Introduction

Radical prostatectomy remains a cornerstone in the management of high-risk prostate cancer, yet its technical demands are significant. The aggressiveness of the tumor, coupled with its proximity to critical neurovascular structures, requires exceptional surgical precision to achieve oncologic control without compromising urinary and sexual function. Robot-assisted surgery—led by systems such as the Da Vinci platform—has already reshaped the surgical landscape by improving dexterity, visualization, and control.

Pushing this evolution further, mixed reality (MR) navigation systems are now being integrated into robot-assisted radical prostatectomy (RARP), offering immersive, real-time anatomical guidance. By superimposing three-dimensional (3D) models reconstructed from multiparametric MRI and PSMA-PET imaging into the surgical field, MR navigation enhances spatial awareness and supports more nuanced dissection. A recent propensity score–matched cohort study revealed that MR-guided RARP (MR-RARP) significantly improved nerve-sparing rates and reduced positive surgical margins compared to standard RARP—without compromising oncologic safety. Patients undergoing MR-RARP also experienced faster recovery of continence and potency, indicating both oncological and functional advantages. This synthesis of robotic precision and MR visualization represents a transformative step in urologic oncology, with the potential to redefine standards in complex prostate cancer surgery.1,2,3

What Is a Mixed Reality Navigation System?

Mixed reality (MR) navigation is an advanced surgical visualization technology that extends the concept of augmented reality by embedding virtual 3D anatomical reconstructions directly into the surgeon’s view. In the context of RARP, MR systems integrate high-resolution preoperative imaging—most commonly multiparametric MRI or CT—to segment key anatomical structures, including the prostate gland, tumors, neurovascular bundles, seminal vesicles, bladder, and rectum.

These segmented structures are rendered into interactive 3D holograms that are intraoperatively registered to the patient’s anatomy. This alignment is achieved through real-time imaging or stereo video capture, allowing the MR system to project the virtual models onto the actual operative field—typically via a head-mounted display or integrated robotic console. This immersive visualization allows for accurate, real-time spatial orientation and tumor localization, enabling surgeons to preserve delicate neurovascular structures while achieving precise excision of malignant tissue.

Compared to conventional 2D imaging or static console overlays, MR navigation enhances depth perception and anatomical context. It becomes particularly valuable in high-risk cases, where intricate anatomical variations and tumor invasiveness demand tailored, patient-specific approaches. Clinical feasibility studies support the use of MR navigation to improve decision-making during dissection and to minimize residual tumor presence. As this technology evolves, it is poised to enhance both surgical confidence and patient safety.4,5,6,7

Study Design: Propensity Score–Matched Cohort Analysis

To evaluate the impact of MR navigation on surgical outcomes, researchers have employed propensity score–matched (PSM) cohort studies—widely regarded as a rigorous statistical method for reducing confounding in observational settings. PSM helps mimic randomization by balancing key preoperative variables between patients receiving MR-RARP and those undergoing standard RARP, thereby isolating the effect of the intervention.

In the studies under discussion, patients were matched on clinical factors such as age, PSA levels, Gleason score, and tumor stage. Matching was typically done using a 1:1 nearest-neighbor algorithm without replacement to ensure comparability. These analyses were often conducted within single-institution or single-surgeon frameworks to maintain surgical technique consistency and minimize procedural variability.

Primary outcomes assessed included positive surgical margin rates, nerve-sparing accuracy, intraoperative metrics such as blood loss and operative time, and early postoperative functional recovery. Notably, continence and erectile function were evaluated using validated patient-reported outcome tools. Across matched cohorts, MR-RARP demonstrated superior performance in nerve preservation and margin negativity, without increasing operative risk or compromising cancer control.

Importantly, newer studies emphasize the inclusion of institutional and surgeon-level variables in the matching process, recognizing their influence on surgical outcomes. These refinements further validate the utility of MR in enhancing precision surgery for prostate cancer.89,10,11

Reference:

  1. Liu W, Zhou S, Yu X, Yu Y, Su H, Miao Q, Gao M, Cao Z, Bi J, Chen L, Wang J, Zhang M. The application of mixed reality navigation system in robot-assisted radical prostatectomy for high-risk prostate cancer: a propensity score‑matched cohort study. Prostate Cancer Prostatic Dis. 2025 Jul 25. doi: 10.1038/s41391-025-01003-5. Epub ahead of print. PMID: 40715667.

  2. Canda AE, Aksoy SF, Altinmakas E, Koseoglu E, Falay O, Kordan Y, Çil B, Balbay MD, Esen T. Virtual reality tumor navigated robotic radical prostatectomy by using three-dimensional reconstructed multiparametric prostate MRI and 68Ga-PSMA PET/CT images: A useful tool to guide the robotic surgery? BJUI Compass. 2020 May 9;1(3):108-115. doi: 10.1002/bco2.16. PMID: 35474863; PMCID: PMC8988524.

  3. Stefano Puliatti, Maria Chiara Sighinolfi, Bernardo Rocco, Vipul Patel, Porpiglia Francesco, Salvatore Micali, Ahmed Eissa, Pietro Torricelli, Giampaolo Bianchi, First live case of augmented reality robot-assisted radical prostatectomy from 3D magnetic resonance imaging reconstruction integrated with PRECE model (Predicting Extracapsular extension of prostate cancer), Urology Video Journal,

  4. Mehralivand S, Kolagunda A, Hammerich K, Sabarwal V, Harmon S, Sanford T, Gold S, Hale G, Romero VV, Bloom J, Merino MJ, Wood BJ, Kambhamettu C, Choyke PL, Pinto PA, Türkbey B. A multiparametric magnetic resonance imaging-based virtual reality surgical navigation tool for robotic-assisted radical prostatectomy. Turk J Urol. 2019 Sep 1;45(5):357-365. doi: 10.5152/tud.2019.19133. PMID: 31509508; PMCID: PMC6739087.

  5. Mehralivand S, Kolagunda A, Hammerich K, Sabarwal V, Harmon S, Sanford T, et al. A multiparametric magnetic resonance imaging-based virtual reality surgical navigation tool for robotic-assisted radical prostatectomy. Turk J Urol 2019; 45(5): 357-65.

  6. Della Corte M, Quarà A, De Cillis S, Volpi G, Amparore D, Piramide F, Piana A, Sica M, Di Dio M, Alba S, Porpiglia F, Checcucci E, Fiori C. 3D virtual models and augmented reality for radical prostatectomy: a narrative review. Chin Clin Oncol 2024;13(4):56. doi: 10.21037/cco-24-31

  7. Rodler, S.; Kidess, M.A.; Westhofen, T.; Kowalewski, K.-F.; Belenchon, I.R.; Taratkin, M.; Puliatti, S.; Gómez Rivas, J.; Veccia, A.; Piazza, P.; et al. A Systematic Review of New Imaging Technologies for Robotic Prostatectomy: From Molecular Imaging to Augmented Reality. J. Clin. Med. 2023, 12, 5425. https://doi.org/10.3390/jcm12165425

  8. Rechtman M, Forbes A, Millar JL, Evans M, Dodds L, Murphy DG, Evans SM. Comparison of urinary and sexual patient-reported outcomes between open radical prostatectomy and robot-assisted radical prostatectomy: a propensity score matched, population-based study in Victoria. BMC Urol. 2022 Feb 7;22(1):18. doi: 10.1186/s12894-022-00966-0. PMID: 35130897; PMCID: PMC8822814.

  9. Lu YC, Huang CY, Cheng CH, Huang KH, Lu YC, Chow PM, Chang YK, Pu YS, Chen CH, Lu SL, Lan KH, Jaw FS, Chen PL, Hong JH. Propensity score matching analysis comparing radical prostatectomy and radiotherapy with androgen deprivation therapy in locally advanced prostate cancer. Sci Rep. 2022 Jul 21;12(1):12480. doi: 10.1038/s41598-022-16700-7. PMID: 35864293; PMCID: PMC9304348.

  10. Hou W, Wang B, Zhou L, Li L, Li C, Yuan P, Ouyang W, Yao H, Huang J, Yao K and Wang L (2022) Single-site multiport vs. conventional multiport robot-assisted radical prostatectomy: A propensity score matching comparative study. Front. Surg. 9:960605. doi: 10.3389/fsurg.2022.960605

  11. Khanmammadova, N.; Jiang, J.F.; Gomez, R.K.M.; Gao, A.; Chu, T.Y.; Shahait, M.; Myklak, K.; Lee, D.I.; Das, A.K. Propensity Score Matching Analysis of Differential Outcomes in Holmium Laser Enucleation of the Prostate vs. Robotic-Assisted Simple Prostatectomy. J. Clin. Med. 2024, 13, 5135. https://doi.org/10.3390/jcm13175135