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Electromagnetic navigation improves minimally invasive robot-assisted lung brachytherapy

Objective: Recent advances in minimally invasive thoracic surgery have renewed an interest in the role of interstitial brachytherapy for lung cancer. Our previous work has demonstrated that a minimally invasive robot-assisted (MIRA) lung brachytherapy system produced results that were equal to or better than those obtained with standard video-assisted thoracic surgery (VATS) and comparable to results with open surgery. The purpose of this project was to evaluate the performance of an integrated system for MIRA lung brachytherapy that incorporated modified electromagnetic navigation and ultrasound image guidance with robotic assistance. Methods: The experimental test-bed consisted of a VATS box, ZEUS® and AESOP® surgical robotic arms, a seed injector, an ultrasound machine, video monitors, a computer, and an endoscope. Our previous custom-designed electromagnetic navigational software and the robotic controller were modified and incorporated into the MIRA III system to become the next-generation MIRA IV. Inactive brachytherapy seeds were injected as close as possible to a small metal ball target embedded in an opaque agar cube. The completion time, the number of attempts, and the accuracy of seed deployment were compared for manual placement, standard VATS, MIRA III, and the new MIRA IV system. Results: The MIRA IV system significantly reduced the median procedure time by 61% (104 s to 41 s), tissue trauma by 75% (4 attempts to 1 attempt), and mean seed placement error by 64% (2.5 mm to 0.9 mm) when compared to a standard VATS. MIRA IV also reduced the mean procedure time by 48% (85 s to 44 s) and the seed placement error by 68% (2.8 mm to 0.9 mm) compared to the MIRA III system. Conclusions: A modified integrated system for performing minimally invasive robot-assisted lung brachytherapy was developed that incorporated electromagnetic navigation and an improved robotic controller. The MIRA IV system performed significantly better than standard VATS and better than MIRA III.