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Outcomes of Robot-Assisted Radical Prostatectomy with the HUGO RAS Surgical System: Initial Experience at a High-Volume Robotic Center - Beyond the Abstract

The last two decades have witnessed a significant evolution of the robotic-assisted surgical systems,1 and several novel robotic platforms are emerging as innovative solutions and competitors for the leadership in the marketplace.2 The HUGO Robot-Assisted Surgery (RAS) System (Medtronic©, USA) has recently received CE mark approval for urological procedures, and we previously described our surgical setup with this novel robotic platform, including the first procedure performed in Europe.3,4 However, data on the clinical outcomes of patients operated with this surgical robot is lacking. For this reason, we described surgical outcomes of robot-assisted radical prostatectomy (RARP) performed at our Institution with the HUGO RAS System.

We analyzed data of 112 patients who received RARP ± extended pelvic lymph-node dissection (ePLND) at OLV hospital (Aalst, Belgium) between February and November 2022. All procedures were performed by experienced robotic surgeons. ePLND was performed in men with a preoperative risk for nodal involvement ≥5%.5 Our trocar placement and arm carts disposition in the operative room were previously described.3 RARP was performed with a trans-peritoneal, anterior approach following validated steps and metrics.6,7 Monopolar curved shears, bipolar fenestrated grasper, and large needle driver were used in a three-instrument configuration. The urethral catheter was removed on postoperative day 2.8

We described baseline, peri- and post-operative characteristics of our cohort. Urinary continence was defined as the use of no/one safety pad. Kaplan-Meier curve assessed the time to continence recovery after surgery.

 Baseline characteristics. Median (interquartile range [IQR]) age and Body Mass Index were 65 (60, 70) years and 26 (24, 29), respectively (Supplementary Table 1). Median (IQR) preoperative PSA level was 7.9 (5.8, 10.7) ng/ml. A total of 38 (34%) patients had International Society of Urologic Pathology (ISUP) group ≥3 tumor on prostate biopsy. On preoperative MRI, median (IQR) prostate volume was 40 (32, 55) cc, and 26 (23%) patients had a suspicion of extra-prostatic disease.

Intra- and post-operative. Median (IQR) operative and console time were 180 (145, 200) and 150 (145, 175) minutes, respectively (Supplementary Table 2). No intraoperative complication was recorded. Median (IQR) estimated blood loss was 400 (250, 575) ml. A total of 27 (24%) patients received an ePLND. Overall, a total of nine (8%) patients experienced postoperative complications (Supplementary Table 3). Median length of stay was 3 days (IQR: 3, 4).

Final pathology and follow-up. On final pathology, 48 (43%), 34 (31%) and 4 (4%) patients had ISUP group 3-5 tumors, evidence of extraprostatic extension and lymph node involvement, respectively (Table 1). Median (IQR) number of lymph nodes removed was 15 (9, 19). A total of 10 (9%) patients had positive surgical margins. Among 68 patients with available data on the first PSA after surgery, 60 (88%) had undetectable PSA.

Early urinary continence. Data on urinary continence recovery was available for 107 (96%) patients. Median follow-up for patients who did not recover urinary continence after surgery was 40 (IQR: 29, 85) days. The 1- and 3-months probabilities of urinary continence recovery were 36% (95% confidence interval [CI]: 28%, 47%) and 81% (95%CI: 72%, 89%; Figure 1), respectively. Median time to urinary continence recovery was 36 days (95%CI: 34, 44).
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Figure 1:  Urinary continence (UC) recovery after robot-assisted radical prostatectomy (RARP) performed with HUGO RAS robotic system.

In this clinical investigation, we described surgical outcomes of RARP using the novel HUGO RAS system. In this regard, only a few studies are available to date. For instance, Ragavan et al compared outcomes of 17 cases performed with HUGO RAS with those of similar number of patients operated with daVinci robots.9 They described optimal peri-operative outcomes, with operative time consistent with our results. Of note, postoperative PSA was undetectable for all patients, whereas positive surgical margins were found in 23% of men. This is in contrast with our results and, among possible explanations, we acknowledge our technique for apical dissection – the Collar technique10– that allowed us to minimize positive margins rate, and that we were able to adequately translate to the novel HUGO RAS platform. That said, the main focus of Ragavan and colleagues was to compare outcomes of patients operated with different platforms. Moreover, their study, given the small sample size, included only a few patients with aggressive disease and lacked nerve-sparing surgeries and as such, it is difficult to draw definite conclusions about surgical outcomes of RARP performed with HUGO RAS. By contrast, we previously described our surgical setup with this new robotic platform,3 and now we were able to assess our peri-operative, early oncologic, and functional outcomes in an adequately large cohort that included the entire spectrum of patients receiving surgery for prostate cancer. For these reasons, we are positive that our study provided relevant data on clinical outcomes that followed the introduction of HUGO RAS into the robotic market.

In conclusion, this is the first report of surgical outcomes of robot-assisted radical prostatectomy executed with the HUGO RAS system. Awaiting future investigations with longer follow-up, this study provides relevant data on peri-operative, early oncologic, and functional data of RARP performed with this new robotic platform.

Written by: Carlo A. Bravi1,2 Marco Paciotti1,2,3 Eleonora Balestrazzi1,2,4 Adele Piro1,2,5 Federico Piramide1,2,6 Maria Peraire1,2 Luca Sarchi1,2 Angelo Mottaran1,2,4 Luigi Nocera1,2,7 Pieter De Backer2 Geert De Naeyer1,2 Frederiek D’Hondt1,2 Ruben De Groote1,2 Alexandre Mottrie1,2

  1. Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
  2. ORSI Academy, Ghent, Belgium
  3. Department of Urology, Humanitas Research Hospital, IRCCS, Rozzano, Milan, Italy
  4. Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
  5. Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
  6. Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
  7. Division of Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy

References:

  1. Falagario U, Veccia A, Weprin S, Albuquerque EV, Nahas WC, Carrieri G, et al. Robotic-assisted surgery for the treatment of urologic cancers: recent advances. Expert Review of Medical Devices 2020;0:1. doi:10.1080/17434440.2020.1762487.
  2. Farinha R, Puliatti S, Mazzone E, Amato M, Rosiello G, Yadav S, et al. Potential contenders for the Leadership in Robotic Surgery. Journal of Endourology 2021. doi:https://doi.org/10.1089/end.2021.0321.
  3. Bravi CA, Paciotti M, Sarchi L, Mottaran A, Nocera L, Farinha R, et al. Robot-assisted Radical Prostatectomy with the Novel Hugo Robotic System: Initial Experience and Optimal Surgical Set-up at a Tertiary Referral Robotic Center. European Urology 2022:1–5. doi:10.1016/j.eururo.2022.04.029.
  4. Sarchi L, Mottaran A, Bravi CA, Paciotti M, Farinha R, Piazza P, et al. Robot‐assisted radical prostatectomy feasibility and setting with the Hugo™ robot‐assisted surgery system. BJU Int 2022:1–5.doi:10.1111/bju.15819.
  5. Gandaglia G, Fossati N, Zaffuto E, Bandini M, Dell’Oglio P, Bravi CA, et al. Development and Internal Validation of a Novel Model to Identify the Candidates for Extended Pelvic Lymph Node Dissection in Prostate Cancer. European Urology 2017;72:1–9. doi:10.1016/j.eururo.2017.03.049.
  6. Martini A, Falagario UG, Villers A, Dell'Oglio P, Mazzone E, Autorino R, et al. Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy. European Urology 2020;78:583–91. doi:10.1016/j.eururo.2020.07.017.
  7. Mottrie A, Mazzone E, Wiklund P, Graefen M, Collins JW, De Groote R, et al. Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative. BJU Int 2021;128:103–11. doi:10.1111/bju.15311.
  8. Develtere D, Bravi CA, Piazza P, Bravi CA, Pandey A, Berquin C, et al. Early Catheter Removal on Postoperative Day 2 After Robot-assisted Radical Prostatectomy: Updated Real-life Experience with the Aalst Technique. European Urology Focus 2021. doi:10.1016/j.euf.2021.10.003.
  9. Ragavan N, Bharathkumar S, Chirravur P, Sankaran S. Robot-Assisted Laparoscopic Radical Prostatectomy Utilizing Hugo RAS Platform: Initial Experience. Journal of Endourology 2022:1–4. doi:10.1089/end.2022.0461.
  10. Bianchi L, Turri FM, Larcher A, De Groote R, De Bruyne P, De Coninck V, et al. A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The “Collar” Technique. European Urology Focus 2018:1–9. doi:10.1016/j.euf.2018.01.004.
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