Emerging Robotics Platforms Foster Competition, Encourage Innovation

The introduction of robotic surgery platforms to minimally invasive surgery has provided many benefits to both patients and surgeons worldwide. Urologists, the early pioneers of robotic surgery, identified the key benefits for urologic-specific procedures, such as radical prostatectomy (RP), and adoption of the approach proceeded at a breathtaking pace. Data indicate that even 10 years ago more than 85% of RPs were being conducted robotically (RALP) in the United States.¹

Robotic surgery has been found to be more cost-effective overall when used in major urologic procedures. Bolenz and colleagues reported on the cost differential between open, laparoscopic (LRP), and robotic versions of RP and noted that although total direct costs were higher for the minimally invasive techniques, the differences were not significant.² Functional outcomes for RALP are also superior. Results from the recently published multicenter, randomized, controlled LAP-01 trial demonstrated that 3-month continence rates were higher for RALP (54% vs 46%) compared with LRP. Similar benefits were also seen for kidney, ureteral, and bladder cancer.

Intuitive Surgical, Inc. (ISRG), the manufacturer of the most prolific robotics platform, enabled many of these advancements in urologic surgery by working with urologists to develop new instruments and newer and more facile versions of their da Vinci robotics platform. This work has enabled unrestricted growth in the hospital markets, with ISRG reporting more than 80% of the market share and boasting a total install base of 1.5 million robotic cases performed worldwide at the end of 2021.³ Furthermore, ISRG’s latest investor report demonstrated a staggering 22% growth rate in da Vinci-powered robotic procedures in the second quarter of 2023, with over 8000 robots deployed globally to date.⁴

Many of the surgical patents that prohibited other major companies from introducing robotics platforms expired between 2016 and 2022,⁵ and several competitors have introduced their own platforms.

The Hugo RAS system, from Medtronic, is one. The device, with its focus on modularity, portability, and flexibility, was publicly introduced in 2022. Hugo RAS is an “open” console design where a 32-inch widescreen display with dedicated 3-dimensional glasses and a controller sit in front of the surgeon. The controller is connected to 4 independent robotic arms with 6 joints each, a set-up that reduces instrument collision and improves maneuverability.⁶ Surgical vision for the platform is provided by the 3-dimensional TIPCAM produced by Karl Storz.⁶ The Hugo RAS system is still pending US Food and Drug Administration (FDA) approval in the United States, but approval was granted in 2022 by the European Union.⁷

Dr. Ruben Olivares, of the Clínica Santa Maria in Santiago, Chile, performed the first-ever procedure using the Hugo RAS system.⁸ Dr. Alexandre Mottrie, the founder and chief executive officer of Orsi Academy, performed the first procedure in Europe at the OLV Hospital in Aalst, Belgium.⁹ Dr. Mottrie commented on several positive aspects of the platform, including the open console design, which allows the surgeon to have improved communication with the bedside assistant and oversight of the patient during surgery.¹⁰ The platform’s downsides include the 3-dimensional goggles, which appear to be difficult for surgeons to adapt to, as well as the lack of advanced instrumentation such as a vessel sealer or stapler.¹⁰

CMR Surgical Ltd., headquartered in the United Kingdom, has developed a robot-assisted surgery platform called Versius.¹¹ It was released in 2018 for use in minimally invasive surgical procedures. Versatility is one of the platform’s main deliverables, and the manufacturer emphasized that Versius will “[allow] you to operate the way you did laparoscopically, with all the benefits of robotic surgery.”¹¹ Similar to the Hugo RAS platform, individual robotic arms—or “independent bedside units”—allow for flexibility in port placement and surgical approaches. Although Versius has not yet received FDA approval for use in the United States, the device has been utilized across Europe, Australia, and India. Overall, Versius seems to be vying to be a top competitor for the Hugo RAS platform in the European market, and it may be more cost-effective than the da Vinci platform.

Johnson & Johnson (J&J) also has big plans to enter the robot-assisted surgery sphere with a next-generation surgical robot, Ottava, which is being developed in conjunction with one of the original ISRG co-founders, Dr. Frederic Moll.¹² The platform aims to utilize 6 minimally invasive surgical arms (compared with the traditional 4 to 6) for abdominal surgical procedures. It was originally scheduled to undergo human trials in 2022; however, those trials were delayed due to technical development challenges and supply chain disruptions caused by the COVID-19 pandemic. According to the latest J&J investor call transcripts, the company intends to provide a substantial update on the progress of the Ottava project before the end of the year.

Finally, Ascensus Surgical has introduced a second-generation robotics platform called Luna.¹³ Luna distinguishes itself from the competition by building on the first-generation Senhance robotics platform and integrating enhanced tactile feedback and artificial intelligence (AI) features.¹³ According to remarks from the Ascensus team, the new features will allow surgeons to receive real-time augmented AI information to facilitate safer and more predictable surgical outcomes.

It is clear that the future of minimally invasive surgery is bright, and the increasing competition in robot-assisted surgical platform production will enhance innovation and support the creation of new and exciting technologies to make surgery even more accessible to patients around the world.

Akhil Abraham Saji, MD, Fellow at the University of Southern California, is a urologist specializing in minimally invasive surgery and urologic oncology with an interest in technology-driven innovation within health care.

References

1. Leow JJ, Chang SL, Meyer CP, et al. Robot-assisted versus open radical prostatectomy: a contemporary analysis of an all-payer discharge database. Eur Urol. 2016;70(5):837-845. doi:10.1016/j.eururo.2016.01.044
2. Bolenz C, Freedland SJ, Hollenbeck BK, et al. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2014;65(2):316-324. doi:10.1016/j.eururo.2012.08.059
3. Intuitive announces preliminary fourth quarter and full year 2021 results. Intuitive Surgical. January 12, 2022. Accessed August 23, 2023. https://isrg.intuitive.com/news-releases/news-release-details/intuitive-announces-preliminary-fourth-quarter-and-full-year-1/
4. Intuitive announces second quarter earnings. Intuitive Surgical. July 20, 2023. Accessed August 17, 2023. https://isrg.intuitive.com/news-releases/news-release-details/intuitive-announces-second-quarter-earnings-3/
5. Could patent expirations be a chink in Intuitive Surgical’s armor? mddionline.com. August 25, 2016. Accessed August 17, 2023. https://www.mddionline.com/business/could-patent-expirations-be-chink-intuitive-surgicals-armor
6. Raffaelli M, Gallucci P, Voloudakis N, et al. The new robotic platform Hugo^TM RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases. Updates Surg. 2023;75(1):217-225. doi:10.1007/s13304-022-01410-6
7. Medtronic gets CE mark for Hugo robotic-assisted surgery system. NS Medical Devices. October 12, 2021. Accessed August 18, 2023. https://www.nsmedicaldevices.com/news/medtronic-hugo-robotic-assisted-surgery/
8. First procedure in the world with Medtronic Hugo^TM robotic-assisted surgery system performed at Clínica Santa Maria in Chile. Medtronic News. June 22, 2021. Accessed August 18, 2023. https://news.medtronic.com/2021-06-22-First-Procedure-in-the-World-with-Medtronic-Hugo-TM-Robotic-Assisted-Surgery-System-Performed-at-Clinica-Santa-Maria-in-Chile
9. Surgical robotics enters a new era. mddionline.com. February 2, 2022. Accessed August 18, 2023. https://www.mddionline.com/robotics/surgical-robotics-enters-new-era
10. Leading robotic surgeon spills the tea on Medtronic’s Hugo. mddionline.com. October 6, 2022. Accessed August 18, 2023. https://www.mddionline.com/robotics/leading-robotic-surgeon-spills-tea-medtronics-hugo
11. Versius surgical system. CMR Surgical. Accessed August 19, 2023. https://cmrsurgical.com/versius
12. Whooley S. BREAKING: Johnson & Johnson finally unveils its new robot-assisted surgery system. MassDevice. November 19, 2020. Accessed August 19, 2023. https://www.massdevice.com/breaking-johnson-johnson-finally-unveils-its-new-robot-assisted-surgery-system/
13. Kronemyer B. There’s more than meets the eye with the Luna surgical robot. mddionline.com. March 9, 2023. Accessed August 19, 2023. https://www.mddionline.com/robotics/theres-more-meets-eye-luna-surgical-robot