Technology is evolving rapidly, and its impact on robotic surgery, particularly in the field of urology, cannot be ignored. Intuitive Surgical’s da Vinci system deserves recognition for dominating the market and providing a reliable robotic platform over the past 2 decades. However, the expiration of key patents in 2019 marked the beginning of a new era for robotic master-slave systems. This highly competitive market has witnessed the emergence of multiple robotic platforms in recent years, which hold the potential to drive faster innovation, develop high-quality products, reduce costs, and ultimately increase the availability of robotic systems worldwide, benefiting a larger number of patients. One of these breakthroughs is the Medtronic Hugo RAS (Robotic-assisted Surgery) System, which obtained CE mark approval for urology and gynecology in Europe in late 2021.

The Hugo RAS System offers key distinctive features when compared to conventional da Vinci consoles. It employs pistol-type controls to maneuver the surgical robotic instruments, which are independently located in 4 separate carts. The trocars have diameters of 11 mm and 8 mm for the endoscope and instruments, respectively. The system’s open console design incorporates 3D high-definition vision, requiring dedicated goggles but offering several advantages. The direct contact between the surgeon and the operating room team allows for real-time and easier communication, enhancing teamwork during procedures. Moreover, the Hugo RAS System facilitates teaching and training, providing an unobstructed view of the surgical field that allows trainers and trainees to observe and learn surgical techniques effortlessly. The intuitive control interface and customizable settings further support the training process, enabling new surgeons to efficiently acquire the necessary skills. For instance, wrist rotation can be electronically enhanced via a multiplier (up to 2). This allows for a rotation range of 520°, potentially facilitating surgical movements, particularly during suturing. Lastly, we mention Touch Surgery, a cloud-based video-capture solution that provides anonymized records with artificial intelligence–automatic surgical phase recognition.

Although the system has a larger footprint compared to other platforms, its modularity stands out as a possible major advantage. Each robotic arm cart possesses 6 joints, offering flexibility for different surgical configurations through independent docking. This modularity potentially improves mobility of the robotic arms, making the Hugo RAS System ideal for performing multiquadrant surgeries. Nonetheless, given these arguments, to better understand and optimize system capabilities, it is crucial to emphasize the significance of comprehensive initial technical training by relying on appropriate facilities. This training should involve all the surgical team (surgeon, bed assistant, and scrub nurse) and concentrate on providing a detailed overview of the fundamental aspects of the procedure, as well as the appropriate tilt and docking angles to avoid collision due to the lack of automatic targeting inherited by the multimodular fashion. In preparation for the first-in-human case,¹ our group dedicated dry lab training sessions and therefore tested the feasibility and optimal setting in preclinic cadaveric scenarios of robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy,^2,3 without experiencing technical issues or the necessity to modify any step of our surgical techniques.⁴

Our extensive experience with the Hugo RAS System has resulted in the largest published series of RARP to date, characterized by safe and complication-free procedures. Bravi et al have provided valuable insights by reporting perioperative and 3-month continence outcomes from an initial cohort of 112 patients who underwent RARP using the Hugo RAS System.⁵ Similarly, Paciotti et al have contributed to our understanding by presenting 3-month continence and potency rates of 62 patients who underwent bilateral nerve-sparing RARP with the Hugo RAS System, employing our Aalst technique.⁴ While the evidence supporting the use of the Hugo RAS System in RARP is robust, its application in other oncologic procedures, such as robot-assisted radical cystectomy and robot-assisted partial nephrectomy, remains anecdotal.^6,7 Notably, Gallioli et al reported a single case of laparoscopic conversion due to continuous collision between the robotic arms⁷; however, the limited sample size of the series (n=10) hinders drawing meaningful conclusions.

Finally and interestingly, few positive reports exist also regarding nononcologic procedures, where concerns surrounding cost-effectiveness have often restricted the widespread adoption of robotic approaches in such cases.^8-10

Taken together, the Hugo RAS System demonstrates promising potential as a viable alternative in today’s competitive market of robotic platforms. However, to solidify these preliminary findings, we eagerly anticipate large-scale clinical studies that can confirm the system’s efficacy and ideally compare its performance to established references in the field, such as Intuitive Surgical’s da Vinci system. The culmination of such research will undoubtedly shape the future of robotic surgery and further enhance patient care.