COMMENT
Robotic surgery is a reality in the practice of urologists in developed and in several
undeveloped countries. The first clinical procedures were performed in 2000 and since
then was observed a fast spread in surgical practice, especially in Urology (1).
The Intuitive company remained exclusive in the market of production of robotic platforms
in the past two decades. With the end of patent, different companies are developing
new robotic platforms. The market will select which equipment will add real clinical
benefits to be incorporated into daily practice (2).
To be able to evaluate a new technology, is necessary to remember the main issues
related to the standard robotic platform with impact on the improvement of quality
and surgical technique. Among them, it is important to mention (3, 4):
Surgeon's ergonomic;
Surgeon autonomy in controlling the camera and others instruments.
Three dimensions vision;
Tremor elimination;
Instruments that allow a wide movement similar to surgeon hands;
Safety devices.
Is also important quote the issues and limitations of the first platforms that still
hinder or preclude them from being implemented in many centers. Among them can be
mentioned: high cost, availability for training and qualification.
Thus, for a new technology to be interesting, it must offers the same benefits and
supply some needs and limitations not met by other platforms.
The company that is entering in the competition and in this technological race is
Medtronic. One of the largest medical device companies in the world produced its first
robotic surgery platform called Hugo™ RAS (HR) - Medtronic, Minneapolis, MN, USA.
This platform emerged with the aim of offering a safe tool that allows the surgeons
to operate with the same quality as they perform with the "standard" platform.
As a challenge, this technology comes with the proposal of having more accessible
cost, allowing access to a greater number of patients and the training of more surgeons.
The "open" console brings the concept that people in training can follow the surgery
with the same view of the surgeon, improving the learning curve. Other possible benefit
is to be multi-modular with the objective of being more versatile and able to favor
"docking" using only the necessary number of arms.
To talk about incorporating a new technology, is necessary remember that there are
two sorts of surgeon's profiles. Those who have no experience with robotic surgery
and those who are already used to the Da Vinci (DV) platform and in this moment must
adapt to a new one.
The aim of this article is to report the results that are already in the literature
and our initial experience as well as future perspectives important to highlight.
LITERATURE REVIEW
The literature about Hugo™ RAS system (Medtronic, Minneapolis, MN, USA) and Urology
is still scarce due to the fact that the first surgeries with this platform started
in 2021.
The initial studies proposed to prove the safety and functionality of this platform
in performing oncological and non-oncological urological surgeries.
Among the uro-oncologic surgeries, the radical prostatectomy is the urologic surgery
most performed worldwide. In this direction, it is also the most discussed topic at
articles. The use of HR to treat prostate cancer appears to be a safe technique, without
losing agility and maintaining satisfactory perioperative results (5-8).
The same feasibility was identified when performing adrenalectomies and nephrectomies.
Despite these studies being observational and with few patients included, the initial
results described generate an inference that the using the HR the oncologic results
are satisfactory and maintains the perioperative results obtained with the standard
platform (9-11).
The application of the new robot system is not restricted to the cases already mentioned,
studies have also shown a role in non-oncological surgeries such as simple prostatectomy,
sacropexy and others (12-14).
Description and characteristics of the new platform
For the adoption and adaptation with a new platform, it is of fundamental importance
for the surgeon to have detailed knowledge of the platform and its resources, as well
as its limitations.
It is important to highlight that before the start of the transition to the new platform,
our team already had the experience of more than 2,000 procedures with the "Da Vinci"
platform and, therefore, it is natural to compare different parts of each equipment
with the other.
The HR robot consists of a surgeon console, modular Arms carts and a main tower (Figure-1).
Figure 1
Complete system with surgeon console, main tower, and modular Arms carts (from the
right to left).
Console
3D screen
In the DV robot, the surgeon is "immersed" in the console and the surgeon needs to
remove the head from the console to have visual contact with the operating room.
In HR, the surgeon looks at a "television screen" with 3D glasses and, with that,
it is possible to follow the team's movement.
It is important to highlight that the surgeon's glasses have a sensor that, if the
surgeon looks to the sides, the arms are locked for safety. This feature of the HR
has the advantage of allowing other people to follow the surgery with the same view
of the surgeon and allows the surgeon to keep informed about everything that is happening
around, however, the great disadvantage is that external factors can disturb the concentration
of surgeon.
Our impression is that this console allows a better ergonomic position because is
possible to sit more comfortably. In DV the surgeon has to lean a little forward to
have a great view of the screen (Figure-2).
Figure 2
A) Fellows and students watching the surgery with the same 3D view of the surgeon;
B) HUGO™ RAS console, pay attention to the surgeon's ergonomics; C) Sensor on top
of the screen that, when the surgeon removes his face, the arms stop working, D: DV
Console, pay attention to the surgeon's ergonomics.
For some surgeons the open console was strange and more challenging because the frequency
of movements in the room distracts the surgeon attention. However, in our case to
avoid this, we placed the monitor facing the wall and request that as few people as
possible circulate in the operating room during the procedure. The image quality is
excellent, the major difference is that we do not have the feeling of being immersed
and the image is a little further away, in our view this does not affect the performance
of surgeries.
Pedal
The Pedal is similar to the DV containing additional pedals for future harmonic instruments
implementation. In contrast with DV, the HR pedals have some safety mechanisms for
activation energy and changing the arm in movement (Figure-3).
Figure 3
A) Pedal of Da Vinci; B) Pedal of Hugo™ RAS.
For both monopolar and bipolar power activation, it is necessary to initially press
the pedal for 1.5 seconds, release it and then activate it again. If the energy pedals
remain for more than 30 seconds without being used, a new activation will be necessary.
In the same way is the instruments swap pedal; in the DV one click is enough and the
arm in use changes, in the HR it is necessary to keep it pressed for 1.5 seconds for
the change occurs.
Initially these issues did not please us, as it delayed the procedure since we often
did not activate it. However, with the passing of the procedures, activation became
something natural.
We believe that, for surgeons at the beginning of the learning curve, this is an important
safety mechanism, as we often experience surgeons in training inadvertently activating
the energy pedals, however, we believe that it may be an option that could be activated
according to the surgeon preference and necessity.
Manual control
HR hand control has a different format than DV. In HUGO™, we hold it as if it were
a "revolver handle", we work with the index fingers and the first finger, and the
third finger is used for the "Clutch" (Figure-4 and Figure 5).
Figure 4
A) Manual control of Hugo™ RAS (right hand); B) Manual control of HUGO™ RAS (left
hand); C) manual control of Da Vinci.
Figure 5
A) manual control of Da Vinci; B) Manual control of Hugo™ RAS.
The "trigger" button has two functions. A superficial grip locks the arm, and a deep
grip performs the "clutch", that is, the surgeon moves his hands to have poor ergonomics
without the tweezers moving inside the patient. This double function is one of the
functions that we least like about this console, because often we just touch it superficially
and the arm locks, and the idea was to make a clutch. But we also observed that with
more cases performed these events became more infrequent.
Modular arms
The HR has modular arms carts. In this perspective, the surgeon can decide how many
arms are needed for each type of procedure. The arms have a wide range of motion and
can be placed in a very versatile way.
Initially, we believed that, as it is multi-modular, it would occupy less space in
the operating room, however the arms are still large with a robust base and takes
up more space than DV (Figure-6).
Figure 6
A) Da Vinci Xi arms; B) Hugo™ RAS Modular arms.
The arms of the HR have 85 cm, bigger than those of the DV that have 53 cm (Figure-7).
These longer arms make it a little more difficult for the assistant to manipulate
and are more susceptible to collisions during the procedure.
Figure 7
A) Da Vinci Xi arm length; B) Hugo™ RAS Modular arm length.
This is an important point of attention because the assistant always works in a more
uncomfortable way in relation to the DV and he needs to be attentive to robot arm
does not collide with his body.
Instruments
The HR instruments are shorter than DV instruments (Figure-8).
Figure 8
A) Table with Da Vinci instruments; B) Table with HR instruments
HR Maryland forceps has 53 cm and HR large needle driver has 52 cm. The longest HR
instrument commonly used in urology is the double fenestrated with 54.3 cm total length.
DV Maryland forceps and large needle driver has, respectively, 62 cm total and 61
cm total size. The longest DV instrument used in urology is prograsper with 63 cm
(Figure-9).
Figure 9
A and B) DV prograsper total length; C and D) HR large needle driver total length;
E and F) HR bipolar maryland forceps total length.
The instruments disposable in Hugo™ RAS are: scissors, fenestrated bipolar, Maryland
bipolar, large needle driver, extra-large needle driver, Cadiere forceps, Cadiere
secure, double fenestrated and toothed claw.
The needle driver has an excellent gripping force, and the system has a possibility
to set a "2 times" rotation. This was a very interesting characteristic that facilitated
the performance of the vesicourethral anastomosis. There are two kinds of needle driver:
the large and the extra-large.
Scissors are more delicate and sharper, however, at the moment they are still single-use
and every 40-50 minutes you have to change a new one. At first, we found it odd and
worried about the cost. But the company does not charge extra for this.
The great advantage is that we operate all the time with excellent quality scissors.
When we close the scissors, they give a little bounce. At first it seemed strange
but during the procedure it did not impact safety and quality. But it is certainly
a relevant point for the company to improve.
Regarding the traction instruments, it is important to highlight that the Cadiere
forceps does not have a great traction capacity, making some steps of the procedure
difficult, being more recommended to use the "cadiere secure" or the "toothed".
To perform urology surgeries the instrument from DV most missed was the Tenaculum
to traction the prostate adenoma during simple prostatectomy. To remedy the lack of
this instrument, the surgical assistant needed to use laparoscopic toothed gripping
forceps to help trace the adenoma during the procedure, which we have as a weakness
as it impairs the speed and autonomy of the surgeon.
Main Tower
The main tower is very similar to the DV Xi. The components are a HD screen, a Karl
Storz Imagem system and a Valleylab energy platform.
The image generated by Storz shows a brilliant tridimensional high-definition view
and helps to identify the correct surgical plans during the procedure.
The endoscope can be placed in each one of all arms carts. This point can be extremely
helpful during performing a surgery with steps in different quadrants.
DOCKING
At first moment, as it was a multi-modular platform, we believed that docking could
be made easier. However, we believe it is one of the biggest challenges in daily practice.
For each module, a precise positioning in relation to the table is required. Each
arm is attached respecting two angles. The first is the tilt angle - inclination of
the operative arm compared to the operative bed. The second angle is between the robotic
arm and the head of the patient.
The Medtronic recommends angles for each arm according to the surgery and add that
alterations may be necessary according to the patient's body type, the patient's pathology
or the surgeon's preference. (Figure-8) In the first cases we try to reproduce exactely
what the suggested regarding the docking, trocater's placement and patient suggested
position. But in few cases, we realized that, to reproduce our technique some modification
must be performed (Figures 9-11). Important to point out is that the angle of the
arms can be adjusted according to surgeon preference without compromise the functioning
of the arms carts.
Figure 10
A) Medtronic recommendations for prostatectomy. The endoscope trocar (yellow circle)
is placed 16 cm or less from the target. The right arm trocar is placed in a line
5 cm bellow the endoscope line and need stay at least 8 cm distant from the endoscope
(black circle). The left arm trocar follows the same instructions of right arm in
contralateral side (black circle). The fourth arm of surgeon is placed in the same
line of endoscope trocar, with 8 cm or more distant from the right arm. The assistant
trocar (orange circle) needs to be placed at least 5 cm distant from the left arm.
All trocars need to stay at least 2 cm from bone prominence; B) Medtronic recommendations
for left nephrectomy. The endoscope trocar (yellow circle) is placed at least 5 cm
from the line where will be placed the left and right arm of surgeon. At least 5 cm
of distance between the fourth arm trocar and right hand of surgeon. The robotic trocars
need to be placed at least 8 cm distant from each other. The assistant trocar should
be placed medial to the left and right arms and near the median line of patient, at
least 5 cm from the other trocars.
Figure 11
A) Image of trocers placement - radical prostatectomy with Hugo™ RAS; B) Right parcial
nephrectomy with Hugo™ RAS.
SECURITY
The HR system has many more safety features than the DV. When operating with the HR,
the team must get used to triggering different alarms.
The goggle sensor and the pedal drive system make the procedure safer, especially
for surgeons at the beginning of the learning curve.
It is important to highlight that, so far, we have not experienced any adverse events
with the platform, and we believe that it is a technology that follows all the necessary
protocols to perform safe robotic surgery.
SURGICAL TECHNIQUE
In radical prostatectomy, it was possible to perform the same standard of surgical
technique since the first procedure, making it possible to perform surgery with the
same technical rigor used in surgeries with the DV. It is only necessary to adapt
it to the assistant's portal.
Regarding partial nephrectomy, we believe that we will need more time for adaptation,
the concept of trocar placement changes a lot in relation to the DV. These modifications
are necessary to reduce conflict. In this procedure, we found it very difficult for
the assistant to carry out some steps, which made it difficult at times for an adequate
presentation. The procedures with HR were uneventful, respecting all oncological principles.
However, we believe that it is still necessary to improve the standard placement of
trocars to facilitate the performance of a procedure with the same standards as the
DV.
SIMULATOR AND PERMISSION TO USE
The HR has a simulator with some tasks like manipulation of needle, using of instruments,
suture exercises and others. The repetitive exercises in simulators reduce the time
necessary in dry and wet lab. For new robotic surgeons it allows get familiar with
the platform and acquire a proficiency in some robotic activities.
The quality of simulator and exercises presented is excellent and similar to DV.
About the permission to surgeon use, Medtronic suggests the Hugo™ RAS should be used
by medically trained surgeons with a full understanding of the safe operation of the
system, in accordance with the hospital's credentialing policies regarding the use
of new equipment. This robot access policy is more flexible and comprehensive compared
to DV, delegating to the hospital the function of releasing qualified surgeons for
the procedure.
LIMITATIONS AND FUTURES PERSPECTIVES
Some limitations of the Hugo™ platform must be considered here, for example, the lack
of glasses and 3D vision to assistant in the surgical field. The 3D glasses for the
assistant would allow better image quality and approximation between the surgeon's
and assistant's vision. The absence of some auxiliary resources for more complex surgeries,
such as firefly with indocyanine green (fluorescence capability that uses near-infrared
technology) and the use of robotic ultrasound, which are present on the Da Vinci platform
and not on the Hugo™ RAS, is a limitation of the new robotic model.
Indocyanine green is most used in urological surgeries for complex partial nephrectomies
- large renal tumors or with multiple renal arteries - and also for vascularization
assessment during neobladder surgery. In other specialties such as gynecology, this
feature is also important, for example, for identifying sentinel lymph nodes.
Robotic ultrasound on the Da Vinci platform allows combined intrabdominal vision and
ultrasound, helping in various situations such as demarcation of tumor boundaries
during complex partial nephrectomies.
CONCLUSIONS
HR has more safety and training features for new surgeons without previous experience
with robotic surgery.
The surgeon may realize a training with the simulator until be comfortable with the
console and realizing automatic and natural movements. At least 8 hours in simulator
training Is suggested.
The surgeon training is so important like the team training. A team motivated and
familiarized with the robotic assisted system and docking is extremely important to
the success of the platforms transition.
For surgeons with experience with the DV, the transition seems to be friendlier in
radical prostatectomy, however, for partial nephrectomy, the transition is more challenging,
and the team must already have experience with the new platform.
We believe that Medtronic could improve the software to make it more personable. The
activation of the energy, the double function of the trigger button and the necessity
of keep holding the bottom to change the arms, could be a configuration option according
to the preference of the surgeon. Others features that need to be developed are 3D
glasses for the surgical assistant, firefly with indocyanine green and robotic ultrasound
with vision for the console surgeon.
The size of the Arms module must be reduced the size of the arm as well to facilitate
the docking and bed side assistant work.
We need a larger casuistic to be able to construct more solid considerations about
this new robotic platform.