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Updated: May 1, 2026
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Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion
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Actionable Feedback on Signal-to-Background Ratios During Drop-in Radioguided Surgery
Berkay A Cakal1,2,3, Kateryna Pirkovets1,4, Vera A Ottens1,4
1Interventional Molecular Imaging Laboratory, Leiden University Medical Centre, Leiden, The Netherlands.
Summary
Real-time signal-to-background ratio (SBR) feedback during prostate-specific membrane antigen (PSMA)-targeted radioguided surgery (RGS) improved surgical perception and efficiency. This enhanced feedback system, integrated into robotic consoles, aids in better discrimination of cancerous lesions.
Area of Science:
- Nuclear medicine and surgical oncology
- Minimally invasive robotic surgery
- Molecular imaging and diagnostics
Background:
- Radioguided surgery (RGS) using prostate-specific membrane antigen (PSMA)-targeted tracers faces challenges with low intraoperative signal intensity.
- Limited signal intensity hinders accurate target discrimination based solely on probe counts per second during surgery.
- Existing methods lack real-time contrast information, increasing cognitive load for surgeons.
Purpose of the Study:
- To evaluate if real-time signal-to-background ratio (SBR) feedback improves surgical perception, decisiveness, and scanning efficiency in PSMA-targeted RGS.
- To assess the integration of a graphical user interface (GUI) for live SBR feedback into a robotic console.
- To determine the impact of SBR feedback on probe handling and target discrimination during salvage RGS procedures.
Main Methods:
- Retrospective analysis of 10 patients from the TRACE-II trial undergoing salvage RGS with 99mTc-PSMA.
- Comparison between standard counts per second feedback (control) and live SBR feedback via a GUI (experiment).
- Quantification of scanning performance using total and target scan durations, with probe trajectories reconstructed via video tracking.
Main Results:
- Fourteen PSMA-avid lesions were successfully resected and confirmed as cancerous.
- Real-time SBR feedback group showed reduced median total scan duration (455s to 237s) and target scan duration (299s to 212s).
- Normalized median target scan duration decreased significantly with SBR feedback (21.1 to 5.3 s/cps), indicating improved efficiency.
Conclusions:
- Streaming real-time SBR feedback into robotic consoles enhances surgical perception and decisiveness in PSMA-RGS.
- The GUI-integrated SBR feedback digitizes contrast information, reducing cognitive load and improving target discrimination.
- Findings support further multicenter studies to establish standardized SBR-based performance metrics for RGS.
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