The Hugo RAS Robotic System: A Brief Overview of Current Evidence in Urological Surgery

Abstract

The advent of minimally invasive surgery within the field of urology has seen its pivotal turning point during the early 2000s, when robotic surgery was implemented. With the spectrum of available robotic systems on the market currently, this article aims to briefly summarize the current clinical evidence on the latest platform to date in urological surgery—Medtronic's Hugo™ RAS system. A literature review was carried out from December 1, 2022, to April 31, 2023, and yielded an initial search of 34 articles. A total of 10 studies were eventually included, ranging from case reports, cadaveric studies to cohort studies of interest related to radical prostatectomy, partial nephrectomy, and simple and radical nephrectomy. Baseline patient demographics, technicalities of the system such as docking and port placement, and perioperative outcomes were documented as relevant. The new Hugo RAS robotic system offers advanced spatial features and extended capabilities as a novel robotic platform. As its adoption continues to grow and its application expanded to other potential aspects such as endourology, future studies are eagerly awaited to assess and validate its safety profile and clinical utility as a novel surgical platform.

Introduction

The adaptation of minimally invasive surgery has permeated across various surgical subspecialties—with clinical outcomes established to be superior to that of open approaches. Laparoscopic surgeries took precedence in the earlier phases of surgical advancements, of which was followed by the introduction of robot-assisted surgery in the early 2000s. ¹ Ever since then, the advantages of robot-assisted surgery have been well established—translating into better outcomes, both technically and clinically. ²

Current robotic platforms that aid in the paradigm shift include the Da Vinci surgical system by Intuitive, California; Versius by Cambridge Medical Robotics, Cambridge, United Kingdom; ALF-X by Senhance, Telelap, Morrisville USA; Revo-I by Meere, Yongin South Korea; and Micro Hand S by Tianjin University, China. Each individual system has demonstrated its utility across different subspecialities—of which Da Vinci and Versius robotic systems have commanded the most presence within the fields of urological surgery.

The Hugo™ RAS system (Medtronic, Minneapolis) is the latest robotic surgical platform on the market—priming itself on the concept of an “open” console layout, a system tower and four independently extendible arm carts with ergonomically designed trocar placements. This provides a variety of configurations to fit different types of operations, surgeon preferences, and individual patient needs. ³ The Hugo RAS system also grants surgeons better surgical dexterity while preserving operative accuracy in the most efficient way possible, providing greater ease of use and reducing the surgeon's fatigue over time. ⁴ Till date, it has already been trialed across various surgical subspecialities, demonstrating its operative flexibility across gynecological, abdominal, and urological surgeries.

Henceforth, we aim to perform a brief appraisal of the existing literature pertaining to Hugo RAS in urology—providing a narrative overview of the current evidence in major urological surgeries, detailing both technical and clinical aspects of the modern robotic platform.

Methods

Literature search

A search was carried out from December 1, 2022, to April 31, 2023, across multiple databases, with the search terms “Hugo RAS,” “Urological robotic surgery,” and “Robotics.” Thirty-four articles were included in the initial search. Duplicates were excluded and articles were screened. One study that reported on colectomy and another study that reported on gynecological procedures were excluded. Studies that focused on other novel robotic platforms were also excluded.

Two articles were excluded as they were letters to the editor. After exclusion, a total of 10 studies were finalized for review. Among the included studies, seven studies reported data solely on radical prostatectomy for prostate cancer, two studies reported on partial nephrectomy done for renal masses (either benign or malignant), and one study reported on radical nephrectomy carried out for renal cell carcinoma, simple nephrectomy for nonfunctioning kidney, radical prostatectomy for prostate cancer, and simple prostatectomy for benign prostatic hyperplasia.

Results

Hugo RAS in robot-assisted nephrectomy

The practical use of Hugo RAS in nephrectomy has not garnered as much evidence thus far, partially owing to the relative anatomic complexity of kidney resection. One study published outcomes on simple and radical nephrectomy, ⁵ whereas two studies reported outcomes on partial nephrectomy (robot-assisted partial nephrectomy),^4,6 although the study by Bravi et al. was performed as a preclinical cadaveric study. In all studies, patients were placed in a full lateral flank position—with Gallioli et al. opting for a 60° angle, whereas Bravi et al. opting for a 90° angle.

Trocar placement was similar between the two studies, with 5 trocars inserted in total, 8 cm distance between trocars and 2 cm away from bony prominences. Docking time, docking angle, and console time are detailed in Table 1. All surgeries were performed transperitoneally. Postoperatively, Gallioli et al. reported a case of conversation to laparoscopic partial nephrectomy—this was due to a combination of factors: difficult surgical field in view of concomitant liver enlargement, as well as collision of robotic arms due to crowded trocar placement. The same patient then developed a pseudo-aneurysm necessitating arterial embolization 3 days after surgery, serving as the only major Clavien–Dindo (CD) III and above postoperative complication across all studies.

Table 1.

Characteristics of Studies Included

Study characteristics										Intra-operative details							Post-operative outcomes
Author	Year	Study period	Study design	Inclusion and exclusion criteria	Hospital/database	Country	Type of surgery	Sample size (for each type of surgery)	Age (years)	Docking time (min)	Port placement time (min)	Console time (min)	Operation time (min)	Estimated blood loss (mL)	Tilt angle (°)	Docking angle (°)	Postoperative complications	Length of hospital Stay (days)
Alfano et al.	2023	June–October 2021	Retrospective	Localized prostate cancer	Hospital Pacifica Salud	Panama	RARP	15	Median: 62 Range: 59–67	Median: 7	—	—	Median: 235 Range: 213–271	Median: 300 Range: 100–310	1. Endoscope: −45 2. Right arm: −30 3. Left arm: −30 4. Fourth arm: +15	1. Endoscope: 185 2. Right arm: 230 3. Left arm: 140 4. Fourth arm: 105	One patient experienced gastrointestinal bleed due to gastritis	Median: 2
Bravi et al.	2023	February–November 2022	Retrospective	Localized prostate cancer	Onze-Lieve-Vrouwziekenhuis Hospital	Belgium	RARP ±ePLND	112	Median: 65 Range: 60–70	Not specified	—	—	Median: 180 Range: 145–200	—	—	—	—	—
Bravi et al.	2022	February 2022	Case series	—	Onze-Lieve-Vrouwziekenhuis Hospital	Belgium	RARP±ePLND	5	Median: 64 Range: 57–65	Median: 2	—	Median: 120 Range: 110–150	Median: 170 Range: 140–180	Median: 400 Range: 400–700	1. Endoscope: −45 2. Surgeon's left hand: −30 3. Surgeon's right hand: −30 4. Fourth arm: +30	1. Endoscope: 175 2. Surgeon's left hand: 140 3. Surgeon's right hand: 225 4. Fourth arm: 105	One patient experienced acute urinary retention that was treated with catheterization	Median: 3. Range: 2–4
Bravi et al.	2022	—	Cadeveric study	—	Onze-Lieve-Vrouwziekenhuis Hospital	Belgium	RAPN	3	—	Median: 7	—	Median: 85	Median: 105	—	1. Endoscope: −30 2. Surgeon's left hand: −30 3. Surgeon's right hand: +30 4. Fourth arm: −30	1. Scope: 90 2. Right arm: 215 3. Left arm: 45 4. Fourth arm: 135	—	—
Gallioli et al.	2023	February–December 2022	Prospective	All patients with a renal mass eligible for RAPN	Autonomous University of Barcelona	Spain	RAPN	10	Median: 68 Range: 61–75	Median: 9.5 Range: 9–14	—	Median: 138 Range: 124–162	Median: 138	Median: 90 Range: 75–100	Left RAPN: 1. Surgeon's left hand/First arm (cranial cart): 30° tilted-down position 2. Endoscope: 30° tilted-down position 3. Fourth arm cart: 30° tilted-down position 4. Surgeon's right-hand cart: maximum tilted-up Right RAPN: 1. Surgeon's left hand: Maximum tilt-up 2. Endoscope: 30° tilted-down position 3. Fourth arm cart: 30° tilted-down position 4. Surgeon's right-hand cart/First arm (cranial cart): 30° tilted-down position	Left RAPN: 1> Surgeon's left hand/First arm (cranial cart): 45 2. Endoscope: 90 3. Fourth arm cart: 135 4. Surgeon ‘s right-hand cart: 215 Right RAPN: 1. Surgeon's left hand: 145 2. Endoscope: 270 3. Fourth arm cart: 225 4. Surgeon's right-hand cart/First arm (cranial cart): 315	CD2 - Pneumonia CD3a - Bleeding due to a pseudoaneurysm requiring selective arterial embolization on postoperative day 3 CD2 - Anemia	Median: 4 Range: 3–6
Paciotti et al.	2022	February–March 2022	Retrospective	—	OLV hospital (Aalst, Belgium)	Belgium	RARP±ePLND	RARP without ePLND: 15 RARP with ePLND: 4	Median: 65 Range: 62–70	—	—	Median: 150 Range: 117–161	Median:180 Range: 151–189	Median: 450 Range: 300–610	—	—	CD ≥2: Two patients One patient had acute urinary retention that was treated with catheterization	Median: 3 Range: 2–3
Ragavan et al.	2022	September 2021–April 2022	Retrospective	Localized prostate cancer	—	India	RARP±ePLND	17	Median: 68 Range: 66–72	—	Median: 10	Median: 170 Range: 160–205	Median: 195 Range: 180–240	—	—	—	—	Median: 1 Range: 1–2
Ragavan et al.	2022	2021–2022	Prospective	Benign or malignant prostate or renal masses	—	India	Simple prostatectomy, radical prostatectomy, simple nephrectomy, radical nephrectomy	Simple prostatectomy: 1 Radical prostatectomy: 3 Simple nephrectomy: 2 Radical nephrectomy: 1	Median: 61.8 Range: 54–76	Median: 12	Median: 10	-	Median: 176	Median: 150	—	—	—	Median 1 (1–3)
Sarchi et al.	2022	—	Cadeveric study	—	—	Belgium	RARP	3	—	—	—	Median: 70	Median: 90	—	Endoscope: −45 Surgeon's left hand: −30 Surgeon's right hand: −30 Fourth arm: +30	Endoscope: 175 Surgeon's left hand: 140 Surgeon's right hand: 225 Fourth arm: 105	—	—
Totaro et al.	2022	March–May 2022	Case series	Localized prostate cancer	Università Cattolica del Sacro Cuore	Italy	RARP	7	—	Median: 11.6	—	Median: 121.9	Median: 155	—	1. Endoscope: −45 2. Surgeon's left hand: −40 3) Surgeon's right hand: −40 4. Fourth arm: +30	1. Endoscope: 175 2. Surgeon's left hand: 140 3. Surgeon's right hand: 225 4. Fourth arm: 105	—	—

ePLND, extended pelvic lymph node dissection; RAPN, robot-assisted partial nephrectomy; RARP, robot-assisted radical prostatectomy.

Hugo RAS in robot-assisted prostatectomy

A total of eight studies have published clinical data on the application of the Hugo RAS robotic system on transperitoneal robot-assisted simple or radical prostatectomy.^3,5,7–12 All patients were positioned in either a supine or steep Trendelenburg position and the docking process was done at the prescribed angles given by Medtronic. As the arm carts could be independently arranged, a lithotomy position while 0° supine was also adopted in some studies to accommodate the placement of the camera cart in between the patient's legs.^5,7,11

Docking, port, trocar placement times, docking, and tilt angles are detailed, respectively, in Table 1. Standard operative steps for robot-assisted radical prostatectomy (RARP) were followed in all studies. Postoperative clinical outcomes were largely favorable, with no reports of postoperative complications CD III or higher. One patient experienced an unrelated gastrointestinal bleed due to gastritis, ⁷ whereas two more had acute retention of urine that was managed conservatively with urinary catheterization.^9,10 In terms of oncological outcomes, Ragavan et al. ¹¹ managed to demonstrate comparable resection margin rates between the Hugo RAS and the DaVinci system as well—but this is to be caveated by variations in robotic surgical techniques that could have accounted for the noninferiority in results.

Discussion

The benefits that the novel Hugo RAS system has to offer are elaborate—ranging from design of its independent arm carts that enable for a diverse range of surgical configurations, a nonenclosed console model that facilitates open real-time operative discussion across the surgical team, to enhanced wrist rotational capabilities for added benefit in intracorporeal suturing and accurate reanastomosis.^3,7,8,10 The flexibility of surgical configurations could support ease of translation of pre-existing surgical techniques to the Hugo RAS system, as exemplified by Bravi et al. in their translation of a technique for apical dissection in RARP with the Hugo RAS system. ⁸

This could also help improve the accessibility to different target anatomies in surgery. ⁹ Studies have described preliminary results that demonstrate the feasibility and safety of the Hugo RAS system^7,9—Bravi et al. described how the ability of the system tower and its visualization system to support both robot-assisted surgery and traditional laparoscopy could confer advantages in cases requiring conversion.^1,9 Future studies are eagerly awaited to evaluate the performance of the system in the form of long-term postoperative outcomes.

Aside from its benefits, limitations are also to be expected during its nascency. With its new docking process and customizable set-up, the implementation process may require more time and training for the staff and surgical team due to the modified docking and console settings.^7,12 The open console and new design of hand controls might require a learning curve as surgeons have had many years of experience with a different platform in another operative setting. ¹¹ For instance, surgeons accustomed to console settings of pre-existing robotic systems may find it hard to adapt to the pistol handgrip with an inbuilt clutch that Hugo RAS offers. ¹

Moreover, the docking process can be more challenging as all arms are attached to individual karts, which must be placed in the correct position with appropriate arm angulation. ⁷ Nevertheless, this may be overcome by having a properly trained surgical team, as described by Bravi et al.—having a reference table with docking angles in the operation theater and marking optimal positions of the arm carts on the ground for quicker repositioning during subsequent surgeries can mitigate this. The initial learning curve has also been observed to be short in experienced robotic surgeons, attributed to the surgeon's overall experience and robotic console skill transferability across different platforms. ⁶

The Hugo RAS system also currently lacks a system to integrate images from multiple sources, such as ultrasound images or three-dimensional reconstructions. ⁶ In addition, having four separate independent carts would mean a larger footprint around the patient and a slightly higher risk of arm collision.^3,5 The open console design also requires the surgeon to sit in a relatively erect posture, which may be ergonomically disadvantageous for the surgeon during complex and prolonged surgeries. ⁵

Conclusion

In this era of minimally invasive surgery, the rapid adoption of the Hugo RAS system since its inception in 2021 is a testament of the growing popularity of robotic surgery across the world. The enhanced features that it offers would allow for increased operative diversity in the surgical field and pave the way for precision-based surgeries. The evidence in the literature thus far continues to affirm its usage in the clinical setting, with no major drawbacks or concerns cited. Moving forward, large scale multicenter studies are highly anticipated to provide robust information on this new surgical system, as well as to determine how it fares compared with its other robotic predecessors.