Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: surgical technique and results of the first human trial

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.

Robot-assisted Radical Prostatectomy with the KangDuo Surgical System Versus the da Vinci Si System: A Prospective, Double-center, Randomized Controlled Trial

BACKGROUND

The KangDuo Surgical Robot (KD-SR) is a newly developed surgical robot.

OBJECTIVE

To compare the safety and efficacy of robot-assisted radical prostatectomy (RARP) using the KD-SR with those of the da Vinci Si Surgical System (DV-SS-Si).

DESIGN, SETTING, AND PARTICIPANTS

A prospective double-center noninferiority randomized controlled trial was conducted among 18-75-yr-old patients with suspected T1-2N0M0 prostate cancer (PCa) scheduled for RARP.

INTERVENTION

RARP with the KD-SR (KD-RARP) versus RARP with the DV-SS-Si (DV-RARP).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was surgical success, defined as follows: surgery can be performed according to the established protocol, without switching to other surgical modalities, and without secondary surgery due to surgical complications after surgery. The secondary outcome was short-term functional and oncological outcomes. The noninferiority threshold was set at 10%.

RESULTS AND LIMITATIONS

Eighty patients were enrolled, while the full analysis set finally included 79 patients (40 with KD-RARP and 39 with DV-RARP). The success rate was 100% in both groups. We could not find differences in urinary continence rate at 1, 2, 3, and 4 wk after catheter removal between the groups (p > 0.05). The rate of Clavien-Dindo grade II adverse events was 20% in the KD-RARP group and 17.9% in the DV-RARP group (p = 0.82), and no grade ≥III adverse events occurred. The median operation time was significantly longer in the KD-RARP group than in the DV-RARP group (177.5 vs 145 min, p = 0.012). The main limitations were the short follow-up period and that survival was not considered as the primary outcome.

CONCLUSIONS

The KD-SR is a viable option for RARP, with acceptable short-term outcomes compared with the DV-SS-Si for T1-2 PCa.

PATIENT SUMMARY

This is the first prospective randomized controlled trial to compare the KangDuo Surgical Robot (KD-SR) versus the da Vinci Si Surgical System (DV-SS-Si) for robot-assisted radical prostatectomy, which determines that the KD-SR is noninferior to the DV-SS-Si regarding safety and efficacy for T1-T2 prostate cancer.

Suitability of the MP1000 Platform for Robot-assisted Prostatectomy: A Prospective Randomised Controlled Trial

Background and objective

Robot-assisted radical prostatectomy (RARP) is widely used because of the many advantages of a robotic approach. The da Vinci Si robot is one of the most commonly used surgical robot systems, but it may be associated with higher costs owing to the use of consumable surgical supplies. Our aim was to conduct a preliminary investigation of the capability of the MP1000 system for RARP.

Methods

In this prospective, multicentre, single-blinded study, we randomly assigned 42 patients scheduled to undergo RARP between April and September 2021 to a da Vinci Si group (control) or an MP1000 group (intervention). Patients underwent RARP performed using the assigned robotic system and were followed up at 3-mo intervals. The primary outcome was the rate of conversion to open/laparoscopic surgery. Secondary outcomes were installation and operation times, intraoperative blood loss, postoperative surgical margin status, hospital stay, incontinence, complications, safety indicators, and surgeon ergonomics.

Key findings and limitations

All procedures were successfully completed without conversion to open/laparascopic surgery or major complications. Secondary outcomes, including oncological and ergonomic indicators, did not differ significantly between the groups over the study period. One patient in the control group experienced dysuria (Clavien-Dindo grade 3). No patients had incontinence at 3 mo. A limitation of the study is the small sample size.

Conclusions and clinical implications

RARP with the MP1000 system is feasible, safe, and effective in the management of localised prostate cancer.

Patient summary

We assessed the effectiveness and safety of the new MP1000 robot system for robot-assisted removal of the prostate in comparison to the da Vinci Si robot. We found no difference in effectiveness or safety among 42 patients with prostate cancer who were assigned randomly to one of the two systems. We conclude that the MP1000 is a suitable robot for this surgery.

Suitability of the MP1000 system for robot-assisted partial nephrectomy: a multicenter randomized controlled noninferiority trial

PURPOSE

This study aimed to compare the safety and effectiveness of the MP1000 surgical system with the da Vinci Si robot system in robot-assisted partial nephrectomy (RAPN) through a prospective, single-blinded, randomized controlled trial.

MATERIALS AND METHODS

A total of 62 patients who were scheduled to undergo RAPN were randomly assigned to either the da Vinci Si robot or MP1000 group. A noninferiority test was conducted with a noninferior intermediate value of 10%. The study compared installation and operation times, estimated blood loss, warm ischemia time, postoperative surgical margin, rate of conversion to open surgery, eGFR level, complications, and other safety indicators between the two groups.

RESULTS

All procedures were successfully completed without the need for conversion to open or laparoscopic surgery, and no major complications were observed during the process. The test of noninferiority was achieved. There were no significant differences in median installation time, operation time, complication rate at 3 months, rate of positive surgical margin, and eGFR level at 3 months between the groups. Additionally, no evidence of recurrence was found on imaging in both groups. No difference in National Aeronautics and Space Administration task load index results for ergonomic considerations. A limitation of this study was its small sample size.

CONCLUSIONS

The MP1000 system is a suitable platform for RAPN with safety and effectiveness compared with da Vinci Si system.

Robotic colorectal surgery and future directions

As the adoption of robotic-assisted procedures expands across various surgical specialties, colorectal surgery stands out as a prominent beneficiary. This rise in usage can be traced back to the increased accessibility of robotic platforms and a growing institutional shift towards cutting-edge surgical methods. When compared with traditional laparoscopic methods, robotic techniques offer distinct advantages. Their true potential shines in surgeries involving complex anatomical regions, where the robot's enhanced dexterity and range of motion prove invaluable. The three-dimensional, magnified view provided by robotic systems further boosts surgical precision and clarity. These advantages render robotic assistance especially suitable for colorectal surgeries, notably in intricate areas such as the rectum and endoluminal spaces. As the medical world emphasizes minimally invasive surgical methods, there's a pressing need to evolve and optimize robotic techniques in colorectal surgery. This article traces the evolution of robotic interventions in colorectal surgeries, highlighting both its historical milestones and anticipated future trends. We'll also explore emerging robotic tools and systems set to reshape the colorectal surgical arena.

Emerging multi-port soft tissue robotic systems: a systematic review of clinical outcomes

Multiple novel multi-port robotic surgical systems have been introduced into clinical practice. This systematic review aims to evaluate the clinical outcomes of these novel robotic systems to conventional laparoscopic technique and established da Vinci robotic surgical platforms. A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to the PRISMA guidelines from 2012 to May 2023. Studies comparing clinical outcomes of novel multi-port robotic surgical systems with laparoscopic or the da Vinci platforms were included. Case series with no comparison groups were excluded. Descriptive statistics were used to report patient and outcome data. A systematic narrative review was provided for each outcome. Twelve studies comprised of 1142 patients were included. A total of 6 novel multi-port robotic systems: Micro Hand S, Senhance, Revo-i MSR-5000, KangDuo, Versius, and Hugo™ RAS were compared against the laparoscopic or the da Vinci robotic platforms. Clinical outcomes of these novel robotic platforms were comparable to the established da Vinci platforms. When compared against conventional laparoscopic approaches, the robotic platforms demonstrated lower volume of blood loss, shorter length of stay but longer operative time. This systematic review highlighted the safe implementation and efficacy of 6 new robotic systems. The clinical outcomes achieved by these new robotic systems are comparable to the established da Vinci robotic system in simple to moderate case complexities. There is emerging evidence that these new robotic systems provide a viable alternative to currently available robotic platforms.

Revolutionizing urology: the advancements and applications of robotic platforms

Robot-assisted surgery is developing as an acme of minimally invasive surgery, given its utmost dominance over laparoscopic surgery. The objective was to review the status of robotic surgery in urological practice with its advantages and disadvantages in current scenario. We conducted a literature search using MEDLINE and identified 72 articles which were relevant to urology. Single-port and various multiport robotic platforms like Da Vinci, Versius, Hugo RAS, Revo-I, Senhance, Mantra, Avatera, Hinotori, and MicroSurge are described with pros and cons. With a surge in different medical surgical robots purging into the market and a race to become the next standard of care in robotic surgery, it is only a matter of time when robotic surgery becomes financially comparable to laparoscopic surgeries.

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.

Clinical applications of robotic surgery platforms: a comprehensive review

Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time.

Navigating Now and Next: Recent Advances and Future Horizons in Robotic Radical Prostatectomy

Robotic-assisted radical prostatectomy (RARP) has become the leading approach for radical prostatectomy driven by innovations aimed at improving functional and oncological outcomes. The initial advancement in this field was transperitoneal multiport robotics, which has since undergone numerous technical modifications. These enhancements include the development of extraperitoneal, transperineal, and transvesical approaches to radical prostatectomy, greatly facilitated by the advent of the Single Port (SP) robot. This review offers a comprehensive analysis of these evolving techniques and their impact on RARP. Additionally, we explore the transformative role of artificial intelligence (AI) in digitizing robotic prostatectomy. AI advancements, particularly in automated surgical video analysis using computer vision technology, are unprecedented in their scope. These developments hold the potential to revolutionize surgeon feedback and assessment and transform surgical documentation, and they could lay the groundwork for real-time AI decision support during surgical procedures in the future. Furthermore, we discuss future robotic platforms and their potential to further enhance the field of RARP. Overall, the field of minimally invasive radical prostatectomy for prostate cancer has been an incubator of innovation over the last two decades. This review focuses on some recent developments in robotic prostatectomy, provides an overview of the next frontier in AI innovation during prostate cancer surgery, and highlights novel robotic platforms that may play an increasing role in prostate cancer surgery in the future.

Robotic urologic surgery using the KangDuo-Surgical Robot-01 system: A single-center prospective analysis

BACKGROUND

The KangDuo-Surgical Robot-01 (KD-SR-01) system is a new surgical robot recently developed in China. The aim of this study was to present our single-center experience and mid-term outcomes of urological procedures using the KD-SR-01 system.

METHODS

From August 2020 to April 2023, consecutive urologic procedures were performed at Peking University First Hospital using the KD-SR-01 system. The clinical features, perioperative data, and follow-up outcomes were prospectively collected and analyzed.

RESULTS

A total of 110 consecutive patients were recruited. Among these patients, 28 underwent partial nephrectomy (PN), 41 underwent urinary tract reconstruction (26 underwent pyeloplasty, 3 underwent ureteral reconstruction and 12 underwent ureterovesical reimplantation [UR]), and 41 underwent radical prostatectomy (RP). The median operative time for PN was 112.5 min, 157.0 min for pyeloplasty, 151.0 min for ureteral reconstruction, 142.5 min for UR, and 138.0 min for RP. The median intraoperative blood loss was 10 mL for PN, 10 mL for pyeloplasty, 30 mL for ureteral reconstruction, 20 mL for UR, and 50 mL for RP. All procedures were successfully completed without conversion, and there were no major complications in any patient. The median warm ischemia time of PN was 17.3 min, and positive surgical margin was not noted in any patient. The overall positive surgical margin rate of RP was 39% (16/41), and no biochemical recurrence was observed in any RP patient during the median follow-up of 11.0 months. The surgical success rates of pyeloplasty and UR were 96% (25/26) and 92% (11/12) during the median follow-up of 29.5 months and 11.5 months, respectively.

CONCLUSION

The KD-SR-01 system appears feasible, safe, and effective for most urological procedures, based on our single-center experience.

Senhance robotic radical prostatectomy: A single-centre, 3-year experience

BACKGROUND

Senhance Surgical System is a novel robotic platform used in University Hospital Centre Zagreb since February 2019. In this study, we present our 3-year experience with this platform.

PATIENTS AND METHODS

Data were prospectively collected for 200 patients who underwent extraperitoneal robotic radical prostatectomy (RRP) from May 2019 to March 2022.

RESULTS

The median age of the patients was 65 years, and the prostate-specific antigen was 6.9 ng/mL. Clinically, most of the patients had T1c stage. The estimated blood loss was 250 mL, and there were 6 conversions to laparoscopic and 2 to open prostatectomy. There were 15 early postoperative complications, 11 Clavien-Dindo classification grade I, 3 grade II and 1 grade IV. Functional outcomes in the first 150 patients: 140 patients (93.3%) had good urinary control. Thirteen patients underwent additional oncological treatment.

CONCLUSION

RRP performed with the Senhance robotic platform is a feasible and safe procedure with good initial results.

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 Urology: History from PROBOT® to HUGOTM

The advent of robotic surgical systems had a significant impact on every surgical area, especially urology, gynecology, and general and cardiac surgery. The aim of this article is to delineate robotic surgery, particularly focusing on its historical background, its evolution, its present status, and its future perspectives. A comprehensive literature review was conducted upon PubMed/MEDLINE, using the keywords "robotic surgical system", "robotic surgical device", "robotics AND urology". Additionally, the retrieved articles' reference lists were investigated. Analysis concentrated on urological surgical systems for laparoscopic surgery that have been given regulatory approval for use on humans. From the late 1980s, before daVinci® Era in 2000s, ancestor platform as Probot® and PUMA 560 were described to outline historical perspective. Thus, new robotic competitors of Intuitive Surgical such as Senhance®, Revo-I®, Versius®, Avatera®, Hinotori®, and HugoTM RAS were illustrated. Although daVinci® had high level competitiveness, and for many years represented the most plausible option for robotic procedures, several modern platforms are emerging in the surgical market. Growing competition through unique features of the new robotic technologies might extend applications fields, improve diffusion, and increase cost-effectiveness procedures. More experiences are needed to identify the role of these new advancements in surgical branches and in healthcare systems.

The Availability, Cost, Limitations, Learning Curve and Future of Robotic Systems in Urology and Prostate Cancer Surgery

Robot-assisted surgical systems (RASS) have revolutionised the management of many urological conditions over the last two decades with robot-assisted radical prostatectomy (RARP) now being considered by many to be the preferred surgical approach. Intuitive Surgical has dominated the market during this time period with successive iterations of the da Vinci model. The expiration of patents has opened the RASS market and several new contenders have become available or are currently in development. This comprehensive narrative review aims to explore the merits of each robotic system as well as the evidence and barriers to their use. The newly developed RASS have increased the versality of robotic surgical systems to a wider range of settings through advancement in technology. The increased competition may result in an overall reduction in cost, broadening the accessibility of RASS. Learning curves and training remain a barrier to their use, but the situation appears to be improving through dedicated training programmes. Outcomes for RARP have been well investigated and tend to support improved early functional outcomes. Overall, the rapid developments in the field of robot-assisted surgery indicate the beginning of a promising new era to further enhance urological surgery.

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.

Robot-assisted Partial Nephrectomy with the Newly Developed KangDuo Surgical Robot Versus the da Vinci Si Surgical System: A Double-center Prospective Randomized Controlled Noninferiority Trial

BACKGROUND

The KangDuo surgical robot (KD-SR) was recently developed in China.

OBJECTIVE

To compare the safety and efficacy of the KD-SR versus the da Vinci Si Surgical System (DV-SS-Si) for robot-assisted partial nephrectomy (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

A double-center prospective randomized controlled noninferiority trial of patients aged 18-75 yr with a suspicion of T1a N0M0 renal cancer (RENAL nephrometry score ≤9) was conducted.

INTERVENTION

RAPN with the KD-SR versus the DV-SS-Si.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the success rate of operation. The operation was successful if (1) there was no open or laparoscopic conversion, (2) the warm ischemia time was <30 min for RENAL nephrometry scores of 4-6 or 40 min for RENAL nephrometry scores of 7-9, and (3) the pathological margin was negative. The secondary endpoint was the estimated glomerular filtration rate (eGFR). A threshold of 10% was set to demonstrate noninferiority.

RESULTS AND LIMITATIONS

From September 2020 to March 2021, 100 participants were enrolled, of whom 99 (49 in the KD-SR group and 50 in the DV-SS-Si group) were finally included in the full analysis set and 98 (49 in the KD-SR group and -49 in the DV-SS-Si group) in the per-protocol set. Baseline demographic and clinical characteristics were similar between the two groups. All surgeries were completed successfully. The eGFR at postoperative weeks 4-12 and adverse events were similar between the two groups. The docking time and suture time per stitch were longer in the KD-SR group. The main limitation was that a negative margin was considered as the primary outcome rather than survival.

CONCLUSIONS

The KD-SR achieved noninferior outcomes as compared with the DV-SS-Si regarding safety and efficacy for T1a tumors.

PATIENT SUMMARY

The first trial comparing the KangDuo surgical robot (KD-SR) versus the da Vinci Si Surgical System for robot-assisted partial nephrectomy showed that the KD-SR is a viable option for minimally invasive treatment of T1a renal tumors.

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Robot-assisted partial nephrectomy with a new robotic surgical system: feasibility and perioperative outcomes

PURPOSE

To evaluate the feasibility and safety of a novel robotic system (KD-SR-01) for partial nephrectomy.

METHODS

Seventeen patients with small renal mass (SRM) (≤4 cm) underwent KD-SR-01 robotic partial nephrectomy (KD-RPN) from December 2020 to March 2021 in our institution. The operative outcomes and perioperative data, including clinical and histological data, were prospectively collected and analyzed.

RESULTS

In total, 10 men and 7 women, with a median age of 51 years, underwent KD-RPN. Four transperitoneal procedures and 13 retroperitoneal procedures were successfully performed without conversion to open or conventional laparoscopic surgery. The docking time and robotic operative time were 3.3 min and 68.6 min, respectively. The warm ischemia time was 16.9 min. No major intraoperative or postoperative complications (Clavien grade ≥ III) occurred. The duration of postoperative hospital stay was 5 days. Pathologic examination revealed nine clear cell carcinomas, two papillary cell carcinomas, one oncocytoma, and five angiomyolipoma. All surgical margins were negative. The estimated globular filtration rate (eGFR) on the 1st postoperative day was significantly decreased compared to the preoperative eGFR (91.7±12.9 ml/min vs. 97.9±10.7 ml/min, P =0.036). However, no significant difference was observed between the preoperative eGFR and the value on the 4th postoperative day (95.7±13.4 ml/min vs. 97.9±10.7 ml/min, P=0.427).

CONCLUSION

KD-RPN was safe and feasible for the treatment of SRM. The early oncologic and functional outcomes were promising. Long-term follow-up and well-designed prospective comparative studies with the da Vinci platform are needed to corroborate these findings.

Mapping of clinical research on artificial intelligence in the treatment of cancer and the challenges and opportunities underpinning its integration in the European Union health sector

BACKGROUND

Although current efforts are made to diminish the incidence and burden of disease, cancer is still widely identified late at stage. This study aims to conduct a systematic review mapping the existent and emerging clinical research on artificial intelligence (AI) in the treatment of cancer and to underpin its integration challenges and opportunities in the European Union (EU) health sector.

METHODS

A systematic literature review (SLR) evaluating global clinical trials (CTs; published between 2010 and 2020 or forthcoming) was concluded. Additionally, a horizon scanning (HS) exercise focusing on emerging trends (published between 2017 and 2020) was conducted.

RESULTS

Forty-four CTs were identified and analyzed. Selected CTs were divided into three research areas: (i) potential of AI combined with imaging techniques, (ii) AI's applicability in robotic surgery interventions and (iii) AI's potential in clinical decision making. Twenty-one studies presented an interventional nature, nine papers were observational and 14 articles did not explicitly mention the type of study performed. The papers presented an increased heterogeneity in sample size, type of tumour, type of study and reporting of results. In addition, a shift in research is observed and only a small fraction of studies were completed in the EU. These findings could be further linked to the current socio-economic, political, scientific, technological and environmental state of the EU in regard to AI innovation.

CONCLUSION

To overcome the challenges threatening the EU's integration of such technology in the healthcare field, new strategies taking into account the EU's socio-economic and political environment are deemed necessary.

Telemedicine and Telementoring in Urology: A Glimpse of the Past and a Leap Into the Future

Telemedicine is the process of utilizing telecommunications and digital relay to perform, teach, or share medical knowledge. The digital era eased the incorporation of telemedicine to different areas of medical care, including the surgical care of Urologic patient mainly through telementoring, telesurgery, and telerobotics. Over the years, Telemedicine has played an integral part in a physicians' ability to provide high quality medical care to remote patients, as well as serve as an educational tool for trainee physicians, in the form of telementoring. During the COVID-19 pandemic, telemedicine has played a vital role in combatting the health implications of confinements. Challenges of telemedicine implementation include cost, ethical considerations, security, bandwidth, latency, legal, and licensure difficulties. Nevertheless, the future of telemedicine, specifically telementoring, promises several improvements and innovative advancements that aim to bridge the gap in technological divides of urologic care. In this review, we build on what is already known about telemedicine focusing specifically on aspects related to telementoring, telestration, and telesurgery. Furthermore, we discuss its historical role in healthcare with a special emphasis on current and future use in urology.

Future Platforms of Robotic Surgery

Among the various robotic devices that exist for urologic surgery, the most common are synergistic telemanipulator systems. Several have achieved clinical feasibility and have been licensed for use in humans: the standard da Vinci, Avatera, Hinotori, Revo-i, Senhance, Versius, and Surgenius. Handheld and hands-on synergistic systems are also clinically relevant for use in urologic surgeries, including minimally invasive and endoscopic approaches. Future trends of robotic innovation include an exploration of more robust haptic systems that offer kinesthetic and tactile feedback; miniaturization and microrobotics; enhanced visual feedback with greater magnification and higher fidelity detail; and autonomous robots.

Partial nephrectomy through retroperitoneal approach with a new surgical robot system, KD-SR-01

BACKGROUND

To present our experiences with partial nephrectomy (PN) through retroperitoneal approach (RP) with the Kangduo robotic system.

METHODS

From December 2020 to February 2021, the perioperative data of 11 patients underwent PN through RP with the Kangduo robotic system were collected prospectively.

RESULTS

For the R.E.N.A.L. nephrometry score, 72.7% of patients had a low score (4-6) and 27.3% of patients had a medium score (7-9). Seven tumours were posterior (P), four tumours were on the midline (X). All procedures were completed successfully. The median warm ischemia time was 18.5 (IQR, 13.7-21.0) min. None of the patients had positive surgical margins at definitive histology (all pT1a). No high-grade perioperative complications or device-related adverse events occurred. At a mean follow-up of 8 ± 0.8 months, no complications occurred in all patients.

CONCLUSIONS

RPPN using the novel Kangduo robotic system is a safe and effective option for managing posterior and lateral renal tumours with R.E.N.A.L. nephrometry scores ≤9.

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.

Comparing Revo-i and da Vinci in Retzius-sparing robot-assisted radical prostatectomy: a preliminary propensity score analysis of outcomes

PURPOSE

. This study aims to compare perioperative and oncologic outcomes between matched cohorts of localized Prostate cancer (PCa) operated on by the same surgeon using the DaVinci Si robot and the Revo-i robot.

MATERIALS AND METHODS

Non-metastatic prostate cancer patients undergoing Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RARP) from January 2016 to December 2020 were matched one-to-one (33:33) to DaVinci Si controls using nearest neighbor propensity score matching according to the following covariates: age, American Society of Anesthesiology (ASA) score, body mass index, previous abdominal and endoscopic surgery, pre-operative prostate specific antigen (PSA), prostate volume, ISUP grade group, tumor stage, and need for pelvic lymphadenectomy. Outcomes of interest were estimated blood loss, length-of-stay, complication rate, operative times, positive surgical margins, and biochemical recurrence at six months.

RESULTS

Both cohorts were similar in estimated blood loss, rate of margin positivity, and rate of complications. Length of stay was significantly shorter with the Revo-i cohort. The DaVinci showed faster console, suture, total operation times. Positive margin rate and biochemical recurrence at six months were similar in both groups.

CONCLUSION

Despite the longer suture, console, and operative time compared to the da Vinci in the authors' institution, the Revo-i robot-assisted radical prostatectomy had equivalent short-term oncologic outcomes with the da Vinci standard.

Robotic donor hepatectomy: Are we there yet?

In living donor liver transplantation (LDLT) the safety of the live donor (LD) is of paramount importance. Despite all efforts, the morbidity rates approach 25%-40% with conventional open donor hepatectomy (DH) operations. However, most of these complications are related to the operative wound and despite increased self- esteem and satisfaction in various quality of life analyses on LD, the most common grievance is that of the scar. Performing safe and precise DH through a conventional laparoscopic approach is a formidable task with a precipitous learning curve for the whole team. Due to the ramifications the donor operation carries for the donor, the recipient, the transplant team and for the LDLT program in general, the development and acceptance of minimally invasive DH (MIDH) has been slow. The robotic surgical system overcomes the reduced visualization, restricted range of motion and physiological tremor associated with laparoscopic surgery and allows for a comparatively easier transition from technical feasibility to reproducibility. However, many questions especially with regards to standardization of surgical technique, comparison of outcomes, understanding of the learning curve, etc. remain unanswered. The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH, appreciating the existing challenges and its future role.

New robotic surgical systems in urology: an update

PURPOSE OF REVIEW

The landscape of robotic surgical systems in urology is changing. Several new instruments have been introduced internationally into clinical practice, and others are in development. In this review, we provide an update and summary of recent surgical systems and their clinical applications in urology.

RECENT FINDINGS

Robotic-assisted laparoscopic surgery is increasingly becoming a standard skillset in the urologist's technical armamentarium. The current state of the robotic surgery market is monopolized because of a number of regulatory and technical factors but there are several robotic surgical systems approved for clinical use across the world and numerous others in development. Next-generation surgical systems commonly include a modular design, open access consoles, haptic feedback, smaller instruments, and machine learning.

SUMMARY

Numerous robotic surgical systems are in development, and several have recently been introduced into clinical practice. These new technologies are changing the landscape of robotic surgery in urology and will likely transform the marketplace of robotic surgery across surgical subspecialties within the next 10--20 years.

Robotic surgical systems in urology: What is currently available?

Robotic assistance in laparoscopic surgery was introduced at the turn of this millennium, marking a milestone in the history of surgery. Urologists were early adopters of robotic technology and the indications of robot-assisted surgery in urology are expanding. Over the last 20 years, the da Vinci surgical system was the dominant system in the robotic surgical market. However, the recent expiration of Intuitive patents has allowed new systems to enter the market more freely. We performed a nonsystematic literature review using the PubMed/MEDLINE search engines. The aim of this review was to briefly summarize the currently available robotic surgical systems for laparoscopic urologic surgery. New surgical devices have already been launched in the robotic market and the da Vinci systems have some competition. The innovation of robotic technology is continuing, and new features such as an open-console design, haptic feedback, smaller instruments, and separately mounted robotic arms have been introduced. A new robotic era is rising, and new systems and technologies enhancing patient care are welcomed.

Revo-i assisted robotic central pancreatectomy

Central pncreatectomy (CP) can be one of procedures for function-preserving pancreatectomy for patients with benign or low grade malignant pancreatic tumors. Surgeons have to deal with two cut surface of the pancreas when performing CP, which can be associated with severe complication, such as postoperative pancreatic fistula. Fine and delicate surgical skill is highly required for safe CP. With the advance of minimally invasive surgery, CP is now thought to be one of appropriate procedures for function-preserving minimally invasive pancreatectomy. Robotic surgery is thought to make complicated surgical procedure easy and effective. Recently, Korean robotic surgical system, Revo-i, was successfully developed by Meeraecompany and have been proved its safety and feasibility in several recent reports. A 56-year old woman was referred for a body of pancreatic lesion. Contrast abdominopelvic CT revealed a pancreatic body tumor measuring around 1.2 cm in diameter. The patient underwent a robot-assisted central pancreatectomy using Revo-i. The patient endured the procedure well and was discharged to home at postoperative day 9. This report showed a successful case of central pancreatectomy performed with the Korean robotic surgical system Revo-i.

Retzius-sparing robot-assisted radical prostatectomy: Perioperative and immediate continence outcomes of an initial series

OBJECTIVE

The objective of this work is to present initial perioperative, immediate continence and oncological results in a series of 25 prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy.

MATERIAL AND METHODS

We retrospectively analyzed a series of 25 patients treated with Retzius-sparing robot-assisted radical prostatectomy for cT1-T2b prostate cancer between 2018-2019. The 5 stages of surgery are described. We make a descriptive statistic of our initial series and its outcomes in terms of immediate continence, defined as the use of 0 pad/diapers or 1 safety pad/diaper every 24 hours, one week after catheter removal.

RESULTS

Median follow-up, 6 months (3-18). Median PSA, 6.1 ng/ml (4-14.3). All surgeries were performed through a posterior intrafascial approach, and bilateral nerve-sparing was carried out in 84% of the cases. Affected surgical margins were present in 28%, being the apex the most frequent site of affectation. Surgical complications: 1 (4%) patient required transfusion of blood products in the immediate postoperative period. Mean hospital stay was 48 hours. Functional outcomes: 80% of the patients present immediate continence. 80% of continent patients do not require the use of any safety pads/diapers. Oncological outcomes: 84% are free of biochemical-progression in a median follow-up of 6 months.

CONCLUSIONS

Initial functional results in terms of immediate continence are very satisfactory in patients who have undergone Retzius-sparing robot-assisted radical prostatectomy without negative impact on prognosis.

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.

First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma

Robotic surgery systems have been developed to overcome the limitations of laparoscopic surgery. Recently, Meerecompany Inc. in Korea successfully manufactured a robotic surgical system called Revo-i. A 65-year old woman was referred for a pancreatic head tumor, detected as an incidental finding during a routine check-up. Contrast abdominopelvic CT revealed a pancreatic uncinate tumor measuring around 13 mm in diameter, with no other focal lesions. The patient underwent a robot-assisted pancreaticoduodenectomy (laparoscopic resection and robotic reconstruction) using Revo-i. The patient's recovery was uneventful and discharged on postoperative day 7. Our case showed the technical feasibility of the Korean robotic surgical system Revo-i. Further experiences are mandatory to validate this finding.

Retzius sparing robotic assisted radical prostatectomy vs. conventional robotic assisted radical prostatectomy: a systematic review and meta-analysis

CONTEXT

Retzius sparing robotic assisted radical prostatectomy appears to have better continence rates when compared to conventional robotic assisted radical prostatectomy, however, concern with high positive surgical margin rates exist.

OBJECTIVE

To systematically evaluate evidence comparing functional and oncological outcomes of retzius sparing robotic assisted radical prostatectomy and conventional robotic assisted radical prostatectomy.

EVIDENCE ACQUISITION

The systematic review was performed in accordance with the Cochrane guidelines and the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Bibliographic databases searched were PubMed/MEDLINE, Cochrane central register of controlled trials-CENTRAL (in The Cochrane library-issue 1, 2018). We used the GRADE approach to assess the quality of the evidence.

EVIDENCE SYNTHESIS

The search retrieved 137 references through electronic searches of various databases. Six were included in the review. RS-RALP was associated with better early continence rates (≤ 1 month) (moderate quality evidence) (RR 1.72, 95% CI 1.27, 2.32, p 0.0005) and at 3 months (low quality evidence) (RR 1.39, 95% CI 1.03, 1.88, p 0.03). Time to continence recovery, number of pads used and pad weight are better with RS-RALP. Based on very low quality evidence, RS-RALP did not alter 6 and 12 months continence rates. Based on very low quality evidence, RS-RALP did not alter T2 positive margin rates (RR 1.67, 95% CI 0.91, 3.06, p 0.10) and T3 positive margin rates (RR 1.08, 95% CI 0.68, 1.70, p = 0.75). Short-term biochemical free survival appears to be similar between the two approaches. Based on low-quality evidence, RS-RALP did not alter overall and major complication rates.

CONCLUSIONS

RS-RARP appears to have earlier continence recovery when compared to Con-RARP which does not come at a significant oncologic cost. Whilst there was a trend towards higher PSM rates with RS-RALP, this did not achieve statistical significance. Furthermore this trend appeared to be less pronounced with T3 disease, where the PSM rates are almost similar.

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.

Progression to chronic kidney disease in patients undergoing nephrectomy for small renal masses: a price to pay for a therapeutic success?

Nephrectomy, which constitutes a gold-standard procedure for the treatment of renal-cell carcinoma (RCC), has been widely discussed in the past decade as a significant risk factor of the development of chronic kidney disease (CKD). RCC is the third most common genitourinary cancer in the United States, with an estimated more than 65,000 new cases and 14,970 deaths. The aim of this review was to precisely and comprehensively summarize the status of current knowledge in CKD risk factors after nephrectomy, the advantages of minimally invasive vs. radical nephrectomy, post-nephrectomy biomarkers of CKD, ways of post-operative CKD prevention and, therefore, better understand why various aspects of CKD after nephrectomy. The majority of current studies indicated a better long-term kidney function preservation in patients undergoing partial nephrectomy in comparison to those after radical nephrectomy. Furthermore, a nephron-sparing surgery should be a preferred first-line procedure among young patients with small renal masses. As partial nephrectomy is followed by a greater risk of adverse outcomes relative to radical nephrectomy, a potential survival benefit should always be considered especially in the elderly or patients with comorbidities.