This systematic review explores machine learning (ML) applications in surgical motion analysis using non-optical motion tracking systems (NOMTS), alone or with optical methods. It investigates objectives, experimental designs, model effectiveness, and future research directions. From 3632 records, 84 studies were included, with Artificial Neural Networks (38%) and Support Vector Machines (11%) being the most common ML models. Skill assessment was the primary objective (38%). NOMTS used included internal device kinematics (56%), electromagnetic (17%), inertial (15%), mechanical (11%), and electromyography (1%) sensors. Surgical settings were robotic (60%), laparoscopic (18%), open (16%), and others (6%). Procedures focused on bench-top tasks (67%), clinical models (17%), clinical simulations (9%), and non-clinical simulations (7%). Over 90% accuracy was achieved in 36% of studies. Literature shows NOMTS and ML can enhance surgical precision, assessment, and training. Future research should advance ML in surgical environments, ensure model interpretability and reproducibility, and use larger datasets for accurate evaluation.

Introduction: Preterm infants’ growth is typically monitored through weight, body length (BL) and head circumference (HC). However, 3D cranial volume (CrV) is considered a more accurate indicator of brain growth than 2D HC. The PreemieScanner is a novel 3D measuring device that simultaneously measures BL, HC and CrV. Its clinical usability was tested in a simulated NICU setting. Materials and methods: Three extremely low birth weight (ELBW; BW < 1,000 gram) dolls with Optiflow breathing systems, (tubes positioned either at the front or back of the head) were used. Nurses conducted scan sessions and marked anatomical landmarks on 3D PreemieScanner images. As control, nurses measured HC manually with a standard measuring tape. Key outcomes were: (1) Measurement success rate, (2) Precision—percentage within clinically allowed limits, ±0.4 cm for BL, ±0.3 cm for HC, ±12 ml for CrV, and 3) accuracy—mean or median measurement error (MME) relative to the ground truth. Results: Thirty-five scan sessions resulted in 100% successful measurements for BL and HC; 80% for CrV. BL MME −3.3% (p < 0.001); 40% (42/105) within precision limits. HC MME (Optiflow-front) 0.0% (p = 0.63); 89% (51/57) within limits. HC MME (Optiflow-back) −0.4% (p = 0.91). 93% (43/46) within limits. MME HC measuring tape, (Optiflow-front) −0.8% (p < 0.001), 88% (50/57) within limits, and MME (Optiflow-back) −1.1% (p < 0.001), 83% (40/48) within limits. MME CrV (Optiflow-front) −1.8% (p = 0.01), 86% (31/36) within limits, MME CrV (Optiflow-back) −1.3% (p < 0.001), 98% (45/46) within limits. Conclusions: The PreemieScanner is a reliable, comprehensive device for measuring BL, HC and CrV in ELBW infants. It integrates smoothly into routine care with minimal disturbance. HC measurements demonstrated higher accuracy and precision than traditional tape method. CrV measurements, with 93% within precision limits, can be regarded as acceptable, enabling development of CrV growth reference charts, enhancing clinical growth monitoring.

Background: Preoperative planning of patients diagnosed with pancreatic head cancer is difficult and requires specific expertise. This pilot study assesses the added value of three-dimensional (3D) patient models and computer-aided detection (CAD) algorithms in determining the resectability of pancreatic head tumors. Methods: This study included 14 hepatopancreatobiliary experts from eight hospitals. The participants assessed three radiologically resectable and three radiologically borderline resectable cases in a simulated setting via crossover design. Groups were divided in controls (using a CT scan), a 3D group (using a CT scan and 3D models), and a CAD group (using a CT scan, 3D and CAD). For the perceived fulfillment of preoperative needs, the quality and confidence of clinical decision-making were evaluated. Results: A higher perceived ability to determine degrees and the length of tumor–vessel contact was reported in the CAD group compared to controls (p = 0.022 and p = 0.003, respectively). Lower degrees of tumor–vessel contact were predicted for radiologically borderline resectable tumors in the CAD group compared to controls (p = 0.037). Higher confidence levels were observed in predicting the need for vascular resection in the 3D group compared to controls (p = 0.033) for all cases combined. Conclusions: “CAD (including 3D) improved experts’ perceived ability to accurately assess vessel involvement and supports the development of evolving techniques that may enhance the diagnosis and treatment of pancreatic cancer”.

Endovascular intervention is a minimally invasive method for treating cardiovascular diseases. Although fluoroscopy, known for real-time catheter visualization, is commonly used, it exposes patients and physicians to ionizing radiation and lacks depth perception due to its 2D nature. To address these limitations, a study was conducted using teleoperation and 3D visualization techniques. This in-vitro study involved the use of a robotic catheter system and aimed to evaluate user performance through both subjective and objective measures. The focus was on determining the most effective modes of interaction. Three interactive modes for guiding robotic catheters were compared in the study: 1) Mode GM, using a gamepad for control and a standard 2D monitor for visual feedback; 2) Mode GH, with a gamepad for control and HoloLens providing 3D visualization; and 3) Mode HH, where HoloLens serves as both control input and visualization device. Mode GH outperformed other modalities in subjective metrics, except for mental demand. It exhibited a median tracking error of 4.72 mm, a median targeting error of 1.01 mm, a median duration of 82.34 s, and a median natural logarithm of dimensionless squared jerk of 40.38 in the in-vitro study. Mode GH showed 8.5%, 4.7%, 6.5%, and 3.9% improvements over Mode GM and 1.5%, 33.6%, 34.9%, and 8.1% over Mode HH for tracking error, targeting error, duration, and dimensionless squared jerk, respectively. To sum up, the user study emphasizes the potential benefits of employing HoloLens for enhanced 3D visualization in catheterization. The user study also illustrates the advantages of using a gamepad for catheter teleoperation, including user-friendliness and passive haptic feedback, compared to HoloLens. To further gauge the potential of using a more traditional joystick as a control input device, an additional study utilizing the Haption Virtuose robot was conducted. It reveals the potential for achieving smoother trajectories, with a 38.9% reduction in total path length compared to a gamepad, potentially due to its larger range of motion and single-handed control.

Since the introduction of robot-assisted laparoscopic surgery, efforts have been made to incorporate force sensing technologies to monitor critical components and to provide force feedback. The advanced laparoscopic robotic system (AdLap RS) is a robotic platform that aims to make robot technology more sustainable through the use of the fully reusable shaft-actuated tip-articulating (SATA) instruments. The SATA instrument driver features electronics and sensors exposed to the sterile environment, which complicate the sterilisation process. The aim of this study was to develop and validate smart sensing in stepper motors using the back electromotive force in a newly developed Smart SATA Driver (SSD), eliminating the need for sensors in the sterile environment. Methods: The stepper drivers were equipped with TMC2209 ICs featuring StallGuard technology to measure back EMF. The tip was actuated up until a set StallGuard threshold value was reached, at which the resulting tip force was measured. This cycle was repeated ten times for a range of threshold levels. A regression analysis with a power series model was used to determine the quality of the fit. Results: The SSD is capable of exerting tip forces between 2.4 and 8.2 N. The back EMF force test demonstrated a strong correlation between obtained StallGuard values and measured tip forces. The regression analysis showed an R-squared of 0.95 and a root Mean squared error of 0.4 N. Discussion: The back EMF force test shows promise for force feedback, but its accuracy limits real-time use due to back EMF fluctuations. Future improvements in motor stability and refining the back EMF model are needed to enable real-time feedback. Conclusion: The strong correlation during the back EMF force test shows its potential as a low-budget method for detecting motor stalls and estimating tool–tissue forces without the need for sensors in laparoscopic instruments.

Background: To validate whether the SATA-LRS, a novel reusable articulating laparoscopic instrument, fits surgical practice, a pre-clinical study was performed. Methods: Thirteen medical doctors used the instrument in a laparoscopic endoscopic inguinal hernia repair (TEP)-like task inside a cadaver. A set of sensors on the instrument handle detected motion and articulation of the instrument tip. Data from the sensors and video recordings were used to assess the amount and type of movement of the instrument and the time spent on tasks. questionnaire was used to gain insight into the participants’ perception of the contextual factors. Results: There was no difference between task time and instrument tip velocities when using articulation (or not) and all participants used articulation at least half of the task time. Instrument-handle movement, indicating the user’s hand and arm movement, was significantly reduced when using articulation. The questionnaire indicated strong acceptance of the instrument and the experimental setup, and a desire to use the instrument in surgery by most participants. Conclusions: The added articulation feature of the SATA-LRS instrument was deemed beneficial by the participants, showed no increased handling complexity or time spent on the task and was used frequently when enabled, indicating intuitiveness.

Negative Pressure Wound Therapy (NPWT) is a treatment that promotes healing of chronic wounds. Despite high prevalence of chronic wounds in Low- and Middle-Income Countries (LMICs), NPWT devices are not available nor affordable. This study aims to improve chronic wound care in LMICs by presenting the Wound Care (WOCA) system, designed for building, testing and use in LMICs. Design requirements were formulated using input from literature, ISO standards, and wound care experts. The WOCA design was developed to provide safe, portable, user-friendly and affordable NPWT to patients in LMICs. The design features an adjustable operating pressure ranging from −75 to −125 mmHg, a battery for portability, a 300 ml canister, overflow protection, and system state alarms. An Arduino controls the pressure and monitors the system state. Three prototypes were developed and built in Nepal, and their performance was evaluated. Pressure control was 125 ± 10 % mmHg, internal leakage was 7.5 ± 4.3 mmHg/min, reserve capacity was 189 ± 16.9 ml/min, and overflow protection and alarm systems were effectively working. Prototype cost was approximately 280 USD. The WOCA demonstrates to be a locally producible NPWT device that can safely generate a stable vacuum. Future research will include clinical trials situated in LMICs.

Background: Laparoscopic surgery requires a complex set of motor skills. Currently, basic laparoscopic skills training is performed in a static environment, while intraoperatively, abdominal tissue is often moving. The aim of this study was to develop a dynamic training platform and evaluate its impact on laparoscopic skills acquisition in a box trainer. Methods: The Dynamic Laparoscopic Platform (DyLaP) includes a moving base which has been intergrated with the Lapron box trainer and the ForceSense objective measurement system. Dynamic training was evaluated in a comparative study where novices were divided into a static and dynamic training group, performing six training trials of a peg transfer task with the DyLaP. Afterwards, both groups performed a dynamic exam task. Task manipulation (force) and instrument efficiency (path length and time) were measured. Results: Participants (n = 12) exhibited a significant difference (p < 0.05) in time, path length, and maximum force between the static and dynamic groups in the first trial. Learning curves were most prevalent in the dynamic group. Conclusions: The DyLaP can be used to provide a challenging and realistic training environment. From the comparative peg transfer study, it can be concluded that dynamic training significantly affects laparoscopic skill acquisition. More research is needed to evaluate dynamic training effects in force-based training tasks.

Laparoscopic surgery offers significant benefits to patients in low-resource settings compared to open surgery such as faster recovery, less pain, and lower infection rate. However, there exist significant barriers to the safe introduction of laparoscopy such as high costs and limited availability of trained staff. Low- and middle-income country (LMIC) hospitals suffer from higher post-surgical infection which might be due to the limited facilities for the sterile reprocessing of laparoscopic instruments. To design a solution to this issue, a detailed understanding of local settings was needed. Therefore, this research applied a context-driven design approach, based on the Roadmap for Design of Surgical Equipment for Safe Surgery Worldwide. Over several design phases, the need for a reprocessing device was established. An analysis of the sterile reprocessing of laparoscopic instruments led to a list of context-specific design requirements. These were translated to a final conceptual design of a laparoscopic instrument cleaner using a waterfall design method. Finally, a usability study of the loading system of the device was conducted with nurses in four Indian hospitals. A root-cause analysis of the usability study showed that the device was not intuitive enough to use for Indian nurses. A redesign of the loading system was made to improve its ease of use. The design process used in this study can be used as an example for designers wanting to address the critical issue of context-specific medical devices worldwide, or more specifically, the sterile supply of surgical instruments in resource-constrained environments.

Objective: Navigation through tortuous and deformable vessels using catheters with limited steering capability underscores the need for reliable path planning. State-of-the-art path planners do not fully account for the deformable nature of the environment. Methods: This work proposes a robust path planner via a learning from demonstrations method, named Curriculum Generative Adversarial Imitation Learning (C-GAIL). This path planning framework takes into account the interaction between steerable catheters and vessel walls and the deformable property of vessels. Results: In-silico comparative experiments show that the proposed network achieves a 38% higher success rate in static environments and 17% higher in dynamic environments compared to a state-of-the-art approach based on GAIL. In-vitro validation experiments indicate that the path generated by the proposed C-GAIL path planner achieves a targeting error of 1.26±0.55mm and a tracking error of 5.18±3.48mm. These results represent improvements of 41% and 40% over the conventional centerline-following technique for targeting error and tracking error, respectively. Conclusion: The proposed C-GAIL path planner outperforms the state-of-the-art GAIL approach. The in-vitro validation experiments demonstrate that the path generated by the proposed C-GAIL path planner aligns better with the actual steering capability of the pneumatic artificial muscle-driven catheter utilized in this study. Therefore, the proposed approach can provide enhanced support to the user in navigating the catheter towards the target with greater accuracy, effectively meeting clinical accuracy requirements. Significance: The proposed path planning framework exhibits superior performance in managing uncertainty associated with vessel deformation, thereby resulting in lower tracking errors.

Peripheral autonomic nerve function (ANF) impairment (ANFI) can be one of the first indicators for leprosy or leprosy neuropathy. However, within leprosy, hardly any ANF assessment methods are used in current practice. Skin temperature could be a proxy measure to assess ANF. Therefore, this research aims to explore whether low-cost infrared (IR) video thermography can be used as an ANF assessment tool by measuring the skin temperature response (STR) of human hands before, and after applying a cold pressor test (CPT). A protocol was defined to perform a baseline measurement, apply CPT, and record the resulting STR curve during 15 minutes. An IR video camera connected to a mobile phone was selected as sensor. A setup was developed to immobilize the position of the hands and fingers relative to the camera. A Python script was developed to extract the hand palm skin temperature STR curve from an IR video for 12 ulnar and median innervated regions of interest (ROI) in 1s intervals. A Matlab script was developed to post-process the raw temperature data into filtered data. This data is used to calculate key metrics that describe the STR curve. This approach was evaluated on technical accuracy and precision by comparing IR data for 3 cameras to a reference sensor. The variability caused by the observer analyzing the data was studied by analyzing the same video 5 times by 2 observers. The subject variability was studied by enrolling 7 subjects into a pilot, testing them daily for 5 consecutive days. The results show a high mean Interclass correlation of 0.94 between the 3 IR cameras and the reference sensor. Bland-Altman plots show a mean accuracy of +0.090°C between the cameras and the reference, and a variation between −1.30 and +1.50°C. High agreement was shown between observers analyzing the data. The pilot test showed high variability in STR curve within subjects. Although the general shape of the STR was similar, the location of the steep increase in recovery varied strongly within and between subjects. This study shows that a low-cost, portable IR camera can be used to measure STR of human hands after CPT. A pilot study showed high subject variability for repeated testing of the STR curve. Future research is needed to establish its value in assessing ANF in leprosy patients or other systemic and local neuropathies and traumatic nerve conditions.

Diffuse Reflectance Spectroscopy (DRS) can provide tissue feedback for pedicle screw placement in spine surgery, yet the integration of fiber optics into the tip of the pedicle probe, a device used to pierce through bone, is challenging, since the optical probing depth and signal-to-noise ratio (SNR) are affected negatively compared to those of a blunt DRS probe. Through Monte Carlo simulations and optical phantom experiments, we show how differences in the shape of the instrument tip influence the acquired spectrum. Our findings demonstrate that a single bevel with an angle of 30∘ offers a solution to anticipate cortical breaches during pedicle screw placement. Compared to a blunt probe, the optical probing depth and SNR of a cone tip are reduced by 50%. The single bevel tip excels with 75% of the optical probing depth and a SNR remaining at approximately ⅔, facilitating the construction of a surgical instrument with integrated DRS.

Objective: Cemented total hip arthroplasty (THA) demonstrates superior survival rates compared to uncemented procedures. Nevertheless, most younger patients opt for uncemented THA, as removing well-fixed bone cement in the femur during revisions is complex, particularly the distal cement plug. This removal procedure often increases the risk of femoral fracture or perforation, haemorrhage and weakening bone due to poor drill control and positioning. Aim of this study was to design a novel drill guide to improve drill positioning. Methods and procedures: A novel orthopaedic drill guide was developed, featuring a compliant centralizer activated by a drill guide actuator. Bone models were prepared to assess centralizing performance. Three conditions were tested: drilling without guidance, guided drilling with centralizer activation held, and guided drilling with centralizer activation released. Deviations from the bone centre were measured at the entry and exit point of the drill. Results: In the centralizing performance test, the drill guide significantly reduced drill hole deviations in both entry and exit points compared to the control (p < 0.05). The absolute deviation on the exit side of the cement plug was 10.59mm (SD 1.56) for the 'No drill guide' condition, 3.02mm (SD 2.09) for 'Drill guide - hold' and 2.12mm (SD 1.71) for 'Drill guide - release'. The compliant drill guide centralizer significantly lowered the risk of cortical bone perforation during intramedullary canal drilling in the bone models due to better control of the cement drill position. Clinical and Translational Impact Statement: The drill guide potentially reduces perioperative risks in cemented femoral stem revision. Future research should identify optimal scenarios for its application.

Objective: Detecting the cancerous growth margin and achieving a negative margin is one of the challenges that surgeons face during cancer procedures. A smart electrosurgical knife with integrated optical fibers has been designed previously to enable real-time use of diffuse reflectance spectroscopy for intraoperative margin assessment. In this paper, the thermal effect of the electrosurgical knife on tissue sensing is investigated. Methods: Porcine tissues and phantoms were used to investigate the performance of the smart electrosurgical knife after electrosurgery. The fat-to-water content ratio (F/W-ratio) served as the discriminative parameter for distinguishing tissues and tissue mimicking phantoms with varying fat content. The F/W-ratio of tissues and phantoms was measured with the smart electrosurgical knife before and after 14 minutes of electrosurgery. Additionally, a layered porcine tissue and phantom were sliced and measured from top to bottom with the smart electrosurgical knife. Results: Mapping the thermal activity of the electrosurgical knife's electrode during animal tissue electrosurgery revealed temperatures exceeding 400 °C. Electrosurgery for 14 minutes had no impact on the device's accurate detection of the F/W-ratio. The smart electrosurgical knife enables real-time tissue detection and predicts the fat content of the next layer from 4 mm ahead. Conclusion: The design of the smart electrosurgical knife outlined in this paper demonstrates its potential utility for tissue detection during electrosurgery. Significance: In the future, the smart electrosurgical knife could be a valuable intraoperative margin assessment tool, aiding surgeons in detecting tumor borders and achieving negative margins.

Collision feedback about instrument and environment interaction is often lacking in robotic surgery training devices. The PoLaRS virtual reality simulator is a newly developed desk trainer that overcomes drawbacks of existing robot trainers for advanced laparoscopy. This study aimed to assess the effect of haptic and visual feedback during training on the performance of a robotic surgical task. Robotic surgery-naïve participants were randomized and equally divided into two training groups: Haptic and Visual Feedback (HVF) and No Haptic and Visual Feedback. Participants performed two basic virtual reality training tasks on the PoLaRS system as a pre- and post-test. The measurement parameters Time, Tip-to-tip distance, Path length Left/Right and Collisions Left/Right were used to analyze the learning curves and statistically compare the pre- and post-tests performances. In total, 198 trials performed by 22 participants were included. The visual and haptic feedback did not negatively influence the time to complete the tasks. Although no improvement in skill was observed between pre- and post-tests, the mean rank of the number of collisions of the right grasper (dominant hand) was significantly lower in the HVF feedback group during the second post-test (Mean Rank = 8.73 versus Mean Rank = 14.27, U = 30.00, p = 0.045). Haptic and visual feedback during the training on the PoLaRS system resulted in fewer instrument collisions. These results warrant the introduction of haptic feedback in subjects with no experience in robotic surgery. The PoLaRS system can be utilized to remotely optimize instrument handling before commencing robotic surgery in the operating room.

Background: The steep radiation dose gradients in cervical cancer brachytherapy (BT) necessitate a thorough understanding of the behavior of afterloader source cables or needles in the curved channels of (patient-tailored) applicators. Purpose: The purpose of this study is to develop and validate computer models to simulate: (1) BT source positions, and (2) insertion forces of needles in curved applicator channels. The methodology presented can be used to improve the knowledge of instrument behavior in current applicators and aid the development of novel (3D-printed) BT applicators. Methods: For the computer models, BT instruments were discretized in finite elements. Simulations were performed in SPACAR by formulating nodal contact force and motion input models and specifying the instruments’ kinematic and dynamic properties. To evaluate the source cable model, simulated source paths in ring applicators were compared with manufacturer-measured source paths. The impact of discrepancies on the dosimetry was estimated for standard plans. To validate needle models, simulated needle insertion forces in curved channels with varying curvature, torsion, and clearance, were compared with force measurements in dedicated 3D-printed templates. Results: Comparison of simulated with manufacturer-measured source positions showed 0.5–1.2 mm median and <2.0 mm maximum differences, in all but one applicator geometry. The resulting maximum relative dose differences at the lateral surface and at 5 mm depth were 5.5% and 4.7%, respectively. Simulated insertion forces for BT needles in curved channels accurately resembled the forces experimentally obtained by including experimental uncertainties in the simulation. Conclusion: The models developed can accurately predict source positions and insertion forces in BT applicators. Insights from these models can aid novel applicator design with improved motion and force transmission of BT instruments, and contribute to the estimation of overall treatment precision. The methodology presented can be extended to study other applicator geometries, flexible instruments, and afterloading systems.

Endovascular interventions are minimally invasive procedures that utilize the vascular system to access anatomical regions deep within the body. Image-guided assistance provides valuable real-time information about the dynamic state of the vascular environment. However, the reliance on intraoperative 2-D fluoroscopy images limits depth perception, prompting the demand for intraoperative 3-D imaging. Existing image registration methods face difficulties in accurately incorporating tissue deformations compared to the preoperative 3-D model, particularly in a weakly supervised manner. Additionally, reconstructing deformations from 2-D to 3-D space and presenting this intraoperative model visually to clinicians poses further complexities. To address these challenges, this study introduces a novel deformable model-to-image registration framework using deep learning. Furthermore, this research proposes a visualization method through augmented reality to guide endovascular interventions. This study utilized image data collected from nine patients who underwent transcatheter aortic valve implantation (TAVI) procedures. The registration results in 2-D indicate that the proposed deformable model-to-image registration framework achieves a modified dice similarity coefficient (MDSC) value of 0.89±0.02 and a penalization of deformations in spare space (PDSS) value of 0.04±0.01, offering an improvement of 3.5%-98.6% over the state-of-the-art image registration approach. Additionally, the accuracy of registration in 3-D was evaluated using a dataset obtained from an intervention simulator, resulting in a mean absolute error (MAE) of 1.51±1.02 mm within the region of interest. Overall, the study validates the feasibility and accuracy of the proposed weakly supervised deformable model-to-image registration framework, demonstrating its potential to provide intraoperative 3-D imaging as intervention assistance in dynamic vascular environments.

Our research highlights the potential of Diffuse Reflectance Spectroscopy (DRS) in detecting cortical breaches during pedicle screw placement. We propose a sideways-looking fiber-optic probe, integrating diffuse light emission with both forward and sideways light collection. Experiments on an optical tissue phantom validate the probe’s potential to distinguish bone tissues and provide real-time guidance for spine surgery. Our findings prove that DRS with diffuse emission can detect perpendicular breaches, and demonstrate how the integration of a 45^◦ slanted fiber coated with gold enables parallel breach detection, advancing spine surgery by allowing for accurate pedicle screw placement.

Purpose. Patient-tailored intracavitary/interstitial (IC/IS) brachytherapy (BT) applicators may increase dose conformity in cervical cancer patients. Current configuration planning methods in these custom applicators rely on manual specification or a small set of (straight) needles. This work introduces and validates a two-stage approach for establishing channel configurations in the 3D printed patient-tailored ARCHITECT applicator. Methods. For each patient, the patient-tailored applicator shape was based on the first BT application with a commercial applicator and integrated connectors to a commercial (Geneva) intrauterine tube and two lunar ring channels. First, a large candidate set was generated of channels that steer the needle to desired poses in the target region and are contained in the applicator. The channels’ centrelines were represented by Bézier curves. Channels running between straight target segments and entry points were optimised and refined to ensure (dynamic) feasibility. Second, channel configurations were selected using geometric coverage optimisation. This workflow was applied to establish patient-tailored geometries for twenty-two patients previously treated using the Venezia applicator. Treatment plans were automatically generated using the in-house developed algorithm BiCycle. Plans for the clinically used configuration, T P clin , and patient-tailored configuration, T P arch , were compared. Results. Channel configurations could be generated in clinically feasible time (median: 2651 s, range 1826-3812 s). All T P arch and T P clin plans were acceptable, but planning aims were more frequently attained with patient-tailored configurations (115/132 versus 100/132 instances). Median CTV_IR D 98 and bladder D 2 c m 3 doses significantly improved ( p < 0.001 and p < 0.01 respectively) in T P arch plans in comparison with T P clin plans, and in approximately half of the patients dosimetric indices improved. Conclusion. Automated patient-tailored BT channel configuration planning for 3D printed applicators is clinically feasible. A treatment planning study showed that all plans met planning limits for the patient-tailored configurations, and in selected cases improved the plan quality in comparison with commercial applicator configurations.

BACKGROUND AND PURPOSE: Although MRI-based image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) has resulted in favorable outcomes, it can be logistically complex and time consuming compared to 2D image-based brachytherapy, and both physically and emotionally intensive for patients. This prospective study aims to perform time-action and patient experience analyses during IGABT to guide further improvements. MATERIALS AND METHODS: LACC patients treated with IGABT were included for the time-action (56 patients) and patient experience (29 patients) analyses. Times per treatment step were reported on a standardized form. For the patient experience analysis, a baseline health status was established with the EQ-5D-5L questionnaire and the perceived pain, anxiety and duration for each treatment step were assessed with the NRS-11. RESULTS: The median total procedure time from arrival until discharge was 530 (IQR: 480–565) minutes. Treatment planning (delineation, reconstruction, optimization) required the most time and took 175 (IQR: 145–195) minutes. Highest perceived pain was reported during applicator removal and treatment planning, anxiety during applicator removal, and duration during image acquisition and treatment planning. Perceived pain, anxiety and duration were correlated. Higher pre-treatment pain and anxiety scores were associated with higher perceived pain, anxiety and duration. CONCLUSION: This study highlights the complexity, duration and impact on patient experience of the current IGABT workflow. Patient reported pre-treatment pain and anxiety can help identify patients that may benefit from additional support. Research and implementation of measures aiming at shortening the overall procedure duration, which may include logistical, staffing and technological aspects, should be prioritized.