The Urologist at a Crossroads: Mapping Out a New Decade of Robotics

By: Sylvia L. Alip, MD and Koon Ho Rha, MD, PhD | Posted on: 01 May 2022

The COVID-19 pandemic has highlighted the need for a re-evaluation of operative efficiency, gainful resource allocation and the benefit of minimally invasive options in decreasing recovery times. Moreover, with the expiration of patents of the da Vinci™ (Intuitive Surgical, Sunnyvale, California) in 2019, such as those for Endowrist® technology and the repositioning/reorientation of the master/slave configuration),1 market forces have indeed caught up with the robotic giant. In 2019 alone, 2 robotic systems gained CE regulatory approval for commercial release: the avatera (avateramedical GmbH, Jena, Germany)2 and the Versius® system (CMR Surgical, Cambridge, UK).3 Meanwhile, 2 experimental telemanipulator systems were unveiled in the same year: the Enos robotic single-access surgical system (Titan Medical, Inc., Ontario, Canada, previously SPORT™ Single Port Orifice Robotic Technology) and the Hugo™ Robotic-Assisted Surgery (Medtronic PLC, Dublin, Ireland).4,5 Medtronic, a company eclipsing Intuitive’s sales 8 times over,6 will likely become a main player in urology as the banner surgery performed using its new robot was a cadaveric laparoscopic prostatectomy.7 Johnson & Johnson, in their latest corporate release, aimed to start clinical trials using their new Verb-Auris robot in the second half of 2022.8 In Asia, the hinotori™ robot (Medicaroid Corporation, Kobe, Japan) was approved by the Japanese Ministry of Health, Labor and Welfare for commercial use in August 2020,9 while the EMARO robot (Riverfield, Inc., University of Tokyo, Japan), a first in its class of pneumatically driven robots that offer improved haptic feedback using force sensors,10 has yet to receive approval.

The authors have recently written extensively on the 7 commercially licensed telemanipulator robots, as well as several promising experimental ones for both handheld and telemanipulator systems. Some of the latter are solely dedicated to specific surgeries, such as single-port surgery (MIRA®, Miniaturized In Vivo Robotic Assistant, Virtual Incision, University of Nebraska, Lincoln, Nebraska), and transurethral bladder surgery (TURBot – Vanderbilt University, Nashville, Tennessee).4 There is a trove of new ideas and concepts in robotic surgery, and this has driven the course of urology in various directions. Three important areas of discussion have materialized, and it is on these areas that goals may be set and future studies may be focused.

Previously, a race to prove supremacy in domains of efficiency, oncologic outcomes and functional outcomes was in play among open surgery, purely laparoendoscopic and robotic surgery champions. Although this question has largely been unresolved (as pentafecta inferiority or superiority of a single modality has not been supported by robust and consistent evidence), most institutional guidelines have incorporated all modalities in their recommendations (in prostate cancer, for example) and have counseled urologists to advise patients on technical equivalence. More recently, as new robotic systems come to the fore, the game has changed. Not only are we dealing with equipoise among open, laparoendoscopic and robotic systems, but also potentially among the various available robotic systems. Thus, the first important area of robotic development in the near future is the robust comparison of outcomes across all domains, cost included.

“Previously, a race to prove supremacy in domains of efficiency, oncologic outcomes and functional outcomes was in play among open surgery, purely laparoendoscopic and robotic surgery champions.”

The authors published one of the first propensity matched robot-vs-robot retrospective studies (see figure), which showed equivalence of morbidity and short-term oncologic outcomes of radical prostatectomy. The Revo-i (Meerecompany, Seoul, South Korea), however, had longer operative times than the Da Vinci standard.11 This short difference in operative time of 30 minutes may be weighed against a substantial difference in cost.12 The recently published TRUST (TransEnterix European Patient Registry for Robotic-Assisted Laparoscopic Procedures in Urology, Abdominal, Thoracic and Gynecologic Surgery) performed 871 procedures on the Senhance® telerobotic system (previously Tele-lap Alf-x; Asensus Surgical, formerly Transenterix Surgical Inc; North Carolina)13 which was first introduced in 2016. Albeit no comparisons to the da Vinci were made, 141 prostatectomies were successfully performed on Senhance, and this sizeable volume is the first step in the direction of comparative trials with another new robotic system.

Figure. Suturing of the peritoneal reflection after a Retzius-sparing radical prostatectomy in da Vinci Si (A) and Revo-i (B).

The second crucial area of robotic development is effective integration into existing surgical training programs. Institutional investments in da Vinci systems, including training simulators, compatible accessories, and retro-fit operating theaters, may make it difficult to switch or adopt newer robots. Compatibility across platforms, standardization to allow modularity and linking of platforms may be considerations in the future.

The third area is the application of artificial intelligence (AI) to robotics. While the Robotic Consensus Group defined robotic technology in 2008 as “remote telepresence manipulators that [did] not generally function without the explicit and direct control of a human,”14 reflecting existing technology then, AI refers to the computational capability of the machine to mimic and perform human cognitive tasks.15 Most AI applications in urology are used as predictive models, from diagnosis and staging to procedural outcomes, treatment response, survival and prognosis. More recently, surgeons are using machine learning and neural networks to automate the dVRK (for movements of the da Vinci research kit). In a recent study by Hwang et al, the first “superhuman” performance by an automated system was reported, with the dVRK achieving a 94.1% success rate in peg transfer with handovers, higher than that of an expert surgical resident (93.2%).16 More and more studies are being done on AI, so much so that the Society of Gastrointestinal and Endoscopic Surgeons Artificial Intelligence Task Force recently published consensus recommendations on an annotation framework for surgical video to aid physicians and researchers in the implementation of video-based AI.17

“Most AI applications in urology are used as predictive models, from diagnosis and staging to procedural outcomes, treatment response, survival and prognosis.”

In a time unlike any other, with such a wealth of tools in the urologic arsenal, a new paradigm arises. Some may say that in gaining technological momentum we slowly remove the human surgeon from the equation, essentially shooting ourselves in the foot. On the contrary, the onus of the urologist now grows with a keen understanding of all available options. This new paradigm of selecting not only the best technique but also the most appropriate technology has served not to diminish but to strengthen the central role of the urological surgeon in an era of robots and automation.

  1. Rassweiler JJ, Goezen AS, Klein J et al: New robotic platforms. In: Robot Urol, 3rd ed. Edited by H. John and P. Wiklund. Cham, Switzerland: Springer Nature 2018; pp 3–38.
  2. avateramedical: CE Mark for avatera®, the First German System for Robot-Assisted, Minimally Invasive Surgery, Setting the Foundation for Strategic Growth Plans. Jena, Germany; November 14, 2019. Available at Accessed February 22, 2022.
  3. Huddy JR, Crockett M, Nizar AS et al: Experiences of a “COVID protected” robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic. J Robot Surg 2022; 16: 59.
  4. Alip SL, Kim J, Rha KH et al: Future Platforms of Robotic Surgery. Urol Clin North Am 2022; 49: 23.
  5. United States Securities and Exchange Commission: Medtronic Form8-K/A (public document). Available at Accessed February 28, 2022.
  6. Tindera M: Robot Wars: $60B Intuitive Surgical Dominated Its Market for 20 Years. Now Rivals Like Alphabet Are Moving In. Forbes Daily Cover, February 14, 2019. Available at Accessed February 22, 2022.
  7. Medtronic: First Procedure in the World with Medtronic Hugo™ Robotic-Assisted Surgery System Performed at Clínica Santa Maria in Chile. PRNewsWire [Internet]. Medtronic PLC; Available at Accessed June 22, 2021.
  8. Seeking Alpha: Johnson & Johnson Q2: 2020-07-16 Earnings Summary 2020. Available at Accessed February 23, 2022.
  9. Medicaroid. A robot that replicates the movements of the surgeon’s hands. Available at Accessed May 2, 2021.
  10. Eisaku N: Surgical robots face cheaper rivals as key patents expire. Nikkei Asia, April 11, 2021. Available at Accessed February 23, 2022.
  11. Alip S, Koukourikis P, Han WK et al: Comparing Revo-i and da Vinci in Retzius-sparing robot-assisted radical prostatectomy: a preliminary propensity score analysis of outcomes. J Endourol 2022; 36: 104.
  12. Hye-seon L: Locally developed surgical robot unveiled. Korea Biomedical Review, March 15, 2018. Available at https://www.koreabiomed. com/news/articleView.html?idxno=2800. Accessed March 7, 2022.
  13. Stephan D, Darwich I and Willeke F: The TransEnterix European Patient Registry for Robotic-Assisted Laparoscopic Procedures in Urology, Abdominal, Thoracic, and Gynecologic Surgery (“TRUST”). Surg Technol Int 2021; 38: 103.
  14. Herron DM, Marohn M and SAGES-MIRA Robotic Surgery Consensus Group: A consensus document on robotic surgery. Surg Endosc Other Interv Tech 2008; 22: 313.
  15. Shah M, Naik N, Somani BK et al: Artificial intelligence (AI) in urology—current use and future directions: an iTRUE study. Turkish J Urol, suppl., 2020; 46: S27.
  16. Hwang M, Thananjeyan B, Seita D et al: Superhuman Surgical Peg Transfer Using Depth-Sensing and Deep Recurrent Neural Networks. arXiv December 23, 2020. Available at Accessed January 2022.
  17. Meireles OR, Rosman G, Altieri MS et al: SAGES consensus recommendations on an annotation framework for surgical video. Surg Endosc 2021; 35: 4918.