The Senhance™ surgical robotic system ("Senhance") for total hysterectomy in obese patients: a pilot study

Exploring robotic total hysterectomies: a multi-site experience with the Senhance Surgical System

Robotic-assisted surgery emerged as a technological advancement in the twentieth century, with gynaecology being a key adopter of this approach. The Senhance Surgical System has gained prominence for total hysterectomies from single-site experiences, but multi-site reporting are still lacking in present literature. This multi-site study, conducted at Klaipeda University Hospital and Academic Teaching Hospital Feldkirch, aimed to explore the safety and feasibility of total hysterectomies with the Senhance Surgical System. The study involved 295 cases, showcasing a well-established routine with minimal procedure times. The average age of the patients was 53.5 years (SD: 10.3 years), ranging from 18 to 80 years. The patients' BMI averaged 25.6 kg/m2 (SD: 6.2 kg/m2), ranging from a minimum of 17.7 kg/m2 to a maximum of 69.5 kg/m2. The duration of surgery varied between 30 and 215 min, with a median of 95 min (IQR: 81-116). The docking time was a median of 3 (IQR: 2-5) min and varied between 1.0 and 30.0 min, with a minimum to a maximum range of 1.0 to 122 min. Conversion (3 cases, 1%) and adverse events (6 cases, 2%) were infrequent. Additionally, robotic malfunctions were recorded minimally in 4,1% (12 cases) of the procedures, and pain on a 0-10 visual pain scale was reduced from mild [2.7 (± 1.2)] one day postoperative to minimal [0.9 (± 0.5)] at discharge. Overall, a great routine with the Senhance Surgical System proves good control and, thus, feasibility and safety. Therefore, the Senhance Surgical System is a viable option for total hysterectomy.

Multi-silicone bilateral soft physical twin as an alternative to traditional user interfaces for remote palpation: a comparative study

Teleoperated medical technologies are a fundamental part of the healthcare system. From telemedicine to remote surgery, they allow remote diagnosis and treatment. However, the absence of any interface able to effectively reproduce the sense of touch and interaction with the patient prevents the implementation of teleoperated systems for primary care examinations, such as palpation. In this paper, we propose the first reported case of a soft robotic bilateral physical twin for remote palpation. By creating an entirely soft interface that can be used both to control the robot and receive feedback, the proposed device allows the user to achieve remote palpation by simply palpating the soft physical twin. This is achieved through a compact design showcasing 9 pneumatic chambers and exploiting multi-silicone casting to minimize cross-noise and allow teleoperation. A comparative study has been run against a traditional setup, and both the control and feedback of the physical twin are carefully analyzed. Despite distributed tactile feedback not achieving the same performance as the visual map, the soft control and visual feedback combination showcases a 5.1% higher accuracy. Moreover, the bilateral soft physical twin results always in a less invasive procedure, with 41% lower mechanical work exchanged with the remote phantom.

The new surgical robot Hugo™ RAS for total hysterectomy: a pilot study

Background

With the rising popularity of robotic surgery, Hugo™ RAS is one of the newest surgical robotic platforms. Investigating the reliability of this tool is the first step toward validating its use in clinical practice; and presently there arelimited data available regarding this. The literature is constantly enriched with initial experiences, however no study has demonstrated the safety of this platform yet.

Objectives

This study aimed to investigate its reliability during total hysterectomy.

Materials and Methods

A series of 20 consecutive patients scheduled for minimally invasive total hysterectomy with or without salpingo-oophorectomy for benign disease or prophylactic surgery were selected to undergo surgery with Hugo™ RAS. Data regarding any malfunction or breakdown of the robotic system as well as intra- and post-operative complications were prospectively recorded.

Results

Fifteen of the twenty patients (75.0%) underwent surgery for benign uterine diseases, and five (25.0%) underwent prophylactic surgery. Among the entire series, an instrument fault occurred in one case (5.0%). The problem was solved in 4.8 minutes and without complications for the patient. The median total operative time was 127 min (range, 98-255 min). The median estimated blood loss was 50 mL (range:30-125 mL). No intraoperative complications were observed. One patient (5.0%) developed Clavien-Dindo grade 2 post-operative complication.

Conclusions

In this pilot study, Hugo™ RAS showed high reliability, similar to other robotic devices.

What is new?

Present findings suggest that Hugo™ RAS is a viable option for major surgical procedures and deserves further investigation in clinical practice.

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.

Introducing the New Surgical Robot HUGO™ RAS: System Description and Docking Settings for Gynecological Surgery

This study provides a detailed description of the new HUGO™ RAS System and suggests docking settings for gynecological surgery. The system is composed of an "open" surgical console with an HD-3D passive display, a system tower, and four arm carts. Each arm has an extremely wide range of adaptability resulting from the numerous joints. The human cadaver labs were performed at the ORSI Academy between August and December 2021. All procedures were performed by two surgical teams, each composed of a high-volume surgeon experienced in robotic surgery, gynecologic oncology, and pelvic sidewall surgery, and one bedside assistant. Three main gynecological surgical scenarios were identified: standard pelvic surgery, pelvic sidewall surgery, and para-aortic/upper abdominal surgery. Concerning the port placement, the chosen options were called "straight" and "bridge"; instead, the so-called "compact" and "butterfly" configurations were identified for the arm cart positioning. Four cadavers were used to perform total hysterectomy, radical hysterectomy, pelvic exenteration, pelvic and para-aortic lymphadenectomy, and omentectomy. We performed several tests, identifying the best system configurations to draw the proper efficiency from the flexibility of the system in all gynecological surgical scenarios. The straight port placement seems to be adequate for standard pelvic surgery. The bridge trocar position is best to reach the deeper and lateral anatomical regions of the female pelvis. The compact and butterfly arm cart allocations are adequate for both straight and bridge port placement. When deep pelvic surgery was performed, the bedside assistant became more proficient by working with a standard laparoscopic instrument from an ancillary port placed in the left iliac fossa. The arm carts needed to be moved in an open manner, like for the proposed butterfly configuration. On the contrary, the compact disposition left enough space to assist from Palmer's point port. Several basic and advanced gynecological surgical procedures were performed and completed successfully without encountering any technical or surgical issue, the results obtained were judged sufficient to proceed with the clinical experience in daily practice. The HUGO™ RAS system is flexible and highly performative in various surgical scenarios.

Update of Robotic Surgery in Benign Gynecological Pathology: Systematic Review

Background and Objectives: Since the Food and Drug Administration's (FDA) approval in 2005, the application of robotic surgery (RS) in gynecology has been adopted all over the world. This study aimed to provide an update on RS in benign gynecological pathology by reporting the scientific recommendations and high-value scientific literature available to date. Materials and Methods: A systematic review of the literature was performed. Prospective randomized clinical trials (RCT) and large retrospective trials were included in the present review. Results: Twenty-two studies were considered eligible for the review: eight studies regarding robotic myomectomy, five studies on robotic hysterectomy, five studies about RS in endometriosis treatment, and four studies on robotic pelvic organ prolapse (POP) treatment. Overall, 12 RCT and 10 retrospective studies were included in the analysis. In total 269,728 patients were enrolled, 1721 in the myomectomy group, 265,100 in the hysterectomy group, 1527 in the endometriosis surgical treatment group, and 1380 patients received treatment for POP. Conclusions: Currently, a minimally invasive approach is suggested in benign gynecological pathologies. According to the available evidence, RS has comparable clinical outcomes compared to laparoscopy (LPS). RS allowed a growing number of patients to gain access to MIS and benefit from a minimally invasive treatment, due to a flattened learning curve and enhanced dexterity and visualization.

Ultra-minimally invasive surgery in gynecological patients: a review of the literature

In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m²), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.

Potential Contenders for the Leadership in Robotic Surgery

Purpose: To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. Materials and Methods: A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci^® system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Results: Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I^®, Versius^®, and Senhance^® are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. Conclusions: The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.

Research progress and development trend of surgical robot and surgical instrument arm

BACKGROUND

In recent years, surgical robots have become an indispensable part of the medical field. Surgical robots are increasingly being used in the areas of gynaecological surgery, urological surgery, orthopaedic surgery, general surgery and so forth. In this paper, the development of surgical robots in different operations is reviewed and analysed. In the type of master-slave surgical robotic system, the robotic surgical instrument arms were located in the execution terminal of a surgical robot system, as one of the core components, and directly contact with the patient during the operation, which plays an important role in the efficiency and safety of the operation. In clinical, the arm function and design in different systems varies. Furtherly, the current research progress of robotic surgical instrument arms used in different operations is analysed and summarised. Finally, the challenge and trend are concluded.

METHODS

According to the classification of surgical types, the development of surgical robots for laparoscopic surgery, neurosurgery, orthopaedics and microsurgery are analysed and summarised. Then, focusing on the research of robotic surgical instrument arms, according to structure type, the research and application of straight-rod surgical instrument arm, joint surgical instrument arm and continuous surgical instrument arm are analysed respectively.

RESULTS

According to the discussion and summary of the characteristics of the existing surgical robots and instrument arms, it is concluded that they still have a lot of room for development in the future. Therefore, the development trends of the surgical robot and instrument arm are discussed and analysed in the five aspects of structural materials, modularisation, telemedicine, intelligence and human-machine collaboration.

CONCLUSION

Surgical robots have shown the development trend of miniaturisation, intelligence, autonomy and dexterity. Thereby, in the field of science and technology, the research on the next generation of minimally invasive surgical robots will usher in a peak period of development.

Robotic-assisted radical prostatectomy with the Senhance® robotic platform: single center experience

OBJECTIVE

To describe our institution's initial experience with robot-assisted radical prostatectomy (RARP) using the Senhance^® robotic system.

PATIENTS AND METHODS

A prospective analysis of 127 robot-assisted radical prostatectomies was performed. Patient demographics, preoperative and intraoperative parameters, histopathological examination results, intraoperative and early postoperative complications were obtained and analyzed.

RESULTS

The median patient age was 61.0 ± 6.36 (from 37 to 73) years, with a mean body mass index of 26.2 ± 3.79 kg/m². Of 127 patients, 16.5% (n = 21) underwent a pelvic lymph node dissection, 29.1% (n = 37) underwent one sided or bilateral nerve sparing. Post-operative extracapsular invasion (≥ pT3) was found in 15% (n = 19) of the cases and a Gleason score ≥ 7 in 74.8% of all patients. Our median operative time was 180 ± 41.98 min [interquartile range (IQR) 150-215], and median blood loss was 250 ± 236 (IQR 175-430) ml. Of 127 patients, 33.9% (n = 43) had positive margins, of them 28.7% in pT2 and 57.9% in pT3. Fifteen patients (11.8%) experienced complications, of them only three had Clavien-Dindo ≥ 3. Operation time decreased by about 60 min and estimated blood loss decreased by about 200 ml from the initial experience of each surgeon.

CONCLUSIONS

Robotic prostatectomy using a Senhance^® robotic system is feasible, and warrants further study to determine whether it can improve patient outcomes.

A Historical Review of Medical Robotic Platforms

This paper provides a brief history of medical robotic systems. Since the first use of robots in medical procedures, there have been countless companies competing to developed robotic systems in hopes to dominate a field. Many companies have succeeded, and many have failed. This review paper shows the timeline history of some of the old and most successful medical robots and new robotic systems. As the patents of the most successful system, i.e., Da Vinci® Surgical System, have expired or are expiring soon, this paper can provide some insights for new designers and manufacturers to explore new opportunities in this field.

The TransEnterix European Patient Registry for Robotic-Assisted Laparoscopic Procedures in Urology, Abdominal, Thoracic, and Gynecologic Surgery ("TRUST")

INTRODUCTION

Robotic surgery was first introduced in the mid-1980s, and at the end of the '90s, the da Vinci® System (Intuitive Surgical Inc., Sunnyvale, California) was introduced in Europe and held a monopoly for years afterward. In 2016, Senhance™ digital laparoscopic platform (TransEnterix Inc., Morrisville, North Carolina) came to the market. This new platform is based on laparoscopic movements and is designed for laparoscopic surgeons. This study shows the surgical outcomes of patients after different visceral, colorectal, gynecological, and urological surgical procedures done with the Senhance™ digital laparoscopic platform with a focus on safety.

MATERIALS AND METHODS

The study population consists of 871 patients who underwent robotic surgery with the Senhance™ platform. The most common procedures were hernia repairs (unilateral and bilateral), cholecystectomies, and prostatectomies. The procedures were performed in five centers in Europe between February 2017 and July 2020 by experienced laparoscopic surgeons.

RESULTS

220 (25.3 %) out of 871 patients had a unilateral hernia repair, 70 (8.0%) a bilateral hernia repair, 159 (18.3%) underwent a cholecystectomy, and 168 (19.3%) a prostatectomy. The other procedures included visceral, colorectal, and gynecological surgery procedures. The median docking time was 7.46 minutes for the four most common procedures. The duration of surgery varied from 32 to 313 minutes, the average time was 114.31 minutes. Adverse events were rare overall. There were 48 (5.5 %) adverse events out of 871 patients, 24 of them (2.8 % of all cases) were severe. Out of all 24 severe adverse events, five events (20.8%) were likely related to the robot, 17 events (70.8%) were unlikely related to the robot, and two events (8.3%) could not be categorized. Regarding complications following unilateral hernia repairs, data from 212 patients was available. Thirteen (6.1%) complications occurred, and six of those (2.8%) were serious. Out of 68 patients with a bilateral hernia repair, six patients (8.8%) developed complications, three of which were severe (4.4%). The complication rate was 2.8% in the patients following a cholecystectomy (4/144); two of them serious. After prostatectomy, six out of 141 patients (4.3 %) had complications; one serious (0.7%) No mortality was observed. Data about unplanned conversions to laparoscopic surgery could be collected from 761 patients which is a rate of 3.7%. There were 12 conversions out of 760 procedures to open surgery (1.6%).

CONCLUSIONS

Our series shows these procedures are safe and reproducible. The findings suggest that the surgical results after robotic surgery with the Senhance™ system are promising. Long-term data regarding complication rates should be the subject of future studies.

New development on hysteroscopy for endometrial cancer diagnosis: state of the art

Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.

Perioperative and long-term outcomes of robot-assisted versus laparoscopy-assisted hemicolectomy for left-sided colon cancers: a retrospective study

The objective of this study is to evaluate the perioperative and long-term outcomes of robot-assisted hemicolectomy (RAH) versus laparoscopy-assisted hemicolectomy (LAH) for left-sided colon cancers. Patients who underwent RAH and LAH from January 2012 to December 2018 were reviewed retrospectively. Patient characteristics and perioperative outcomes were compared between the two groups. Follow-up consultations were conducted to evaluate the long-term outcomes of these procedures. A total of 460 patients were included (RAH, n = 205; LAH, n = 255). There was no difference in patient characteristics between the two groups. Compared with the LAH group, the RAH group showed longer operative time (150.23 ± 43.77 min vs. 125.85 ± 38.67 min, p < 0.001) and higher surgery cost (6.33 ± 1.50 vs. 2.88 ± 0.72 thousand $, p < 0.001) and total hospital cost (14.97 ± 3.05 vs. 9.05 ± 2.31 thousand $, p < 0.001). No significant differences in tumor pathology, TNM staging, and perioperative outcomes were observed. There were no obvious differences in the 3-year and 5-year overall survival (OS) or 3-year and 5-year disease-free survival. Cox multivariate analyses showed that age, body mass index, and intravascular cancer embolus were independent risk factors for OS. Moreover, the robotic approach was not an independent risk factor for prognosis of left-sided colon cancers. RAH is an appropriate operation method for left-sided colon cancer, with perioperative and long-term outcomes comparable to those of laparoscopy. Meanwhile, RHA has longer operative time and higher cost.

An early experience with the Senhance surgical robotic system in colorectal surgery: a single-institute study

BACKGROUND

We present our initial single-centre experience with Senhance surgical robot-assisted colorectal surgery and examine its safety and feasibility.

METHODS

From June 2019 to December 2019, patients who underwent Senhance surgical robot-assisted colorectal surgery in our hospital were retrospectively analysed. We focused on the short-term outcomes.

RESULTS

In total, 46 patients were enrolled in the study. Colorectal cancer was the most common indication for surgery (39 patients). The median total operation time was 283 min, and the median blood loss was 50 cc. Meanwhile, the median number of harvested lymph nodes was 20. Elderly age, advanced American Society of Anaesthesiologists stage, and right-sided colon surgery were associated with the occurrence of complications greater than grade III.

CONCLUSION

Our findings demonstrate the feasibility and safety of the Senhance surgical robotic system in colorectal surgery. Care should be taken regarding the indications and patient selection.

Role of uterine manipulator during laparoscopic endometrial cancer treatment

Endometrial cancer (EC) is the most frequent gynecologic malignancy with 61,000 new cases diagnosed per year in the USA. Gynecologic Oncology Group (GOG) LAP2 randomized study demonstrated a superimposable 5-year overall survival between laparotomic and laparoscopic approaches in EC treatment. In this context the uterine manipulator (UM) represents a valuable tool in order to increase the ergonomics of surgical gesture during a laparoscopic total hysterectomy. Despite the proven safety of the minimally invasive approach in EC treatment, neither the indication whether to use or not, nor the recommendation concerning a specific type of UM are provided by international guidelines. This narrative review aims to collect all the main findings in the literature about UM use to investigate its safety in EC patients. Based on the analysis of the literature research, the main results were categorized into two manipulator-related problems: the iatrogenic LVSI, and the retrograde tumor spillage. LVSI is defined as the presence of tumor cells within an endothelium-lined space. An electronic search was performed using the following keywords: 'uterine manipulator', and 'endometrial cancer'. The electronic database search provided a total of 93 studies. Of whom, 12 case reports, 5 studies not in English language, and 65 works not fitting the review scope were excluded from the analysis. Eleven studies were considered eligible for the purpose of the study. The most recent studies have highlighted the safety of the uterine manipulator in the early-stage EC laparoscopic treatment. All types of manipulators are considered to be fairly safe but its application should be tailored according to tumor dimension and grade of myometrial infiltration.

Quality of life and sexual functioning of patient affected by endometrial cancer

INTRODUCTION

Thanks to timely diagnosis and medical advancement the number of endometrial cancer (EC) patients achieving long term survival is constantly increasing and here comes the necessity to move forward with the understanding of post-treatment sexual adjustment and with the strategies to enhance sexual functioning (SF) and quality of life (QoL) in this population. In this scenario we designed this study aiming to summarize and analyze the available scientific evidence regarding QoL and especially SF in patients affected by EC who underwent surgical and adjuvant treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and endometrial cancer. The main findings considered in the present review were: the study design, the number of patients included in each study, the information about pathology (histology and stage of disease), the questionnaires administered and the principal results concerning SF and QoL.

EVIDENCE SYNTHESIS

A total of thirteen studies, between 2009 and 2018, treating the aspects of SF and QoL in patients affected by EC were extracted. The principal findings of different studies were organized in the following sections: 1) overall SF in EC patients (reasons for sexual inactivity); 2) impact of EC on SF when compared to benign gynecological disease or healthy controls-focus on surgery; 3) minimally invasive surgery versus classical laparotomic approach and SF of EC patients; 4) surgery alone versus VBT versus EBRT and SF of EC patients; 5) focus on RT; 6) the mutual correlation between sociodemographic, relational, psychological, clinical/metabolic factors and the SF of EC patients.

CONCLUSIONS

Considering the widespread diffusion of female sexual dysfunction among EC patients and the relatively good prognosis, especially in early stage disease, it undoubtedly looms the need for proactive countermeasures to maximize the sexual well-being and QoL of these patients. A wide range of intervention in a multi-modal physical and mental perspective should be considered.

Percutaneous-assisted vs mini-laparoscopic hysterectomy: comparison of ultra-minimally invasive approaches

To assess the feasibility and the safety of the ultra-minimally invasive (U-MIS) approaches in gynecology, we compared our experience in percutaneous assisted hysterectomy (PSS-H) with a series of 3 mm mini-laparoscopy hysterectomy (m-LPS-H). 126 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive hysterectomy: 80 patients received PSS approach and 46 m-LPS approach. For both groups, we evaluated intra and perioperative outcomes, post-operative pain and cosmetic outcomes. The baseline characteristics were comparable between the two study groups. As well, no differences were reported in the clinical indications for hysterectomy, principally fibroids/adenomyosis, endometrial hyperplasia and early stage endometrial cancer. The median operative time was 88.5 (40-190) minutes for PSS-H group and 95.0 (42-231) minutes in m-LPS-H group (p = 0.131). No differences were detected in median estimated blood loss (p = 0.104) as well, in the uterine manipulator usage (p = 0.127) between the two different surgical approaches. Only 1 (2.2%) conversion to standard laparoscopy occurred in m-LPS-H group (p = 0.691). One intra-operative complication was recorded 1 (1.3%) in the PSS-H group (p = 0.367). The post-operative early complication was recorded in five cases of PSS-H group (p = 0.158), none for m-LPS-H procedures. The results in post-operative pain detection was statistically significant after 4 h in favor of m-LPS-H group (p = 0.001). After 30 days no differences in cosmetic satisfaction were detected between the two groups (p = 0.206). PSS-H and m-LPS-H are two valid U-MIS alternatives for benign gynecological conditions and low/intermediate risk endometrial cancer.

Novel virtual reality based training system for fine motor skills: Towards developing a robotic surgery training system

BACKGROUND

Training surgeons to use surgical robots are becoming part of surgical training curricula. We propose a novel method of training fine-motor skills such as Microscopic Selection Task (MST) for robot-assisted surgery using virtual reality (VR) with objective quantification of performance. We also introduce vibrotactile feedback (VTFB) to study its impact on training performance.

METHODS

We use a VR-based environment to perform MST with varying degrees of difficulties. Using a well-known human-computer interaction paradigm and incorporating VTFB, we quantify the performance: speed, precision and accuracy.

RESULTS

MST with VTFB showed statistically significant improvement in performance metrics leading to faster completion of MST with higher precision and accuracy compared to that without VTFB.

DISCUSSION

The addition of VTFB to VR-based training for robot-assisted surgeries may improve performance outcomes in real robotic surgery. VTFB, along with proposed performance metrics, can be used in training curricula for robot-assisted surgeries.

The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis

Since the first robotic single-site hysterectomy was performed, the research focused on the use of robotic single-site surgery (RSSS) for all gynecological conditions. This review aims to examine the studies available in the literature on RSSS in gynecology both for benign and malignant indications. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). All the articles were grouped into three sets based on the surgical indication (Group 1, 2, and 3 for benign, malignant, and mixed diseases, respectively). Two hundred and fifty total studies were analyzed, and 27 articles were included in the review. A total of 1065 patients were included in the analysis. Of these, 605 patients were included in group 1, 260 in group 2, and 200 in group 3. Ten (1.7%) patients with benign pathology, 16 (6.2%) patients with malignant disease, and 5 (2.5%) patients with both diseases developed major complications. Two (0.3%) patients in group 1, 3 (1.2%) patients in group 2 and 5 (2.5%) in group 3 were converted to a different type of surgery. No significant differences were found between groups for BMI (p = 0.235), operative time (p = 0.723), estimated blood loss (EBL) (p = 0.342), and hospital stay (p = 0.146). The complications and conversions incidence through pooled analysis showed a higher general conversion rate (p = 0.012) in group 3 (3.0%) and higher complications rate (p = 0.001) in group 2 (5.3%) compared to the other groups. RSSS seems to be a feasible and safe procedure for all gynecological surgical procedures. A long-term analysis would be necessary before considering the RSSS oncologically safe for patients with malignant disease.

Laparoscopic Robotic Surgery: Current Perspective and Future Directions

Just as laparoscopic surgery provided a giant leap in safety and recovery for patients over open surgery methods, robotic-assisted surgery (RAS) is doing the same to laparoscopic surgery. The first laparoscopic-RAS systems to be commercialized were the Intuitive Surgical, Inc. (Sunnyvale, CA, USA) da Vinci and the Computer Motion Zeus. These systems were similar in many aspects, which led to a patent dispute between the two companies. Before the dispute was settled in court, Intuitive Surgical bought Computer Motion, and thus owned critical patents for laparoscopic-RAS. Recently, the patents held by Intuitive Surgical have begun to expire, leading to many new laparoscopic-RAS systems being developed and entering the market. In this study, we review the newly commercialized and prototype laparoscopic-RAS systems. We compare the features of the imaging and display technology, surgeons console and patient cart of the reviewed RAS systems. We also briefly discuss the future directions of laparoscopic-RAS surgery. With new laparoscopic-RAS systems now commercially available we should see RAS being adopted more widely in surgical interventions and costs of procedures using RAS to decrease in the near future.

Initial Experience With a New Robotic Surgical System for Cholecystectomy

Background. Laparoscopic cholecystectomy has been the gold standard treatment for symptomatic cholelithiasis for more than 3 decades. Robotic techniques are gaining traction in surgery, and recently, the Senhance^™ robotic system was introduced. The system offers advantages over other robotic systems such as improved ergonomics, haptic feedback, eye tracking, and usability of standard laparoscopic trocars and reusable instruments. The Senhance was evaluated to understand the feasibility, benefits, and drawbacks of its use in cholecystectomy. Study Design. A prospectively maintained database of the first 20 patients undergoing cholecystectomy with the Senhance was reviewed at a single hospital. Data including operative time, console time, set up time, and adverse events were collected, with clinical outcome and operative time as primary outcome measures. A cohort of 20 patients having laparoscopic cholecystectomy performed by the same surgeon was used as a comparator group. Results. The 2 groups had comparable demographic data (age, sex, and body mass index). In the Senhance group, 19 of the 20 procedures (95%) were completed robotically. The median (interquartile range) total operating, docking, and console times were 86.5 (60.5-106.5), 11.5 (9-13), and 30.8 (23.5-35) minutes, respectively. In the laparoscopic group, the median (interquartile range) operating time was 31.5 (26-41) minutes. Postoperatively, only one patient had a surgical complication, namely a wound infection treated with antibiotics. Conclusion. Our results suggest that Senhance-assisted cholecystectomy is safe, feasible, and effective, but currently has longer operative times. Further prospective and randomized trials are required to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Robotic surgery using Senhance® robotic platform: single center experience with first 100 cases

Until recently, robotic surgery has been associated only with the da Vinci robotic system. A novel Senhance^® robotic system (TransEnterix Surgical Inc., Morrisville, NC, USA) was introduced almost 5 years ago. Published reports on experience using this robotic platform are very limited. We present a prospective analysis of the first 100 robotic surgeries in abdominal surgery, gynecology, and urology in Klaipeda University Hospital, Klaipeda, Lithuania. Out of 100 operated patients during the mentioned period, 49 were female and 51 men, age range 27-79 years, on an average 55 years. 39 underwent robotic abdominal surgical procedures, 31-urological, and 30 gynecological surgeries. Duration of surgery varied from 30 min to 6 h and 5 min, on an average 2 h 25 min. Almost half 49 (49%) were operated on for malignant diseases: prostate cancer-27, renal cell carcinoma-1, endometrial cancer-7, ovarian cancer-1, colorectal cancer-13 (7 colon and 6 rectum). In-hospital stay was on an average 4 days, range 1-15 days. There were 3 (3%) conversions: two to laparoscopy (both undergoing robotic radical prostatectomy) and one to open (undergoing total hysterectomy). 6 (6%) complications occurred during 30 postoperative days, 2 demanding surgery. According to the Clavien-Dido classification, they were grade II in 3, grade III a in 1 and grade III b in 2 cases. There was no mortality in this patient population. Our experience with different types of robotic surgeries allows us to state that the Senhance^® robotic system is feasible and safe in general surgery, gynecology, and urology, and wider implementation of this system worldwide is simply a question of time.

Sexual function and quality of life of patients affected by ovarian cancer

INTRODUCTION

The sexual function (SF) in patients affected by malignancies represents an important aspect influencing the quality of life (QoL). The most frequent symptoms reported are the decreased sexual desire, dyspareunia, and/or problems with arousal or achieving orgasm. The present study is aimed at analyzing the available scientific evidence regarding the QoL and especially SF of patients affected by ovarian cancer who underwent surgical and medical treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and ovarian cancer. The principal findings considered in the present review were: the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered and the principal findings concerning SF and QoL.

EVIDENCE SYNTESIS

The studies selected were 5 prospective series and 3 case control cross-sectional studies. The scores used were focused on SF, QOL, fatigue and psychological aspects. All studies reported a decreased SF and QOL. Different factors coexist in the influence on outcomes such as physical, hormonal, psychological, self body image, and mechanic outcomes.

CONCLUSIONS

SF represents a fundamental aspect strictly related with QoL. Patients with ovarian cancer (as well all oncological patients) experience a reduction in their SF after diagnosis of malignancy and they should receive adequate counseling regarding this aspect.

Primary debulking surgery vs. interval debulking surgery for advanced ovarian cancer: review of the literature and meta-analysis

INTRODUCTION

Epithelial ovarian cancer (EOC) is the seventh most common cancer among women in the world and the leading cause of death from gynecological malignancies. The standard treatment for advanced EOC consists of optimal primary debulking surgery (PDS) associated with an adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) have been proposed in the management of advanced EOC to increase the rate of complete citoreductive surgery and to reduce morbidity and mortality. This systematic review and meta-analysis is conducted to compare the oncologic and postoperative outcomes of NACT and IDS with PDS followed by chemotherapy in patients with ovarian cancer.

EVIDENCE ACQUISITION

We conducted a search on the electronic databases PubMed/Medline, Cochrane and Scopus. All randomized controlled trials, cohort and case-control studies comparing PDS and IDS in ovarian cancer published in English until 28 February 2019 were considered eligible.

EVIDENCE SYNTHESIS

Twenty studies were included in the systematic review. As regards the meta-analysis, only studies that allowed the data we needed to be extracted were included: five were included for the evaluation of overall survival (OS) and PFS and 9 for the evaluation of major postoperative complications and days of hospital stay.

CONCLUSIONS

From the meta-analysis of the current available literature, none of the two investigated procedures has proven to be superior in terms of OS and PFS in the treatment of advanced ovarian cancer. However surgical complexity and postoperative complications are reduced in the IDS group.

Management of postoperative chylous ascites after surgery for ovarian cancer: a single-institution experience

Postoperative chylous ascites is a rare complication from operative trauma to the cisterna chyli or lymphatic vessels in the retroperitoneum. In the present study, we aimed to identify the incidence of postoperative chylous ascites in patients treated for ovarian cancer and to describe its management. We retrospectively reviewed all patients submitted to surgery for ovarian cancer at our Institution from October 2016 to November 2018. We analyzed the clinicopathological features, including the primary tumor histology, stage, grade, surgical procedure, median number of harvested pelvic and para-aortic lymph nodes. We described our experience in the diagnosis and management of chylous ascites. Five hundred and forty-six patients were submitted to surgery for ovarian cancer and 298 patients received pelvic and/or para-aortic lymphadenectomy. Chylous ascites occurred in 8 patients with an incidence of 1.4% in the overall population and a 2.68% among patients receiving lymphadenectomy. All patients received total parenteral nutrition (TPN) with Olimel N4E 2000 mL (Baxter^®) and somatostatin therapy with 0.2 mL per 3 times/day for a median of 9 days (range 7-11). Median hospital stay was 15 days (range 7-16). All patients were successfully managed conservatively and none required surgical correction. Conservative management of chylous ascites with TPN, somatostatin and paracentisis is feasible and effective. These data should be confirmed by prospective multicentric studies.

Senhance robotic platform for gynecologic surgery: a review of literature

The advantages of endoscopic procedures are well demonstrated in various surgical procedures. In this field, the technological improvement has been significant. One of the most relevant was made by the introduction of robotic surgery that, thanks to the instruments articulation and the precision of movement, made possible to perform even the most complex procedures. The terms "Alf-X" OR "Senhance" OR "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. The principal findings considered in the present review were: the study design, the number of patients included in each study, operative time, estimated blood loss (EBL), conversion rate to standard laparoscopy (SLPS) or laparotomy (LPT), post-operative complications, post-operative hospital stay, and the possible advantages and disadvantages reported by the authors of the studies. A total of eight studies were considered eligible for the present review. The average operative time for TH reported was 110-140 min. In two case-control studies, the operative time was significantly prolonged (P < 0.05) for robotic procedures when compared with SLPS. The EBL was ≤ 100 ml in all studies. Whereas no statistically significant differences were shown in the two case-control studies in terms of conversion to LPT, all studies were in accordance with the post-operative hospital stay, reporting an average of 2 days for total hysterectomy and 1 day for adnexal surgery.

Updates in Urologic Robot Assisted Surgery

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.

Cytoreductive surgery followed by HIPEC repetition for secondary ovarian cancer recurrence

Secondary and tertiary cytoreductive surgery was associated with improved overall survival in platinum-sensitive recurrent ovarian cancer (ROC). Hyperthermic intraoperative intra-peritoneal chemotherapy (HIPEC) is considered an attractive method in the treatment of ROC to deliver chemotherapy with enhanced effect directly at the tumor site. However, another deserving aspect is the feasibility and the oncologic role of HIPEC repetition. Twelve patients affected by secondary ovarian cancer recurrence previously submitted to cytoreduction followed by HIPEC were enrolled for the present study to receive tertiary cytoreduction followed by HIPEC repetition. The median operative time, including time for HIPEC procedure, was 360 min (range 240-540). Average EBL was 325 ml (from 100 to 500 ml). The median hospital stay was of 5 days, from 4 to 10. Low-grade post operatory complications occurred in 2 patients (16.6%) and high-grade complication in 1 case (8.3%). Our study report encouraging data about safety of HIPEC repetition in ovarian cancer treatment.

The future of robotic surgery

How robotics could help shape the future of surgical care.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies using new hybrid CO2 system: preliminary experience in referral center

The most frequent peritoneal surface malignancies originate principally by gastric cancer, colorectal cancer and ovarian cancer. Apart from the origin, peritoneal carcinosis (PC) is considered a negative prognostic factor. The hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal malignancies is considered an attractive method to deliver chemotherapy with enhanced effect directly at the tumor site. The use of such loco-regional approach has proved to improve prognosis of peritoneal carcinomatosis from different origins. Recently, new devices are suitable for loco-regional intraperitoneal chemotherapy as Peritoneal Recirculation System (PRS-1.0 Combat) with CO₂ technology. This is a retrospective study with the aim to assess the perioperative outcomes using PRS. Seventeen patients were enrolled affected by colorectal or ovarian cancer. Complete cytoreduction (RT = 0) was achieved for all cases. Median operative time was 420 min (range: 335-665) and median drugs dose used for HIPEC was 137 mg/m2 (115-756). Median EBL was 200 ml (range 50-1000). Median post-operative hospital stay was 9 days (range: 4-24). Treatment-related early complications were recorded in 8 (47.0%) cases and were G1-G2 Major complications occurred in two (11.7%) cases. Considering our aim to test the PRS in different cases and in different pathologies, the results confirmed that the technique is feasible with good perioperative outcomes.

[Robots in urology-an analysis of current and future devices]

The monopoly of robotic surgical devices of the last 15 years will end in 2019 when key patents of Intuitive Surgical expire. Thus, we can expect an interesting competitive situation in the coming years. Based on personal experience with robot-assisted surgery since 2001, we conducted a search of the current literature together with a search of relevant patents in this field. Finally, we visited the websites of manufacturers of existing and future robotic surgical devices with possible applications in urology. Such devices have to prove that they meet the high-quality standard of the current Da Vinci series (SI, X, XI). For this purpose, we propose to classify the main features of the different devices, such as type of console (closed/open), arrangement of robotic arms (single/multiple carts/attached to operating room table), type of three-dimensional videosystem (by mirror/ocular/using polarizing glasses) or degrees of freedom (DOF) of end effectors (5 vs. 7 DOF). In the meantime, there are also robotic systems used in endourology: Avicenna Roboflex® and the AquaBeam® system for robot-assisted aquablation therapy of the prostate. While Roboflex® improves the ergonomics of flexible ureteroscopy-similar to the Da Vinci robot, AquaBeam® may for the first time eliminate the surgeon, who might only be needed to manage severe postoperative bleeding.

A novel HIPEC technique using hybrid CO2 recirculation system: intra-abdominal diffusion test in a porcine model

The role of loco-regional treatment of peritoneal carcinomatosis using intraperitoneal chemotherapy is still investigated. Actually, new technologies are suitable for these procedures, especially a new hybrid system using CO₂ called Peritoneal Recirculation System (PRS-1.0 Combat). A HIPEC procedure in a porcine model using the PRS system was conducted. The objective of experimentation was to assess the distribution of liquid inside the abdomen, by using methylene blue instead of chemotherapy. Moreover, we positioned six different thermal probes in different abdominal regions inside the abdomen to measure the temperature during procedure. During the procedure, all thermal probes recorded an average temperature of 41.5°. At the end of infusion, the abdomen was emptied and then opened; the tracer distribution was recorded. No technical problems were recorded during the procedure. Good distribution of tracer was recorded. More studies are needed to investigate better this new technology.

First Experiences with the New Senhance® Telerobotic System in Visceral Surgery

Until recently, robotic-assisted surgery has exclusively been connected to the name DaVinci®. In 2016, a second robotic system, the Senhance®, became available. To introduce the new robotic system into clinical routine, detailed team training and an integration program were useful. Within the first 6 months, 116 cases were performed with this system. The integration program intended to start with simple and well-standardized clinical cases. We chose inguinal hernia repair using the TAPP (transabdominal preperitoneal) technique as the starting procedure. Subsequently, we added upper gastrointestinal surgery and cholecystectomies, and colorectal procedures have since also been included. Initial experience with the Senhance system as the first installation in Germany shows that it is suitable for surgery in general and for visceral surgery in particular. The application is safe due to the unproblematically quick changeover to normal laparoscopy and easy to integrate due to the very short system integration times (docking times). Since it is a laparoscopic-based system, following an integration program will enable experienced laparoscopic surgeons to very quickly manage more complex procedures. Due to lower costs, introducing robotic surgery starting with simple and standardized procedures is more feasible. After the establishment of this second robotic system, future studies will have to specifically look at differences in surgical results and basic conditions of different robotic-assisted systems. This paper documents the decision-making process of a hospital towards the integration of a robotic system and the selection criteria used while also demonstrating the planning and execution process during the introduction of the system into clinical routine.