Endoscopic cysto-ventriculostomy is a minimally invasive approach for intracranial cyst treatment. However, inadequate visibility within cystic spaces often complicates identifying adjacent anatomical landmarks like the ventricle, leading to procedural challenges and potential conversion to craniotomy. Frameless stereotaxy is a conventional aid for endoscopic cysto-ventriculostomy.

In 2021, we introduced ROSA (Zimmer Biomet) robot-assisted procedures to enhance outcomes, primarily focusing on cysto-ventriculoscopy. This study outlines our initial experiences with this approach.

Between 2021 and 2023, our institute performed 7 robot-assisted ventriculoscopy procedures, three of which were cysto-ventriculoscopy cases. Patients averaged 51 years, with a mean follow-up of 9 months. Two patients had primary intracerebral cysts, while one had post-irradiation and postoperative compartmentalization of the lateral ventricle, previously undergoing unsuccessful shunting and open fenestration.

Fiducial-based CT scan registration, followed by MR image co-registration, facilitated preoperative planning. Corticospinal tract data, obtained through probabilistic tractography (FMRIB Software Library, 5.0.9, Oxford), aided planning in one case. Patients’ heads were immobilized using a Mayfield skull clamp. Depending on cyst location, patients were positioned prone or laterally. In one complex case, two trajectories were employed to fenestrate an entrapped temporal horn and the trigonal part of the right lateral ventricle, followed by contralateral cella media fenestration through the septum pellucidum. No perioperative complications occurred, and all patients showed neurological improvement postoperatively. Two patients remained asymptomatic with improving radiology, while the third developed re-entrapment of the temporal horn after 2 months, necessitating ventriculo-peritoneal shunting.

Robot-assisted cysto-ventriculoscopy proves safe and effective, offering personalized planning and precise treatment delivery, especially in complex anatomical situations. Integrating tractography-based fiber tracking holds promise for improving patient safety.