Market potentials of robotic systems in medical science: analysis of the Avatera robotic system

Comparison between DaVinci® and Hugo™-RAS Roux-en-Y Gastric Bypass in bariatric surgery

The application of a robotic platform in the bariatric surgical field is intended to enhance the already established advantages of minimally invasive surgery in terms of both technical and clinical outcomes. These advantages are especially relevant for technically challenging multiquadrant operations such as Roux-en-Y Gastric Bypass (RYGB). Consequently, robotic-assisted surgery has emerged as a possible application for bariatric surgeries. The study attempts to assess feasibility and safety of the Hugo™-Robotic-Assisted Surgery System (Hugo™-RAS) platform compared to the DaVinci® Surgical System (DaVinci®-SS) with a focus on complication rates and operative times. We retrospectively reviewed bariatric procedures performed from January 2013 until December 2023. We included all robotic RYGBs performed using Hugo™-RAS and DaVinci®-SS platforms. The study utilized Propensity Score Matching (PSM) analysis to address bias in selection, matching patients based on age, gender, body mass index, comorbidities and past abdominal operations. One hundred thirty-five patients were identified: 90 DaVinci®-SS and 45 Hugo™-RAS procedures. After PSM, each group consisted of 45 patients. There was no discernible disparity observed in relation to early (≤ 30 days) postoperative complications rate (p = 1), mean operative time (for docking time, console time and total operative time: p = 0.176, p = 0.678, p = 0.229, respectively) and postoperative hospital stay (p = 0.052) between DaVinci®-RSS and Hugo™-RAS procedures. Our results suggest that application of both Hugo™-RAS and DaVinci®-SS robotic platforms to RYGB is related to comparable safety profiles. Although DaVinci®-SS remains the most widely adopted platform in clinical practice, this study underscores the potential role of the Hugo™-RAS to provide effective solutions in robotic bariatric procedures.

Robot-assisted radical prostatectomy using the avatera system™: a prospective pilot study

BACKGROUND

Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy.

METHODS

A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place.

RESULTS

The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse.

CONCLUSIONS

All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

Evaluation status of current and emerging minimally invasive robotic surgical platforms

BACKGROUND

The rapid adoption of robotics within minimally invasive surgical specialties has also seen an explosion of new technology including multi- and single port, natural orifice transluminal endoscopic surgery (NOTES), endoluminal and "on-demand" platforms. This review aims to evaluate the validation status of current and emerging MIS robotic platforms, using the IDEAL Framework.

METHODS

A scoping review exploring robotic minimally invasive surgical devices, technology and systems in use or being developed was performed, including general surgery, gynaecology, urology and cardiothoracics. Systems operating purely outside the abdomen or thorax and endoluminal or natural orifice platforms were excluded. PubMed, Google Scholar, journal reports and information from the public domain were collected. Each company was approached via email for a virtual interview to discover more about the systems and to quality check data. The IDEAL Framework is an internationally accepted tool to evaluate novel surgical technology, consisting of four stages: idea, development/exploration, assessment, and surveillance. An IDEAL stage, synonymous with validation status in this review, was assigned by reviewing the published literature.

RESULTS

21 companies with 23 different robotic platforms were identified for data collection, 13 with national and/or international regulatory approval. Of the 17 multiport systems, 1 is fully evaluated at stage 4, 2 are stage 3, 6 stage 2b, 2 at stage 2a, 2 stage 1, and 4 at the pre-IDEAL stage 0. Of the 6 single-port systems none have been fully evaluated with 1 at stage 3, 3 at stage 1 and 2 at stage 0.

CONCLUSIONS

The majority of existing robotic platforms are currently at the preclinical to developmental and exploratory stage of evaluation. Using the IDEAL framework will ensure that emerging robotic platforms are fully evaluated with long-term data, to inform the surgical workforce and ensure patient safety.

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.

Soft tissue surgical robot for minimally invasive surgery: a review

Purpose

The current state of soft tissue surgery robots is surveyed, and the key technologies underlying their success are analyzed. State-of-the-art technologies are introduced, and future directions are discussed.

Methods

Relevant literature is explored, analyzed, and summarized.

Results

Soft tissue surgical robots had rapidly spread in the field of laparoscopic surgery based on the multi-degree-of-freedom movement of intra-abdominal surgical tools and stereoscopic imaging that are not possible in conventional surgery. The three key technologies that have made surgical robots successful are wire-driven mechanisms for multi-degree-of-freedom movement, master devices for intuitive remote control, and stereoscopic imaging technology. Recently, human-robot interaction technologies have been applied to develop user interfaces such as vision assistance and haptic feedback, and research on autonomous surgery has begun.

Conclusion

Robotic surgery not only replaces conventional laparoscopic surgery but also allows for complex surgeries that are not possible with laparoscopic surgery. On the other hand, it is also criticized for its high cost and lack of clinical superiority or patient benefit compared to conventional laparoscopic surgery. As various robots compete in the market, the cost of surgical robots is expected to decrease. Surgical robots are expected to continue to evolve in the future due to the need to reduce the workload of medical staff and improve the level of care demanded by patients.

Robot-assisted oncologic pelvic surgery with Hugo™ robot-assisted surgery system: A single-center experience

Objective

To report the outcomes of intra- and extra-peritoneal robot-assisted radical prostatectomy (RARP) and robot-assisted radical cystectomy (RARC) with Hugo™ robot-assisted surgery (RAS) system (Medtronic, Minneapolis, MN, USA).

Methods

Data of twenty patients who underwent RARP and one RARC at our institution between February 2022 and January 2023 were reported. The primary endpoint of the study was to report the surgical setting of Hugo™ RAS system to perform RARP and RARC. The secondary endpoint was to assess the feasibility of RARP and RARC with this novel robotic platform and report the outcomes.

Results

Seventeen patients underwent RARP with a transperitoneal approach, and three with an extraperitoneal approach; and one patient underwent RARC with intracorporeal ileal conduit. No intraoperative complications occurred. Median docking and console time were 12 (interquartile range [IQR] 7-16) min and 185 (IQR 177-192) min for transperitoneal RARP, 15 (IQR 12-17) min and 170 (IQR 162-185) min for extraperitoneal RARP. No intraoperative complications occurred. One patient submitted to extraperitoneal RARP had a urinary tract infection in the postoperative period that required an antibiotic treatment (Clavien-Dindo Grade 2). In case of transperitoneal RARP, two minor complications occurred (one pelvic hematoma and one urinary tract infection; both Clavien-Dindo Grade 2).

Conclusion

Hugo™ RAS system is a novel promising robotic platform that allows to perform major oncological pelvic surgery. We showed the feasibility of RARP both intra- and extra-peritoneally and RARC with intracorporeal ileal conduit with this novel platform.

Robotic surgery in obstetrics and gynecology: a bibliometric study

We aimed to identify the trends and patterns of robotic surgery research in obstetrics and gynecology since its implementation. We used data from Clarivate's Web of Science platform to identify all articles published on robotic surgery in obstetrics and gynecology. A total of 838 publications were included in the analysis. Of these, 485 (57.9%) were from North America and 281 (26.0%) from Europe. 788 (94.0%) articles originated in high-income countries and none from low-income countries. The number of publications per year reached a peak of 69 articles in 2014. The subject of 344 (41.1%) of articles was gynecologic oncology, followed by benign gynecology (n = 176, 21.0%) and urogynecology (n = 156, 18.6%). Articles discussing gynecologic oncology had lower representation in low- and middle-income countries (LMIC) (32.0% vs. 41.6%, p < 0.001) compared with high income countries. After 2015 there has been a higher representation of publications from Asia (19.7% vs. 7.7%) and from LMIC (8.4% vs. 2.6%), compared to the preceding years. In a multivariable regression analysis, journal's impact factor [aOR 95% CI 1.30 (1.16-1.41)], gynecologic oncology subject [aOR 95% CI 1.73 (1.06-2.81)] and randomized controlled trials [aOR 95% CI 3.67 (1.47-9.16)] were associated with higher number of citations per year. In conclusion, robotic surgery research in obstetrics & gynecology is dominated by research in gynecologic oncology and reached a peak nearly a decade ago. The disparity in the quantity and quality of robotic research between high income countries and LMIC raises concerns regarding the access of the latter to high quality healthcare resources such as robotic surgery.

Last Resort from Nursing Shortage? Comparative Cost Analysis of Open vs. Robot-Assisted Partial Nephrectomies with a Focus on the Costs of Nursing Care

Despite perioperative advantages, robot-assisted surgery is associated with high costs. However, the lower morbidity of robotic surgery could lead to a lower nursing workload and cost savings. In this comparative cost analysis of open retroperitoneal versus robot-assisted transperitoneal partial nephrectomies (PN), these possible cost savings, including other cost factors, were quantified. Therefore, patient, tumor characteristics, and surgical results of all PN within two years at a tertiary referral center were retrospectively analyzed. The nursing effort was quantified by the local nursing staff regulation and INPULS^® intensive care and performance-recording system. Out of 259 procedures, 76.4% were performed robotically. After propensity score matching, the median total nursing time (2407.8 vs. 1126.8 min, p < 0.001) and daily nursing effort (245.7 vs. 222.6 min, p = 0.025) were significantly lower after robotic surgery. This resulted in mean savings of EUR 186.48 in nursing costs per robotic case, in addition to savings of EUR 61.76 due to less frequent administrations of erythrocyte concentrates. These savings did not amortize the higher material costs for the robotic system, causing additional expenses of EUR 1311.98 per case. To conclude, the nursing effort after a robotic partial nephrectomy was significantly lower compared to open surgery; however, this previously unnoticed savings mechanism alone could not amortize the overall increased costs.

User interfaces for actuated scope maneuvering in surgical systems: a scoping review

Background

A variety of human computer interfaces are used by robotic surgical systems to control and actuate camera scopes during minimally invasive surgery. The purpose of this review is to examine the different user interfaces used in both commercial systems and research prototypes.

Methods

A comprehensive scoping review of scientific literature was conducted using PubMed and IEEE Xplore databases to identify user interfaces used in commercial products and research prototypes of robotic surgical systems and robotic scope holders. Papers related to actuated scopes with human–computer interfaces were included. Several aspects of user interfaces for scope manipulation in commercial and research systems were reviewed.

Results

Scope assistance was classified into robotic surgical systems (for multiple port, single port, and natural orifice) and robotic scope holders (for rigid, articulated, and flexible endoscopes). Benefits and drawbacks of control by different user interfaces such as foot, hand, voice, head, eye, and tool tracking were outlined. In the review, it was observed that hand control, with its familiarity and intuitiveness, is the most used interface in commercially available systems. Control by foot, head tracking, and tool tracking are increasingly used to address limitations, such as interruptions to surgical workflow, caused by using a hand interface.

Conclusion

Integrating a combination of different user interfaces for scope manipulation may provide maximum benefit for the surgeons. However, smooth transition between interfaces might pose a challenge while combining controls.

Robot-Assisted Radical Nephrectomy Using the Novel Avatera Robotic Surgical System: A Feasibility Study in a Porcine Model

Purpose: To evaluate the feasibility and intraoperative technical parameters of the new robot-assisted surgical system Avatera by performing bilateral nephrectomy in a live porcine model. Materials and Methods: Six pigs underwent bilateral robot-assisted radical nephrectomy using the Avatera robotic system (RS). The operations were performed by experienced open (Group 1) and laparoscopic (Group 2) surgeons. The operating time, docking time, set-up time, and console time were evaluated. Data regarding intraoperative complications (major or not), injury of adjacent organs, and technical difficulties during the operation were also recorded. Results: Robot-assisted bilateral nephrectomy was completed effectively in all sample pigs. The docking time and set-up time were similar among the two groups, whereas the console time and operating time were significantly longer for the open surgeon group. Two intraoperative minor complications occurred in the open surgeon's group. An inadvertent damage of the renal vein occurred in two cases and the bleeding was controlled effectively. Other than the initial two cases, the estimated blood loss was <50 mL in both groups. Injury of the adjacent organs was not noticed. Conclusions: The study demonstrated that radical nephrectomy using the Avatera robotic surgical system is technically feasible, safe, and valid in pigs. Our results warrant the application of the Avatera RS in other urologic procedures, collecting data for further clinical trials.

Initial experience of robot-assisted partial nephrectomy with Hugo™ RAS system: implications for surgical setting

PURPOSE

Hugo™ RAS system is one of the most promising new robotic platforms introduced in the field of urology. To date, no data have been provided on robot-assisted partial nephrectomy (RAPN) performed with Hugo™ RAS system. The aim of the study is to describe the setting and report the performance of the first series of RAPN performed with Hugo™ RAS system.

METHODS

Ten consecutive patients who underwent RAPN at our Institution between February and December 2022 were prospectively enrolled. All RAPN were performed transperitoneally with a modular four-arm configuration. The main outcome was to describe the operative room setting, trocar placement and the performance of this novel robotic platform. Pre, intra and post-operative, variables were recorded. A descriptive analysis was performed.

RESULTS

Seven patients underwent RAPN for right-side and three for left-side masses. Median tumor size and PADUA score were 3 (2.2-3.7) cm and 9 (8-9), respectively. Median docking and console time were 9.5 (9-14) and 138 (124-162) minutes, respectively. Median warm ischemia time was 13 (10-14) minutes, and one case was performed clamp-less. Median estimated blood loss was 90 (75-100) mL. One major complication (Clavien-Dindo 3a) occurred. No case of positive surgical margin was recorded.

CONCLUSION

This is the first series to prove the feasibility of Hugo™ RAS system in the setting of RAPN. These preliminary results may help new adopters of this surgical platform to identify critical steps of robotic surgery with this platform and explore solutions before in-vivo surgery.

The feasibility of robot-assisted radical cystectomy: an experimental study

PURPOSE

To investigate the feasibility of the avatera system for performing robot-assisted radical cystectomy (RARC) followed by intracorporeal reconstruction of ileal neobladder.

METHODS

Six anesthetized female pigs were used to perform RARC and formation of the intracorporeal orthotopic ileal neobladder. Three surgeons with different level of expertise in the use of robotic systems performed RARC after a short instructional lecture and a 2-h hands-on training. The urinary diversion phase was performed only by the experienced surgeon. The successful completion of the procedure, operative time for demolitive and reconstructive phases, intraoperative blood loss and malfunction of the robotic system were evaluated.

RESULTS

An improvement of the operative time was observed for each surgeon. The experienced surgeon, the fellow and the resident improved their time by 11, 15, and 22 min, respectively, between the first and the second RARC performed. The most significant time difference was demonstrated by the resident, who had no previous experience in using robotic systems. The time difference between the first and the last orthotopic ileal neobladder creation for the experienced surgeon was 51 min.

CONCLUSION

The feasibility of avatera system for performing complex surgical procedure such as RARC with intracorporeal neobladder formation was demonstrated by this experimental study. No major bleeding or severe malfunctions were observed during the procedures. Significant improvement in operative time was demonstrated with the increasing experience from 1st to 6th case.

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

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

Technological Advancements in Uterus Transplantation

Uterus transplantation is barely a decade old and in a young, evolving field it is hard to identify "technological advances" since it is, in of itself, a technological advance. Nonetheless, one can still identify advances in diagnostic imaging that have improved donor screening to avoid graft losses, highlight the adoption of robotic surgery to make the living donor uterus procurement more minimally invasive, and look to a future of biotechnology like perfusion pumps and bioengineering such as synthetic uterus to increase donor supply. Additional technologies are on the horizon and promise to shape the field further.