Intraoperative Performance of DaVinci Versus Hugo RAS During Radical Prostatectomy: Focus on Timing, Malfunctioning, Complications, and User Satisfaction in 100 Consecutive Cases (the COMPAR-P Trial)

Background and objective

The Hugo RAS and DaVinci Xi systems are used for performing robot-assisted radical prostatectomy (RARP). This study aims to compare these two platforms providing granular and comprehensive data on their intraoperative performance.

Methods

The Comparison of Outcomes of Multiple Platforms for Assisted Robotic surgery-Prostate (COMPAR-P) trial is a prospective post-market study (clinicaltrials.org NCT05766163). Enrollment began in March 2023, allocating patients to DaVinci or Hugo RAS for RARP, without selection criteria, for up to 50 consecutive cases. Two experienced console surgeons performed the procedures, following the same technique. Evaluation focused on timing, learning curves, malfunctioning events, complications, and users' satisfaction, using standard statistical methods, including the cumulative summation analysis (CUSUM) for the learning curve assessment.

Key findings and limitations

Fifty patients each were enrolled for DaVinci (DV-RARP) and Hugo RAS (H-RARP) RARP. Baseline features were balanced. DV-RARP showed significantly shorter "setup" and "console" phase durations than H-RARP (37 vs 55 min and 97 vs 126 min, respectively, p < 0.001). A longitudinal timing analysis revealed DV-RARP's flat line, while H-RARP showed a modest decline with breakpoints at 22 and 17 procedures by CUSUM for the setup and console phases. The numbers of malfunctioning events were 4 (DV-RARP) and 20 (H-RARP). DV-RARP had high user satisfaction, while the user satisfaction of H-RARP varied. The comparison was between the first 50 H-RARP and the last 50 DV-RARP cases performed at our institution. This likely accounts for the observed differences in setup and console times between the cohorts. The specialized expertise of the surgeons involved could limit the generalizability of our findings.

Conclusions and clinical implications

This prospective study compared unselected patients who underwent DV-RARP and H-RARP. More malfunctioning events occurred in case of Hugo RAS, but surgical outcomes were similar. Longer operative times for Hugo RAS were attributed to meticulous care with the novel platform. Improvement potential was evident within a few procedures, providing valuable insights for adopting this new platform.

Patient summary

This study compared two advanced robotic systems, DaVinci and Hugo RAS, used to remove the prostate in patients diagnosed with prostate cancer. While both systems showed similar surgical outcomes, the newer Hugo RAS system required more meticulous movements, leading to slightly longer operation times. The findings suggest that, with further experience, both systems can provide effective treatment options for patients undergoing prostate surgery.

Revisional Robotic Bariatric Surgery. Largest Single Centre Prospective Cohort Study and Review of the Literature

Introduction: Robotic bariatric surgery (RBS) has seen a surge in popularity in recent years, yet questions persist about its utility concerning postoperative complications, costs, and technical aspects. RBS, while increasing in number, presents a greater technical challenge associated with more post-operative complications compared to primary bariatric surgery. In this study, we present our single institution experience and review the literature to assess the value of robotic revisional surgery. Material and Method: The retrospective review involved 42 patients (31 females, 11 males) who underwent various procedures, with the most frequent being the conversion of sleeve gastrectomy to gastric bypass (n=30). Encouragingly, no leaks or severe complications were identified. Furthermore, a systematic review indicated comparable outcomes, with decreased complication rates favoring robotic revisional surgery. Results: In direct comparison to standard laparoscopic revisional bariatric surgery, revisional robotic surgery demonstrated superior results in terms of efficacy, safety, and reduced hospital stay. However, rates of mortality, morbidity, and reintervention did not significantly differ between the two approaches. Conclusions: Considering these findings, we advocate for surgeons to acquire proficiency in the robotic technique, as part of the broader process of democratization and standardization of bariatric surgery. Embracing revisional robotic bariatric surgery can lead to improved patient outcomes, and its wider implementation may lead to enhanced surgical care and patient satisfaction in the field of bariatric procedures.

Prechemotherapy Transperitoneal Robotic-Assisted Partial Nephrectomy (RAPN) for a Wilms Tumor: Surgical and Oncological Outcomes in a Four-Year-Old Patient

BACKGROUND

Wilms tumor (WT) is the most frequent renal tumor in children. The SIOP-UMBRELLA Guidelines allow for nephron-sparing surgery (NSS) in syndromic patients, as well as in cases of small (<300 mL) non-syndromic unilateral WTs, without lymph node involvement, and with a substantial expected remnant renal function, following neoadjuvant chemotherapy. We present a case of prechemotherapy transperitoneal robot-assisted partial nephrectomy (RAPN) for a unilateral, non-syndromic Wilms tumor.

METHODS

A four-year-old child presented with a solid mass measuring 3.6 cm in diameter involving the upper right renal pole, incidentally detected during an abdominal echotomography. CT scan and abdominal MRI revealed no local infiltration or lymph node involvement, suggesting that the exophytic mass could be easily resected via an NSS robotic approach. Preoperative imaging did not strongly suggest WT. A virtual 3D reconstruction of the tumor was performed.

RESULTS

After the oncologic board approval, a robot-assisted partial nephrectomy with an intraperitoneal approach was performed. Histopathological analysis confirmed the diagnosis of WT. The patient subsequently received 10 doses of vincristine as adjuvant chemotherapy. A 28-month follow-up showed no tumor recurrence.

CONCLUSIONS

Intraperitoneal RAPN may be an option for selected WT and warrants consideration as a challenging but advantageous approach.

Robotic-assisted Laparoscopic Supracervical Repair of a Chronic Puerperal Uterine Inversion

Surgical correction of a chronic puerperal uterine inversion traditionally requires an anterior or posterior cervical incision to relieve the constricting band. This case is only the second reported case of robotic-assisted correction of a chronic puerperal uterine inversion and the first to avoid a cervical incision. The patient was 5 months postpartum and desired future pregnancy. After a laparoscopic Huntington technique was unsuccessful, a vertical hysterotomy was created in the anterior lower uterine segment and extended toward the fundus until the inversion could be relieved. The incision was repaired in 3 layers and a round ligament plication was performed to provide additional support within the pelvis. The patient's symptoms gradually improved during her postoperative course, and ultrasound 2 weeks after the procedure revealed the uterus in anatomic position in the pelvis. With a paucity of reported cases of laparoscopic correction of chronic puerperal uterine inversion, the present case offers a novel surgical approach that maintains cervical integrity and thereby minimizes long-term effects of the procedure on future pregnancies.

First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique

Introduction

While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.

Methods

Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results

The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.

Conclusion

We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03920-1.

Spin is present in the majority of articles evaluating robot-assisted groin hernia repair: a systematic review

BACKGROUND

The number of scientific articles published each year is increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers' interpretation of results so that they are viewed more favorable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown.

OBJECTIVES/AIM

To determine the frequency and extent of spin in studies assessing robot-assisted groin hernia repair.

METHODS

This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE, and Cochrane Central.

RESULTS

Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p < 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p < 0.05) compared with those who were not.

CONCLUSION

Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.

[Robotic-assisted surgery: yesterday, today, tomorrow]

OBJECTIVE

Analysis of development of «robotic surgery» on the basis of historical prerequisites, review of the possibilities of the new Senhance robotic surgical system and determination of further perspective.

MATERIAL AND METHODS

A prospective group of 51 patients with surgical pathology who underwent surgical interventions using the new Senhance robotic system was analyzed. The study included 51 patients. Robot-assisted cholecystectomy was performed in 20 patients, 31 patients underwent robotic transabdominal preperitoneal plastic surgery.

RESULTS

A short-term analysis of intraoperative and early postoperative data showed the safety of using the Senhance robotic complex for the patient. The ergonomics of this system contributes to significantly less fatigue of the surgeon during the operation, increasing its efficiency and safety.

CONCLUSION

The emergence of competitive robotic systems contributes to the dynamic development of robotic surgery, which in turn will lead to a reduction in the cost of these technologies in the future. Innovative solutions used in modern robotic complexes are based on the principles of machine learning, which in due time will make the «robot surgeon» not just a tool, but a full-fledged member of the operating team.

Robotic Revisional Experience. Single Centre Prospective Cohort Study and Review of the Literature

Background: Robotic bariatric surgery (RBS) has increased in recent years. Many doubts continue to exist regarding its utility in terms of postoperative complications, costs and technical aspects. RBS has increased its number and shows a more technical challenge associated with more post-operative complications compared to primary bariatric surgery. We herein present a single institution experience and review to describe its utility in revisional surgery. Methods: A retrospective review of our experience and a review of the literature has been conducted to evaluate the impact of robotic revisional surgery in the bariatric field. Results: A total of 17 patients (5 female and 12 male) were operated on. Most frequent surgery was conversion of sleeve gastrectomy to gastric bypass (n=9). No leaks were found nor severe complications. A systematic review showed similar results including a decreased number for complications when performing robotic revisional surgery. Conclusions: Revisional robotic surgery shows better results compared to standard laparoscopic revisional bariatric surgery in terms of efficacy, safety and hospital stay. No differences were seen in rates of mortality, morbidity and reintervention between both approaches. We encourage surgeons to learn to perform the robotic technique as part of the process of democratization and standardization of bariatric surgery.

Competing Robotic Systems: A Preview

"The new frontier of robotic surgery is well under way. Current research and development is rapidly progressing, allowing for the creation of many new robotic companies. Each company has its own identity and platform for what their vision for the future entails. The competition generated between these companies will shortly be forcing newer, cheaper, more accessible robotic systems worldwide."

Robotic versus open primary ventral hernia repair: A randomized controlled trial (Robovent Trial)

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Robotic primary ventral hernia repair (PVHR) combines minimal access, closure of defect and pre-peritoneal mesh placement.

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The protocol designs a randomized single-blinded controlled trial comparing robotic PVHR to open PVHR.

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The primary outcome will be the incidence of wound-related complication within 1 month.

Background

The objective of the present study is to compare the outcomes open PVHR and robotic PVHR.

Methods/Design

The present study will be a randomized single-blinded controlled trial with intention-to-treat analysis comparing robotic PVHR to open PVHR in adult patients undergoing elective PVHR with a defect ranging between 1–5 cm. Patient refusing to participate, not able to give informed consent, with history of intra-abdominal surgery contraindicating a robotic surgical approach will be excluded. The intervention will consist in laparoscopic robotically assisted trans-abdominal pre-peritoneal epigastric or umbilical PVHR with closure of fascial defect and non-adsorbable mesh reinforcement. The control will be open pre-peritoneal epigastric or umbilical hernia repair with closure of fascial defect and non-absorbable mesh reinforcement. The primary outcome will be the incidence of wound-related complication within 1 month. The secondary outcomes will be esthetic satisfaction, pain, pain-killers consumption, general complications, costs, operative time and early hernia recurrence.

Discussion

Open PVHR is potentially associated to more wound-related complications, but has the advantages of cost-effectiveness, short operative time and totally extra-peritoneal repair. Laparoscopic PVHR has lower wound-related complications but implies placing the mesh in intra-peritoneal position, requires advanced laparoscopic skills, usually does not allow the closure of the defect, and can lead to excessive pain and pain-killers consumption. Robotic PVHR uses the same laparoscopic access as laparoscopic PVHR, but thanks to the extended range of motion given by the robotic system, allows defect closure, pre-peritoneal placement of the mesh and requires less technical skills.

In the present randomized controlled trial, we expect to show that robotic PVHR leads to better wound-related outcomes than open PVHR.

Trial registration

The present randomized controlled trial was registered into clinicaltrials.gov under registration number NCT04171921.

Robot assisted spinal surgery- A technical report on the use of DaVinci in orthopaedics

Background

Robot assisted procedures have evolved during the last years, today many surgical, units perform laparoscopic procedures with DaVinci on a regular Basis. The major advantages of Robot assisted procedures comprise technical factors and improved visualization. In Spinal surgery endoscopic stabilization of fractures has become a Standard for many.

Purpose

We have employed DaVinci as an access tool for a retroperitoneal lumbar approach followed by a DaVinci assisted corpectomy and cage implantation to treat a fracture of L3.

Study design

A single operation as proof of concept and demonstration of the method was performed.

Methods

The whole procedure was video recorded. Time factors and clinical outcome were documented.

Results

The procedure was performed safely with no complications. The operating time was longer than usual but within reasonable limits. The postoperatrive outcome did not differ from the usual procedure. The visualization of critical structure during preparation of the vertebral body was superior along with superior soft tissue management with DaVinci.

Conclusion

An endoscopic robotic instrument can be used for endoscopic access surgery. Despite major advantages in visualization and handling of the endoscopic instruments all bone and cartilage preparation must be performed in a traditional endoscpic way because no appropriate instruments are available at present. In order to perform full robotic assisted procedures, new instruments need to be developed.

[Robot-assisted vs laparoscopic gastric bypass : First experiences with the DaVinci system in bariatric surgery]

Conventional laparoscopy is the gold standard in bariatric surgery. Internationally, robot-assisted surgery is gaining in importance. Up to now there are only few reports from Germany on the use of the system in bariatric surgery. Since January 2017 we have been performing robot-assisted gastric bypass surgery. It remains unclear whether the use of the robotic system has advantages over the well-established laparoscopic technique. Within a period from January to early August 2017 a total of 53 gastric bypass operations were performed. Of these 16 proximal redo Roux-en-Y gastric bypass operations were performed with the DaVinci Si system versus 29 laparoscopic procedures. A retrospective analysis of the perioperative course was carried out. Body weight, body mass index (BMI), Edmonton obesity staging system (EOSS) and American Society of Anesthesiologists (ASA) classification did not show significant differences. There were also no significant differences in terms of estimated blood loss, intraoperative complications, duration of surgery, postoperative inflammatory parameters and weight loss. There was no mortality and no need for revisional surgery in either group. After laparoscopic surgery there was a delayed occurrence of a leak of the gastrojejunostomy followed by readmission and endoscopic negative pressure wound therapy. The results show that the proximal Roux-en-Y gastric bypass can be performed safely and efficiently using the DaVinci surgical system. Significant differences to the conventional laparoscopic procedure were not found. Larger randomized controlled trials are needed to define the role of the DaVinci system in bariatric surgery.

Skills in minimally invasive and open surgery show limited transferability to robotic surgery: results from a prospective study

BACKGROUND

There is limited evidence on the transferability of conventional laparoscopic and open surgical skills to robotic-assisted surgery. The primary aim of this study was to evaluate the transferability of expertise in conventional laparoscopy and open surgery to robotic-assisted surgery using the da Vinci Skills Simulator (dVSS). Secondary aims included evaluating the influence of individual participants' characteristics.

METHODS

Participants performed four tasks on the dVSS: Peg Board 1 (PB), Pick and Place (PP), Thread the Rings (TR), and Suture Sponge 1 (SS). Participants were classified into three groups (Novice, Intermediate, Experts) according to experience in laparoscopic and open surgery. All tasks were performed twice except for SS. Performance was assessed using the built-in scoring system.

RESULTS

37 medical students and 25 surgeons participated. Experts did not perform significantly better than less experienced participants on the dVSS. Specifically, with regard to laparoscopic experience, total simulator scores were: Novices 68.2 ± 28.8; Intermediates 65.1 ± 31.2; Experts 65.1 ± 30.0; p = 0.611. Regarding open surgical experience, scores were: Novices 68.6 ± 28.7; Intermediates 68.2 ± 30.8; Experts 63.2 ± 30.3; p = 0.305. Although there were some significant differences among groups for single parameters in specific tasks, there was no constant superiority of one group. Laparoscopic and open surgical Novices improved significantly in overall score and time for all three tasks (p < 0.05). Laparoscopic intermediates improved only in PP time (4.64 ± 3.42; p = 0.006), open Intermediates in PB score (11.98 ± 13.01; p = 0.025), and open Experts in PP score (6.69 ± 11.48; p = 0.048). Laparoscopic experts showed no improvement. Participants with gaming experience had better overall scores than non-gamers when comparing all second attempts (Gamer 83.62 ± 7.57; Non-Gamer 76.31 ± 12.78; p = 0.008) as well as first and second attempts together (Gamer 72.08 ± 8.86; Non-Gamer 65.45 ± 11.68; p = 0.039). Musical and sports experience showed no correlation with robotic performance.

CONCLUSIONS

Robotic-assisted surgery requires skills distinct from conventional laparoscopy or open surgery. Basic robotic skills training prior to patient contact should be required.

[Minimally invasive and robot-assisted surgery for pancreatic cystic tumors]

BACKGROUND

The indications for resection of pancreatic cystic lesions (PCL) are often complex and the operative risk has to be balanced against the risk of malignant transformation. The aim of the study was to provide a synopsis of the current treatment results of minimally invasive surgery for PCL.

METHODS

A systematic literature search was performed using the Medline database (PubMed). Subsequently, the retrieved literature was selectively reviewed.

RESULTS

No published prospective randomized controlled trials have yet addressed the comparison of open and minimally invasive surgery of PCL; however, retrospective case studies have demonstrated the feasibility, safety and a comparable morbidity after minimally invasive distal pancreatectomy (DP), pancreatoduodenectomy (PD), central (CP) or total pancreatectomy and enucleation. Whereas most DPs are performed laparoscopically, the experience of minimally invasive PD has been consolidated for the robot-assisted approach but is concentrated in only a few centers. The number of published reports on minimally invasive organ-sparing pancreas procedures (e. g. CP or enucleation) for PCL is scarce; however, the available (selected) results are promising.

CONCLUSION

Minimally invasive surgery for PCL has the potential to reduce the operative trauma to the patients, while at the same time causing comparable or less morbidity. This requires an increasing specialization of complex minimally invasive resections. The clinical use of robotic systems will grow for the latter cases. A prospective registry of the results should be mandatory for quality management.

DaVinci robot-assisted transcervical excision of a parapharyngeal space tumor

Neoplastic processes in the parapharyngeal space represent less than 1% of all head and neck tumors. Due to the complexity, deep location and surrounding vital structures of the parapharyngeal space, resection of tumors from this area can prove challenging. There are a number of surgical approaches traditionally used to access the parapharyngeal space; the choice is dictated by the size of the tumor, its location, its relationship to the great vessels, and suspicion of malignancy. We describe our innovative surgical technique employing DaVinci robot-assisted transcervical excision of a parapharyngeal space tumor. To the best of our knowledge this is the first report of this surgical technique.

Robotic surgery versus laparoscopy; a comparison between two robotic systems and laparoscopy

Laparoscopy has found a role in standard urologic practice, and with training programs continuing to increase emphasis on its use, the division between skill sets of established non-laparoscopic urologic practitioners and urology trainees continues to widen. At the other end of the spectrum, as technology progresses apace, advanced laparoscopists continue to question the role of surgical robotics in urologic practice, citing a lack of significant advantage to this modality over conventional laparoscopy. We seek to compare two robotic systems (Zeus and DaVinci) versus conventional laparoscopy in surgical training modules in the drylab environment in the context of varying levels of surgical expertise. A total of 12 volunteers were recruited to the study: four staff, four postgraduate trainees, and four medical student interns. Each volunteer performed repeated time trials of standardized tasks consisting of suturing and knot tying using each of the three platforms: DaVinci, Zeus and conventional laparoscopy. Task times and numbers of errors were recorded for each task. Following each platform trial, a standardized subjective ten-point Likert score questionnaire was distributed to the volunteer regarding various operating parameters experienced including: visualization, fluidity, efficacy, precision, dexterity, tremor, tactile feedback, and coordination. Task translation from laparoscopy to Zeus robotics appeared to be difficult as both suture times and knot-tying times increased in pairwise comparisons across skill levels.