Breakthrough surgical technologies make leaps from revolution to evolution to eventual competition. As Charles Caleb Colton said, “Imitation is the sincerest form of flattery.”

Credit must go to Intuitive Surgical^® (ISRG) for the revolution they initiated in spreading robotics to widescale community and surgeon acceptance starting with urology.¹ Two decades later, ISRG has a $100+ billion market cap, has advanced into multiple specialties, and has created several evolutions such as Xi^®, SP^® (single port) and Firefly^® fluorescence imaging.

Urological laparoscopic surgery started in earnest in the early 1990s after the success of laparoscopic cholecystectomy in general surgery. Pioneers such as Clayman, Kavoussi and others led the early use in urology for kidney procedures, and other operations soon followed. By the late 1990s complex laparoscopic interventions including even suturing and reconstructions were being pursued by a small group of dedicated minimally invasive urological surgeons. However, the barriers to widespread translation to larger numbers of academic and community urologists and trainees was severely limited by the challenging learning curve and skill requirements. Even with the emergence of laparoscopic radical prostatectomy led by our French colleagues, translation was limited to a few centers and surgeons, and was not embraced by most urologists and only a few uro-oncologists.

Figure 1. ISRG da Vinci Xi robotic system. Figure used with permission of Intuitive Surgical.

During the same 1990s time frame, researchers at the Stanford Research Institute were developing a system for the U.S. military funded by DARPA (Defense Advanced Research Projects Agency) and aimed at battlefield remote surgery, which was then transitioned to a laparoscopic system. The system functioned as a “telepresence manipulator” with multiple instruments, a stereo (3D) camera display and wristed instruments all controlled by the surgeon from a remote console. The platform was soon referred to as a “robot” despite the lack of autonomous function. As project funding slowed, a group of visionary entrepreneurial investors led by Dr. Fred Moll and others licensed the emerging technology and started the company ISRG. The da Vinci^® (fig. 1) system was developed and marketed initially targeted at cardiac surgery but achieved little traction in that specialty. Initial use for radical prostatectomy was reported in Europe and subsequent rapid acquisition and deployment by Dr. Mani Menon at Henry Ford Hospital created a surge of interest and competition in the U.S. to learn robotic prostatectomy. The wristed instruments, steady platform, stereovision, surgeon interface intuitiveness, ease of learning complex tasks such as suturing, and marketing led to rapid adoption at many centers that sought to maintain radical prostatectomy operative volume. Translation to other procedures occurred organically as radical cystectomy, partial nephrectomy and a host of other procedures followed, as well as growth in other markets such as gynecology. A lone competitor company, Computer Motion, was acquired by ISRG in the early 2000s creating a market monopoly. ISRG had a significant intellectual property barrier to competition entering the market as well as market dominance.

While still dominating the sector and developments, ISRG’s first mover advantage, strong intellectual property and market dominance seem to be weakening slowly as others rush to capture lucrative market share globally. Growth is estimated by Verified Market Research to grow from $6.1 billion in 2020 to $22.27 billion by 2028. Competitive systems are now being deployed where patent and regulatory requirements permit and are emerging from Asian (China: KangDuo; Korea: Revo-i and Japan: Hinotori), Europe (CMR Surgical: Versius [fig. 2]) and U.S. (Asensus: Senhance and Medtronic: Hugo^®) manufacturers. How many of these see ultimate regulatory approval and successful financial and clinical adoption in the important U.S. market is yet to be seen.

This panel will review the systems that are emerging in the space of laparoscopic robotic surgery and attempt to give the audience some initial exposure to what information is available about the systems that have reached some urology use. The expert panelists will discuss a “report card” of each system and how the current systems compare in terms of specific form factors, mechanisms and purported advantages. Laparoscopic robotic systems will likely see small mechanical advances going forward but continued scientific progress will appear as augmentations like tumor cell imaging, true imaging-based surgical guidance and subtask cooperative automation.

Figure 2. CMR Surgical Versius robotic system. Figure used with permission of CMR Surgical.

The next urology-focused revolution is rumored to already be in motion in the form of developing “robotic flexible endoscopy” (ISRG: Ion; Auris: Monarch) adapting systems from bronchoscopy to ureteroscopy.² Another company, Virtuoso Surgical, aims to revolutionize rigid endoscopy (enucleation, en-bloc transurethral resection of bladder tumor, hysteroscopy etc) by deploying multiple dexterous robotic 1 mm arms through a 26Fr scope, allowing retraction, precise tissue removal and manipulation.³

Just as competition is inevitable with the emergence of the different larger laparoscopic robotic surgery systems, it is also inevitable that bold urological surgeons, engineers and companies will continue to push all minimally invasive surgery forward and create amazing new opportunities to benefit patients and society. This panel will inform the AUA attendees on the status of current laparoscopic robotic surgery and emerging robotic systems.