Three‐arms off‐clamp robot‐assisted partial nephrectomy with the new Hugo robot‐assisted surgery system

摘要

Robot-assisted surgery (RAS) has taken the upper hand over open and laparoscopic approaches for the main urological procedures due to the established benefits in terms of perioperative and functional outcomes, while showing comparable oncological results [1]. After the introduction of the first Da Vinci platform, novel generations of robotic systems equipped with innovative technical refinements have emerged as alternative solutions to overcome intrinsic platforms limitations [2]. In this context, the Hugo™ RAS system (Medtronic plc, Dublin, Ireland) was introduced as a modular robotic platform with four independent arm-carts, enabling highly customised procedures by adapting the surgical strategy. Additionally, notable technical benefits include a more ergonomic trocar position, an expanded working space for the bed-side assistant, and cost-effectiveness for single procedures. The development of the Hugo RAS system arose as an alternative robotic platform designed to fulfil the requirements of a more ergonomic and customised working environment. Another objective of this system is to enhance the accessibility of RAS for a larger number of patients by improving the cost-effectiveness of each individual procedure, thus alleviating the strain on healthcare systems. Only one pre-clinical study has been published on the Hugo RAS system, conducted at the ORSI Academy (Aalst, Belgium) between August and October 2021 on four cadavers [3]. The authors performed total hysterectomy, radical hysterectomy, pelvic exenteration, pelvic and para-aortic lymphadenectomy, and omentectomy. Moreover, several tests were carried out to identify the best configurations for all gynaecological surgical scenarios. Regarding first in human studies, the main procedures performed on a few patients were: right and left colectomy, radical prostatectomy, and lateral transabdominal adrenalectomy [4, 5]. All the authors reported the feasibility of the Hugo RAS system, with satisfactory intra- and perioperative outcomes without the need for conversion. Robot-assisted partial nephrectomy (RAPN) represents a core urological procedure under continuous evolution and improvement. If on the one hand on-clamp RAPN represents the most popular approach due to the better control of intraoperative bleeding during tumour excision, on the other hand clamping of renal hilum exposes healthy renal parenchyma to potential ischaemic injury. Furthermore, all published off-clamp series have not shown worse results in terms of surgical and postoperative outcomes in comparison to the on-clamp technique [6, 7]. While the application of the Hugo RAS system to radical prostatectomy is rapidly gaining in popularity [8, 9], its potential in the setting of PN has experienced difficulties in achieving success. With this background, we aimed to describe the first experience and surgical setting for off-clamp RAPN with a three-arms configuration using the new Hugo RAS system. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Campus Bio-Medico University (number: PAR 113.22 OSS). Informed consent was obtained from all patients involved in the study. Between October 2022 and March 2023, 18 consecutive patients underwent off-clamp RAPN for renal tumour using the Hugo RAS system at our Institution, a high-volume centre for off-clamp laparoscopic PN. Moreover, we gained experience and became familiar with the Hugo RAS system through an initial series of robot-assisted radical prostatectomies during the same time period, which slowed down the accrual of RAPNs. Postoperative complications were reported according to the Clavien–Dindo classification [10]. Continuous variables are presented as medians and interquartile ranges (IQRs), while frequencies are used to report categorical variables. First surgeon, bed-assistants and all surgical staff taking part in the operations had all completed the technical training on the Hugo RAS s