Robot-assisted sacrocolpopexy using the Hugo-RAS system: initial series with no experience in robotic surgery

Introduction

Robotic-assisted surgery (RAS) was approved by the Food and Drugs Administration in 2000. In the past decades, RAS has gained great popularity in surgical specialties such as urology, gynaecology, general surgery, etc. for its great benefits in relation to 3D vision, magnification, better precision, improved ergonomy, reduced hospital stay and transfusion requirements (1). The robotic platform using the da Vinci system (Intuitive Surgical, Sunnyvale, USA) has dominated the technological sphere for the past two decades. From 2019 a new and emerging robotic systems are expanding the technological landscape of contemporary minimally invasive surgery. The Hugo-RAS robotic platform (Medtronic, Minneapolis, USA) is one of the most popular at present in Europe and some countries in Asia and Latin America. Among the technological innovations of the Hugo-RAS system are its open console, a modular trolley system with separate arms for independent positioning and artificial intelligence (AI)-assisted video image processing. Since the first robotic surgery using the Hugo-RAS system, performed in Chile in 2021, several centres have explored this new technological alternative, but publications are very limited and immature. The vast majority of publications with the Hugo-RAS platform focus on robotic-assisted radical prostatectomy and are performed in centers with previous experience with the da Vinci system (2-13), but RAS urogynecological surgery articles with new Hugo-RAS technology are very few (14-23). In addition, the implementation of the Hugo-RAS system in the inexperienced robotics scenario is an unknown topic and the impact of previous robotics experience has been little reported (24).

Pelvic organ prolapse (POP) is a common condition in women that negatively impacts the quality of life by causing symptoms and effects on body image and sexuality. It has been estimated that 30–40% of women have POP and its morbidity increases by 46% with the ageing population (25-27). Minimally invasive surgical techniques have become more common in pelvic floor urogynaecological surgery like treatment of POP. Even through the first surgical treatment for POP using robotic technology was done in 2004 (28), currently many studies have shown that minimally invasive surgery sacrocolpopexy has established as the gold standard for the advantages of this procedure (29,30).

Recently, our centre acquired the Hugo-RAS technology and we have initiated experience in RARP, partial nephrectomy, adrenalectomy, cystectomy and sacrocolpopexy. Our objectives in this manuscript are to describe our initial experience with robotic-assisted sacrocolpopexy (RASC) using the Hugo-RAS system, as well as to show feasibility and safety of this new technology in a setting of urologists lacking experience in robotic surgery. We consider that our study is necessary because there are few publications based on RASC Hugo-RAS cases and the context of starting robotic surgery within this system, without previous experience on the da Vinci platform, has not been analysed. We present this article in accordance with the AME Case Series reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-61/rc).

Cases presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A prospective-descriptive study was performed on consecutive patients with symptomatic POP who underwent RASC Hugo-RAS between November 2023 and March 2024, and follow-up has been maintained until the preparation of this manuscript. The text of the manuscript was not written with AI and no generative AI or AI-assisted technologies were used. Our study was performed in a case series undergoing a standardised surgical technique, which has been performed with robotic equipment for more than two decades. In addition, the surgeons have extensive experience in the laparoscopic sacrocolpopexy technique and have obtained certification to operate with the Hugo-RAS system having passed the certified training. Furthermore, the Hugo-RAS system has been approved by the EMA since 2022. Therefore, the study adheres to the ethical principles outlined in the Declaration of Helsinki and does not require ethics committee approval as it is not an experimental study.

Our study was conducted in a Public Academic Universitary Centre (monocentric), with post-graduate urology resident training and medical studies attached to Miguel Hernández University of Elche (Spain).

Two urologists with expertise in laparoscopy (without previous experience in robotic surgery completed formal and certified training in robotic surgery specific to the Hugo-RAS system at the ORSI Academy (Melle-Belgium), including simulator, dry and wet lab practice. In our case series all surgeries was done by one surgeon (L.G.P.) (learning curve for laparoscopic SCP completed). Additionally, the rest of the surgical team members also participated in this training process (nurses).

We collected data from consecutive patients with inclusion criteria as follows: women symptomatic with POP of ≥3 stage based on the POP-quantification (POP-Q) system (31) with no contraindication for laparoscopic/robotic surgery and who have signed the informed consent form. Patients with POP <3 stage did not fulfill surgery criteria therefore were not included. All patients underwent a medical history, physical examination, laboratory and urine tests, pelvic and urinary tract ultrasound, Pad test and urodynamic study. In patients who underwent uterine preservation (hysteropexy), uterine disease was previously ruled out by the absence of risk factors for endometrial cancer (significant obesity, tamoxifen treatment, presence of BRCA 1 or 2 and Lynch syndrome) and confirmed by negative cytology and normal uterine ultrasound.

Demographic and preoperative variables included age, body mass index (BMI), American Society of Anesthesiology (ASA) score, previous POP surgery, previous hysterectomy, grade of prolapse (anterior, apical, posterior or combination), and preoperative symptoms (stress urinary incontinence, urge urinary incontinence, occult stress urinary incontinence, constipation). The peri-operative variables included total operative time, estimated blood loss, hospital stay, conversion rate, transfusion rate, catheter dwell time. Peri-operative complications were recorded according to the Clavien-Dindo classification (32). With regard to follow-up variables, anatomical correction of POP was defined as the absence of prolapse or the presence of asymptomatic stage I–II residual prolapse. Recurrence of POP was defined as the reappearance of prolapse of the same or greater stage prior to surgery with symptoms. Resolution of symptoms were evaluated asking to the patients and the subjective satisfaction of the patients was assessed using the PGI-I questionnaire (33). A gynaecological examination was carried out on the day of discharge, at the first check-up at 45 days, at each 6 months during follow-up applying the POP-Q system and the PGI-I satisfaction scale.

SPSS statistical software program (SPSS Inc., Chicago, IL, USA) was used. In relation to the statistical analysis, tests of dispersion and central tendency were used.

The surgical team and the modular arms were positioned based on the recommendations and specifications given by the Hugo-RAS system experts regarding the angles of each modular trolley and each arm (Figures 1,2). The patient is placed in the lithotomy position, with the arms close to the body and in Trendelenburg. A Foley trans-urethral catheter was inserted. A total of 6 trocars are placed for the transperitoneal approach [4 for the robotic arms (10 mm conventional) and 2 for the surgical assistant (5–10 mm)]. The placement of the ports requires measurements on the abdominal wall to ensure collision-free arm movements as show in Figure 3.

Figure 1 Room-set RASC Hugo-RAS. RASC, robotic-assisted sacrocolpopexy.

Figure 2 System Hugo-RAS (Docking).

Figure 3 Trocars placement for RASC Hugo-RAS. RASC, robotic-assisted sacrocolpopexy.

In abdominal sacrocolpopexy, it has been shown that the most suitable mesh is polypropylene mesh, with macropore, non-absorbable monofilament, due to its lower rate of recurrence and its lower risk of infection and erosion. We used the Upsilon Y Mesh (Boston Scientific Corporation, Marlborough, USA) in for cases of vaginal vault prolapse and Uplift mesh (previously divided into two branch) (Neomedic International, Madrid, Spain) for patients with hysteropexy.

The surgical procedure RASC were done by a standardized technique. The procedural steps included dissection, mesh placement, fixation to the cervix or vaginal vault and promontory, and peritonealization (Figure 4). In details, the surgery start looking for proper exposure with a percutaneous stitch passed to fix the sigmoid colon at the abdominal wall (T-Lift-Vectere-France) (Figure 5) At the level of the posterior peritoneum, an incision is made on the right side of the sigmoid colon to expose the promontory (Figure 6). The peritoneal incision extends towards the recto-uterine cul-de-sac following the right utero-sacral ligament to complete posterior vaginal plane. A Colpoassist Vaginal Positioning Device (Boston Scientific) is inserted into the vagina for adequate exposure of the planes (Figure 7). The anterior compartment is dissected in order to access carefully to the vesico-vaginal plane. In cases with uterine preservation, an oval aperture was made below the right broad ligament to pass the anterior branch of the mesh. The mesh is then inserted into the peritoneal cavity. The posterior branch of the mesh is fixated to the posterior plane of the vagina with interrupted absorbable sutures (Vicryl 3/0) (Figure 8). Posteriorly, the anterior branch of the mesh is fixated to anterior plane of the vagina with 4–5 interrupted absorbable sutures (Vicryl 3/0) (Figure 9). The “tail” of the mesh was attached to the sacral promontory with 2 interrupted stitches of non-absorbable multi-filament polyester suture (Ethibon, Ethicon) (Figure 10). Finally, the posterior peritoneum is closed by an uninterrupted suture line using a barbed suture (V-Loc, Covidean) (Figure 11). At the end of surgery, no drainage is placed and a vaginal packing with gauze is inserted.

Figure 4 Schematic view of Sacrocolpopexy technique.

Figure 5 Percutaneous fixation of sigmoidal colon at the abdominal wall.

Figure 6 Incision in the posterior peritoneum to expose the promontory.

Figure 7 Insertion of colpassist vaginal device.

Figure 8 Fixation of posterior branch of the mesh.

Figure 9 Fixation of anterior branch of the mesh.

Figure 10 Fixation of tail of the mesh to the promontory sacral.

Figure 11 Posterior peritoneal closure with barbed suture.

A total of 8 patients underwent RASC Hugo-RAS. Data on baseline characteristics are shown in Table 1. The median age was 51 [interquartile range (IQR), 48–69] years and BMI 26.2 (IQR, 22.8–28.4) kg/m². The majority of patients had ASA score of 1–2 (87.5%). All patients included had a POP-Q stage 3–4 genital prolapse, of which 4 had cystocele and hysterocele (50%), 2 had vaginal vault prolapse (25%), one case has cystocele (12.5%) and one case hysterocele (12.5%). Two cases (25%) had previous POP surgery, other two patients (25%) had a previous hysterectomy, and one patient had a anterior plasty by vaginal approach without mesh (12.5%). Regarding preoperative symptoms, all patients had a sensation of genital bulge (100%), two patients had stress urinary incontinence (25%), two patients have urge urinary incontinence (25%) two patients had difficulty urinating (25%) and one case had dyspareunia (12.5%).

The peri-operative data are show in Table 2. All cases were successfully operated by robotic approach using the Hugo-RAS system without conversion to laparoscopic or open surgery. One patient underwent hysterectomy subtotal and the rest underwent uterus-sparing surgery (hysteropexy) (62.5%). A median total operative time of 230 min (IQR, 190–272 min) was recorded. With regard to intraoperative complications, one patient presented with an opening of the vagina which was repaired at the same time (12.5%). The median estimated blood loss was 275 cc (IQR, 147.5–387.5 cc) and no patient required transfusion of blood products.

In the majority of patients the urethral catheter were removed on the second post-operative day. The postoperative complications occurred in 2 patients and were grade ≤2 on the Clavien-Dindo scale. The median hospital stay was 3 days (2–3 days). One patient had an uncomplicated urinary tract infection that improved with oral antibiotics and another had a fever treated with antipyretics.

After the first control 3 months after surgery, all of patients showed objective anatomical improvement and all patients reported being satisfied or very satisfied with the surgery (the mean of reported subjective improvement with the PGI-I scale was 1.5). At a median follow-up of 15.5 months (IQR, 15–18.5 months), all patients remain without prolapse recurrence, keep satisfied with the prolapse surgery, without POP-related symptoms, no constipation, back-pain, mesh extrusion nor urinary incontinence “de novo” and none have required re-intervention.

Discussion

The first descriptions of suspension techniques for POP repair date back to the 1950s and 1960s. Humphrey GEA & Savage D described the fixation of the uterus to the sacral promontory in 1957. At the same time, other authors such as Ameline A & Hugier J, Embray MP and Falk HC described various abdominal approaches for suspension of uterine prolapse and vaginal vault (34-37). Nezhat et al. presented the first publication about laparoscopic sacral colpopexy for vaginal vault prolapse in 1994 (38). Di Marco et al. described the first RASC for treatment of vaginal vault prolapse in 2004 (28).

Mottaran et al. described the first worldwide report of RASC with the novel Hugo-RAs system in 2023, showing the technical feasibility and safety of the procedure in a series of 5 consecutive patients (14). Panico et al. presented the largest series to date with sixty patients operated of RASC by Hugo-RAS showing a surgical anatomical success of 96.7% and a subjective cure of 98.3%. The authors conclude that RAS Hugo-RAS offers effectiveness both objective and subjective outcomes, with low incidence of complications comparable to standard minimally invasive techniques. In this manuscript with surgeons experienced with the da Vinci system, it is described that they were satisfied with the open console that allows them to sit upright and have direct communication with the surgical team (16).

Collá Ruvolo et al. presented the first comparative analysis of RAS Hugo-RAS and the Da Vince Xi surgical system for POP. This article includes 38 patients with POP divided into two groups, 23 cases (60.5%) operated by the da Vinci system and 15 (39.5%) operated by the Hugo-RAS system. The comparative analysis showed similar operating times (123 minutes for the da Vinci and 120 minutes for the Hugo-RAS system) with no differences between the two groups in terms of anatomical and subjective resolution of POP, perioperative parameters and patient satisfaction (39). This report is in concordance with comparative studies between the da Vinci platform and the Hugo-RAS system, which show similar results with respect to peri-operative, oncological and functional parameters in RARP (40-43).

Gioè et al. present the first European experience from Gemelli hospital with system Hugo-RAS for gynecological surgery. In this series of 138 patients includes a group of 60 patients who underwent POP surgery, reporting a mean operative time of 185 minutes, with minimal bleeding, no intraoperative complications and few postoperative complications (5%). The authors conclude that the Hugo-RAS system for gynaecological surgery is safe with good results in terms of efficacy and perioperative outcomes (17). Other published series confirm the safety and effectiveness of gynaecological surgery using the Hugo-RAS system (18,20,22,23,43). In our study, we obtained slightly longer operative times (230 minutes), with very low perioperative morbidity (low bleeding, short hospital stay and low complication rate) with effectiveness and safety results comparable to the existing scientific literature.

Regarding sacrocolpexy, it is well known that the main advantage of robotic surgery over laparoscopy resides in the suturing and knotting steps, because it is a demanding surgical technique that requires many stitches for mesh fixation and peritoneal closure. In our opinion, the reconstructive steps were simplified with the robotic technology of the Hugo-RAS system. On the other hand, in the evolution and development of the sacrocolpopexy technique in minimally invasive approaches, there has been a tendency to routinely fix the mesh to the levator ani muscles; however, although there is controversy, it has been shown that it does not provide advantages and prolongs the operative time and may add morbidity. With respect to uterine preservation in minimally invasive POP surgery, there is more consensus and a growing trend, since after having ruled out uterine pathology, the procedure without hysterectomy offers benefits in reducing operative time and intraoperative bleeding. In our RASC Hugo-RAS technique, where we did not perform mesh fixation to the levator muscles and the uterus was preserved in most cases, we presented satisfactory objective and subjective results in the treatment of POP.

Robotic surgery has gained wide popularity worldwide for its significant advantages. Over the past two decades, the da Vinci system has dominated the robotic surgery scene and it is since the completion of Intuitive’s patent that new robotic platforms have been added to the current surgical armamentarium. The Hugo-RAS system was approved for clinical application in Europe in 2022 and appears to be the most promising alternative to the da Vinci system, mainly for robotic prostate surgery. Current data suggest clinical use of the Hugo-RAS system in 12 countries/regions where publications are available (Canada, Brazil, Chile, Panama, India, Japan, Taiwan, Portugal, Italy, Belgium, Denmark and Spain). Preliminary results with Hugo-RAS are quite favourable and promising, however, most studies include limited numbers of patients, are conducted in centres with previous experience in robotic surgery with the da Vinci, and some of these institutions are involved in training and development programmes for the Hugo-RAS system (44-46).

The Hugo-RAS system offers innovations such as the open console that allows better ergonomics and greater communication with the surgical team, facilitating the dynamics of the operating room (2-5,13,19) (Figure 12A). In addition, the system include a surgeon’s 3D glasses contain a safety sensor that activates or blocks the robot according to the operator’s head movements (2,3,19) (Figure 12B,12C). Another innovation is the pistol-shaped hand controllers, with a safety lock that releases or locks the command activated by the third finger, together with an ergonomic and intuitive design that also allows for wrist wide range of rotation (2,4,5,9,19) (Figure 13). One of the most interesting innovations of the Hugo-RAS platform is the modular system of separate and independent carts for each robotic arm, which allows for greater versatility in different arm positions to adapt to each patient or type of surgery, although this could increase docking times at the beginning of the curve.

Figure 12 Hugo-RAS innovations. (A) Open console. (B) Ergonomic position surgeon sits upright. (C) Surgeon’s 3D glasses with safety sensor.

Figure 13 Hugo-RAS innovations: pistol-shaped hand controllers.

The implementation of the Hugo-RAS system in inexperienced robotic surgeons has been little studied. In our knowledge, there is only one study available that compares the impact of experience with the da Vinci robot system in RARP with the Hugo-RAS system in novice surgeons who are new to robotics and are starting with the Hugo-RAS system. This study no found differences between the groups and demonstrated the safety and efficacy of the Hugo-RAS system in surgeons with no robotic experience (24). Our study was conducted with surgeons without previous experience in robotic surgery, but completed formal and certified training on the Hugo-RAS platform. As a consequence, we obtained satisfactory results of comparable effectiveness and safety to those in the existing scientific literature. With regard to limitations, our study is a case series, single-centre, and without a control group, but we are not able to establish solid conclusions. However, our case series may reflect the feasibility and effectiveness of RASC-Hugo-RAS, which could be proposed as an alternative technology.

Due to the recent introduction of the Hugo-RAS system, robust comparative data series and external validation are required for the expansion of this new robot in the urological community. The apparently lower costs are an advantage of the Hugo-RAS platform over the da Vinci robot. However, the specific training requirements for each robot and differences between surgeons could limit its implementation in hospitals that have the da Vinci system. Nevertheless, for centers that are just starting out with robotic technology, it could be a cost-effective alternative.

Conclusions

In our initial series, RASC Hugo-RAS is a feasible, safe and effective procedure for the treatment of POP by urologists without experience in robotic surgery as long as adequate training is provided. Further studies need to be done in order to provide robust data.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-61/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-61/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-61/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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