List of Papers By topics Author List
| Paper Info | Reviews | Meta-review | Author Feedback | Post-Rebuttal Meta-reviews |
Authors
Filipe C. Pedrosa, Navid Feizi, Ruisi Zhang, Remi Delaunay, Dianne Sacco, Jayender Jagadeesan, Rajni Patel
Abstract
Percutaneous nephrolithotomy (PCNL) is considered a first-choice minimally invasive procedure for treating kidney stones larger than 2 cm. This treatment modality yields higher stone-free rates than other minimally invasive techniques and is employed when extracorporeal shock wave lithotripsy or uteroscopy, are unsuccessful or infeasible. Using this technique, surgeons create a tract through which a scope is inserted for gaining access to the stones. Traditional PCNL tools, however, present limited maneuverability, may require multiple punctures and often lead to excessive torquing of the instruments which can damage the kidney parenchyma and thus increase the risk of hemorrhage. We approach this problem by proposing a nested optimization-driven scheme for determining a single tract surgical plan along which a patient-specific concentric-tube robot (CTR) is deployed so as to enhance manipulability along the most dominant directions of the stone presentations. The approach is illustrated with eight sets of clinical data from patients who underwent PCNL. The simulated results may set the stage for achieving higher stone-free rates through single tract PCNL interventions while decreasing blood loss.
Link to paper
DOI: https://link.springer.com/chapter/10.1007/978-3-031-16449-1_60
SharedIt: https://rdcu.be/cVRXy
Link to the code repository
N/A
Link to the dataset(s)
N/A
Reviews
Review #2
- Please describe the contribution of the paper
This paper proposes an optimization algorithm that approximates the ellipsoidal geometry and orientation of kidney stones for patient-specific surgical planning in Percutaneous nephrolithotomy (PCNL) using concentric-tube robots (CTRs). The paper evaluates the algorithm using 7 sets of CT data which are segmented to construct point clouds of kidney stones for these cases. Some of the results show promise with respect to positional error generated.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
- This work presents a novel optimization approach of kidney stones for the purposes of surgical planning. When further validated, this could prove informative for patient-specific planning of PCNL procedures.
- The use of CTRs is usually justified by the need for more granular maneuverability because of their ability to create complex curves.
- The importance of this work also lies in the fact that the algorithm doesn’t require human intervention which makes the process much more autonomous, contrary to previous works cited.
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
- Authors should further elaborate on the implication of their results and relate back to the original objectives. The conclusion appears abruptly after the results but more discussion of the cases outputs is needed.
- Error plot shows a deviation for all 7 cases. The authors should discuss what those deviations mean and what the implication of a 1 mm error means.
- Figures need to be larger and clearer to make it easier to see the scale (esp. Fig 1).
- Please rate the clarity and organization of this paper
Excellent
- Please comment on the reproducibility of the paper. Note, that authors have filled out a reproducibility checklist upon submission. Please be aware that authors are not required to meet all criteria on the checklist - for instance, providing code and data is a plus, but not a requirement for acceptance
- The paper describes the generation of point clouds using Slicer3D. More detail would help with respect to filters and marching operations used to segment the CT data.
- Answers to reproducibility checklist make sense and the authors do a good job explaining the algorithm and tools they used.
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review: https://conferences.miccai.org/2022/en/REVIEWER-GUIDELINES.html
- Revise sentence in section “Constrained Inverse Kinematics for CTRs”: “has been addressed with by”.
- Figures need to be more legible and larger.
- Need more commentary on the results and its implication.
- Rate the paper on a scale of 1-8, 8 being the strongest (8-5: accept; 4-1: reject). Spreading the score helps create a distribution for decision-making
7
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
Novel approach and a clear application of it. Paper is well organized and clearly identifies the methods and how they address the problem of limited manipulability in PCNL procedures using CTRs.
- Number of papers in your stack
4
- What is the ranking of this paper in your review stack?
2
- Reviewer confidence
Confident but not absolutely certain
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
Not Answered
- [Post rebuttal] Please justify your decision
Not Answered
Review #4
- Please describe the contribution of the paper
This work proposes a method to design a patient-specific concentric-tube robot for percutaneous nephrolithotomy. Access to kidney stones is difficult and often requires multiple insertions. This work proposes a three-tube CTR to access difficult-to-reach stones, where the first one is straight, and the second two are both straight and curved. The stone is modeled as an ellipsoidal, the principal directions of the ellipsoidal are used to guide the CTR design.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
- Method evaluated on real patient data with clear clinical utility
- Thorough description of the optimization process
- Fairly accessible compute requirements
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
- Minimal evaluation on whether the path is clinical useful (Unclear whether reaching the calyx is sufficient for successful PCNL and whether the whole path of the CTR is feasible without damaging surrounding tissue)
- No comparisons to other methods
- No discussion on the path to clinical deployment after calculating these parameters
- Please rate the clarity and organization of this paper
Excellent
- Please comment on the reproducibility of the paper. Note, that authors have filled out a reproducibility checklist upon submission. Please be aware that authors are not required to meet all criteria on the checklist - for instance, providing code and data is a plus, but not a requirement for acceptance
The optimization problem and the libraries used to solve them are clearly described. The actual values used for the optimization problem are missing (every variable in (4) should be defined as a real number) as are any hyperparameters such as stopping criteria. The small patient sample limits the reproducibility of the results.
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review: https://conferences.miccai.org/2022/en/REVIEWER-GUIDELINES.html
The paper presents a neat engineering solution to personalized CTR design for PCNL. It has a lot of potential for clinical application. An image like Fig 1. with the CTR path and tube segments overlaid would help clarify the contributions.
One question I had was whether 5 h for optimization is a clinically viable solution. From section 5, it was unclear whether the 5 h was for all the runs of the algorithm or for one run (and then repeated twice more). Is the runtime feasible for every patient?
How does the proposed method compare to learning-based methods such as [1]? These tend to be faster than traditional optimization approaches at deployment time.
[1] Liang, Nan, Reinhard M. Grassmann, Sven Lilge, and Jessica Burgner-Kahrs. “Learning-based inverse kinematics from shape as input for concentric tube continuum robots.” In 2021 IEEE International Conference on Robotics and Automation (ICRA), pp. 1387-1393. IEEE, 2021.
Comparisons to previous works are needed. For example, what would the error in reaching the calyx be using the optimization technique in [1] or [2]?
[2] Morimoto, Tania K., Joseph D. Greer, Elliot W. Hawkes, Michael H. Hsieh, and Allison M. Okamura. “Toward the design of personalized continuum surgical robots.” Annals of biomedical engineering 46, no. 10 (2018): 1522-1533.
What is the path to clinical deployment after this? Is it realistic and helpful to calculate the particular length of each section and custom make the CTR for each patient, or is it more realistic to expect an algorithm to need to optimize over a set of pre-made tubes?
While the paper presents the clinical goal as being able to reach the calyx accurately, it is unclear how the ability to reach those points translates to the ability for total stone removal. The cases all differ greatly in how closely the ellipsoids resemble the kidney stones they encompass.
Additionally, any discussion on how closely the paths match the constraints imposed by the anatomy would also help understand the clinical benefits this method could provide. It is usually desired that the robot does not exert much force on the anatomy to avoid damaging the tissue. Does the robot sufficiently match the whole path so that is the case?
More discussion in general on the strengths and limitations of the proposed method would be helpful.
Minor grammar note - “2 cm” instead of “2cm”
- Rate the paper on a scale of 1-8, 8 being the strongest (8-5: accept; 4-1: reject). Spreading the score helps create a distribution for decision-making
4
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
This seems to be a promising approach to a clinically relevant problem but as the paper currently stands, it seems insufficiently validated (in its choice of metric and in comparison to previous works). More discussion on the proposed method’s limitations and path to clinical translation would also make it stronger.
- Number of papers in your stack
5
- What is the ranking of this paper in your review stack?
2
- Reviewer confidence
Somewhat Confident
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
Not Answered
- [Post rebuttal] Please justify your decision
Not Answered
Review #3
- Please describe the contribution of the paper
A nested optimization-driven scheme for determining a single tract surgical plan along which a patient-specific concentric-tube robot (CTR) is deployed to enhance manipulability along with the most dominant directions of the stone presentations.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
1- The topic is interesting 2- Well-Structural writing
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
1-The Novelty is not highlighted, the author should describe more about the Significant improvements of their work. 2- lack of comparison with the state-of-art 3-Some English error but its possible to understand
- Please rate the clarity and organization of this paper
Good
- Please comment on the reproducibility of the paper. Note, that authors have filled out a reproducibility checklist upon submission. Please be aware that authors are not required to meet all criteria on the checklist - for instance, providing code and data is a plus, but not a requirement for acceptance
he dataset is very small, but for primary results it’s ok
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review: https://conferences.miccai.org/2022/en/REVIEWER-GUIDELINES.html
This paper could be more strength by comparing by literature works. in addition, the novelty of this paper need to be improved. However the objective is good but what is new your method compare to other methods? i.e. in terms of accuracy of or time assessment, is there any improvement?
- Rate the paper on a scale of 1-8, 8 being the strongest (8-5: accept; 4-1: reject). Spreading the score helps create a distribution for decision-making
6
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
1- topic 2-well explained 3-promissing results
- Number of papers in your stack
5
- What is the ranking of this paper in your review stack?
2
- Reviewer confidence
Somewhat Confident
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
Not Answered
- [Post rebuttal] Please justify your decision
Not Answered
Review #5
- Please describe the contribution of the paper
This paper proposes a method for surgical planning and designing patient-specific concentric-robot tube (CRT) for Percutaneous nephrolithotomy. The main insight of this paper, in my view, is leveraging the idea of ellipsoidal approximation to kidney stones in the proposed approach of this paper. The proposed approach was tested on clinical data from seven patients.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
The paper and its approach is very clinically relevant. I also find the idea of ellipsoidal approximation to kidney stones to be a very interesting one.
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
The results of the paper were not compared with other approaches in the literature. In addition, the proposed approach still need to be developed further to be applicable in a realistic procedure.
- Please rate the clarity and organization of this paper
Very Good
- Please comment on the reproducibility of the paper. Note, that authors have filled out a reproducibility checklist upon submission. Please be aware that authors are not required to meet all criteria on the checklist - for instance, providing code and data is a plus, but not a requirement for acceptance
I think the paper would benefit from considering many of the items in Section 4 of the reproducibility checklist, especially reporting failure cases and describing the sensitivity regarding parameter changes.
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review: https://conferences.miccai.org/2022/en/REVIEWER-GUIDELINES.html
I have three major concerns regarding this paper as follows:
- Since the proposed surgical planning method is based on preoperative imaging, how does the proposed method account for changes in the patient’s body from the time of the preoperative imaging till the time of the procedure itself?
- In a practice, how would the proposed method deal with the case of having two or more resulting stones after the first iteration of disintegration of the kidney stones? Would their method fit another ellipsoid for the resulting stones? And if so, what guarantees that this would not require a different design of the currently used CRT?
- How does the proposed method compare with previous methods in the literature?
As for minor comments:
- What is the points of showing the results in table 1? I suggest you make this point clear or if it is minor, I suggest removing this table and use the space saved to address the reviewers’ comments.
- I would avoid using abbreviations in the title of the paper without spelling them out first.
- Rate the paper on a scale of 1-8, 8 being the strongest (8-5: accept; 4-1: reject). Spreading the score helps create a distribution for decision-making
4
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
The second major concern listed above can severely affect the usefulness of the proposed approach, and that is why I am leaning towards rejection. However, I look forward to the authors responses to the comments to see if they address these major concerns and that is why it is a “weak” reject.
- Number of papers in your stack
5
- What is the ranking of this paper in your review stack?
2
- Reviewer confidence
Somewhat Confident
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
Not Answered
- [Post rebuttal] Please justify your decision
Not Answered
Primary Meta-Review
- Please provide your assessment of this work, taking into account all reviews. Summarize the key strengths and weaknesses of the paper and justify your recommendation. In case you deviate from the reviewers’ recommendations, explain in detail the reasons why. In case of an invitation for rebuttal, clarify which points are important to address in the rebuttal.
The manuscript received four highly detailed reviews with varied levels of enthusiasm. There is general agreement that the method is interesting, thoroughly and relatively clearly presented, and clinically relevant. However, there are also multiple major concerns: 1) By far the strongest concern is the lack of baselines in the evaluation, and R4 references several methods that may or may not be applicable; It appears that, at a minimum, adequate justification is needed to understand why comparisons to baselines were omitted and how this omission affects conclusions, before the importance of this concern can be assessed. 2) There is minimal to no evaluation concerning the utility and safety of a path, and the results are generally perceived as not well contextualized with the clinical application. 3) There is some concern that the novelty of the method is not clearly presented. The aforementioned points should be addressed during revision.
- What is the ranking of this paper in your stack? Use a number between 1 (best paper in your stack) and n (worst paper in your stack of n papers). If this paper is among the bottom 30% of your stack, feel free to use NR (not ranked).
3/17 (~20th percentile)
Author Feedback
Performance of the renal puncture stands as one of the most critical steps of PCNL. Anatomically, the ideal route for this intervention requires passing through the axis of the targeted renal calyx in order to minimize vascular injury around the calyx while obtaining the largest renal endoscopy angle Miller et al. (2007); Seitz et al. (2012). However, during the stone ablation procedure, a 5 mm radial deviation with respect to the longitudinal axis of the targeted calyx is deemed acceptable given the diameter of the calyceal tracts. On the other hand, the distal end is also amenable to small position errors (usually < 3 mm) as the emitted ultrasonic shock waves affect neighboring regions of each point in the stone.
Multiple approaches have been proposed on the issue of customizable design of CTRs. Burgner et al. (2013a,b) introduced a voxel sampling-based framework to maximize coverage over a given volume. Morimoto et al. (2017, 2018) introduced a surgeon in the loop to guide the design of CTRs for deployment into the kidney. Bergeles et al. (2015) proposed a framework that minimizes robot length and curvature breaking the design problem down into the follow-the-leader deployment and distal manipulability of CTRs. Baykal et al. (2015) incorporated a sampling-based motion planner to produce sets of CTR designs to collectively maximize the reachaility of regions of interest. Although the aforementioned approaches can all be used to design patient-specific CTRs, the novelty of our approach is in providing a comprehensive framework for surgical planning and CTR kinematic design which are independent of user inputs, can be applied seeminglessly across different patients, and once a design is achieved, the constrained inverse kinematics used in the design stage guides the navigation within the kidney. In contrast to Morimoto et al. (2017, 2018), in this work we account for the constraint at the renal pyramids and calyces for all posible configurations in which the CTR is deployed in the kidney. As opposed to Baykal et al. (2015), our method returns one single CTR design, thus not requiring change of tools and consequent redeployment of the robot into the anatomy during the PCNL procedure. Lastly, we believe the time requirements to run our algorithms are quite reasonable as the total runtime for all seven clinical cases presented in the paper, running concurrently took about 5 hours. In contrast, similar optimization driven approaches as in Burgner et al. (2013b) reported on average 36 hours and later improved later to 23 hours per optimization in Burgner et al. (2013a).
At the present stage of our project (similarly to the cases reported in the related works cited in the paper), we have elected to approach the problem considering a static environment where shifting/disintegration of the stone burden are not considered. In order to bring our algorithms closer to clinical applicability, our ongoing work addresses the suggestion of the reviewer in that it includes a sensitivity analysis with regards to perturbations of the stone burden and kidney positions as well as the scattering of stone fragments within the collecting system.
We opted for optimizing the manipulability of the constrained CTR along the so called “main directions” of the patients’ stone presentation. While there are gains to consider, mainly avoiding the need to characterize the workspace of each CTR design at every iteration of the optimization (very time consuming as observed in Burgner et al. (2013a,b), for instance), the drawback is the lack of guarantree that all points in a stone are reachable, given a CTR design and the imposed anatomical constraints. An important remark here is that other approaches such as in Burgner et al. (2013a,b); Morimoto et al. (2017, 2018), also do not guarantee a full volume coverage of the targets of interest and calyceal constraints are not explicitly addressed.
Post-rebuttal Meta-Reviews
Meta-review # 1 (Primary)
- Please provide your assessment of the paper taking all information into account, including rebuttal. Highlight the key strengths and weaknesses of the paper, clarify how you reconciled contrasting review comments and scores, indicate if concerns were successfully addressed in the rebuttal, and provide a clear justification of your decision. If you disagree with some of the (meta)reviewer statements, you can indicate so in your meta-review. Please make sure that the authors, program chairs, and the public can understand the reason for your decision.
There is general agreement that the strenghts of the method are its interesting topic and applicatio which is clinically relevant, a thorough evalaution, and clear presentation. The rebuttal addressed most concerns identified during review.
- After you have reviewed the rebuttal, please provide your final rating based on all reviews and the authors’ rebuttal.
Accept
- What is the rank of this paper among all your rebuttal papers? Use a number between 1/n (best paper in your stack) and n/n (worst paper in your stack of n papers). If this paper is among the bottom 30% of your stack, feel free to use NR (not ranked).
5
Meta-review #2
- Please provide your assessment of the paper taking all information into account, including rebuttal. Highlight the key strengths and weaknesses of the paper, clarify how you reconciled contrasting review comments and scores, indicate if concerns were successfully addressed in the rebuttal, and provide a clear justification of your decision. If you disagree with some of the (meta)reviewer statements, you can indicate so in your meta-review. Please make sure that the authors, program chairs, and the public can understand the reason for your decision.
The paper presents a framework for surgical planning and design of patient-specific concentric-tube robots for PCNL procedures. The topic is clinically relevant, the optimization approach is novel, and the paper is well-presented. The rebuttal addresses most of the concerns from the reviews regarding existing baseline approaches, and gap towards clinical translation.
- After you have reviewed the rebuttal, please provide your final rating based on all reviews and the authors’ rebuttal.
Accept
- What is the rank of this paper among all your rebuttal papers? Use a number between 1/n (best paper in your stack) and n/n (worst paper in your stack of n papers). If this paper is among the bottom 30% of your stack, feel free to use NR (not ranked).
11
Meta-review #3
- Please provide your assessment of the paper taking all information into account, including rebuttal. Highlight the key strengths and weaknesses of the paper, clarify how you reconciled contrasting review comments and scores, indicate if concerns were successfully addressed in the rebuttal, and provide a clear justification of your decision. If you disagree with some of the (meta)reviewer statements, you can indicate so in your meta-review. Please make sure that the authors, program chairs, and the public can understand the reason for your decision.
I believe the authors did a good job of addressing the concerns of the reviewers who did generally agree that the method was interesting and clinically relevant. Given this I would lean towards acceptance.
- After you have reviewed the rebuttal, please provide your final rating based on all reviews and the authors’ rebuttal.
Accept
- What is the rank of this paper among all your rebuttal papers? Use a number between 1/n (best paper in your stack) and n/n (worst paper in your stack of n papers). If this paper is among the bottom 30% of your stack, feel free to use NR (not ranked).
NR