Robot‐assisted radical prostatectomy using hugo RAS system: The pioneer experience in Taiwan and Northeast Asia

Among the novel robotic platforms, the Hugo RAS system is the second most studied platform, next to the da Vinci system, and we aim to address our experiences in radical prostatectomy (RP) with the Hugo RAS system.

Robotic surgeries have thrived since the 1990s because of the need to perform telepresence surgeries, [1][2][3] such as traumatic surgeries, on battlefields.Robotic surgeries may also help resolve medical needs when humans are able to migrate to outer space in the future. 4rrently, under the impact of fifth-generation (5G) wireless communication technology, tremendous revolutions in the medical industry are proceeding.With advances in 5G technology, telepresence and telesurgery can maximise their superiority, and remote surgeries with robotic platforms can be performed with the least latency. 5 the U.S. medical market, 6 the needs are expected to continue growing not only in the overall robotic surgical fields but also in urological surgeries.In Taiwan, there have been over 60 000 robotic surgeries since 2005, 40% of which are in the urological field.
Currently, over 95% of robotic surgeries in Taiwan are performed using the da Vinci system (Intuitive Surgical Inc., Sunnyvale, CA, USA).
In global markets, even during the COVID-19 outbreak, the use of this system maintained a compound annual growth rate of 16%.This rate returned to the pre-pandemic level of 18% when COVID-19 started to calm down in 2022. 7Based on autonomy, current robotic platforms can be categorised as semi-active, synergistic, and active.It was categorised as a synergistic telemanipulator system, and the computer in the console allowed connection to other devices and software, 8,9 making surgeries easier and more innovative.
The remaining robotic surgeries in Taiwan utilised the Senhance robotic system (Asensus Surgical Inc.).In contrast to the da Vinci system, the Senhance robotic system features an open screen that offers two-dimensional (2D) or three-dimensional (3D) imaging.This system represents an evolution of laparoscopic devices, with certain advantages preserved, including haptic sensations.Additionally, it is compatible with commercial laparoscopic trocars.However, some drawbacks are also present, such as limited degrees of freedom in wrist motion. 10In specific procedures such as a prostatectomy performed in the deep pelvis, the intraoperative conversion rate could be as high as 8.4%. 11,12 2019, Medtronic (Minneapolis) introduced their robotic system, Hugo RAS (Medtronic), by demonstrating the first roboticassisted radical prostatectomy (RARP) on a cadaver.4][15][16][17][18][19][20][21] India became the first Asian country to adopt this system for human surgeries.Subsequently, in November 2022, the Taiwan Food and Drug Administration approved the Hugo RAS platform for clinical surgeries, making Taiwan the second Asian country to embrace this system for clinical use.For over a decade, 22 the da Vinci system has been the dominant choice for robotic surgeries in Taiwan, essentially synonymous with robotic procedures.Presently, the Hugo RAS system represents the third option for surgeons and patients in Taiwan.In this report, we present the first 12 cases of RARP performed using the Hugo RAS system.In panels 1A and 1B, the initial 11-mm camera port was positioned above the umbilicus using the open method (port 1).Ports 2 and 3 represent the 8-mm cadiere forceps and bipolar Maryland forceps, respectively.The right-hand 8-mm port 4 was placed with the monopolar scissor.Ports 5 and 6 serve as assistant ports with sizes of 12 and 5 mm, respectively.Ports 2 to 6 were inserted directly from the skin incision under the guidance of the port 1 camera, ensuring a distance of at least 8 cm between the ports.During the operation, the 5-mm assistant port served as the tunnel for the suction tube and 12-mm assistant port allowed large devices, such as laparoscopic graspers and large-sized laparoscopic clip appliers, to be entered.tw/tics2023/en/tics-the-future-of-integrative-urotech-internationalsymposium/; Taichung, Taiwan). Figure 1 illustrates the port displacement and Hugo RAS settings.We recorded basic information regarding the patients and their diseases, robotic arm docking times, surgeon console times, postoperative adverse effects, and hospital stays.RARP was recommended to patients based on the risk categorisation for localised prostate cancer (PCa) by the National Comprehensive Cancer Network. 23I G U R E 2 Docking of robotic arms.The port numbering corresponds to Figure 1.After placing the patient in a 25-degree head-down Trendelenburg position, tilt angles for each port were adjusted for docking.The vertical tilt angles for ports 1 to 4 were −45°, þ15°, −30°, and −30°, respectively.The power tower was positioned on the leg side.Robotic arm carts for ports 1, 2, and 3 were located on the right side of the power tower, while robotic arm cart 4 was located on the left side.After setting the tilt angle, the robotic arms were docked to the ports, and the horizontal angles were adjusted.The designed horizontal angles for ports 1 to 4 were 175°, 105°, 140°, and 220°, respectively, with a variation of up to 5°considered acceptable.

F I G U R E 3
The operation console.(A) The tracking device (red arrow) was integrated into the 3D glasses worn by the operator.The motion from the glasses would be captured by the monitor.(B) The sitting position was natural and comfortable, similar to watching television at home.The controllers were positioned closer to the laparoscopic devices and featured multiple functional buttons.
Draping at one RARP was performed by a circulating nurse and scrub nurse.The docking times of the robotic arms were measured from the incision to the skin until the completion of all port connections.The initial 11-mm camera port was created using the open method, and the ports were positioned in the lazy-W manner as instructed, 19 and executed by the same surgeon.To facilitate the RARP procedure, four robotic arms and two assistant ports were set up (Figures 1 and 2).The RARP operations were carried out by the same surgeon (Figure 3).The RARP procedure and perioperative plans followed a previously published protocol. 24Any intraoperative pauses were recorded separately from the console time.The circulating nurse calculated the blood loss after the closure of all wounds.
Our primary objective was to identify the cutoff case in which our team exhibited the most significantly improved level of coordination.We collected various parameters, including draping time, docking time, time pause for troubleshooting, console time, and blood loss.These data were recorded in Microsoft Excel (Microsoft Corp.) and later analysed using R (R Core Team (2021).R: A language and environment for statistical computing.R Foundation for Statistical Computing, Vienna, Austria.URL https://www.R-project.org/).For the analysis, the "esvisˮ package was utilised to calculate the standard mean difference (SMD).A significance level of α = 0.05 was considered statistically significant.

| RESULTS
During this period, 12 men underwent RARP, including the last case in a live demonstration at the conference.The general data are listed in Table 1.All patients had localised PCa, and none had received neoadjuvant therapy before RARP.Six patients were diagnosed using a transrectal ultrasound (TRUS)-guided systematic biopsy.Two patients were diagnosed with PCa via fusion biopsy using the Prostate Imaging Reporting & Data System (PI-RADS) v.2.0, and score five lesions 25 were identified on 3.0T Magnetic Resonance Imaging.Two men had incidental PCa after transurethral prostate (TURP).The remaining two men accepted theranostic RARP because of highly suspicious PCa, as judged by our nomogram. 26ring the perioperative course, only one man was admitted to the intensive care unit after surgery due to chest tightness and cold sweats.After consulting related subspecialties, he was diagnosed with hyperventilation due to a panic disorder, and no invasive procedures were performed.
The intraoperative data are shown in Table 2, and Hedges' g was calculated as shown in Table 3. Judging from the SMD, after Case 7, the pre-console preparation from draping to the completion of the docking of the robotic arms could be significantly accelerated.After Case 2, an experienced operator could remarkably enhance the console time when performing RARP.The intraoperative pauses for troubleshooting were mostly due to the malpositioning of the docking  ports, which caused collisions of the robotic arms.After Case 3, the intraoperative pauses for troubleshooting were significantly reduced, and the operation was performed better without interruption.

| CONCLUSIONS
The Hugo RAS system is currently the second most frequently studied robotic platform after the da Vinci system. 27Either in the Hugo RAS system or the da Vinci system, a surgeon sitting in front of the console needs to depend on the visual display to imagine the feedback from his/her real surgical fields.In this way, the display technology could be pivotal in a robotic platform.In display technology, 3D polarised glasses are utilised for flat screens of the Hugo RAS system, whereas the da Vinci system adopts a 3D stereoscopic imaging.To some degree, this imaging display distinguishes these two systems.The 3D stereoscopic technology in the da Vinci system directly creates two independent visions for both eyes, while the Hugo RAS system interweaves two full HD (high definition; 1080p) visions to create the entire 3D image.In this way, just like watching 3D movies, the Hugo RAS system requires a pair of polarised glasses for visualisation.In fidelity, the binocular disparity of 3D stereoscopy in the da Vinci system makes the imaging display closer to reality, 28 whereas the 3D flat screen with its matched polarised glasses has inferior quality, especially in the horizontal plane. 27Theoretically, the right and left lenses of polarised glasses are 90°apart, and thus we could discuss the resolution by the categorisation of vertical and horizontal planes.In technology that the Hugo RAS system adopts, the horizontal plane resolution will be halved as the da Vinci system, while the vertical one keeps the same as the da Vinci system. 28wever, in order to gain the 3D stereoscopic reality in the da Vinci system, a surgeon needs to bury his/her head in the headset where the visual reality is synthesised and directly expose his/her eyes to the sharp light projecting from the screen.In this aspect, 3D polarised display technology contributes to some advantages of the Hugo RAS system.First, the 3D glasses used for the display can filter part of the sharp light projecting from the monitor and serve as a barrier for protection. 29Second, 3D polarised display technology does not require the surgeon to be buried in a closed headset, allows surgeons to sit in their natural position, or allows them to communicate with the surgical teams in an open environment.These advantages might greatly increase the surgeon's comfort and the efficiency of the entire surgical team.However, this study included only a single surgeon with the same assistant and nurse.Related subjective questionnaires should be designed in future studies.
The design of the Hugo RAS system is complex and sophisticated: it consists of six hinges and offers seven degrees of freedom for each robotic arm. 20This design can maximally increase the range of motion and manipulation.From our data, the median console time for an experienced urologist 30 for RARP was approximately 145 min in the first 12 cases.This console time seemed to be much shorter than the first 30 cases of RARP performed using the da Vinci system, which required an average of more than 3 h. 22In addition, our initial data demonstrated that after the first two cases, the console time significantly decreased by one standard deviation for a surgeon.This implies that under the current market overwhelmed by the da Vinci system, the Hugo RAS system does not require the surgeon to reboot their learning curve if they are already familiar with it.In addition, our data also indicated that the pre-console preparation was remarkably more efficient in the seventh case, including the intraoperative pauses for dealing with troubleshooting.Similar findings were also reported in the published literature that RARP operated with the Hugo RAS system would not elongate the pre-console preparation and console time compared with RARP operated with the da Vinci system. 21This characteristic might give the Hugo RAS system advantages in the market and make it more acceptable for surgeons operating with the da Vinci system.

T A B L E 2
The intraoperative data.
The robotic arms' draping time (minutes) Intraoperative pause for trouble shooting (minutes)

Hedges' g (with 95% confidence interval)
The robotic arms' draping time a The robotic arms' docking time was calculated using the last 5 cases as the treatment and the first 7 cases as the control.
The operation console time was calculated by using the last 10 cases as the treatment and the first 2 cases as the control.
The Intraoperative pause for trouble shooting was calculated using the last 9 cases as the treatment and the first 3 cases as the control.* p < 0.05.OU ET AL.
This study was approved by the institutional review board of Tungs' MetroHarbor Hospital and the written informed consent was waived (IRB No.C112028).On April 29th and 30th 2023, our trainees received certification courses on the Hugo RAS System (Medtronic, Minneapolis, MN, USA).Surgical observations were performed at Onze-Lieve-Vrouwziekenhuis (Aalst, Belgium) from April 30th to 4 May 2023.On 6 May 2023, the same team operated simulated cases of RARP and bilateral nephrectomies.It took an hour to set up the machines, including the trocar insertion.The console time for the RARP was approximately 120 min.Intraoperative rectal injury F I G U R E 1 Placement of ports.
occurred when dissecting the Denonvilliers' fascia.For bilateral nephrectomies, approximately 90 and 70 min were required for the right and left sides, respectively.Between May 9th and 2 June 2023, we began with our first RARP case using the Hugo RAS system, and the last case was performed in front of urologists as a live demonstration without intraoperative troubleshooting (Tungs' Taichung MetroHarbor Hospital International Conference 2023 Series, URL: https://tconf.sltung.com.

3
Hedge' g for each intraoperative variable (the correction factor J = 0.92).