OF UROLOGY® Vol. 195, 1110-1117, April 2016 1110 j www.jurology.com Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. CONFOCAL ENDOMICROSCOPY DURING ROBOTIC ASSISTED RADICAL PROSTATECTOMY 1111 understand pelvic anatomy to refine surgical tech- We have demonstrated the cystoscopic applica- nique.2 Robotic assisted radical prostatectomy is tion of CLE for the optical diagnosis and grading of currently the most common surgical treatment for bladder cancer,18,19 as well as in vivo visualization localized prostate cancer in the United States.3 of glandular structures in the prostatic urethra.20 Technological advances of the robotic platform We assessed the feasibility of intraoperative CLE include a magnified field of view, tremor filtration and during RARP and evaluated potential clinical ap- improved surgeon ergonomics.4,5 Despite advances plications. We developed an intraoperative confocal in understanding pelvic anatomy and surgical tech- imaging protocol, characterized in vivo microscopic nologies, significant variation remains in the surgi- features of prostatic and periprostatic anatomy, and cal outcomes of radical prostatectomy, including compared ex vivo imaging of fresh surgical prostate positive surgical margins (range 6.5% to 32%)6 and specimens to histopathology. erectile dysfunction (range 7% to 80%).7,8 Image guided surgery may improve intra- operative navigation and surgical outcomes. Optical MATERIALS AND METHODS imaging technologies offer excellent spatial and Instrumentation temporal resolution, are easily integrated into the Confocal endomicroscopy was performed with CellvizioÒ, operating room and can be manipulated with in- and 2.6 or 0.85 mm outer diameter fiberoptic probes were struments commonly used in minimally invasive used for image acquisition (fig. 1, A). The 2.6 mm probe 9 surgery. For radical prostatectomy in vivo and has a spatial resolution of 1 mm, a tissue penetration ex vivo feasibility studies have been reported using depth of 60 mm and FOV of 240 mm. The 0.85 mm probe e near infrared fluorescence imaging,10 OCT11 13 and has a spatial resolution of 3.5 mm, a penetration depth of MPM.14,15 50 mm and a FOV of 320 mm. Probes were sterilized before Similar to OCT and MPM, confocal laser endo- use with the SterradÒ system. microscopy is an optical biopsy technology that aims to provide on demand, high resolution imaging Intraoperative CLE during Robotic Assisted Surgery reminiscent of standard histopathology.16 CLE is The study was conducted with Stanford University insti- approved for endoscopic applications in gastroen- tutional review board and VAPAHCS (Veterans Affairs terology, pulmonology and urology. CLE is based on Palo Alto Health Care System) Research and Develop- a 488 nm laser in conjunction with fluorescein, a ment Committee approval. Patients with clinically local- Food and Drug Administration approved fluo- ized prostate cancer scheduled for RARP were recruited. rophore with a demonstrated safety record.17 Two surgeons (JCL and JTL) performed the operations Figure 1. Intraoperative CLE during robotic prostatectomy. CLE tower arrangement at head of operating room table (A). Imaging probe (2.6 mm) inserted through 12 mm laparoscopic port alongside suction irrigator (B). Confocal imaging of NVB with 2.6 mm imaging probe held by robotic needle driver (C ). TilePro functionality enabled simultaneous display of confocal image and white light stereoscopic view of operative field within surgeon console. Confocal imaging of divided bladder neck using 0.85 mm probe inserted through 19-gauge angiocatheter (D). Confocal image shows vasculature of bladder lamina propria. 1112 CONFOCAL ENDOMICROSCOPY DURING ROBOTIC ASSISTED RADICAL PROSTATECTOMY and image acquisition. Standard 5-port placement con- RESULTS sisting of a 12 mm camera port, 3, 8 mm robotic ports and Between December 2012 and March 2015, 21 pa- a 12 mm assistant port was applied. The decision for tients (mean age 62 years, range 49 to 69) scheduled nerve sparing was based on clinical staging, technical for RARP at VAPAHCS were recruited. Patients feasibility and surgeon discretion. The majority of CLE underwent bilateral (16) or unilateral (5) nerve imaging was performed with a 2.6 mm probe introduced through the 12 mm assistant port (fig. 1, B). The robotic sparing RARP. In vivo CLE imaging was performed needle driver was used to grasp the distal metal tip for in 15 patients and ex vivo imaging was performed imaging (fig. 1, C ). For the 0.85 mm probe 3 strategies on 20 prostates. Patient characteristics and imaging were compared for intracorporeal maneuvering, including details are described in the supplementary table 1) insertion via a standard laparoscopic cholangiogram (http://jurology.com/). catheter holder operated by bedside assistant, 2) insertion Overall 105 in vivo confocal video sequences from via a 5Fr angiocatheter through assistant port and 15 patients were collected. The average image grasping using the robotic needle driver, and 3) insertion acquisition time was 10 minutes (range 3 to 18) per via a 19-gauge angiocatheter introduced suprapubically participant. An average of 7 video sequences (range as a needlescopic port and grasping using the robotic 4 to