Robot-Assisted Laparoscopic Radical Prostatectomy Utilizing Hugo RAS Platform: Initial Experience

Introduction

Robot-assisted surgery is used in the management of many benign and malignant diseases in urology. The most commonly done robot-assisted procedure in urology is radical prostatectomy for the management of prostate cancers. ¹

Open radical prostatectomy is a procedure that was often associated with high morbidity and blood loss. ² The advent of laparoscopy and robotics has helped reduce the associated morbidity. The disadvantage of laparoscopic surgery with its limited maneuverability remained the challenge in performing pelvic surgeries, especially complex steps of reconstruction such as vesicourethral anastomosis. The introduction of the surgical robotic system combined the advantage of minimally invasive surgery with magnification and three-dimensional (3D) vision and the dexterity of an open procedure. ³

Robot-assisted laparoscopic surgery provides advantages both for surgeons and the patients; is preferred for its 3D view, magnified vision, articulating wrists to give multiaxial movement, lack of hand tremor, and surgeon comfort. It is also advantageous from a patient's perspective because of the reduced postoperative pain, decreased duration of hospital stay, early recovery, and minimal blood loss. ^4,5

The most widely available robotic system is the DaVinci surgical systems by Intuitive, California. ⁶ In recent years, other robotic platforms have emerged offering different modalities to widen the reach of robotic surgery. ^7,8,9

One of the newest systems on the market is the Hugo RAS™ robot introduced by Medtronic™. ¹⁰ In continuum with our article initially introducing the Hugo RAS robotic system, herewith we present our experience with utilizing the Hugo RAS system for radical prostatectomy. Secondarily we have also attempted to make a comparison of the outcomes of our study with similar surgeries done with the DaVinci system.

Materials and Methods

Results

A total of 17 radical prostatectomies were performed in the Hugo RAS system. The median age and body mass index (BMI) of the patients were 68 years and 24.6 kg/m². The median preoperative prostate-specific antigen (PSA) value was 12.39. The median operative and dock times were 195 and 170 minutes. The median time to dock the ports was 10 minutes. The time to dock the ports was highest during the first procedure (15 minutes) and subsequently decreased to 5 to 10 minutes from the third case.

There was no notable operative difficulties or anesthetic complications. None of the patients had blood loss severe enough to require transfusions. All patients were either performed as a daycare procedure or had an overnight hospital stay. An R0 resection was achieved in all the patients. All patients underwent template extended pelvic lymph node dissection.

All the patients were doing well at the initial follow-up of 1 week to remove their Foley's catheter and subsequent 1-month follow-up as well.

Data from patients who underwent radical prostatectomy in the DaVinci platform (n = 17) were collected and used to compare the initial outcomes as mentioned earlier. The median age of the Hugo and DaVinci groups was found to be the same. There were no statistically significant differences found between the two groups with respect to age, BMI, preoperative PSA values, and presence of preoperative lower urinary tract symptoms. The demographic profile and preoperative data have been elaborated in Table 1.

The median total operative duration was found to be 210 minutes and 195 minutes in DaVinci and Hugo robotic systems, respectively. The operative details and immediate postoperative details, including histopathologic outcomes, have been shown in Table 2.

None of the patients in both cohorts had achieved erections in the 3-month follow-up period as conventional nerve-sparing surgeries have not been performed as yet in the Hugo platform; the DaVinci patients were selected to match the study population. The median PSA value at 3-month follow-up was 0.07 in both groups and all patients had achieved continence recovery to one protective pad in both groups.

Discussion

Radical prostatectomy involves the removal of the prostate gland, surrounding tissues and the seminal vesicles. It is the standard surgical management offered for prostate carcinoma. There are many approaches to performing this procedure, including open retropubic, open perineal, conventional laparoscopic, and robot-assisted laparoscopic procedure. ¹¹

Hugo RAS robotic platform was recently launched by Medtronic for clinical use. It comprises independent arm carts, an open surgeon console, and a robotic processing unit with an endoscope, energy source, and monitor. ¹²

In our previous study, we introduced an initial clinical trial of the robotic system in urologic procedures. ¹² The purpose of this study was to understand if the newly introduced Hugo RAS system could safely deliver clinical care for patients undergoing radical prostatectomy. We have also attempted to understand if these outcomes were comparable with existing platforms such as the DaVinci robotic system that was available at our institute. Radical prostatectomy is one of the most common robotic procedures in urology and hence was an ideal procedure to understand the merits and demerits of working with the newly launched robotic system.

The port positions in the Hugo robotic system were that of lazy W with the camera in the supraumbilical position and the other three arms placed 8 to 10 cm apart from each other in a lazy W manner. The assistant port (12 mm) was placed above and medial to the right anterior superior iliac spine. The port positions for the Hugo RAS platform are similar as in the DaVinci Si system. However, the posts are placed in a straight line in the DaVinci Xi system.

The docking process in the Hugo system was done at the prescribed angles given by Medtronic. The authors felt that with subsequent procedures on the Hugo RAS, the docking process of the independent arm carts became easier and faster owing to identifying the ideal layout for the arm carts and pre-emptively knowing the docking angles before the procedure began. The authors do feel that although the docking process is slightly longer with the Hugo RAS, the independent arm carts allow for different permutations and combinations for different procedures and larger working space for the assistant surgeon.

The independent arms are kept at a distance from the patient. And hence there is a larger footprint for the Hugo RAS platform compared with the DaVinci. However, because the arms are independent, any arm could be deployed and disconnected (or even replaced) without the surgery being affected.

The steps of the surgery include dropping of the bladder, incision of endopelvic fascia, anterior followed by posterior bladder neck incision, division of seminal vesicles, wide local excision of neurovascular bundles and separation from the rectum, division and suturing of dorsal venous complex, division of urethra, bilateral extended pelvic lymph node dissection and finally urethrovesical anastomosis using continuous sutures. ^13,14 The surgical approach in all cases (both Hugo RAS and DaVinci platforms) had been the standard transperitoneal surgery and none of the steps needed modification or change in the newer platform.

The instruments utilized with the Hugo system were monopolar scissors, fenestrated bipolar, cadiere forceps, and a needle holder. In contrast, prograsp forceps was used instead of cadiere in the DaVinci platform.

With regard to the console system, the surgeons noted easier communication with the surgical team and less strain on the neck while working with an open console of the Hugo system as compared with the closed console of the DaVinci.

The authors did not find any significant difference in the surgical times between the existing and new platform. The slightly higher times in the DaVinci platform might be a reflection of a slightly greater number of advanced cancer undergoing surgery (nonselected patients) and also because of the fact that trainee surgeons perform part of the operation in the existing platform. All the patients enrolled in this study showed no postoperative morbidities during the 1-month follow-up.

With regard to pathologic outcomes, there were no differences noted between the two systems in terms of the margin positivity. The only significant difference seen was the node yield, which was higher with the DaVinci system. This difference in the node yield cannot be explained by the authors and it is postulated that this could be because of the higher number of T3/high-risk disease patients in the DaVinci cohort. There were no differences between the two systems in terms of continence recovery at the 1-month follow-up.

Cost of the robotic surgery had always been a concern. During the study period, the instruments were available free of cost. It is anticipated that the instruments in the Hugo RAS platform might be given more uses per instrument thereby reducing the cost per operation.

The authors are aware that without randomization, the comparative subjects chosen in the DaVinci system are subject to selection bias. This was done purposefully as the authors believe randomization cannot be done safely and ethically with a novel system such as the Hugo RAS. We hope to encourage more studies such as the one presented earlier in different specialities to understand its merits and demerits before attempting randomization.

Conclusion

The authors believe that the Hugo RAS platform provides comparable results to the most common robotic system (DaVinci systems) in terms of operating times, postoperative complications, and length of stay. Although it requires a short learning curve, especially with the pistol grip, it expands the existing array of RAS to increase availability and affordability. In adapting its use to other surgical branches, laboratory simulations can help with understanding the ideal placement and docking of the robotic arms to ensure smooth completion of the procedure.