Proceedings of the 25" ' Annual International Conference of the IEEE EMBS

Cancun. Mexico * September 17-21,2003

Computer Simulation of Prostate Resection for Surgery Training
M. A. Padilla Castaiieda, F. Arambula Cosio
Image and Vision Lab., CCADET, UNAM, P.O. Box 70-186, MCxico, D.F., 04510
Abstract- During a Transurethral Resection of the
Prostate (TURP), a surgeon removes the inner prostate tissue
that obstructs the urinary flow. In this minimally invasive
procedure, the novice surgeons must perform hundreds of
training sessions before acquiring the skills needed. I n this
paper wepresent a three-dimensional (3D) computer model of
the prostate for TURP simulation. The prostate model is
designed to he the hasis of a computer simulator for TURP
training. The model was built from a set of ultrasound images
with a technique that constructs a 3D volumetric mesh of the
prostate shape. We used a set of ultrasound images with the
prostate contour automatically annotated, using a point
distribution model of the prostate which is adjusted by a
genetic algorithm. A mass-spring method is used to model
tissue deformation due to surgical tool interaction. The model
simulates, in real-time: resections; tissue deformations and the
cavity produced by the user as the surgical procedure
progresses.
Keywords-Deformable models, Prostate, Prostatectomy,
Surgery simulation, Surgery training systems.
I. INTRODUCTION
Transurethral resection of the prostate (TURF') is the
modem standard procedure to treat urinary blockage due to
an enlarged prostate gland, as a minimally invasive surgical
procedure it offers significant advantages such as reduced
patient trauma, and short recovery periods. However, the
procedure restricts the movements of the surgeon, provides
limited visibility of the operating site, and requires well-
developed orientation skills using only the monocular view
of the endoscope. A modem training altemative consists of
the development of computer training systems that help the
urology residents to acquire the skills in shorter periods of
time, with less risk for the patients, and in an economically
suitable manner.
The development of surgery training systems involves
the construction of deformable models that simulate tissue
cutting and tissue deformation due to the interaction with the
surgical instruments. The two main groups for real time
simulation of tissue deformation are models based on the
finite element method (FEM) and models based on mass-
spring systems.
Finite element methods use realistic mechanical models
based on continuum mechanics applied over a discretisation
of the entire object into volume elements. Systems based on
FEM provide accurate, off-line, patient specific results, like
the prototype reported by Koch et al. [I]. Bro-Nielsen [2]
simplifies the system equations with a technique called
condensation, unfortunately the method is still slow for even
simple tissue cutting operations.
On mass-spring systems, the object mesh is considered
as a set of nodal 'masses interconnected with their
neighbours by springs. Deformations occur as a result of the
intemal energy produced by the springs and extemal forces
applied on the body. Miss-spring models seem better suited
for surgery training applications, that do not need very
accurate deformations, but require a physical behaviour with
enough visual realism, like the works reported in [ 3] , [4].
In this paper we present a 3D computer model of the
prostate that simulates, in real time, tissue resections and
deformations. The model forms the basis for the
development of a real time computer simulator for TURP
training. The prostate model was built from a set of
ultrasound images, automatically annotated with a point
distribution model (PDM) adjusted by a genetic algorithm
(GA). The deformable behaviour of the prostate is modelled
with the mass-spring method. Resections are modelled
through the removal of nodes and geometrical elements
from the volumetric mesh. Gomes et al. [ 5 ] reported a
training system for TURP, which focus on monitoring the
surgery progress with positional feedback, but does not
include a prostate model that simulates real time physical
behavior.
11. METHODOLOGY
A. Physical model for TURP simulation
The physical behaviour of the prostate is modelled using
the mass-spring method. In this method the continuous
domain R of the defoimable object is approximated by a
geometrical discretisation R', where R' consists of a mesh
formed by an arrangement of geometrical elements of
smaller size, the vertex and edges of every geometrical
element represents nodes and links between them on the
mesh. In this way, objects reflect 8 dynamical nature, by
associating physical characteristics like mass, stiffness and
damping, to nodes and links. Every node represents a mass
point that is interconnected with its neighbours by springs
(links) and which moves in a viscous medium. The dynamic
system is determined by the discretised Lagrange equation
of motion (1).
0-7803-7789-3/03/$17.00 02003 IEEE 1152
where: mi is the mass of the node i in the mesh, at Cartesian
coordinates x i ; yi is the damping coefficient of the node i
(viscosity of the medium); gi is the intemal elastic force
vector; and fi represents all the extemal forces acting on the
node i .
Deformations result l?om the internal elastic energy
produced by the spring arrangement and the extemal forces
applied on the object surface. Typically, mass-spring
systems use simplified linear elasticity models where the
intemal elastic forces acting on the node i are given by (2).
where: p is the stiffness coefficient of the spring
connecting node i and j for all the neighbors in N(i) ; x, is
the current position of node i; xi is the current position of
node j ; and
B. Geometric model of the prostate
is the spring length at rest position.
To reconstruct the three-dimensional shape of the
prostate, the mesh generation method uses a set of
transverse, transurethral, ultrasound images, separated by
intervals of 5mm along the main axis of the gland. All
images were automatically annotated (Fig. I), using a point
distribution model (PDM) adjusted by a genetic algorithm.
The genetic algorithm optimizes the shape and pose
parameters of the PDM of the prostate, through
minimization of an error function that measures the error
between a model instance and the gray level information of
the ultrasound image [6].
Each of the contours of the prostate was sampled in a
radial manner, taking as the origin the centre of the
transurethral ultrasound transducer. The number of samples
is determined by the size of the sampling angle a, which is
the control parameter of the mesh generation method. The
same procedure is applied to the contour of the prostatic
urethra (inner duct) forming a set of cross-sections C with
both capsule (outer perimeter) and urethra samples (Fig.
2.a).
(a) (b)
Fig I . Transurethral ullrasound imagcs with the pm~tate contour^
automatically annatatcd (a) At Smm from the bladder neck (b) At 1Smm
(4 (b)
Fig 2 . 3 0 shape mesh gencration of the prosme. (a) Radial sampling of a
prostatc cross-section with sampling angle a. @) 3D surface mesh
intcrpolated from the transurethral ultrasound cross-sections.
Since it is not possible to identify the prostatic urethra
from ultrasound images, we drew an approximate urethra
contour on each of the ultrasound images. In this manner,
the sampled points of every cross-section c$ (with the
capsule and the urethra contours) in C, represent the control
points of the prostate shape. In order to control the
uniformity of the mesh, we calculated the average length ( I )
of all the segments mi and mij in C, that join the control
points mi and mi of the capsule, and the control point mi
and m, of the urethra, respectively.
The next step is to transform the prostate shape C,
typically composed by 5 to 12 cross-section images
(separated at 5mm), into the new shape C* now composed
by n target cross-sections separated by the average distance
I , previously calculated. C* is generated using cubic spline
interpolation over the control points of C (Fig 2.b). To
model the prostate as a solid body, the algorithm also
interpolates, for every cross-section cs, in C*, k internal
sampled contours from the capsule to the urethra (Fig 3).
Again, the number of k inner contours depends on the I
value. Finally, the last step is to arrange the solid body of
the prostate as a mass-spring mesh of lattice form, where
every node vyk in the body is linked with at most 6 adjacent
nodes ( w + ; ~ , & vji+l.b vj j ,k+; , vi +l j +l . b v; +l i ,k+l and v , +; ~+; , x +I ) .
Figure 4 illustrates the arrangement of the 3D mesh as a
mass-spring system. Additional geometric volume elements
of the form of a pentahedron ( VEI and VE,) are constructed
(Fig. 4). As we will show in section ll.C, the form of these
volume elements is useful for simulating tissue resection
operations.
gcncration of the prostatc
1153
Fig. 4. Volumc dements of thc 3 D mass-spring mcsh of the prostatc.
C. Tissue resection simulafion
The basic tissue removal mechanism during TURP is
the resection or vaporization of small tissue chips. Tissue
resection during TURP modifies significantly the shape of
the prostate. The urologist produces a cavity inside the
obstructed urethra, by resecting the adenomatous tissue until
the capsule is reached. For tissue resection simulation we
use an approach, inspired in [7], that take advantage of the
mass-spring mesh arrangement described in section ILB,
based on pentahedral volume elements.
After a collision between the prostate body and the
resection element of the resectoscope occurs, the contact
node v, of the mesh is detected. Then, it is determined the
list L of volume elements on the vicinity of v,, that are
under of the cutting radius c, (typically 3mm to 5mm ) which
must be removed from the mesh. After that, every volume
element in L and its mechanical elements are removed from
the mesh. When a spring s is being removed, the force fc,
needed to fully compress the spring s is calculated and
added to the resection force fh of its i-adjacent nodes. When
a node m has no more links, the node is removed, and its
force fr, is added to the frk forces of his old &neighbors. In
this way, after a resection occurs, every node j around the
resected zone, posses a compression force fr, that is
progressively determined and used as extemal force in (1).
The local effect of resection is the deformation of the tissue
surrounding the resection zone, as a result of the
contribution-of the resection forces of all the elements
removed from the mesh. The global result of all resections
and the corresponding local tissue deformations is the slight
collapse of theremaining inner tissue.
111. RESULTS
The model described was implemented in C using the
OpenGL libraries for rendering, on a SUN BLADE 2000
workstation (with one processor at 1 Ghz), without
specialized graphics hardware.
The slides on Fig. 5 show a simulated resection of the
prostate model. The figure presents a prostate with an
urethra, almost completely obstructed by the tissue that has
. .
Fig. 5. Cavity produced mar the urethra after some rcscctions. After cvcry
resection the tissue deforms, and af m some tissue reseclions arc pcrformcd
(top Icfl to bottom right) the prostate slightly collapses.
grown in excess (top left slide) The slides also show the
removing process of the adenoma. It can be observed the
cavity produced after several tissue resections from the
obstructed urethra, and .the progressive collapse of the inner
tissue.
In Table 1 is shown the average processing rate
(frames/s) without display for meshes generated with a
sampling angle a fiom 7 to 11 degrees and a cutting radius
c, of 5". Processing rates in Table 1 include collision
1154
detection operations, geometric mesh modifications and
tissue deformation after resection. It can be observed that:the
response rate increases from 11 to 25 Hz as the complexity
of the mesh is reduced (increased sampling angle a) .
TABLE I
AWRAGE PROCESSING RATE NEEDED TOUPDATE THEMODEL AFrER
RESECTION USING A Ca OF 5MM.
a(deg) Processing rate (Hz)
7 11.27
8 12.32
9 13.91
IO 19.84
11 25.50
The model is able to reproduce tissue resections of
different sizes, depending on the cutting radius of the
resectoscope. Along with resections, the model simulates in
real-time tissue deformations and the global collapse of the
prostate capsule as the resection of the adenoma progresses.
ACKNOWLEDGMENT
The authors are grateful to Dr. J orge Mirquez from the
Image and Vision Lab. at CCADET, U", and to Dr.
Alejandro Sinchez, Urology specialist from Clinic. No. 26
of the Mexican Institute of Social Security (IMSS), for their
useful comments and insight provided on the subjects of 3D-
meshes and TURF'.
IV. DISCUSSION
REFERENCES
The results show that the model is well suited for real time
interactions during resection simulation: in the worst case,
the response rate without display is higher than the 10 Hz
(IO frames/s) recommended as the minimum for visual
realism. Unfortunately, a display rate of 8 frmes/s approx.
was observed for a sampling angle of 8 deg., this is below
the 10 frameds recommended. However significantly higher
frame rates should be possible with the use of graphics
acceleration hardware since the processing time of the
model alone (Table 1) would allow for more than 12
framesh at a sampling angle of 8 deg.
not seem mandatory for TURP simulation since the prostate
tissue is very soft to resection and vaporisation, and the
surgical guidance is mainly through feedback' A
passive mechanical interface with position encoders and
working volume restrictions is being developed.
In the short term, it looks difficult to obtain
biomechanical studies of the prostate that allow physical
validation of the model. Fortunately, for a prostatectomy
training system, a model that visually behaves well is
enough. For this reason, we are collaborating with an
urologist to determine the right mechanical properties of the
model, which provide visual realism.
[I 1
Koch, R.M., Gross, M.H., Carls, F.R., Von Buren, S.F., Fankhauser.
G. and Pafish, Y.I.H., "Simulating Facial Surgcry Using Finite
Element Models", Proc. SIGGRAPHPQ Addison-Wcsley Publishing
Co., pp. 421428, 1996.
[2] Bro-Nielaen, M., "Finite Element Modelling in Surgcry Simulation",
Proceedings afthe IEEE, Vol. 86, No. 3, pp. 490-503, March 1998.
[3] Ktihnapfel, U,, Cakmak H.K., M d , H., "Endoscopic surgcry
training using vimal reality and deformable tissue simulation",
Computers and Graphics, 24, pp. 671 -682, 2000.
Stephanides, M., "Rcal-Time Simulation of Deformable Objects
Tools and Application". Computer Animation 2001, Seoul, Korea.
November 7-8,2001,
Computer Assisted TrainingIMonitoring Systemfor N R P Struchtrc
and Design", IEEE Trans. On Information Technology in Biomed.,
Vol. 3, No. 4, pp. 242-250, 1999.
Admbula Cosio, F., Davies, B.L., "Automatcd prostatc recognition: a
key process for clinically effective robotic prostatcctomy", Medical &
Biological Engineering & Computing. Val. 37, No. 2, pp. 236-243,
March 1999.
Catin S., Delingette H., Ayachc N., "A hybrid elastic model for real
time cutting, dcfomtions, and force feedback far surgery training
and simuIatim,.l Thc Visual Computer, 16, pp3.437-452,2000.
[dl Brown, I., Sorkin, S. , BNYnS, C., Latombe, J.C., Montgomery, K.
In opinion of experts in urology, haptic feedback does
[SI Games, M.P.s.F., B mt , A.R.w., Timoncy, A.G., Davies, B.L., - A
[6]
[7]
V. CONCLUSION
We have reported a computer model of the prostate that is
the basis for the development of a real-time virtual reality
simulator for TURP training.. The prostate model is
constructed from a set of ultrasound images which are
automatically annotated. A 3D volumetric mesh of the
prostate is constructed through sampling of the set of
annotated contours. The method allows to control the visual
realism of the 3D mesh with appropriate time response, by
varying its sampling parameter a (radial sampling angle).
1155