(UroToday.com) Monday mornings plenary session continued with an excellent presentation by Dr. Duke Herrell regarding emerging laparoscopic robotic surgical systems in Urology. Dr. Herrell put together a world class panel of urologists from across the globe to discuss some of the new and innovative robots currently being used.
Dr. Herrell began by outlining that most urologists in 1990’s were trained via laparoscopy. However, this was challenging given the steep learning curve and time required to develop skill with laparoscopy. This challenge was mostly overcome with the introduction of the Da Vinci Surgical System by Intuitive Surgical in 1999 which has now become the leading robotic platform with over 6900 units in use worldwide. Over the years Intuitive Surgical have rapidly developed the Da Vinci Surgical platform coming out with the new Xi system and now single port SP system. They have dominated the market for over 20 years with approximately 300 patents and excellent market penetration and acceptance.
Dr. Dasgupta then took the stage to present the Cambridge Medical Robotics (CMR) Versius robotic system. This system includes an open surgeon console with hand controls and the absence of foot pedal control allowing for a more ergonomic surgeon position. The surgeon wears 3D glasses which provides excellent depth perception. The robotic arms are mounted on a modular system that can be positioned around the patient and are approximately 5 mm in size.
Dr. Dasgupta outlined the IDEAL Stage 1 study for the CMR Versius robotic system for radical prostatectomy carried out in the UK. The primary outcomes were feasibility of the system, defined as no surgical complications during a case and no need for conversion to conventional robotic systems. Secondary outcomes were operative times, margin status and return to continence. The system was very easy to use with good articulation of the robotics wrists leading to fine control and superior suturing.
10 patients took part in the IDEAL study with 4 robotic radical prostatectomy, 3 pyeloplasty, 2 radical nephrectomies, and 1 adrenalectomy performed. There were no complications and no conversions which showed that the CMR surgical system was a viable alternative robotic surgical platform.
Dr. Shiroki from Japan then took the stage to discuss the brand new Japanese robotic surgical system called the Hinotori. Hinotori means Phoenix or firebird in Japanese and was the inspiration for the design of the robot. Hinotori is manufactured by Medical Android a new company arising from collaboration between the robotic departments of Kawasaki Industries and Sysmex. The unit consists of an operational unit, 4K vision cart, and surgeon cockpit. It was approved in Japan in 2020 and launched in 2021 with over 20 units currently in use.
The robot is equipped with 4 arms that allow for 8-axis movement and docking-free software-based pivot setting which allows for clearing of space around the trocars. More than 8 types of instruments are available and have 10 lives. The initial 20 prostatectomies performed with this system showed similar outcomes with a slightly increased docking time due to the extra console. Otherwise, the system performed well with excellent visualization and articulation. Future directions include surgical navigation systems, 5G telesurgery, and surgical robot autonomy.
Dr. Zhou from China then joined in via tele link to present the new Kangduo Surgical Robotic system currently in use in China. The Kangduo surgical robotic also includes an open surgical console with 2 screens that can display 3D models and VR reconstructions. The robot consists of 3 arms mounted on a beam linked to the KD-SR vision cart that is compatible with conventional laparoscopes as well. The main differences between the Kangduo surgical robot and Da Vinci systems include the open surgeon console, absence of a manual clutch, and suspended patient cart.
The Kangduo system has been used in multiple randomized control trial settings including pyeloplasty and prostatectomy showing good clinical results. A non-inferiority trial comparing the Kangduo system to the Da Vinci Surgical system showed excellent comparability with only docking time being slightly longer for the Kangduo system.
Dr. Rha from South Korea then took the stage to present the new Korean surgical robotic system called Revo-I which was developed in 2007 and finally approved in 2018. It is being used for urological, general surgery, and OBGYN applications in South Korea. The robot consists of 4 units, the surgeons console, operation cart, vision cart, and a virtual reality training station.
The surgeon console is very similar to the Da Vinci system providing similar touch and feel. Surgical staff such as nursing and anesthesia are very comfortable with using the system given the similarities. The operation cart is smaller than the Da Vinci system and docking times are comparable. 14 different instruments are available for use including a harmonic scalpel and vessel sealers. The vision cart is high definition, and the VR training system is built-in allowing for simulation and training. Approximately 281 cases have been performed with this system in South Korea by urologists, general surgeons, ENT, and OBGYN.
The Revo-I system is 40-60% cheaper than the Da Vinci System and is currently in use in various Asian, Middle eastern, and Mediterranean countries.
Dr. Alexandre Mottrie then joined the stage to inform us about the Hugo RAS surgical system from Medtronic. This system includes 4 modular robotic arms, an open surgeon console with extra screen and patient vision cart. The surgeon console operates with a pistol grip joystick controller which is ergonomic for the hands. 3D glasses are required with use of the console.
The robot has been used in various clinical settings including robotic radical prostatectomy with good visualization, articulation, and outcomes. The robot is useful in multi-quadrant surgery given the modular arms that can be positioned in any configuration around the patient.
The benefits of this system include the open surgeon console, modular arms for multi-quadrant surgery, and cost savings by using less arms for uni-quadrant surgery. Dr. Mottrie concludes that the Hugo-RAS system may represent an excellent contender in the robotic surgery space.
Next, we were joined by Dr. Crivellaro on stage to discuss the Da Vinci Single Port surgical system. He commended all the new robotic systems on the market; however, he points out that most of these systems are iterative versions or improvements on the already established Da Vinci Xi system and that true innovation in the robotic surgery landscape are represented by the introduction of single port robotic systems. These systems are unique and disruptive to the current market. One such system is the Da Vinci SP system. This system uses a single port to deliver an 8 mm flexible camera and three 6 mm robotic instruments. Each instrument has an articulated elbow and deflectable shoulder. The instruments have approximately 12 lives with the camera having 22 lives. The camera is a fixed cost however, Intuitive surgical provides camera changes free of cost.
The Da Vinci SP is designed for work in small spaces and its true applications become apparent in surgery confined to small spaces such as retroperitoneal partial nephrectomy. It allows the surgeon to control traction, application of robotic bulldogs, excision of tumor, and suction. The platform was approved the FDA in 2018 and is scheduled for approval in Europe in 2023. Dr. Crivellaro believes we are still in the early adopter phase however this gap is quickly being bridged and over 100 units are deployed in the United States currently.
Finally, we are joined by Dr. Hemal to discuss the current gold standard in robotic surgery the Da Vinci Xi Surgical System. He described the key features of this system including the Endo-wrist technology which was designed with 7 degrees of freedom and 90 degrees of angulation. Recent introduction of the vessel sealers and extended vessel sealers provide potential for improved efficiency and less blood loss by being able to seal vessels of up to 7 mm. Synchroseal is a next generation vessel sealing device that uses bipolar energy which causes less charring and minimizes lateral spread of energy. Next robotic staplers were introduced with 30 and 45 mm loads and smart clamp technology allowing for accurate stapling and ligation.
The Da Vinci Xi System is versatile and can be used for all body types. It can be side docked and has a targeting function allowing for patient clearance. Side docking also reduces the chance of neuropraxia and can be used in patients with limited hip abduction. Other benefits including multi-quadrant surgery with an overhead docking position that is facilitated by the rotatable boom, targeting feature, and integrated table. Indocyanine green (ICG) is also available which enhances visualization of neurovascular structures and facilities nerve sparing in radical prostatectomy and margin status in partial nephrectomy.
Dr. Hemal concludes that the Da Vinci Xi system is the gold standard for robotic surgery since 2014 providing the best visualization and a wide range of instruments. It is versatile, flexible, and can be used for any BMI. It is cost effective, facile, and allows for training and education. Overall, with widespread deployment more surgeons can use this system to provide excellent care to their patients.
Presented by: S. Duke Herrell, MD Vanderbilt University, Nashville, TN
Expert Panel: Dr. Prokar Dasgupta – CMR Versius Surgical System
Dr. Ryoichi Shiroki – Hinotori Surgical System
Dr. Liqun Zhou - Kangduo Surgical Robotic System
Dr. Rha – Revo-I Robotic Surgical System
Dr. Mottrie – Hugo-RAS Robotic Surgical System
Dr. Crivellaro – Da Vinci SP Robotic Surgical System
Dr. Hemal –Da Vinci Xi Robotic Surgical System
Written by: Sohrab Naushad Ali MD, MSc, FRCSC Endourology Fellow, Department of Urology, University of California Irvine, @sohrabnaushad on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.