Advanced Surgical Planning Research Articles

Additive diagnostic value of 3D transesophageal echocardiography (3DTOE) in diagnosis of Infective endocarditis (IE)

Abstract Introduction The clinical manifestations of infective endocarditis (IE) are highly polymorphic, complicating the diagnostic process and leading to delays in treatment, particularly in elderly or immunocompromised patients. Recent studies advocate for early surgery to improve prognosis in IE patients. Advanced surgical planning for the complex pathomorphological spectrum of IE lesions requires detailed anatomical visualization, which is enhanced by three-dimensional transesophageal echocardiography (3DTOE). Purpose This study analyzed the echocardiographic characteristics of complex IE patients referred for additional evaluation in a tertiary center and assessed the role of 3DTOE in their evaluation. Methods This prospective study included all consecutive patients hospitalized in a tertiary clinical center, referred for IE in Serbia from November 2017 to October 2023. Blood cultures, serological assessment, transthoracic echocardiography (TTE), 2D/3DTOE, abdominal sonography, and cerebral CT or MRI scans were systematically performed within 72 hours of admission. Fifty-nine patients with a definitive diagnosis of IE, according to Duke University criteria, who underwent 2D and 3DTOE at the initial diagnostic examination were analyzed. Echocardiographic findings were defined according to current guidelines, with destructive lesions including abscess, pseudoaneurysm, valve dehiscence, perforation, or chordal rupture. Results Echocardiographic findings (Table 1) revealed statistically significant differences between different echocardiography modalities. The most significant difference was observed between TTE and 3DTOE. However, results between 2D and 3DTOE did not reach statistical significance. TOE provided a more detailed description with a higher number of detected lesions, and 3DTOE was even more precise in identifying destructive lesions, particularly perforations (p<0.001). Concerning, Native Valve IE (NVE), Prosthetic Valve IE (PVE), and Cardiac Device IE (CD IE) groups (Table 2), vegetations were most frequently detected in the NVE and CD IE groups, while destructive lesions were predominant in the PVE group. 3DTOE detected longer vegetations and a higher number of destructive lesions, particularly in the PVE group. Conclusion 3DTOE provides a more detailed and precise morphological description of complex destructive lesions of IE compared to TTE and 2DTOE, which is particularly important for patients with PVE. Table 2

Insights and trends review: Use of extended reality (xR) in hand surgery.

Digital transformation through extended reality (xR)-comprising virtual, augmented, mixed, and substitutional reality-has become an integral part of the future of clinical and surgical practice. xR technologies facilitate advanced surgical planning, training, therapies and education, reshaping both personal and institutional healthcare. This paper examines the potential changes that xR has introduced into the field of hand surgery, exploring how xR enhances patient-centric care, increases medical service efficiency and revolutionizes surgical training, planning and therapeutic interventions. Key areas such as surgical assistance, telemedicine, therapies and rehabilitation, medical training and education, and improving patient understanding are highlighted. By synthesizing the current literature, this narrative review articulates the theoretical and practical implications of xR, offering insights into its transformative potential and supporting continuous educational advancement in medical practice.

Enhancing Mandibular Reconstruction with Surgeon–Bioengineer Collaboration: A Protocol for Virtual Surgical Planning

Background/Objectives: Computer-assisted mandibular reconstruction requires sophisticated technical expertise alongside surgical knowledge. This study aims to establish and validate an efficient collaborative protocol between oral and maxillofacial surgeons and bioengineers for virtual surgical planning in mandibular reconstruction. Methods: We developed a structured protocol with four sequential phases: (1) generation of 3D models from CT data, (2) virtual resection planning, (3) reconstruction design, and (4) surgical guide fabrication. Protocol efficiency was assessed through seven simulation trials measuring planning duration and required revisions. Clinical validation was performed in four mandibular reconstruction cases. Accuracy was evaluated by comparing virtual surgical plans to postoperative outcomes using 3-matic 13.0 software analysis. Results: Protocol implementation showed consistent efficiency across simulations with a mean planning duration of 2.86 working days (SD = 1.35). Only two of seven simulations required design revisions. Clinical application in four cases (three ameloblastomas, one odontogenic myxoma) demonstrated high precision with a mean virtual-to-actual discrepancy of 0.90 mm (SD = 0.34). Successful reconstructions were achieved across varying defect spans (29–53 mm) using both bicortical deep circumflex iliac artery (DCIA) flaps and monocortical iliac block bone grafts. The collaborative workflow resulted in optimized surgical guide design, reduced planning iterations, and improved surgical precision. Conclusions: The established surgeon–bioengineer collaborative protocol enhances the efficiency and accuracy of computer-assisted mandibular reconstruction while making advanced surgical planning techniques more accessible. While initial results are promising, future studies with larger patient cohorts and extended follow-up periods are needed to fully validate the protocol’s long-term benefits and broader applicability.

Contemporary insights into spinopelvic mechanics.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care.

Current Applications of the Three-Dimensional Printing Technology in Neurosurgery: A Review.

In the recent years, three-dimensional (3D) printing technology has emerged as a transformative tool, particularly in health care, offering unprecedented possibilities in neurosurgery. This review explores the diverse applications of 3D printing in neurosurgery, assessing its impact on precision, customization, surgical planning, and education. A literature review was conducted using PubMed, Web of Science, Embase, and Scopus, identifying 84 relevant articles. These were categorized into spine applications, neurovascular applications, neuro-oncology applications, neuroendoscopy applications, cranioplasty applications, and modulation/stimulation applications. 3D printing applications in spine surgery showcased advancements in guide devices, prosthetics, and neurosurgical planning, with patient-specific models enhancing precision and minimizing complications. Neurovascular applications demonstrated the utility of 3D-printed guide devices in intracranial hemorrhage and enhanced surgical planning for cerebrovascular diseases. Neuro-oncology applications highlighted the role of 3D printing in guide devices for tumor surgery and improved surgical planning through realistic models. Neuroendoscopy applications emphasized the benefits of 3D-printed guide devices, anatomical models, and educational tools. Cranioplasty applications showed promising outcomes in patient-specific implants, addressing biomechanical considerations. The integration of 3D printing into neurosurgery has significantly advanced precision, customization, and surgical planning. Challenges include standardization, material considerations, and ethical issues. Future directions involve integrating artificial intelligence, multimodal imaging fusion, biofabrication, and global collaboration. 3D printing has revolutionized neurosurgery, offering tailored solutions, enhanced surgical planning, and invaluable educational tools. Addressing challenges and exploring future innovations will further solidify the transformative impact of 3D printing in neurosurgical care. This review serves as a comprehensive guide for researchers, clinicians, and policymakers navigating the dynamic landscape of 3D printing in neurosurgery.

A benign tumor of substantial size: Mandibular epithelioid osteoblastoma in a socioeconomically challenged patient

Epithelioid osteoblastoma (EOB) is a rare, benign bone tumor characterized by the proliferation of atypical epithelioid osteoblasts within a vascular stroma. It typically presents as a slow-growing painful mass and requires careful differentiation from more aggressive lesions like osteosarcoma for appropriate management. We present a case of an otherwise healthy 30-year-old man who presented with a mandibular EOB measuring 23 cm × 17 cm x 19 cm, causing significant disfigurement and functional impairment. Surgical management involved radical resection and immediate reconstruction using an osteocutaneous fibula free flap. The case emphasizes the importance of multidisciplinary care, advanced surgical planning, and the impact of socioeconomic factors on healthcare access and outcomes.

Does Preoperative Virtual Reality Experience Enhance Implant Positioning Accuracy in Total Hip Arthroplasty?

Purpose Total hip arthroplasty (THA) requires precise implant positioning to ensure long-term success. Herein, we evaluated the effect of virtual reality (VR) on the surgical precision of THA, particularly when used by experienced surgeons. Methods In this single-center, prospective, case-control study, 34 patients who underwent primary THA performed by a single experienced surgeon were divided into the control (without VR simulation) and VR (with VR simulation) groups. Preoperative planning involved the creation of three-dimensional models from computed tomography scans using ZedHip® software (Lexi, Tokyo, Japan). The primary outcomes assessed included the accuracy of implant placement, operative time, and intraoperative blood loss. The secondary outcomes included postoperative hospital stay and in-hospital complications. Results A significant improvement in radiographic inclination (RI) was observed in the VR group as compared to controls. Other surgical parameters, such as radiographic anteversion, operation time, blood loss, and postoperative hospital stay, showed no significant differences between the groups. Discrepancies in planned versus actual implant sizes were notedbut were not significantly different between groups. Conclusion VR application in preoperative planning improved the RI accuracy in acetabular cup placement for THA, demonstrating its potential to enhance surgical precision for experienced surgeons. This study highlights the evolving role of VR, from a training tool to an integral part of advanced surgical planning in orthopedics.

Training in Endoscopic Endonasal Neurosurgical Procedures: A Systematic Review of Available Models

Abstract Background Proficiency in endoscopic endonasal neurosurgery (EEN) requires a unique skill set and is associated with a steep learning curve. Endoscopic simulation models present an opportunity for trainees to enhance their surgical skills and anatomical knowledge in a risk-free environment. To date, four main categories of training modalities have been recorded: cadaveric, synthetic, animal, and virtual reality (VR) models. Objective To analyze the features, advantages, and disadvantages of each EEN training model, describe the stages of simulation training, and propose future directions and an algorithm for EEN training. Methods A comprehensive search was performed including studies published before August 2023. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed in the search and selection of studies included. Terms for searching title and abstract were (“simulation”) AND (“endoscopic endonasal”) AND (“neurosurgery”). Articles were screened for duplicates. Results We identified 176 references, and 43 studies met the inclusion criteria. Twelve articles described cadaveric models, with 7 of them studying internal carotid artery injury management and 3 of them cerebrospinal leak management; 14 articles illustrated synthetic models, 1 article described animal models, and 16 articles outlined VR simulations. Conclusion Cadaveric models provide realistic hands-on surgical training with acceptable cost and remain the gold standard method for training. Synthetic models are most effective for preoperative surgical planning and animal models are best suited for testing of hemostatic techniques. VR simulations may become the primary training tool for novices to acquire basic anatomical knowledge as their role in advanced surgical planning is evolving.

Evaluation and Management of Posterior Tibial Plateau Fractures.

Tibial plateau fractures are caused by high-energy or low-energy trauma and result in complex injuries that require careful management of both osseous injuries and associated soft tissues. The posterior aspect of the tibial plateau can be involved in a variety of fracture patterns, requiring systematic evaluation, imaging, and advanced surgical planning to address these complex injuries. Early classification systems failed to classify posterior plateau fractures; however, three-dimensional imaging and newer classification schemes, including the Quadrant System and 3D systems, have incorporated posterior column lesions. There has been a growing body of literature focused on fixation principles and plating options for posterior column fractures. Furthermore, there are multiple approaches for surgeons to choose between, including a direct posterior, posteromedial, posterolateral (including Lobenhoffer and lateral condyle osteotomy), and combined posterior approach. This article presents a guide for managing posterior tibial plateau fractures, including the initial evaluation and management, descriptions of the surgical approaches, principles of fixation, and the associated outcomes and complications.

Multidisciplinary Advanced Surgical Planning for Slide Tracheoplasty Using 3D-Printed Models.

The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling. 3D-printed patient-specific trachea models were used in pre-operative ASP sessions consisting of a multidisciplinary case discussion and hands-on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre- and post-session confidence. Statistical analysis was performed via Wilcoxon and Kruskal-Wallis tests. Forty-eight surveys were collected across nine sessions and 27 different physicians. On a 5-point Likert scale, models were rated as "very realistic", "very useful" (both median of 4, IQR 3-4 and 4-5, respectively). Overall confidence increased by 1.4 points (+/- 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions "strongly" impacted their surgical plan or anticipated performance (median 4, IQR 4-5), regardless of training level or experience. 3D-printed patient-specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST. 4 Laryngoscope, 134:3395-3401, 2024.

Complex oral rehabilitation using complete fixed denture prosthesis in atrophic maxillae

ABSTRACT This study aims to show a surgery-prosthetic resolution of complex atrophic maxillae with bone grafts, implants, and fixed implant prostheses in an elderly patient with radiographic follow-up. This article describes the clinical case of an elderly woman, 65 years old, who lost all superior teeth when she was 25 years old and had severe atrophic maxillae. Due to the maxillae, bone situation was planned an osteotome for sinus floor elevation and an allogeneic bone graft followed. After 16 months of bone integration, seven osseointegrated implants were placed. After 6 months of implant osseointegration, a complete fixed implant denture. Is it possible to conclude that using advanced surgical and prosthetic planning is possible to recover the esthetic and function of a severe and complex clinical case.

U-NetCTS: U-Net deep neural network for fully automatic segmentation of 3D CT DICOM volume

The accurate segmentation of computed tomography (CT) scan volume is an essential step in radiomic analysis as well as in developing advanced surgical planning techniques with numerous medical applications. When this process is performed manually by a clinician, it is laborious, time consuming, prone to error, and its success depends to a large extent on the level of experience. In this work, we propose an automated deep learning (DL) segmentation framework for CT images called U-Net CT Segmentation (U-NetCTS) to combine the DL U-Net and CT images in the domain of automatic segmentation. Experimental results show that U-NetCTS framework can segment different CT DICOM image regions of interest in a range of random CT volumes. A statistical and qualitative comparison of the CT slices automatically segmented by U-NetCTS framework and ground-truth images indicates that U-NetCTS framework achieves a high level of accuracy, where the Tanimoto coefficient, dice similarity coefficient, and peak signal-to-noise ratio values are 99.06%, 99.52%, and 53.29 dB, respectively. The DC value is also higher than that of state-of-the-art DL techniques for automatic segmentation of CT images of various human organs. Furthermore, a total amount of 3595 CT slices is employed in this study with various CT region of interest to validate the results.

TRACHEAL BRONCHUS OR BRONCHUS SUIS AND ITS IMPORTANCE IN LUNG TRANSPLANT

TYPE: Late Breaking Abstract TOPIC: Imaging INTRODUCTION: Tracheal bronchus (TB) is an aberrant bronchus arising from within 2cm of right lateral wall of supracarinal trachea. The term, bronchus suis, is given when the entire right upper lobe (RUL) is supplied by this bronchus. CASE PRESENTATION: Incidence is estimated at ∼1% (0.1-5%). TB can be classified into supernumerary - usual bronchial supply to affected lung segment is present or displaced - usual bronchial supply to affected lung segment is absent. It is usually an incidental finding, and most patients are asymptomatic. Occasionally patients may have recurrent RUL pneumonia due to focal emphysema or mucus impaction. Improvisation of airway anastomotic technique is required during lung transplantation (LT). DISCUSSION: 5 cases of donor, and 1 case of recipient TB have been reported in literature. Possible options for the airway anastomosis are en-bloc double LT with a tracheal anastomosis, left single LT alone, bilateral LT with left lung and right middle and lower lobe (following donor lung RUL lobectomy), and bilateral LT with a modified right tracheobronchial anastomosis. En-bloc double LT has higher airway anastomotic complication rate compared to bilateral sequential LT. Length of bronchial stump is made as short as possible in the donor lung to maximize the benefit of pulmonary-to-bronchial collateral blood supply. The neo-upper lobe bronchus created by suturing the apical TB and the RUL bronchus of the donor is anastomosed to the RUL bronchus of the recipient in a double-barrel fashion. CONCLUSIONS: Early identification of TB allows for appropriate recipient selection and advanced surgical planning for successful single or bilateral LT. DISCLOSURE: No significant relationships. KEYWORD: tracheal bronchus, bronchus suis, lung transplant

Implementation of functional imaging using 11C-methionine PET-CT co-registered with MRI for advanced surgical planning and decision making in prolactinoma surgery

PurposeTo report the first experience of our multidisciplinary team with functional imaging using 11C-methionine positron emission tomography-computed tomography (11C-methionine PET-CT) co-registered with MRI (Met-PET/MRICR) in clinical decision making and surgical planning of patients with difficult to treat prolactinoma.MethodsIn eighteen patients with prolactinoma, referred to our tertiary referral centre because of intolerance or resistance for dopamine agonists (DA), Met-PET/MRICR was used to aid decision-making regarding therapy.ResultsMet-PET/MRICR was positive in 94% of the patients. MRI and Met-PET/MRICR findings were completely concordant in five patients, partially concordant in nine patients, and non-concordant in four patients. In five patients Met-PET/MRICR identified lesion(s) that were retrospectively also visible on MRI. Met-PET/MRICR was false negative in one patient, with a cystic adenoma on conventional MRI. Thirteen patients underwent transsphenoidal surgery, with nine achieving full biochemical remission, two clinical improvement and near normalized prolactin levels, and one patient clinical improvement with significant tumour reduction. Hence, nearly all patients (94%) were considered to have a positive outcome. Permanent complication rate was low. Three patients continued DA, two patients have a wait and scan policy.ConclusionMet-PET/MRICR can provide additional information to guide multidisciplinary preoperative and intraoperative decision making in selected cases of prolactinoma. This approach resulted in a high remission rate with a low rate of complications in our expert centre.

Three-dimensional printing applications in veterinary surgery

Thanks to three-dimensional (3D) image structuring methods, 3D printing products have been used for many purposes in veterinary medicine in recent years. It can be used in many stages like vocational training in veterinary surgery, informing the patient before the operation, surgery planning, surgical method rehearsal, patient-specific intraoperative drilling and cutting guide, patient-specific implant, prosthesis, or orthosis production. The fact that the patient-specific model can be produced with 3D printing and its similarity to reality, the economic and minimal microbial risk makes 3D models attractive. It is inevitable that its effective use will become widespread in Turkey with its advantages such as the advantages it provides in treatment, being economical and allowing patient-specific procedures. In this article, the potential of the use of 3D printing products in veterinary medicine and especially in veterinary surgery, the stages of 3D printing production, current applications, areas of use, current situation, and future are examined in detail. Thanks to the 3D model, the physiopathology and treatment process can be shown more clearly on the organ model to patient owners, providing great convenience to veterinarians. Veterinarians can produce any material that they can use in clinical practice with 3D printing. Apart from these basic applications, advanced surgical planning and rehearsal procedures, production and intraoperative use of patient-specific drilling and cutting guides, production of patient-specific implants and various biomaterials, and other applications that have been studied have effective advantages in increasing the success of treatment. In case the surgical method requires a complex series of procedures and the area to be operated includes complex and intricate structures, the success of the surgery is increased by performing advanced surgical planning with 3D printing products. Thanks to this rehearsal, shortening the operation and anesthesia time, reducing the possibility of mistake and iatrogenic damage in the surgical procedure, pre-planning the materials and implants to be used according to this model, and bending the implants if necessary, giving the ideal shape before the operation provide important advantages. It is inevitable that 3D printing will be used more widely and effectively in veterinary surgery in the near future. Studies on the use of 3D printing technology in veterinary clinical sciences, especially in veterinary surgery, will provide significant benefits and original contributions to veterinary surgery practice.

Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes.

Background:Facial feminization is a critical step in a transfeminine patient’s surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures.Methods:An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns.Results:A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM.Conclusions:FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.

Computer-assisted surgical planning of complex bone tumor resections improves negative margin outcomes in a sawbones model.

Several technologies have been implemented in orthopedic surgery to improve surgical outcomes, usually focusing on more accurate execution of a surgical plan, but the development of the plan itself is also of great importance. The purpose of this study is to examine whether the use of preoperative computer planning platforms can improve the surgical plan? Eight surgeons created a preoperative surgical plan to resect a distal femur parosteal osteosarcoma in two settings: (1) Using a 2-D and 3-D CT scan only (current standard); and (2) using a computer-assisted planning platform. The plans were thereafter virtually executed using a novel surgical navigation system and a Sawbones model. This simulated model was derived from, and identical to, an actual patient scenario. The outcomes of interest were the number of positive margin cuts, and the volume of the resected specimen. Using the surgical plan developed with computer assistance, there were 4 positive margin cuts made by 2 surgeons. In comparison, using standard planning, there were 14 positive margin cuts made by all 8 surgeons (p = 0.02). The resection volume was larger in the computer-assisted plans (96 ± 10 mm3) than in the standard plans (88 ± 7 mm3) (p = 0.055). Computer-assisted planning significantly decreased the risk of a positive margin resection in this Sawbones tumor model used to simulate resection of a primary bone sarcoma. This proof of concept study highlights the importance of advanced surgical planning and sets the ground for developing beneficial surgical planning systems.

Extracapsular extension on multiparametric magnetic resonance imaging better predicts pT3 disease at radical prostatectomy compared to perineural invasion on biopsy.

Risk assessment for non-organ-confined prostate cancer (PCa) is important in the surgical planning for radical prostatectomy (RP). Perineural invasion (PNI) on prostate biopsy has been associated with adverse pathological outcomes at prostatectomy. Similarly, the identification of suspected extracapsular extension (ECE) on multiparametric magnetic resonance imaging (mpMRI) has been shown to predict non-organ-confined disease. However, no prior study has compared these factors in predicting adverse pathology at prostatectomy. We evaluated mpMRI ECE and prostate biopsy PNI on multivariable analysis to determine their ability to predict pathological stage at time of RP. We retrospectively investigated the prostatectomy database at our institution to identify men who underwent prostate biopsy with pre-biopsy mpMRI and subsequent RP from 2013-2017. Multivariable regression analysis was performed to compare the association of mpMRI ECE (mECE) and PNI on prostate biopsy on the likelihood of finding pT3 disease on pathology post-prostatectomy. Of a total 454 RP between 2013 and 2017, 191 patients met our inclusion criteria. Stage pT2 and pT3+ were found in 120 (62.8%) and 71 (37.2%) patients, respectively. Patients with mECE had 4.84 cumulative odds of worse pathological stage on RP (p=0.045) compared to PNI on biopsy, which showed cumulative odds of 2.25 (p=0.048). When controlling only for those patients without PNI, mECE was still found to be a significant predictor of pT3 disease at RP (p=0.030); however, in patients without mECE, PNI was not significant (p=0.062). While mECE and biopsy PNI were both associated with worse pathological stage on RP, mECE had significantly higher cumulative odds compared to PNI. The significant predictive ability of mECE adds further clinical value to the use of mpMRI in PCa management. While validation in a larger cohort is required, these factors have important clinical implications with regards to early diagnosis of advanced disease and surgical planning.

Mazor X Stealth Robotic Technology: A Technical Note

Minimally invasive techniques in spine surgery have continued to advance as robotic technology has evolved over several generations. Although traditional techniques for placing pedicle screws are still widespread in practice, newer technology has increased the reliability of accurately placing instrumentation with smaller incisions and subsequent decreased length of stay. Additionally, advancements in planning software have improved the ability to align posterior instrumentation to assist with rod placement on multilevel constructs. This paper describes the surgical techniques and operative workflow for placing pedicle screws with the latest robotic technology. The robotic platform, registration, surgical planning, and placement of instrumentation are discussed in detail. Advantages of the Mazor X Stealth Edition compared with the previous generation robot include obviating the need for K wires and eliminating the need for a percutaneous pin, as navigation is integrated into the robot. Our use of this new technology has been encouraging. Using the techniques described in this paper, the first 90 pedicle screws placed with the Mazor X Stealth Edition robot yielded 100% grade A accuracy on the Gertzbein-Robbins scale confirmed on immediate postoperative CT. There were no complications experienced in any case. In our experience, this robotic technology has the potential to improve patient outcomes and is associated with advanced surgical planning compared with more traditional techniques.

Abstract 50: Occlusal &amp; Dental Outcomes Following Facial Allotransplantation

Purpose: Most of the literature surrounding face transplantation focuses on immunology, function, and psychology. Dental and orthognathic outcomes remain persistently underreported. This study sought to review the worldwide face transplant experience, and for the first time, evaluate dental, orthognathic, and skeletal outcomes. Methods: All composite allografts containing maxilla and/or mandible with alveolus were examined, and dental and orthognathic complications recorded. Clinical photographs, radiographs, and/or CT scans from the literature were analyzed using Angle’s Classification, cephalometrics, and facial profile angles. The most recent orthognathic outcomes of our three facial transplant patients are also presented. Results: The worldwide experience consists of 45 face transplantations; 25 patients received allografts containing maxilla or mandible, and 16 (64%) involved double-jaw. All documented patients had at least one dental/occlusal complication: TMJ ankylosis (9/25, 36%), dental caries and extractions (32%), palatal fistula (28%), Angle class II malocclusion (24%), class III (12%), open bite (20%), maxillary rotation (8%), skeletal non-union (8%), hardware infection (4%); 28% of patients underwent revision surgeries involving Lefort I, III, or mandibular osteotomies. Imaging conducive to Angle, cephalometric, or facial profile angle analysis was available in 100% (7) of reported maxilla, and 63% (10) of double jaw transplants. The majority of maxilla-only transplants had insufficient teeth, while soft tissue profile was most commonly class II. Double jaws were equally Angle class I, II, or III, but mostly class I or class III with regard to facial angle profile. All of our patients have received maxilla and/or mandible, and all have required dental extractions. Angle classification, cephalometrics, and facial profile angles vary across our patients, while class III soft tissue facial profile appears to predominate. Conclusion: Dental and orthognathic complications remain extremely common but underreported after facial allotransplantation involving either single or double jaw composites. In fact, every documented face transplant has at least one occlusal or skeletal defect. The risk of malocclusion increases with simultaneous transplantation of maxilla and mandible, and often necessitates revision surgery in this unique population. Craniofacial principles and advanced surgical planning should be utilized to achieve facial balance. Additionally, we must standardize the way in which face transplant patients are presented in the literature.