Novel Robotic Platforms for Robot-Assisted Laparoscopic Surgery in Urology: A Narrative Review

Abstract

Robot-assisted surgery (RAS) has been integrated into clinical practice to overcome several limitations of conventional open or laparoscopic surgery. After the expiration of the long key patent period of Intuitive Surgical, various robotic systems (RSs) have been developed aiming at improving certain characteristics of the first robotic platform, the Da Vinci RS. This narrative review provides an overview of the current RSs used in urology along with the initial results from their application in urologic procedures. Nine robotic platforms are being analyzed regarding their unique characteristics as well as their efficacy, safety, feasibility, and outcomes in urologic, oncological, or non-oncological operations. The main barrier to the wide application of RAS has been the increased cost that refers to both acquisition and maintenance costs. Besides, the health inequality resulting from the lack of expert robotic surgeons and the difficulty of performing robot-assisted procedures in provincial hospitals should be overcome. However, large properly designed comparative studies are required to establish the role of newly introduced RSs. In addition, urologists should keep abreast of new developments and research in robot-assisted urologic procedures.

Introduction

The revolution year for minimally invasive surgery was 2000 when the Da Vinci robotic system (RS) (Intuitive Surgical, Sunnyvale, CA, USA) received approval from the Food and Drug Administration (FDA) in the United States. In recent years, robot-assisted surgery (RAS) has been widely accepted because of the significant advantages that presents over open surgery such as reduced blood loss, shorter hospital stay, and faster recovery.¹ In addition, RAS offers three-dimensional (3D) and high-resolution vision of the surgical field along with better dexterity; therefore, it improves the precision of the surgeon’s movements.² The long key patent period of Intuitive Surgical led to the absence of competition in the medical market and the monopolization of the Da Vinci RS. According to Intuitive Surgical, the revenue was $1.74 billion, and, worldwide, 8285 systems were installed in the third quarter of 2023, resulting in a 13% increase compared with 2022.³ In 2019, the patent period expired enabling novel RS to enter the market. The alternative surgical systems have attempted to overcome some of the limitations of the Da Vinci RS such as the cost, the closed console that compromises the surgical team’s cooperation, the lack of haptic feedback, and the reduced working space for the assistant.²

This narrative review aims to provide an overview of the current RSs in urology along with the initial results from their application in urologic procedures.

Materials and Methods

A literature review of the last 10 years was undertaken with a search in one database, that is, PubMed/MEDLINE, in October 2023. Original and review articles in English were included. The reference list of the retrieved articles was also analyzed. Only robotic platforms that have obtained regulatory approval for human use were considered. When applicable, the search was directed to publications that focused on the application of RS in urologic surgical procedures. The keywords searched included “Da Vinci Xi” (n = 517), “Da Vinci SP” (n = 372), “Hugo-Ras” (n = 76), “Versius” (n = 52), “Senhance” (n = 77), “Revo-I” (n = 19), “Avatera” (n = 14), “Hinotori” (n = 18), “‘Kangduo” (n = 11), and “Dexter robotic system” (n = 8).

Robotic Surgical Systems

Da Vinci

The Da Vinci RS (Intuitive Surgical) received FDA approval in 2000 and dominated the medical market for over 20 years. During this span, the company introduced four versions of this multiport robotic surgical system: Da Vinci standard, Da Vinci S, Da Vinci Si, and Da Vinci Xi. All of them comprise the same components, that is, a closed surgeon console, a patient cart in which the robotic arms are mounted, and a vision system that does not require the use of specific glasses. In addition, the console of the Da Vinci Xi offers 3D high-definition (HD) visualization without requiring the use of specific glasses. While being seated, the surgeon can control the arm’s movements through loop-like handles. This RS adopts the EndoWrist technology, reproducing human wrist movements with seven degrees of freedom. Moreover, it is combined with a system that removes hand tremors and reduces movements from 1:1 to 5:1, permitting the transmission of precise movements. The Da Vinci Si and Da Vinci Xi RS have upgraded their vision through the integration of Firefly fluorescence imaging technology, providing essential information on different anatomical structures.^1,2

The patient cart of the Da Vinci Xi uses instruments and an endoscope with an 8-mm diameter. One of the characteristics that distinguishes this RS from the rest in the market is that the identical structure of the robotic arms allows the versatile repositioning of the camera and the instruments. The design of the patient cart optimizes the docking, increases the range motion of the arms, and reduces the clashing, enabling the patient’s access from any quadrant. The Da Vinci single-port (SP) system received FDA approval for application in urologic procedures in 2018. The patient cart consists of a single arm with a 12 × 10 mm fully articulating endoscope and three articulating instruments through a 25-mm multichannel port at a single incision. The instruments are double-jointed as they are designed with an elbow and a wrist, facilitating distal triangulation inside the patient’s body.^1,2

Hinojosa-Gonzalez et al. published a systematic review including seven studies, which compared multiple and SP robot-assisted radical prostatectomy (RARP). The authors demonstrated that the blood loss, operative times, positive surgical margins, complication and continence rates, erectile function, and biochemical recurrence were comparable between the two approaches. Interestingly, in the SP RARP group, it was noted that the length of hospital stay was shorter and the need for opioid consumption was reduced.⁴ However, the level of evidence of this study is low because of the lack of randomized control trials and the small sample size of the SP RARP group (324 patients). Similar perioperative and postoperative outcomes were presented in a recent narrative review including three studies regarding robot-assisted partial nephrectomy (RAPN). However, it was highlighted that the SP cases included low-complexity renal tumors and the number of patients included was small. Many authors report that the learning curve of SP robotic surgery is mainly correlated with the handling of the articulating SP camera and the loss of Endowrist technology, even in the case of experienced robotic surgeons.⁵ Although the initial outcomes of the use of the SP RS seem promising, larger comparative studies with conventional multiarm robotic surgery are required.

Hugo RAS system

The Hugo-RAS (Medtronic, Minneapolis, USA) obtained regulatory approval in the European Economic Area for gynecological and urology operations in 2021 and for general surgery in 2022. Currently, it is available in Europe, Japan, and Canada. It consists of an open surgeon console, four independent robotic arms that are attached to individual carts, and a system tower. The open console provides 3D HD vision through the surgeon’s glasses in which a tracking device based on the head-tracking technology has been implanted. Moreover, the console comprises two hand controllers with a pistol-shaped device with a clutch mechanism. The operation ports are 8 mm in diameter, whereas the diameter of the endoscope port is 11 mm.

Until now, Hugo-RAS has found its greatest application in urology. The largest clinical series with 112 patients who underwent RARP with or without extended lymph node dissection has been published by Bravi et al. Preoperatively, 38 patients presented with International Society of Urological Pathology grade group ≥3 tumor on prostate biopsy. In the final pathology report, extraprostatic disease was confirmed in 34 patients and positive surgical margins in 10 of them. Regarding functional results, the probability of urinary continence was 36% at 1 month and 81% at 3 months. Among patients for whom the data at the first postoperative month were available, 88% (60/68) presented with undetectable PSA (<0.1 ng/mL).⁶ Alfano et al. described a small clinical series of 15 consecutive patients who underwent transperitoneal RARP with Hugo-RAS. All operations were successfully performed without major complications or need for conversion. Five cases had positive surgical margins, nine patients were continent, and all of them had undetectable PSA values 4 weeks postoperatively.⁷ Ragavan et al. aimed to assess the safety and feasibility of RARP performed with Hugo-RAS in a clinical series of 17 patients. The authors compared these outcomes with an analogous group of 17 patients undergoing RARP with the Da Vinci RS. Operative and docking times were comparable between the groups. No intraoperative or postoperative complications were recorded during the first month postoperatively.⁸

Table 1.

Features of the Different Robotic Systems

Robotic system	Approval/Year	Number of robotic cart arms	Surgeon console	Instrument diameter (mm)	Camera diameter (mm)	3D Vision	Instrument use	Haptic feedback	Procedures safety & feasibility
Da Vinci Xi^®	FDA/2014 CE Mark/2014	1	Closed	8	8	Yes	10 times	No	-Wide range of operations
Da Vinci SP^®	FDA/2018	1	Closed	6	12 × 10	Yes	10 times	No	-Radical prostatectomy -Partial nephrectomy -Ureteral reconstruction -Children: pyeloplasty
Hugo™ RAS	CE Mark/2021	4 independent	Open	8	11	Yes (glasses with head tracking technology)	NA	No	-Radical prostatectomy -Partial nephrectomy -Radical cystectomy -Ureteral reimplantation -Ureterolithotomy -Sacrocolpopexy
Versius^®	CE Mark/2019	4 independent	Open	5	10	Yes (through polarized glasses)	NA	Yes	- General surgery (hernia repair, cholecystectomy, colorectal resection etc) -Urology (radical prostatectomy, nephrectomy) -Gynecology (hysterocolpectomy)
Senhance^®	FDA/2017 (not for urology) CE Mark/2016	4 independent	Open	3 5 10	10	Yes (through polarized glasses)	Unlimited	Yes	-Gynecology (hysterectomy, adnexal surgery) -General surgery (colectomy, cholecystectomy) -Urology (radical prostatectomy, nephrectomy, pyeloplasty, adrenalectomy) -Children: general surgery, urology
Revo-I^®	KMFDS/2017	1	Closed	7.4	10	Yes	20 times	No	-General surgery (cholecystectomy, pancreatectomy) -Gynecology (fallopian tube dissection) -Urology (partial nephrectomy, radical prostatectomy)
Avatera^®	CE Mark/2019	1	Semi-closed	5	10	Yes	Single	No	-Radical prostatectomy -Pyeloplasty
Hinotori^®	JMHLW/2020	1	Semi-closed	NA	NA	Yes	NA	No	-Radical prostatectomy -Radical & partial nephrectomy -Adrenalectomy -Telesurgery: preclinical study
Kangduo SR^®	NA	1	Open	NA	NA	Yes (through polarized glasses)	NA	NA	-Pyeloplasty -Partial nephrectomy -Radical prostatectomy
Dexter^®	CE Mark/2020	3?	Open	8	10	Yes	Single	Yes	-Urology (radical prostatectomy) -General surgery (cholecystectomy, hernia repair etc)

The first clinical series of transperitoneal RAPN utilizing the Hugo-RAS system was reported by Gallioli et al. In their study, the data of seven patients with right side tumor and three patients with left side one were analyzed. As far as intraoperative parameters are concerned, the median warm ischemia time was 13 minutes, whereas one case was carried out clamp-less. None of the patients had positive surgical margins. Conversion to laparoscopic partial nephrectomy was necessary in one case owing to the combination of hepatomegaly with inappropriate trocar placement. This patient underwent selective arterial embolization owing to a bleeding pseudoaneurysm.⁹ Recently, Gaya et al. described the surgical approach of robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit with Hugo RAS RS in two patients, giving insights for further studies on bladder cancer.¹⁰

Hugo-RAS has been used in non-oncological urologic procedures as well. Ellorieta et al. described a clinical series of six surgeries (two ureteral reimplantations, one ureterolithotomy, one pyeloplasty, and one simple nephrectomy). The postoperative course was uneventful, while no system faults were reported.¹¹ In the uro-gynecology section, the largest clinical study was conducted by Panico et al., including 60 cases of robot-assisted sacrocolpopexy. No need for conversion to laparotomy was reported. The only intraoperative complication was a small opening in the anterior vaginal wall, which was repaired intraoperatively. In the 30-day follow-up, one Clavien–Dindo Grade I and three Clavien–Dindo Grade II complications were reported. Within a 3-month period postoperatively, the improvement of the outcomes according to Pelvic Organ Prolapse Quantification classification was statistically significant. More precisely, the anatomical cure rate was 96.7%, and the subjective cure rate was 98.3%.¹²

Versius surgical system

The Versius robotic platform (Cambridge Medical Robotics Ltd., Cambridge, UK) obtained the European CE Mark in March 2019. It is routinely used in Europe, Middle East, Asia, Australia, and Latin America.¹³ It comprises a surgeon console and three or four individual bedside units for each working arm. The console’s design is open, allows the surgeon to be in standing or sitting position, and provides 3D HD vision through polarized glasses. Moreover, the surgeon receives haptic feedback from the handles. The robotic arms take advantage of the V-wrist technology, providing fully wristed instruments with seven degrees of freedom. Safety and feasibility preclinical studies for radical nephrectomy, prostatectomy, and lymph node dissection in cadavers and porcine models were published in 2020.²

In the last 2 years, there has been an increase in publications regarding the clinical use of the Versius RS in general surgery (hernia repair, cholecystectomy, esophageal, or colorectal resection).^14

–17 Soumpasis et al. have published the largest surgical registry so far, including 2083 cases performed with Versius surgical system (731 general surgery, 374 colorectal, 228 hernia, 554 gynecology, 177 urology, and 19 thoracic). As far as urologic procedures are concerned, two intraoperative complications occurred: one bleeding during a radical nephrectomy and one fatal myocardial infarction during prostatectomy. None of them was related to malfunction of the RS. It was reported that 16.6% of the urologic operations needed conversion to an alternative technique, whereas the 90-day mortality rate reached 3.4%.¹⁸ Recently, Hussein et al. presented the results of 106 benign and malignant urologic procedures performed with the Versius RS. Robotic operation arm’s malfunction arose in two cases, whereas conversion to open surgery was needed in six cases. Postoperatively, eight patients presented major complications. The matched analysis of various operations performed with Versius vs Da Vinci RS did not demonstrate significant difference in perioperative results.¹⁹

Owing to the unique features of Versius, RS Kayser et al. assessed its performance in robotic reconstructive procedures such as intracorporeal suturing and knot tying in small boxes with a volume as small as 106 mL simulating pediatric-sized cavities. The wristed 5-mm instruments with shorter articulating jaws, alongside with their small size and flexibility, make robotic interventions in children appear feasible.²⁰ Nevertheless, ongoing preclinical evaluation should be performed before RAS application to newborns or infants.

Senhance surgical system

The Senhance RS (Ascensus Surgical, Durham, Morrisville, NC, USA) received regulatory approval in Europe in 2014 and became the first robotic platform that obtained FDA clearance for general surgery and gynecology operations in 2017. Currently, it is available in Europe, USA, Russia, and Japan, and its purchase cost is $1.3 million. According to the annual review of Ascensus Surgical, nine systems were installed and over 3100 procedures were performed during 2022, resulting in a 29% increase compared with 2021.²¹ This multiport RS consists of a surgeon console and up to four independent robotic arms, which are mounted to separate carts. The surgeon console provides 3D HD visualization via polarized glasses and has an open design facilitating communication with the surgical team. The manipulation of the camera is based on an infrared eye-tracking system, adapting the surgical field to the surgeon’s eye movements. It is a digital laparoscopy system; thus, the robotic instruments are compatible with the traditional laparoscopic trocars, enabling the rapid conversion to conventional laparoscopy. Moreover, one of the most essential features of this novel robotic platform is that it provides haptic feedback to the surgeon, allowing tactful tissue handling and preventing its injury. The instruments are 3, 5, and 10 mm in diameter and can be reused after sterilization.

The largest volume of publications is related to gynecology, general and colorectal surgery.^22,23 As far as urologic procedures are concerned, radical prostatectomy is the most frequently reported. Samalavicius et al., among other abdominal surgeries, demonstrated its feasibility and safety in 27 cases of extraperitoneal RARP and four other urologic procedures (one nephrectomy, one pyeloplasty, one pyelolithotomy, and one varicocelectomy). Two cases of RARP needed to be converted to laparoscopic approach because of anatomical difficulties. In addition, two patients required blood transfusion postoperatively (Clavien–Dindo II), whereas one patient presented with postoperative epididymitis (Clavien–Dindo II) and another one with urethral stricture (Clavien–Dindo IIIa). Concerning postoperative continence, the authors noted that 80.76% of the patients (21/27) were continent 30 days postoperatively.²⁴ Subsequently, Venckus et al. reported a large series of 127 patients undergoing RARP with the Senhance robotic platform. The mean operation time and the postoperative blood transfusion rate were similar to the RARP performed by the Da Vinci RS. The overall percentage of complications was lower with the Senhance than with laparoscopic radical prostatectomy (LRP) and Da Vinci RARP (11.8% vs 13.4% vs 18.5%). The operation time was diminished by 60 minutes and the estimated blood loss by 200 mL as the experience of the surgeon increased.²⁵ Kulis et al. published a prospective comparative study between LRP (n = 61) and extraperitoneal RARP with Senhance RS (n = 107). RARP performed with this novel robotic platform provided functional and oncological outcomes comparable with laparoscopy. Although the prices differ by country, it was reported that the additional cost per RARP using Senhance RS was $920 compared with LRP.²⁶ Recently, Hudolin et al. presented the largest series to date with 200 patients who underwent extraperitoneal RARP. Fifteen postoperative complications were reported (11 Clavien–Dindo Grade I, 3 Grade II, and 1 Grade IV). Moreover, six cases were converted to laparoscopy and two to open prostatectomy.²⁷

Kastelan et al. published a case series of 30 upper urinary tract procedures performed with the Senhance surgical system (adrenalectomies n = 9, nephrectomies n = 6, kidney cyst fenestration n = 11, and pyeloplasties n = 4) without significant complications.²⁸ Finally, Puentes et al. demonstrated the safety and feasibility of Senhance RS in performing various general surgery and urology procedures in eight pediatric patients. The fact that this new robotic platform offers 3-mm instruments and 5-mm articulating instruments makes it a safe and effective option in pediatric procedures.²⁹

Revo-I surgical robot

The Revo-I surgical system (Meere Company Inc., Yongin, Republic of Korea) received regulatory approval from the Korean Ministry of Food and Drug Safety in 2016. It consists of a four-arm operation cart, an enclosed surgeon console, and an HD vision system. The instruments that are integrated to the three working arms have a diameter of 7.4 mm, offer seven degrees of freedom, and can be reused up to 20 times.

Feasibility studies of cholecystectomy, fallopian tube dissection, and partial nephrectomy using the Revo-I surgical system were published in 2016.^30
–32 The first human trial by Chang et al. in 17 patients undergoing Retzius sparing radical prostatectomy provided promising perioperative and oncological results.¹ Recently, a propensity score-matched comparison between Revo-I and Da Vinci Si RS in Retzius sparing radical prostatectomy demonstrated similar perioperative and short-term oncological results. It was also described that the Revo-I group had longer operative time and shorter hospital stay compared with Da Vinci Si.³³

Avatera system

The Avatera robotic surgical system (Avateramedical, Jena, Germany) was granted the European CE Mark in November 2019 for urologic and gynecological procedures. It is a two-component RS, composed of a closed-console control unit for the surgeon and a patient cart. The console provides 3D full HD vision, whereas the slender eyepiece facilitates the communication of the surgeon with the surgical team. The patient cart consists of three arms for the 5-mm fully articulated, single-use, disposable instruments and one arm for the 10-mm endoscope.

The safety and feasibility of radical nephrectomy and radical cystectomy performed by Avatera RS were assessed in preclinical studies in porcine models.^34,35 An experimental study demonstrated that urologic procedures can be performed safely and effectively with the Avatera RS after adequate dry-lab training.³⁶ The first case series of 14 radical prostatectomies has recently been published. All operations were successfully performed without major intraoperative complications or need for conversion. Moreover, it was reported that in the 6-month follow-up, 78.6% of the patients were continent, whereas 77.7% of the nerve-sparing patients mentioned erections adequate for sexual intercourse.³⁷ Kallidonis et al. described the surgical technique of robot-assisted pyeloplasty with Avatera RS, evaluating also its safety and feasibility in a case series of nine patients. The median hemoglobin drop was 0.7 g/dL (range 0.4–1), whereas no intraoperative or postoperative complications in a follow-up of 9.3 ± 2.8 months were noted.³⁸ Currently, Avateramedical is facing economic problems.

Hinotori surgical robot system

The Hinotori RS (Medicaroid Corporation, Kobe, Hyogo, Japan) obtained regulatory approval from the Japanese Ministry of Health, Labor and Welfare in August 2020. It is a master-slave robotic platform that possesses three units: an operation unit, a surgical unit, and a vision unit. Four operating arms with eight axes of motion are mounted to the patient cart, whereas an anti-shake and “docking-free” mechanism decreases the interference between arms and the bedside assistant. The surgical unit has a semi-closed console design with microscope-like eyepiece providing 3D view of the surgical area.¹

After the encouraging preclinical results of various urologic procedures in porcine models and cadavers, the first clinical study of 30 patients undergoing radical prostatectomy with the Hinotori RS demonstrated its safety in 2022.¹ Recently, clinical series with small sample sizes proved the safety of partial and radical nephrectomy performed with this new RS alongside with similar perioperative outcomes to Da Vinci RS.^39,40 In addition, the performance of the Hinotori platform was described in a series of six adrenalectomies, whereas a case report of distal pancreatectomy was recently published.^41,42 Finally, a preclinical study showed the safety of short-distance telesurgical robotic surgery conducted with the Hinotori RS.⁴³

Kangduo surgical robot-01

Τhe KangDuo-Surgical Robot-01 (KD-SR-01) platform (Suzhou KangDuo Robot Co., Ltd., China) has been developed in China. It is a master-slave RS that includes a surgeon console, a patient cart, and a vision cart. The open surgeon console consists of two master manipulators and a 3D HD monitor, allowing the surgeon to control the instruments accurately with passive polarizing glasses in an ergonomic way. The patient cart is integrated with two working arms for the instruments, which have seven degrees of freedom for movements and one arm for the endoscope, which is compatible with various 3D laparoscopic display systems.

The initial clinical applications of the Chinese surgical system were in urology and general surgery.^44,45 The completion of the first clinical series of pyeloplasty and partial nephrectomy through a retroperitoneal approach using the KD-SR in China was announced in 2021.^44,46 Besides, a case report of robot-assisted pyeloplasty in horseshoe kidney was recently published.⁴⁷ A prospective randomized controlled trial by Li et al. showed that partial nephrectomy performed with KD-SR achieved noninferior outcomes regarding safety and efficacy in T1a tumors compared with Da Vinci Si surgical system.⁴⁸ Lately, in a sample of 16 patients, Fan et al. demonstrated that RARP using the KD-SR has similar short-term oncological and functional results compared with the Da Vinci Si robotic platform with the disadvantage of longer operation time.⁴⁹

Dexter robot

The Dexter RS (Distalmotion, Lausanne, Switzerland) obtained the European CE mark in 2020 and is an open robotic platform that is merged into the current operating room equipment. It consists of a surgeon console that can remain sterile, allowing the surgeon to be transferred seamlessly between a robot-assisted procedure and a laparoscopic setup. Moreover, it includes two patient carts for the actuation of fully articulated single-use instruments and a robotic endoscope arm that is compatible with any 3D endoscopic system. The small footprint of Dexter RS provides enough space for the circulation of the surgical staff, whereas the switch to laparoscopic mode is carried out within seconds until the folding of robotic arms.

The first urological surgery, a radical prostatectomy, performed with the Dexter RS was carried out in March 2022 in Bern with the trocars positioning being similar to that of standard laparoscopy.⁵⁰ The initial results of the first case series of 10 RARPs performed with Dexter RS suggest its safety and feasibility; however, larger studies are required to confirm these findings.⁵¹

Cost

The main barrier to the wide application of RAS is the increased cost that refers to both acquisition and maintenance costs. If RAS is applied to a large volume of patients and by experienced surgeons of different specialties, its benefit for the health care systems may be remarkable. Many studies have shown that RARP is correlated with similar survival and oncological results, whereas its perioperative and functional outcomes are improved compared with those of LRP. A large-scale cost-utility study with 7 years of follow-up demonstrated that RARP is more costly than LRP. However, it was reported that if RARP is carried out by experienced robotic surgeons in high-volume centers (>150 cases/year), the procedure may become cost-effective at most willingness-to-pay ratios because of the extensive usage as well as the briefer operative time and hospital stay.⁵² Recently, a comparative cost-effectiveness analysis from nine surgical centers in the United Kingdom showed that intracorporeal RARC (iRARC) is costlier than open radical cystectomy. On the contrary, iRARC was related to a reduced hospital stay, admission to the intensive care unit, and readmission rate. Nonetheless, the high equipment and theater costs of iRARC were partially counterbalanced by these savings resulting in an incremental cost-effectiveness ratio that exceeded the thresholds of most public health care systems. However, the subgroup analysis demonstrated that iRARC was more than 75% likely to be cost-effective in patients above 70 years old with stage tumors T3 or greater and those with bad performance status.⁵³ Ultimately, a multicentric cost-comparison analysis of RARC reported that 81% of the costs were attributed to the operative time and length of hospitalization, whereas only 16% of the costs were because of the robotic instrumentation. Although there are broad differences between the cost analyses for RAS, it is clear that the use of RAS in high-volume centers and in several specialties along with the reduction of operative time and hospital stay could make it an economically acceptable therapeutic option.⁵⁴

Discussion

The Da Vinci robotic surgical system monopolized the medical market since its FDA approval in 2000. The expiry of the key patent period allowed the landscape to become more competitive as new RSs had the ability to enter the market. In this direction, various companies are currently conducting preclinical and clinical studies to prove the safety and clinical applicability of their novel RSs in several surgical procedures. Among them, the most frequently studied procedure in urology is the RARP followed by oncological and reconstructive operations of the upper urinary tract along with functional surgeries. The Senhance RS presents the largest volume with 200 extraperitoneal RARPs, followed by the Versius and Hugo-RAS surgical systems with more than 100 urologic operations. The studies with the Hinotori system involved 30 RARPS, whereas clinical series with fewer than 20 cases have used Dexter, Avatera, Kangduo, and Revo-I RSs. Owing to the advantages of RAS, ultimately, its safety and feasibility have been studied in various pediatric urological diseases. More specifically, the Versius and Senhance systems were evaluated in preclinical and clinical studies, respectively, because of the small size of their articulating instruments.^20,29

Despite the extensive application of the Da Vinci system, there are several alternative systems available that possess unique characteristics. The open surgeon console of the Versius, Senhance, Hugo-RAS, Dexter, and Avatera RS facilitates the communication of the surgeon with the surgical team in contrast to the closed console of the Da Vinci system.^{22,34,50,55,56} Moreover, the Senhance and Hugo-RAS systems show the potential of controlling the camera through an infrared eye-tracking and a head-tracking system, respectively.^22,55 One of the advantages of the novel RSs that is absent from the Da Vinci system is the haptic feedback. This is provided in the Senhance and Versius systems, permitting careful tissue handling, structure identification, and tissue protection.^12,27 To reduce tissue injury and improve the esthetic outcome, various companies have attempted to reduce the size of the instruments used. More precisely, Avatera and Versius surgical systems use 5-mm instruments.^1,20,57 The smallest instruments in diameter, which touch 3 mm, are offered in Senhance RS.²⁹

In the real world, one of the restrictions that has become more prominent during the COVID-19 pandemic is the difficulty of performing robot-assisted procedures in provincial hospitals because of the lack of expert robotic surgeons. The development of a telesurgical robotic platform could overcome this barrier, enabling patients to undergo specialized operations near their homes. The importance of this venture was highlighted 23 years ago when the first transatlantic cholecystectomy was performed with a latency time of 155 ms.⁵⁸ Since then, several attempts have been made to evolve robotic telesurgery, performing major operations in animal models. The first preclinical study of short-distance telesurgical robotic gastrectomy using the Hinotori system was recently described with a latency time of 125 ms. Despite the feasibility of these operations in animal models, several factors related to their application to humans should be considered, such as ethical, legal, and cybersecurity issues (Table 1).⁴³

Conclusions

The monopoly of the Da Vinci RS has reached its end since novel RSs entered the market. Over time, the evolution of technology and the development of new RSs will further define their capabilities. Therefore, large properly designed comparative studies with promising oncological and functional outcomes are required to establish their role. It is crucial that urologists keep abreast of new developments and research in robotic surgery as the landscape continues to grow.

Footnotes

Authors’ Contributions

P. Kallidonis: Review and critical revisions. K.G.: Review and article editing. V.T.: Review and article editing. P. Katsakiori: Article editing and critical revisions. T.V.: Critical revisions. E.L.: Conceptualization and critical revisions.

Author Disclosure Statement

The authors have nothing to disclose.

Funding Information

This research received no external funding for the research, authorship, and/or publication of this article.

Abbreviations Used

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