New multiport robotic surgical systems: a comprehensive literature review of clinical outcomes in urology

Initial experience with the novel modular robotic system Carina in urology: a prospective study on safety feasibility and surgical settings

Robot-assisted surgery has transformed urology, but widespread adoption remains limited by the high cost, complex setup, and rigid system design. This prospective single-center study evaluates the safety and efficacy of the novel modular Carina in 19 upper and lower urinary tract surgeries. All cases were completed robotically without conversion, with one major complication. For partial nephrectomy (PN), median operative time (OT) was 120 min with 50 mL estimated blood loss (EBL), including one off-clamp PN completed in 77 min (EBL: 50 mL). Pyeloplasty had a median OT of 105 min (EBL: 50 mL), while radical prostatectomy (RP) achieved a median OT of 150 min (EBL: 50 mL). Radical cystectomy was completed in 301 min without major complications, and an uncomplicated postoperative course. Median docking times were 5 and 8 min for upper and lower tract surgeries, with negative margins and preserved renal function in all PN, and social continence post-RP. The Carina system demonstrates procedural safety and feasibility in complex urological procedures. The modular design may enhance workflow and space utilization, suggesting the potential for promising tool and broader clinical applications. Further validation with larger sample sizes and long-term follow-up is needed.

Robotic-assisted partial nephrectomy using the HugoTM robotic-assisted surgery platform Initial experience and insights

INTRODUCTION

Robotic-assisted surgery (RAS) is a vital modality in the armamentarium of minimally invasive surgeons. The Hugo™ RAS system (Medtronic®) is one of the newest platforms on the market and has little surgical outcomes data. Herein, we describe our early experience performing robotic-assisted partial nephrectomy (RAPNx) with the Hugo™ RAS platform.

METHODS

We conducted a retrospective review of patients who underwent a RAPNx with the Hugo™ RAS platform between April and December 2023 at the University Health Network in Toronto, ON. One surgeon performed all procedures using a three-arm transperitoneal approach. Anesthetic, operative, and pathologic reports were assessed to collect pre-, intra- and postoperative variables.

RESULTS

Eleven patients were included. The mean age was 51 years, 45.0% were female, and 63.6% had a right-sided mass. Mean tumor size was 2.9 cm. Mean warm ischemia time was 18.9 minutes (standard deviation [SD] 7.12) and mean estimated blood loss was 179 ml (SD 63.6). Mean robot docking time was 232 seconds (SD 106.5), mean total console time was 93 minutes (SD 21.4), and mean total operative time was 165.6 minutes (SD 34.1). There were no intraoperative complications. On pathology review, most tumors were a clear-cell variant (72.7%) and staged pT1a (81.8%). All margins were negative. One patient sustained a port site infection.

CONCLUSIONS

This is the first North American case series using the Hugo™ RAS platform for RAPNx. Our findings underscore that the platform is safe and effective for performing RAPNx with comparable outcomes to other robotic platforms.

A Global Perspective on the Adoption of Different Robotic Platforms in Uro-Oncological Surgery

Robotic platforms have played a crucial role in minimally invasive surgery, especially for uro-oncological procedures. da Vinci robotic platforms have been the most widely adopted for more than two decades and remain the benchmark worldwide. However, access to robotic platforms varies widely across the globe, mainly because of high costs. More recent platforms, such as the Hugo RAS, KangDuo, and others, are lower-cost alternatives. We provide an overview of the distribution of robotic platforms for uro-oncological surgery across countries on the basis of published evidence. da Vinci robotic platforms remain the most widely adopted, with studies reported from 42 countries, followed by the Hugo RAS in 12 countries. Despite advances, many countries lack data, especially in Africa, South America, and parts of Asia, emphasizing the need for multidisciplinary collaboration, training, and policy initiatives. Recently approved novel platforms may contribute to expansion of access to robotic surgery in underserved regions. PATIENT SUMMARY: We reviewed the use of robotic systems for surgery for urological cancers around the globe. We found that the da Vinci system is the most widely used worldwide, but there is a gap in access to these robots in Africa, South America, and parts of Asia. New platforms that are less expensive could lead to wider use of robotic surgery in the future.

Validation of objective performance metrics via an intelligent medical network in gynecological oncology robotic surgery

BACKGROUND

Automated performance metrics (APMs) are potentially useful to accurately assess and improve surgeon skills and patient outcomes, while their clinical use is currently limited. We report on the use of the Medicaroid Intelligent Network System (MINS™), a network support system platform used together with the "hinotori" surgical robot system (hinotori™) for the collection of data logs from surgeries, and discuss its potential to improve surgical outcomes.

METHODS

This study prospectively evaluated the efficacy of MINS™ for collecting data logs in gynecologic oncologic robotic surgery between December 2022 and February 2024 in nine patients. MINS™ regularly communicated with the hinotori™ via a secure network to collect and send system logs to a cloud server, quantifying various performance data for the evaluation of surgical outcomes.

RESULTS

Clinical data on hinotori™ movement were successfully extracted. The number of operation arm (OA) changes was significantly higher in Patient No. 7, who underwent pelvic lymph node dissection. OA3 monopolar was used more frequently than OA1 bipolar for coagulation (mean: 6.7% vs 2.5%, P ˂0.001). The error count and percentage of inactive time associated with OA collisions decreased dramatically after Patient No. 6, following the version upgrade in July 2024.

CONCLUSION

MINS™ utilizes technology to connect the hinotori™ to various systems via the Internet, allowing objective evaluations of surgical procedures from data logs. MINS™ is a clinically applicable APM system that objectively analyzes a surgeon's individuality and has the potential to improve surgical techniques and promote standardization.

Feasibility evaluation of the Versius surgical system: robot-assisted hysterectomy for benign and malignant gynaecological lesions

INTRODUCTION

The application of minimally invasive surgery allows for radical and precise removal of the gynaecological lesion while simultaneously reducing the side effects and complications associated with surgical treatment. This paper aims to share our direct experience with the implementation of the CMR Versius robotic platform in the treatment of benign and malignant gynaecological lesions.

METHODS

This study included patients who underwent hysterectomy in the Department of Obstetrics, Gynaecology, and Gynaecologic Oncology at the Regional Polyclinical Hospital in Grudziadz, Poland. A total of 50 patients were included in the study: 29 underwent laparoscopic surgery and 21 underwent robot-assisted surgery using the CMR Versius system.

RESULTS

It was found that in the case of non-radical hysterectomy, the duration of surgery differed significantly (96.5 vs. 134.6 min, p < 0.01) in the groups of patients undergoing laparoscopic and robotic surgery. There were also no statistically significant differences in loss of blood parameters, rate of complications and conversions to other type of surgery after the laparoscopic and robotic surgeries. Both groups did not differ significantly in terms of hospitalisation time after surgery.

CONCLUSION

Versius CMR surgical robot assistance provides safe and effective support for MIS procedures in gynaecology.

Evaluating Postoperative Morbidity and Outcomes of Robotic-Assisted Esophagectomy in Esophageal Cancer Treatment-A Comprehensive Review on Behalf of TROGSS (The Robotic Global Surgical Society) and EFISDS (European Federation International Society for Digestive Surgery) Joint Working Group

BACKGROUND

Esophageal cancer, the seventh most common malignancy globally, requires esophagectomy for curative treatment. However, esophagectomy is associated with high postoperative morbidity and mortality, highlighting the need for minimally invasive approaches. Robotic-assisted surgery has emerged as a promising alternative to traditional open and minimally invasive esophagectomy (MIE), offering potential benefits in improving clinical and oncological outcomes. This review aims to assess the postoperative morbidity and outcomes of robotic surgery.

METHODS

A comprehensive review of the current literature was conducted, focusing on studies evaluating the role of robotic-assisted surgery in esophagectomy. Data were synthesized on the clinical outcomes, including postoperative complications, survival rates, and recovery time, as well as technological advancements in robotic surgery platforms. Studies comparing robotic-assisted esophagectomy with traditional approaches were analyzed to determine the potential advantages of robotic systems in improving surgical precision and patient outcomes.

RESULTS

Robotic-assisted esophagectomy (RAMIE) has shown significant improvements in clinical outcomes compared to open surgery and MIE, including reduced postoperative pain, less blood loss, and faster recovery. RAMIE offers enhanced thoracic access, with fewer complications than thoracotomy. The RACE technique has improved patient recovery and reduced morbidity. Fluorescence-guided technologies, including near-infrared fluorescence (NIRF), have proven valuable for sentinel node biopsy, lymphatic mapping, and angiography, helping identify critical structures and minimizing complications like anastomotic leakage and chylothorax. Despite these benefits, challenges such as the high cost of robotic systems and limited long-term data hinder broader adoption. Hybrid approaches, combining robotic and open techniques, remain common in clinical practice.

CONCLUSIONS

Robotic-assisted esophagectomy offers promising advantages, including enhanced precision, reduced complications, and faster recovery, but challenges related to cost, accessibility, and evidence gaps must be addressed. The hybrid approach remains a valuable option in select clinical scenarios. Continued research, including large-scale randomized controlled trials, is necessary to further establish the role of robotic surgery as the standard treatment for resectable esophageal cancer.

Open vs. Robot-Assisted Artificial Urinary Sphincter Implantation in Women with Stress Urinary Incontinence: A Multicenter Comparative Study

Background: The artificial urinary sphincter has been an effective treatment for stress urinary incontinence caused by intrinsic sphincter deficiency in women. However, the use of this device has been limited by the technical difficulties and risks associated with the open implantation procedure. Preliminary studies using robotic techniques have shown promising results, but only one small study has compared robotic to open procedures. This study aims to compare the outcomes of robotic and open artificial urinary sphincter implantation in women with stress urinary incontinence due to intrinsic sphincter deficiency in a large multicenter cohort. Methods: Data were collected retrospectively from female patients who underwent open or robot-assisted artificial urinary sphincter implantation from 2006 to 2020 at 12 urology departments. The primary outcome was the rate of complications within 30 days after surgery, graded using the Clavien-Dindo Classification. Perioperative and functional outcomes were compared between the two groups. Results: A total of 135 patients were included, with 71 in the robotic group and 64 in the open group. The open group had a higher rate of intraoperative complications (27.4% vs. 12.7%; p = 0.03) and postoperative complications (46.8% vs. 15.5%; p < 0.0001). More patients in the robotic group achieved full continence (83.3% vs. 62.3%; p = 0.01). The open group had higher explantation (27.4% vs. 1.4%; p < 0.0001) and revision rates (17.5% vs. 5.6%; p = 0.02). The estimated 1-year explantation-free survival rate was higher in the robotic group. (98.6% vs. 78.3%; p = 0.001). Conclusions: Robot-assisted implantation may reduce perioperative morbidity and improve functional outcomes compared to open implantation in women with stress urinary incontinence.

Robotic-assisted surgery for the treatment of urologic cancers: recent advances

INTRODUCTION

Recent advancements in single-port surgery, robotic platforms, 3D models and artificial intelligence have transformed surgical procedures, especially in urology. These innovations enhance precision, safety, and efficacy, reducing invasiveness and recovery times. The review focuses on the latest in robotic-assisted surgery for genitourinary cancers, highlighting the shift toward personalized, minimally invasive treatments.

AREAS COVERED

A bibliographic search across PubMed, Scopus, and EMBASE databases focused on the last four years of innovations in robotic surgery for urologic tumors. The review highlights the use of the Da Vinci Single Port robotic system, available robotic platforms worldwide, advancements in 3D virtual models, artificial intelligence in robotic surgery and the application of molecular imaging for assessing primary lymph nodes and treating lymph node metastases and local recurrences in prostate cancer.

EXPERT OPINION

The integration of single-port surgery, new robotic platforms, 3D models and artificial intelligence in urological oncology promises transformative impacts on diagnosis, treatment and cost-effectiveness. Despite benefits like enhanced precision and expanded surgical access, challenges such as high costs, training needs, and technological integration barriers persist. Collaboration and further research are critical to optimize outcomes, improve safety protocols, and ensure equitable global access to these innovations.

Outcomes of da Vinci® versus Hugo RAS® radical prostatectomy: focus on postoperative course, pathological findings, and patients' health-related quality of life after 100 consecutive cases (the COMPAR-P prospective trial)

BACKGROUND

This study aims to prospectively compare the outcomes of robot-assisted radical prostatectomy (RARP) performed using the Hugo RAS and da Vinci Xi systems, focusing on the postoperative course, pathological findings, and health-related quality of life.

METHODS

The COMPAR-P trial, a prospective post-market study (clinical-trials.org NCT05766163), commenced in March 2023, enrolling patients for RARP performed with either da Vinci or Hugo RAS without selection criteria for up to 50 consecutive cases per system. Two experienced console surgeons performed the procedures according to a standardized technique. The study evaluated differences between da Vinci and Hugo RAS regarding the postoperative course, pathology findings, 30-day PSA value, functional metrics, and health-related quality of life using SF-36 and University of California Los Angeles Prostate Cancer Index questionnaires.

RESULTS

Fifty patients underwent DV-RARP and H-RARP each. Postoperative complications, pathological data, and quality of life metrics did not significantly differ between the groups. Noteworthy limitations include the comparison between the first 50 H-RARP and last 50 DV-RARP cases, as well as the potential influence of surgeons' specialized expertise on the generalizability of findings.

CONCLUSIONS

This prospective study of 100 unselected patients undergoing RARP with either da Vinci or Hugo RAS systems reveals comparable outcomes in postoperative course, pathology, functional metrics, and health-related quality of life. However, further research with larger sample sizes, longer follow-up periods, and diverse surgical expertise is essential to validate these findings and better understand the implications for clinical practice.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database

BACKGROUND

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions.

OBJECTIVE

The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU).

METHODS

Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models.

RESULTS

Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001).

CONCLUSIONS

Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Safety and feasibility of "three arms settings" robot-assisted radical prostatectomy using the Hugo RAS system: surgical set-up in a double-center large case series

PURPOSE

Robot-assisted laparoscopic radical prostatectomy (RARP) is the most common robotic procedures performed in urologic oncology. The Hugo Robot-Assisted Surgery (RAS) System (Medtronic, USA©) has recently been launched on the market and is characterized by the modularity of four different independent arm carts. The aim of this study is to describe and evaluate safety and feasibility of three-arms setting for RARP using the Hugo RAS™ System in a large case series.

METHODS

Between October 2022 and December 2023, a large case series of patients from two tertiary referral center who underwent RARP through HUGO™ RAS were prospectively enrolled. Informed written consent was obtained before the procedure and a three-arms setting was used in every case. Follow-up was scheduled according to EAU guidelines.

RESULTS

A total of 86 patients were included in this study and underwent RARP with Hugo™ RAS System. Median Console time time was 114 min (IQR, 75-150), median docking time 4 min (IQR, 3-5). Lymphadenectomy was successfully performed when indicated in 19 patients (22.1%). A vesicourethral anastomosis using the modified Van Velthoven technique was successfully achieved in all cases. No post-operative complications > Clavien II up to 30 post-operative days were reported. In all patients, catheter was removed on the 7th postoperative day.

CONCLUSION

We conducted the first large case series of RARP through the novel Hugo™ RAS System using a three-arms configuration. This innovative robotic platform showed an easily accessible docking system, providing excellent perioperative outcomes.

Evaluation of Clinical Research on Novel Multiport Robotic Platforms for Urological Surgery According to the IDEAL Framework: A Systematic Review of the Literature

Background and objective

Several novel multiport robotic systems have been developed and introduced in clinical practice after regulatory approval. The objective of this systematic review was to assess the evolution status of novel robotic platforms approved for clinical use in urological surgery according to the IDEAL framework.

Methods

A systematic review was conducted using the Medline and Scopus databases according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (CRD42024503227). Comparative or noncomparative studies reporting on any urological procedures performed with novel robotic platforms (Hugo RAS; Versius, KangDuo, Senhance, REVO-I, Avatera, Hinotori, Dexter, or Toumai) were selected and included in the analysis.

Key findings and limitations

Seventy-four eligible studies were included, of which 67 (90.5%) were noncomparative surgical series representing developmental or explorative studies according to the IDEAL criteria. Only one randomised controlled trial (comparing KangDuo vs da Vinci robot-assisted partial nephrectomy) was included. The trial showed comparable perioperative outcomes between the two robotic systems. Four studies assessed clinical outcomes for patients undergoing urological procedures using a REVO-I (1 study), Senhance (2 studies), or Hinotori (1 study) system in comparison to the same procedures performed using a da Vinci system. All studies revealed outcomes comparable to those with the da Vinci system. Limitations include the small sample size in all studies, and assessment of first-generation novel platforms versus the fourth-generation multiarm da Vinci system in most of the comparative studies.

Conclusions and clinical implications

A few poor-quality studies have compared the use of novel robotic platforms to da Vinci systems in urological surgery and demonstrated comparable results. Most studies can be classified as developmental or explorative, representing the initial steps of clinical research. Large multicentre series are needed to understand whether these novel robots could offer advantages beyond cost reductions over the da Vinci systems.

Patient summary

We reviewed research on new robotic systems for surgery in urology. Several studies have shown the feasibility and safety of these new robots during the most common procedures. Very few studies have assessed clinical outcomes with the new robots in comparison to the reference standard, which is a fourth-generation da Vinci robot. Large multicentre studies are needed to understand whether the new robots could offer advantages other than cost savings over the da Vinci robot.

Evaluation of the hinotori™ Surgical Robot System for accurate suturing in small cavities

The hinotori™ Surgical Robot System (hinotori™, Medicaroid, Kobe, Japan) is increasingly being utilized primarily in urology and adult surgery; however, data on its application in pediatric surgery are lacking. This preclinical study aimed to evaluate the limitations of this system for accurate suturing in small cavities designed for pediatric and neonatal applications. Two trained operators performed simple ligature sutures (easy task [ET]) and hepaticojejunostomy sutures (difficult task [DT]) within five differently sized boxes, ranging from 5123 to 125 mL. The suture time, number of internal and external instrument/instrument collisions, instrument/box collisions, and suture accuracy were evaluated. The suture accuracy was assessed using the A-Lap Mini endoscopic surgery skill assessment system. As a result, an increase in the number of collisions and extended suturing times were observed in boxes with volumes smaller than 215 mL. Despite these variations, there were no significant differences between the boxes, and all tasks were precisely performed in all boxes (p = 0.10 for the ET and p = 1.00 for the DT). These findings demonstrate the capability of the hinotori™ system to perform precise suturing techniques within tightly confined simulated neonatal cavities as small as 125 mL. To advance the integration of pediatric robotic surgery utilizing the hinotori™ system, additional trials comparing it with conventional laparoscopic and thoracoscopic techniques using pediatric and animal models are necessary to assess its clinical safety and applicability.

Cost analysis of new robotic competitors: a comparison of direct costs for initial hospital stay between Da Vinci and Hugo RAS for radical prostatectomy

Robotic surgery with Da Vinci has revolutionized the treatment of several diseases, including prostate cancer; nevertheless, costs remain the major drawback. Recently, new robotic platforms entered the market aiming to reduce costs and improve the access to robotic surgery. The aim of the study is to compare direct cost for initial hospital stay of radical prostatectomy performed with two different robotic systems, the Da Vinci and the new Hugo RAS system. This is a projection study that applies cost of robotic surgery, derived from a local tender, to the clinical course of robotic radical prostatectomy (RALP) performed with Da Vinci and Hugo RAS. The study was performed in a public referral center for robotic surgery equipped with both systems. The cost of robotic surgery from a local tender were considered and included rent, annual maintenance, and a per-procedure fee covering the setup of four robotic instruments. Those costs were applied to patients who underwent RALP with both systems since November 2022. The primary endpoint is to evaluate direct costs of initial hospital stay for Da Vinci and Hugo RAS, by considering equipment costs (as derived from the tender), and costs of theater and of hospitalization. The direct per-procedure cost is €2,246.31 for a Da Vinci procedure and €1995 for a Hugo RALP. In the local setting, Hugo RAS provides 11% of cost saving for RALP. By applying this per-procedure cost to our clinical data, the expenditure for the entire index hospitalization is € 6.7755,1 for Da Vinci and € 6.637,15 for Hugo RALP. The new Hugo RAS system is willing to reduce direct expenditures of robotic surgery for RALP; furthermore, it provides similar peri-operative outcomes compared to the Da Vinci. However, other drivers of costs should be taken into account, such as the duration of OR use-that is more than just console time and may depend on the facility's background and organization. Further variations in direct costs of robotic systems are related to caseload, local agreements and negotiations. Thus, cost comparison of new robotic platform still remains an ongoing issue.

Revolutionary Advances of Robotic Surgery in Urology Field

The advent of robotic surgery has significantly impacted various surgical fields, particularly urology, gynecology, general surgery, and cardiac surgery. While the da Vinci robotic platform has been predominant over the past two decades, recent years have witnessed the emergence of new robotic platforms in Japan, now actively used in clinical practice. Currently, the available systems in Japan, alongside the da Vinci, include the Hinotori, Senhance, Hugo Ras, and Saroa surgical systems. This review focuses on comparing the notable functions of each system in urologic surgery, emphasizing the areas in which they differ from the da Vinci robotic platform. The development of new robotic systems is ongoing, promising not only cost reductions but also the introduction of innovative devices and educational systems. Soft robotics, which constructs robotic devices using soft, adaptable materials, has the potential to become central to the next generation of robotic surgery. Moreover, the collaboration between Artificial Intelligence (AI) and robotic surgery significantly contributes to increasing efficiency, accuracy, and safety in the medical field, with more innovative applications expected in the future.

hinotoriTM vs. da Vinci®: propensity score-matched analysis of surgical outcomes of robot-assisted radical prostatectomy

hinotori™ is a recently developed surgical robot system. The present study aims to compare intraoperative and postoperative outcomes of robot-assisted radical prostatectomy (RARP) by the hinotori™ system compared with those of the longer-established da Vinci® system. This study includes 100 consecutive patients who underwent RARP by da Vinci® and 60 patients who underwent RARP by hinotori™. To minimize imbalances of patient demographics between the two groups, 1:1 propensity score-matching was performed, and 43 patients each were assigned to the da Vinci® and hinotori™ groups after matching. In the propensity score-matched cohort, we could not find significant differences in patient demographics between the two groups. Surgical outcomes, operative time, and console time in the hinotori™ group were significantly longer than those in the da Vinci® group. Meanwhile, we could not find significant differences in other outcomes between the two groups, such as estimated blood loss, intraoperative complications, major postoperative complications (Clavien-Dindo grade 3 or 4) or length of hospital stay after surgery. The rate of positive cancer margin in the hinotori™ group was higher than that in the da Vinci® group, but significant difference could not be found between the two groups. Moreover, we could not find significant differences in urinary continence rates after surgery between the da Vinci® and hinotori™ groups. Our results suggest that the hinotori™ surgical robot system could provide comparable surgical outcomes to that of the da Vinci® system for patients undergoing RARP.

A narrative review of the Medtronic Hugo RAS and technical comparison with the Intuitive da Vinci robotic surgical system

Medtronic launched the Hugo Robotic-Assisted Surgery (RAS) System in 2021, offering a modular alternative to the incumbent market leader in surgical robotics, the Intuitive da Vinci (dV) surgical system. A detailed technical review of the Hugo RAS was conducted to explore the strengths and weaknesses of this new robotic surgical system. Each component of the system-vision tower, arm cart, and surgeon console-was compared against the existing dV systems. The docking process, instrumentation, and external arm movement trajectories were analyzed. The modular Hugo RAS provides the possibility of operating using up to four arm carts. It has certain design features that are unique to itself, and others that have been implemented to address the shortcomings of the dV Si. While Medtronic's first-generation robot offers distinct advantages over the older Intuitive systems, the true test of its mettle will be its performance compared to the latest dV Xi.

Ergonomics in Urology: Current Landscape and Future Directions

Optimal ergonomics are essential to improving clinical performance and longevity among urologists, as poor ergonomics can contribute to work-related injury and physician burnout. While a majority of urologists experience muscular injury throughout their career, women and trainees are disproportionately affected. These disparities are exacerbated by the lack of formal ergonomics education within urologic training programs. This review provides an overview of practical approaches to optimize ergonomics across working environments for urologists and trainees. We highlight intraoperative techniques and novel devices which have been shown to reduce work-related injury, and we identify knowledge gaps to guide future areas of ergonomic research.

The use of Versius CMR for pelvic surgery: a multicentric analysis of surgical setup and early outcomes

INTRODUCTION

Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery.

METHODS

This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed.

RESULTS

A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures.

CONCLUSIONS

Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.

Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System

Minimally invasive surgery (MIS) in gynecology was introduced to achieve the same surgical objectives as traditional open surgery while minimizing trauma to surrounding tissues, reducing pain, accelerating recovery, and improving overall patient outcomes. Minimally invasive approaches, such as laparoscopic and robotic-assisted surgeries, have become the standard for many gynecological procedures. In this review, we aim to summarize the advantages and main limitations to a broader adoption of robotic-assisted surgery compared to laparoscopic surgeries in gynecology. We present a new surgical system, the Dexter Robotic System™ (Distalmotion, Switzerland), that facilitates the transition from laparoscopy expertise to robotic-assisted surgery.

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study

PURPOSE

To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model.

METHODS

Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated.

RESULTS

In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation.

CONCLUSIONS

Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction: initial experience with the novel avatera system

PURPOSE

This pilot study was designed to interpret the technically specific features of the avatera robotic system and present our initial experience with this novel platform in robot-assisted pyeloplasty (RAP).

METHODS

A single-center prospective study was conducted including all patients who underwent RAP with the avatera robotic system from June 2022 to October 2022 in our Department. Transperitoneal robot-assisted dismembered pyeloplasty was performed in all cases. The trocar placement and the surgical technique were similar in all patients. The successful completion of the procedures, operation time (including draping, docking and console time), decrease in hemoglobin postoperatively, and presence of any complications were the study's primary endpoints.

RESULTS

In total, nine patients underwent RAP using the avatera system. All procedures were successfully completed. The draping of the robotic unit was completed in a median time of 10 min (range 7-15), while the median docking time was 17 min (range 10-24). The median console time was 88 min (range 78-116) and no complications were noticed. The median hemoglobin drop was calculated to 0.7 g/dL (range 0.4-1). During the mean follow-up of 9.33 ± 2.78 months, no late postoperative complications were noticed.

CONCLUSION

The early outcomes of the use of the novel avatera system in RAP are presented. All operations were successfully completed with safety and efficacy, without complications or significant blood loss.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).