Mechatronic Resectoscope Emulator for a Surgery Simulation Training

System of the Prostate

M.A. Padilla, F. Altamirano, F. Arambula & J. Marquez
AbstractIn this work is presented the development of
a mechatronic interface for a surgery simulation system for
training Transurethral Resection of the Prostate (TURP). The
interface emulates a real resectosope and allows to perform
the most important movements of the surgical tool during a
TURP. The interface is able to work in conjuntion with a
virtual reality software with a deformable tissue model of the
prostate, in order to simulate tissue resection and deformation.
The current prototype has ve degrees of freedom, which are
enough to have a realistic simulation of the surgery movements.
The results show that the interface is suitable for a real time
surgery simulation training system of the prostate without force
feedback.
I. INTRODUCTION
The prostate gland is located next to the bladder in
human males, with the urethra running from the bladder
neck through the prostate to the penile urethra (Fig. 1). A
frequent condition in men above 50 years old is the benign
enlargement of the prostate known as Benign Prostatic Hy-
perplasia (BHP), which in some cases results in signicant
blockage of the urinary ow. The standard surgical procedure
to treat a hypertrophied prostate gland is the Transurethral
Resection of the Prostate (TURP). It essentially consists of
the removal of the inner lobes of the prostate in order to
relieve urinary outow obstruction. TURP is one of the most
performed surgical procedures in urology, however mastering
the TURP technique requires a highly developed hand-eye
coordination which enables the surgeon to orientate inside
the prostate, using only the monocular view of the lens of
the resectoscope. Currently TURP is taught through example
from an experienced surgeon, but training introduces risk
of severe haemorrhage for the patients. As a consequence,
the resident of urology has very restricted opportunities to
practice the procedure, but must perform hundreds of training
sessions during a period of four years before acquiring the
skills needed.
An alternative consists of the development of computer
simulation systems for surgery training that bring the urology
residents the opportunity to practice an unlimited of times,
with less risk for the patients, and in an economically
suitable manner, before practicing with real patients. More-
over, simulation of several physiological phenomena, like
bleeding, coagulation, and charring, among others, could be
incorporated in order to enhance the realism of the training
process.
M.A. Padilla, F. Altamirano, F. Arambula & J.Marquez are with Image
Analysis and Visualization Lab, CCADET, Universidad Nacional Autonoma
de Mexico, P.O.Box 70-186, Mexico, D.F., 04510 {miguel.padilla,
fernando.arambula}@ccadet.unam.mx
Fig. 1. Prostate gland position.
Gomes et al. [3] reported an interesting hybrid computer-
assisted training system for TURP, that use a resectable
physical phantom and a computer model of the prostate.
The aim of using traditional physical phantoms is to pro-
vide the surgeon with more realistic haptic feedback than
virtual reality techniques can provide. Positional feedback is
provided by an optical tracker and the 3D computer model
of the prostate. However, the 3D model used is a rigid
geometric model of the prostate capsule, without deformation
and resection simulation. Additionally, a phantom based
simulator requires continuous expense on replacements.
Manyak et al. [4] reported the construction of a virtual
reality surgery simulation system of the lower urinary track.
They considered only the surface of the urinary track, re-
constructed from the Visible Human Project dataset [5] with
texture mapping for visual realism. However, the prostatic
urethra behaviour depends on the conditions of the tissue
from the capsule to the urethra. As a consequence, a vol-
umetric model of the prostate should be consider in order
to simulating realistic TURP procedures. Sweet, et al. [6]
reported the experience of using the TURP virtual training
system described in [7]. They studied the effectiveness of
translating the skills acquired in their virtual environment to
the operating room. The surgery simulation system for TURP
reported in [7] uses an image-based approach for simulating
bleeding when the resecting loop contacts surface vessels.
The loop triggers precalculated movies of blood ow, that
is then oriented and mapped on the virtual environment.
However, how they model tissue deformation is not clear;
moreover as in [4] they used only the surface representation
of the urethra.
In [1] and [8] we reported the development a 3D de-
Proceedings of the 29th Annual International
Conference of the IEEE EMBS
Cit Internationale, Lyon, France
August 23-26, 2007.
FrA09.5
1-4244-0788-5/07/$20.00 2007 IEEE 1750
formable volumetric model of the prostate for TURP simula-
tion that involves tissue deformation and resection, consider-
ing the gland as a viscoelastic solid. In this work we describe
the development of the virtual resectoscope interface for our
simulator. Section 2 of this paper describes the development
of the mechatronic interface that emulates the resectoscope;
section 3 briey describes the interaction scheme between the
virtual resectoscope and the tissue model; nally in section
5 we present the conclusions and future perspectives of this
work.
II. MECHATRONIC DESIGN
In order to obtain a realistic simulation of the most
important movements of the surgeon during a TURP, a
mechanism was designed based on a disk-ring array (Fig.
2). Due to difculties in repreducing the seven degrees of
freedom, we decided at the moment to reproduce only the
ve most important degrees (Fig. 2.a). In this manner the
mechanism provides ve axes of movement. Three of these
axes are rotational and the other two are linear displacements
of the resectoscope. We ignore for the moment two additional
translation degrees of the resectoscope sheath. However, in
opinion of an expert urologist, the ve movements repro-
duced are enough for having a realistic reproduction of the
real movements during cistoscopies and TURP procedures.
The disk-ring array is mounted in a plastic box. Inside
the box is placed and registered a phantom of the prostate
constructed from the 3D model of the gland [8], this phantom
is the physical reference of the 3D computer model and also
allows to limit the resecting volume during the simulation.
The correct localization of the phantom is important for the
interface, since it does not provide for the moment reacting
forces, and as a consecquence, the trainee could easily miss
the spatial orientation inside the prostate at the early stages
of the training process. Registration of the phantom is made
by calculating the orientation and position with respect to
the reference system of the interface, by doing the principal
component analysis of the phantom shape, where every shape
point is sampled with the head of the resectoscope.
Fig. 2. Resectoscope degrees of freedom. a) Linear (a and b) and rotational
movements (c, d and e). b) Digital encoders for rotational axes.
A. Axes movement sensors
1) Rotational axes : Optical encoders from USDigital
(HEDS-9040 and HEDS-9140 models) [10] are used in order
to sense each of the three rotational movements. Each en-
coder is placed in each rotation axe, so with this arrangement
we can measure the direction and the angle rotated by the
user on each axis (Fig. 2.b).
2) Linear axes : The linear displacement (in/out) of
the surgical tool is measured with a linear precision multi-
turn potentiometer. The shaft of the potentiometer has a
metallic disk with a rubber band which is in contact with
the cylindrical body of the resectoscope. The output voltage
of the potentiometer varies according to the position of the
resectoscope from 0 to 23 cm, which corresponds to the
useful resectoscope displacement range. The resecting loop
has a linear movement of 36 mm, this distance is sensed with
an array of two linear Hall effect sensors and two permanent
magnets, as shown in Fig. 3.
Fig. 3. Hall effect sensors array for controling the resecting loop.
B. Sensor Data Processing
For monitoring we used, as described in next section a set
of microcontroller for real time sensing. Since translational
sensors produced analog signals, is easy and fast to use one
microcontoller for sensing and processing all translations:
we used an LP3500 card [11], which is a low-power, single-
board computer with a Rabbit 3000 8 bit microcontroller at
7,4 MHz and programmed in C language with the Dynamic
C compiler [2]. On the other hand, since the rotation sensing
produces digital signals, the complexity of processing it is
higher, so we used a set of PIC microcontrollers of Microchip
Technology [12] for monitoring in parallel rotational move-
ments.
1) Optical Sensors: Each optical sensor give us three
output signals: CH. A, CH. B and CH. I (as shown in Fig. 4).
We ignored signal CH. I, since this signal is useful only when
the optical sensor gives a complete turn, however our three
sensors will never turn completely. To determine the position
and direction of rotation, channels A and B are enough.
For each rotational axe a program was developed on a PIC
microcontroller for calculating from the two out of phase
signals, the angular position of each rotational axis. The
program is based on storing the previous value given by
the sensor to the microcontroller and comparing it with the
present value, with the aim to detect any change in the phase
between CH. A and CH. B. The angular distance of rotation
is determined by counting the number of pulses of CH. A.
2) Multi-Turn Potentiometer : The acquisition of the po-
tentiometer output signal is made through one of the analog
channels of the LP3500 microcontroller. The conguration of
the potentiometer is a voltage divider whose output measures
the resecting loop movements.
The signal is in the interval from 3.23 to 4.50V that
corresponds to the movement of the resectoscope from 0 to
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Fig. 4. Signals of each digital encoder for rotational movements.
23cm. The mathematical model of this sensor corresponds to
a linear device. For this reason, efcient linear interpolation
of the linear device model was directly programmed as a
routine of the LP3500.
3) Hall Effect Sensors : The output signal of the Hall
effect sensors array is measured through two analog channels
of the LP3500, the program in C is in charge of signal acqui-
sition, addition and nal displacement calculation, through
interpolation using a lookup table. The mathematical model
obtained is nonlinear and at off-line stage, a lookup table
with 148 interpolated values that corresponds to a resolution
of 0.5mm of the non-linear curve were calculated, in order
to obtain in real-time the displacement of the resecting loop.
Finner displacements behind 0.5mm are calculated in real-
time by doing linear interpolation of the precalculated values.
III. INTERACTION WITH THE VIRTUAL MODEL
As we mention in the last section, monitoring of the
resectoscope movements are performed with an embebed
electronic system consisting on ve microcontrollers: four
PIC microcontrollers for digital signal monitoring of the
optical sensors, for rotations; the LP3500 card for the analog
signals of the multi-turn linear potentiometer and hall-effect
sensor, for translations.
The ve microcontrollers in the embebed system run
together in parallel in order to monitoring the movements
in real time; the system sends the movements information
in the form of moving commands to the virtual model. The
real-time resectoscope movements consequently reect the
interaction between the surgeon and the tissue model. The
interactions (tissue deformation and resection) between the
virtual tool and the prostate model are consequence of the
collision between them (See section III.B).
A. Resectoscope movements monitoring
Sensors information is send to the model in 3D continu-
ously in asynchronous way through serial port at 57600 bits
per second (BPS). The information ow in the electronic
system is as follows (Fig. 5): The card LP3500 makes
a request of digital data to the master PIC, in parallel
while the data of the digital sensors are received in the
reading bus of a serial port C, the signals of the analogical
sensors are acquired with the DAC of the LP3500 card
and stored in an shipment data array. Data request done
by the LP3500 is received by the master PIC, which asks
for the information of each of the digital sensors to the
corresponding slave PIC, while the slave PIC continuously
calculate in parallerl the rotational axes position. Therefore
when they recived the data request the shipment is made
immediately with the last sensed data. These requests and
data reception are made by the PIC serial port. After the
master PIC receives the complete information of the digital
sensors, sends it to the LP3500 by its serial port C, which
stores the arriving information in the shipment data array.
When the incoming array is full the LP3500 card sends byte
by bye the information of the resectoscope position to the
3D model through its B serial port.
Fig. 5. Microcontrollers embebed system.
B. Virtual model interaction
We modeled the virtual resectoscope as a 3D surface
mesh. The prostate model were inplemented as a deformable
mass-spring system. We developed a collision detection
mechanism for our simulator based on the representation of
triangular meshes with hierarchical sphere-trees. Our imple-
mentation detects all collisions between the resectoscope and
the prostate in real-time and allows the hierarchical structure
updating for mesh modication after tissue cuttings. After
a collision is detected the soft tissue must slightly deform
before the tissue resection occurs. Tissue deformations result
from the reacting forces due to collisions, where reacting
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forces are the forces needed to separate the colliding objects
and depends on the penetration depth of the resectoscope
inside the prostate, and the mechanical properties of the soft
body (prostate). For the moment, tissue resection is done
without local mesh renement, so tissue cutting is performed
as two operations: removing triangles from surface mesh and
adding the inner triangles exposed by the cut. More details
of the prostate model and the collision detection mechanism
are available in [8] and [9] respectively.
IV. CONCLUSION AND FUTURE WORK
In this paper we have presented the development of a
virtual resectoscope interface for a surgery simulation system
of the prostate, without force feedback for the moment. In
Fig. 6 a view of the mechatronic device and the virtual model
could be seen.
Fig. 6. View of the mechatronic device and the virtual model
We performed metrological tests by using a ZEISS MC850
Coordinates Measuring Machine with an accuracy of 3 m,
with 96% of condence [13], and by comparing the data
measured by our interface and the ones measured by the
coordinate machine, for the same positions of the resecto-
scope head. After doing metrological evaluation we obtained
accurate specications of the mechatronic interface. The tests
made reveals that as the resectoscope is moving inside the
virtual urethra, starting from the mechanical reference point,
the displacement error increase until reaching an acceptable
statistical error of 2.14 mm when the resecting head is
located around 7 cm from the reference point. This is an
acceptable error rate for simulation, but more effort must
be made for stablishing the real approximate position of
the prostate inside a patient with respect of an anatomic
reference, in order to setup the virtual prostate position
correctly in the simulator. For greater distances, the error
increase drastically until reaching 7mm approximately, so
mechanical adjustments must be made in order to reduce
errors of movements when the resecting head is located
farther from origin. The response time of the movements
monitoring is 44 ms (23 Hz approximately). Surgery simula-
tions systems must run at least at a response rate of 20 Hz in
order to be visually realistic, at least as a low cinema movie.
If we consider that the mininimal correct response rate of the
full system must include collision, deformation, cutting and
rendering, which are highly demanding computing tasks that
together could hardly run at 28-30 Hz, the electronic system
must be enhanced in order to monitoring movements with at
more acceptable rate from 60 to 100 Hz. The mechatronic
prototype has been evaluated by an urology specialists and
in his opinion visual feedback is more important than haptic
feedback and does not seem mandatory for TURP simulation,
however we are also planning in the near future to include
force feedback to the mechatronic device. We are also
planning to evaluates the usefulness of the system with a
group of residents in urology, as soon as the full virtual
simulation system will be nished.
V. ACKNOWLEDGMENTS
The authors are grateful to Dr. Sergio Duran, Urology
specialist from Instituto Nacional de Rehabilitaci on, for their
useful comments and insight provided on the mechatronic
interface and TURP.
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