Robot-assisted Surgery Research Articles

Application of CUSUM analysis in assessing learning curves in robot-assisted sacrocolpopexy performed by experienced gynecologist

BackgroundThe aim of this study was to assess the learning curve of robotic-assisted sacrocolpopexy by applying CUSUM analysis based on operation time, complication rate and conversion rate to open laparotomy.MethodsA retrospective study was conducted with 50 consecutive robotic-assisted sacrocolpopexy surgeries performed from June 2018 and June 2023 by a single experienced gynecologist. Baseline patient demographics, intraoperative parameters and postoperative outcomes were collected. Cumulative sum (CUSUM) of robotic-assisted sacrocolpopexy operation time was analyzed to determine breakpoints between learning phases using piecewise linear regression. This allowed the detection of subtle shifts in surgical parameters and ultimately surgeon proficiency and competency. Continuous variables, such as age, length of hospitalization and op time, were reported as mean (standard deviation). One-way analysis of variance was employed to compare continuous variables. Categorical variables were expressed as percentages and analyzed using the chi-square test.ResultsThe regression identified breakpoints at case 8.47 (95% CI 8.0, 9.0) and case 34.41 (95% CI 32.7, 36.1), with an R2 value of 0.87, which agrees with that of the second-order polynomial equation. The breakpoints were rounded to the next whole number at case 9 and 35. The Learning, Proficiency, and Competency phases consisted of 9, 26, and 15 cases, respectively in this consecutive series. This suggests that the surgeon achieved proficiency after the first 9 cases and competency after 35 cases. There were no intraoperative nor short-term post-operative complications during the span of this study. Furthermore, there were no conversions to open laparotomy. CUSUM analysis based on complication and conversion rate, therefore, was not available.ConclusionAccording to CUSUM analysis, surgical proficiency of robotic-assisted sacrocolpopexy was attained after the first 9 cases, and stabilization of operation time was achieved after 35 cases. This statistical tool has proven to be useful in objectively assessing learning curves for new surgical techniques, and the transition from laparoscopic sacrocolpopexy to robotic-assisted sacrocolpopexy seems achievable. This, however, may vary with each surgeon’s manual dexterity and experience level. Further investigation with several surgeons and institutions is needed to define a more accurate and generalized learning curve of robotic-assisted sacrocolpopexy.

A spatial motion constraint method for robot-assisted joint replacement surgery

A spatial motion constraint method for robot-assisted joint replacement surgery

Operator Experience With Robot-Assisted Laparoscopic Rectal Resection and the Impact of Using an Extra Arm on Surgical Outcomes.

Although robot-assisted surgery has been rapidly gaining popularity in recent years, few reports have examined the impact of individual robotic arm movements on surgical outcomes. This study investigated the relationship between extra arm (EA) usage and experience of surgeons in robot-assisted surgery. A total of 176 robot-assisted rectal resections were performed by three surgeons from 2018 to 2022. Each surgeon's first 20 cases categorized in the Early group and the 21st-40th cases in the Late group. Sixty cases in the Early group and 60 cases in the Late group were included to compare patient background, EA motion, and surgical outcomes. More anastomoses were performed closer to the anus in the Late group (p = 0.001). Console time was significantly shorter in the Late group (196 min vs. 153 min, p = 0.020). EA injuries, improper grasping, and intraoperative problems (intraoperative bleeding, misidentification of layers) were significantly less frequent in the Late group (p = 0.001). As experience with robot-assisted surgery increases, appropriate and safe use of an EA was achieved, and operative time and intraoperative problems were reduced.

Artificial Intelligence in Urology: New Technologies with Major Potential

<p dir="ltr"><span>The present paper described how Artificial intelligence (AI) is revolutionizing urology, with applications in diagnosis, treatment planning, and patient monitoring. This review highlights AI's role in key urological areas, such as cancer detection, robotic-assisted surgeries, and personalized patient care. These advancements significantly enhance clinical decision-making and treatment outcomes. Thus, we can clearly state that AI has immense potential to redefine urological practice, fostering accuracy, efficiency, and patient-centered care. However, the integration of these technologies requires addressing challenges like data security, ethical concerns, and regulatory validation. Future efforts should focus on developing robust, evidence-based AI tools to ensure their safe and effective deployment in clinical settings.</span></p><div><span><br /></span></div>

Efficient data-driven joint-level calibration of cable-driven surgical robots

Accurate joint position estimation is crucial for the control of cable-driven laparoscopic surgical robots like the RAVEN-II. However, any slack and stretch in the cable can lead to errors in kinematic estimation, complicating precise control. This work proposes an efficient data-driven calibration method, requiring no additional sensors post-training. The calibration takes 8–21 min and maintains high accuracy during a 6-hour heavily loaded operating. The Deep Neural Network (DNN) model reduces errors by 76%, achieving accuracy of 0.104∘, 0.120∘, and 0.118 mm for joints 1, 2, and 3, respectively. Compared to end-to-end models, the DNN achieves better accuracy and faster convergence by correcting original inaccurate joint positions. Additionally, a linear regression model offers 160 times faster inference speed than the DNN, suitable for RAVEN’s 1000 Hz control loop, with slight compromises in accuracy. This approach should significantly enhance the accuracy of similar cable-driven robots.

Barriers and recommendations for the implementation of robot-assisted minimally invasive surgery in Africa.

Robotic surgery offers several advantages to the African setting, including shorter hospital stays, faster return to work, and increased overall productivity. However, its adoption has been limited by several factors. This review aims to present the barriers to implementation, and recommendations for integrating robotic surgery into the African healthcare system. Use of robotic surgery in Africa is primarily limited to Egypt and South Africa. Barriers faced by other countries were categorized into economic, infrastructural, systemic, and training-related. They include limited healthcare budgets, initial costs of robotic systems, patients' inability to afford robotic procedures, out-of-pocket healthcare financing, inadequate power supply, limited internet connectivity, poor healthcare leadership, and insufficient surgeon training facilities. Public-private partnerships, provision of loans and subsidies, introduction of cheaper robotic systems, and local manufacturing of robotic equipment will serve as cost-effective innovations. It is also important to improve healthcare financing and strengthen healthcare leadership across Africa. To address the lack of surgeon training facilities, remote assistance for surgeon training can be used to create a mentor-mentee relationship between robotic surgeons in any part of the world and surgical trainees in Africa to facilitate knowledge transfer. Prior investment in electricity and network infrastructure is however necessary. Establishment of fellowships to provide early exposure to robotic surgery should also be explored. AI-integrated robotic surgery can also enhance precision and safety, and provide tailored training tools for surgeons. Similar barriers to the adoption of surgical robotics are faced across Africa. By implementing the provided recommendations, robotic surgery can still be widely adopted in African settings, despite the delay.

Limitations of current robot-assisted pedicle screw insertion systems

OBJECTIVE As robot systems for spine surgery have been developed, they have demonstrated a high degree of accuracy in screw placement without sacrificing safety or surgical efficiency. These robotic systems offer preoperative planning and real-time feedback to enhance surgical precision and mitigate human error. Nevertheless, limitations to their optimal performance remain. The authors analyzed the initial 100 cases of pedicle screw placements performed using the Mazor X robot at their institution, presenting case examples to illustrate the limitations that were experienced, and reviewed current literature on the limitations of robot-assisted spine surgery, emphasizing their impact on accuracy and safety. METHODS This was a retrospective review of the first 100 cases of robot-assisted pedicle screw placement at the authors’ institution between December 2019 and June 2024. All intraoperative CT scans were reviewed for screw accuracy. Malpositioned screws, near misses (screw deviation without injury to the patient), or abandoned robot-assisted attempts were identified, and the underlying reasons were evaluated to determine the limitations of current robot technology. RESULTS Of the first 100 cases of robot-assisted pedicle screw placement, there were 20 screw-related complications, of which 14 were near misses, 1 involved neurological injury caused by screw malposition, and 5 were cases in which a robot-assisted attempt was abandoned before manual screw placement. The authors identified the following limitations with current robot technology: registration errors, spine movement after registration, patient body habitus, artifact from metallic implants, poor bone differentiation, skiving, soft-tissue interference, and physical constraints. CONCLUSIONS Despite the advancements of spine robot systems, several limitations persist, especially in mobile or unstable spine locations and around critical structures. The authors’ experience, with provided case examples, further illustrates technical nuances important to understanding and navigating around these limitations. The need for standardized reporting metrics to evaluate and classify emerging technologies is highlighted, emphasizing ongoing technological innovation to enhance the efficacy of robot-assisted spine surgery.

Multi-Objective Safety-Enhanced Path Planning for the Anterior Part of a Flexible Ureteroscope in Robot-Assisted Surgery.

In robot-assisted flexible ureteroscopy, planning a safety-enhanced path facilitates ureteroscope reaching the target safely and quickly. However, current methods rarely consider the safety impact caused by body motion of the anterior part, such as impingement on the lumen wall and sweeping motion risk, or the method can only be used in collision-free situations. The kinematic model of the anterior part under C-shaped and S-shaped collision bending is first analysed. Considering the newly defined impingement cost and sweeping area, the differential evolution algorithm is adopted to optimise the path in the configuration space. Experiments were performed to verify the effectiveness of the method. Compared with the competing algorithm, the proposed algorithm reduced impingement cost and sweeping area by an average of 31.0% and 8.64%. Force measurement experiments verified the rationality of the impingement cost expression. The experimental results proved the feasibility of the proposed path planning algorithm.

A novel robotic-assisted thoracic surgery (RATS) technique: dual-portal RATS (DRATS) as a reduced-port RATS

A novel robotic-assisted thoracic surgery (RATS) technique: dual-portal RATS (DRATS) as a reduced-port RATS

Predictors of cost of admission for robot-assisted pedicle screw placement.

The authors investigated the predictors of cost of admission (CoA) for robot-assisted pedicle screw placement to assess the value of robotic systems in spine operations. Demographic, operative, and postoperative variables were retrospectively collected from 506 patients undergoing robot-assisted spine surgery utilizing the ExcelsiusGPS robot at two high-volume tertiary care centers from 2017 to 2023. Perioperative parameters were evaluated against total hospital admission cost utilizing the Kruskal-Wallis and Wilcoxon rank-sum tests followed by multivariable linear regression. The majority of patients were female (53.6%), 50-80 years of age (77.7%), and White (73.9%); had at least 1 comorbidity (58.1%); and presented with an average functional preoperative Frankel grade (57.5%). The mean CoA was $69,458 ± $47,910. On univariable analysis, demographic data including sex, age, race, and Frankel grade were not associated with CoA. The presence of a comorbidity, however, was associated with increased CoA (p < 0.001). Intraoperatively, one-third of the operations (31.8%) were revisions from prior operations and were subsequently associated with increased CoA (p = 0.021). Thoracic-level operations constituted roughly one-quarter of the cohort (24.1%) and were also associated with increased CoA (p < 0.001). Intraoperative durotomies occurred in 7.7% of patients, leading to increased CoA (p = 0.003). Extended surgical durations also demonstrated elevated CoA (p < 0.001). Postoperatively, the median length of stay (LOS) was 3 days, and an LOS of greater than 3 days was one of the primary drivers of cost (p < 0.001). Postoperative complications occurred in just 6.3% of the cohort but were also associated with increased CoA (p < 0.001). On multivariable analysis, LOS, number of screws placed, operative duration, and postoperative complications were the primary predictors of increased CoA. Understanding the drivers of cost in robot-assisted pedicle screw placement is crucial to elucidate the value associated with the use of robotic systems in spine surgery. These results indicate that patient and surgical complexity influence cost and that robotic systems may augment management in spine surgery. Further investigation is warranted to determine the long-term benefits and cost-effectiveness of new technologies compared with traditional techniques in spine surgery.

Totally Intracorporeal Robot-Assisted Bilateral Ileal Ureter Replacement for the Treat-ment of Ureteral Strictures using Kangduo Surgical Robot 2000 Plus.

Ureteroplasty using buccal or lingual mucosa graft Is feasible for complex proximal ureteral stricture (1, 2). Ileal ureter replacement is considered as the last resort for ureteral reconstruction. Totally intracorporeal robot-assisted ileal ureter replacement can be performed safely and effectively (3). In China, the KangDuo Surgical Robot 2000 Plus (KD-SR-2000 Plus) has been developed featuring two surgeon consoles and five robotic arms. This study aims to share our experience with totally intracorporeal robot-assisted bilateral ileal ureter replacement using KD-SR-2000 Plus. A 59-year-old female patient underwent a complete intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. The surgical procedure involved dissecting the proximal ends of the bilateral ureteral strictures, harvesting the ileal ureter, restoring intestinal continuity, and performing an anastomosis between the ileum and the ureteral end as well as the bladder. The data were prospectively collected and analyzed. The surgery was successfully completed with single docking without open conversion. The length of the harvested ileal ureter was 25 cm. The docking time, operation time and console time were 3.4 min., 271 min and 231 min respectively. The estimated blood loss was 50 mL. The postoperative hospitalization was 6 days. No perioperative complications occurred. It is technically feasible to perform totally intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. A longer follow-up and a larger sample size are required to evaluate its safety and effectiveness.

Development of the X-Sketch: A Modular Skeleton Proprioception System for a Laparo-Endoscopic Single-Site Surgical Robot

Development of the X-Sketch: A Modular Skeleton Proprioception System for a Laparo-Endoscopic Single-Site Surgical Robot

Modular and Fault-Tolerant Three-Axial FBG-Based Force Sensing for Transoral Surgical Robots

Modular and Fault-Tolerant Three-Axial FBG-Based Force Sensing for Transoral Surgical Robots

Early Experience of the Single-Port Robotic Transvesical Radical Prostatectomy: Case Series

Purpose: This study evaluated the feasibility and safety of single-port transvesical robotic radical prostatectomy.Materials and Methods: Four patients underwent a transvesical robotic radical prostatectomy using a singleport robotic system. The procedure involved a 2.5-cm suprapubic incision to access the anterior bladder wall, which was incised by approximately 2 cm. Utilizing a floating-docking technique.Results: All surgeries were successfully completed without the need for additional ports or open conversion. Intraoperative complications were not observed. The median (interquartile range, IQR) console time was 159 (96–198) minutes. The median (IQR) estimated blood loss was 350 (300–700) mL. The median (IQR) duration for Foley catheter removal and patient discharge postsurgery was 7.5 (6–10) days. None of the patients experienced total incontinence after Foley catheter removal, and at 1-month postsurgery, all patients used only a safety pad. Pathology revealed positive surgical margins in 2 patients (both with pT3a and pT3b), with one of these patients having a persistent prostate-specific antigen level of 0.48 ng/mL at 1-month postsurgery. Additionally, 2 patients experienced gross hematuria within 2-week postdischarge.Conclusion: This series demonstrates that single-port robotic transvesical radical prostatectomy is a feasible procedure with favorable perioperative functional outcomes. This offers the advantage of rapid continence recovery without oncological disadvantages.

Characterization and modelling of carbon black nanocomposite strain sensor on pneumatic driven flexible catheter for pulmonary surgery robots

The pulmonary surgery robot is equipped with a flexible catheter designed to navigate narrow bronchi and perform precise surgical operations on lesions, offering benefits such as minimal invasiveness and high flexibility. This study focuses on the shape control and strain sensing of the catheter’s tip. A gas-driven control platform was developed for a three-channel catheter, incorporating miniaturized precision valves to enhance the accuracy of pneumatic pressure control. Concurrently, ultra-thin flexible strain sensors were fabricated using PDMS and carbon black to detect bending strain, and their sensing performance was assessed to identify optimal fabrication parameters. Finally, the control platform and strain sensors were integrated to validate the system’s capability to manage the catheter’s bending shape while simultaneously sensing its deformation. This integration provides a theoretical foundation for enhancing the precision and safety of catheters in practical applications of surgical robots.

Laparoscopic lateral pancreaticojejunostomy in the current era: A narrative review.

Chronic pancreatitis is a benign disease which causes recurrent abdominal pain and loss of pancreatic function. Lateral pancreaticojejunostomy (LPJ) is a commonly performed drainage procedure for this condition. While usually performed through an open approach, there have been few cases of laparoscopic approaches for this condition. A literature review was conducted to understand the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ). We conducted a comprehensive literature search using PubMed, Embase and Cochrane Library to find the articles published until 1 st October 2023. We excluded studies involving paediatric patients or robotic assisted surgeries. Our evaluation focussed on pain relief scores, morbidity, hospital stay length, mortality rates and the development of endocrine and exocrine deficiencies in the patients. The patients in the analysis had a mean age of 36.5 and a male to female ratio of 1.4:1. The mean main pancreatic duct diameter was 11.5 mm. Tropical pancreatitis was identified as the primary cause. The surgical procedure was performed using 4 ports with minimal bleeding and a 13% morbidity rate. The conversion rate was 15%. The average operative time was 260 min and the mean hospital stay was 5.7 days. The results for pain control were excellent, as 90% of patients did not report pain in most series at the end of 3 years. The laparoscopic surgical management of chronic calcific pancreatitis with LPJ offers a safe and effective solution for pain relief in carefully chosen patients. However, further comprehensive studies with large sample sizes are essential to establish a more conclusive comparison between LLPJ and open surgery.

Incidence of Incisional Hernias after Single-Port Versus Multi-Port Robotic Radical Prostatectomy.

Purpose: To determine if single-port robotic-assisted radical prostatectomy (SP-RARP) has higher rates of incisional hernias when compared with multi-port robotic-assisted radical prostatectomies (MP-RARP). Materials and Methods: A retrospective, single-institution review of all consecutive robotic prostatectomy cases between January 2017 and December 2022. Analyzed multi-port and single-port robotic prostatectomies performed by two high-volume surgeons. Measured primary outcome for the development of incisional hernias, as defined by computed tomography imaging and clinical documentation. Multivariable logistic regression was used to determine the effect of the single-port approach on incisional hernia outcomes. Results: A total of 493 patients were included in the study (320 SP-RARPs and 173 MP-RARPs). The overall incisional hernia rate was 8.5% (SP-RARP 8.1% vs MP-RARP 9.2%, p = 0.669). A median follow-up time was 16.6 months and a median time from procedure to hernia diagnosis was 7.4 months. SP-RARP had shorter OR time than the MP-RARP (236 minutes vs 276 minutes, p < 0.001). Patients who developed hernias had higher body mass index (BMIs) than those who did not (30.7 vs 29, p = 0.009). Multivariable logistic regression analysis revealed that patients with higher BMI (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.14) and a history of prior operation (OR 2.23, 95% CI 1.71-4.29) were more likely to develop incisional hernias. Cox regression analysis accounting for the difference in follow-up period demonstrated that SP-RARP 3.4× more likely to develop incisional hernias than MP-RARP (hazard ratio 3.38, 95% CI 1.50-7.58). Conclusions: Patients with higher BMIs and prior history of abdominal surgeries are at increased risk of developing postoperative incisional hernias. SP-RARP procedures confer a higher risk of postoperative incisional hernias.

Surgical experience overcomes the impact of prostatic-urethral anatomy on continence recovery after robotic prostatectomy: comprehensive analysis on 366 cases.

To investigate the relationship between a set of prostate-urethral complex (PUC) measurements and incontinence after robot-assisted radical prostatectomy (RARP). The study included data from patients undergoing RARP performed by 2 expert surgeons between 2019 and 2022, with data about preoperative magnetic resonance imaging (MRI) and functional follow-up. Continence status was assessed according to a stringent definition (no PADS used). MRIs were evaluated to calculate prostatic urethral length, membranous urethral length, membranous urethral width, levator ani thickness, and prostate shape. The association of PUC measurements with continence after RARP was studied. Secondarily, we evaluated whether pre-determined cut-off values of PUC measurements could be associated with time to continence. Cumulative hazard incidence analysis was performed by the Nelson-Aalen hazard function. Cumulative incidence hazard curves were built; the Peto-Peto test was used to evaluate the difference among the curves. 366 patients were included. At the 12-month follow-up, 333 patients (90.1%) were continent. Classification of PUC measurements overlapped between continent and noncontinent patients. However, a statistically significant difference was observed for levator ani thickness, greater in continent patients (12.8mm vs. 11.7; p = 0.02). Multivariable models found BMI as independent predictor of incontinence (HR 1.04, 95% C.I 1.00-1.07, p = 0.04). None of PUC measurements associated with incontinence. Also, cumulative hazard incidence analysis at 3 / 6 / 12-months found no statistically significant difference in PUC measurements. No association was found between anatomical characteristics of PUC and continence or time to continence after RARP performed by proficient surgeons. Our data would suggest that once the surgeon has surpassed the learning curve, anatomical variations do not significantly affect the appropriate and proficient execution of the prostate apex dissection during RARP.

SGR-AutoLap: Surgical gesture recognition-based autonomous laparoscope control for human-robot shared control in semi-autonomous minimally invasive surgical robot

Purpose This paper aims to investigate the problem of vision based autonomous laparoscope control, which can serve as the primary function for semi-autonomous minimally invasive surgical robot system. Providing the surgical gesture recognition information is a fundamental key component for enabling intelligent context-aware assistance in autonomous laparoscope control task. While significant advances have been made in recent years, how to effectively carry out the efficient integration of surgical gesture recognition and autonomous laparoscope control algorithms for robotic assisted minimally invasive surgical robot system is still an open and challenging topic. Design/methodology/approach The authors demonstrate a novel surgeon in-loop semi-autonomous robotic-assisted minimally invasive surgery framework by integrating the surgical gesture recognition and autonomous laparoscope control tasks. Specifically, they explore using a transformer-based deep convolutional neural network to effectively recognize the current surgical gesture. Next, they propose an autonomous laparoscope control model to provide optimal field of view which is in line with surgeon intra-operation preferences. Findings The effectiveness of this surgical gesture recognition methodology is demonstrated on the public JIGSAWS and Cholec80 data sets, outperforming the comparable state-of-the-art methods. Furthermore, the authors have validated the effectiveness of the proposed semi-autonomous framework on the developed HUAQUE surgical robot platforms. Originality/value This study demonstrates the feasibility to perform cognitive assistant human–robot shared control for semi-autonomous robotic-assisted minimally invasive surgery, contributing to the reference for further surgical intelligence in computer-assisted intervention systems.

Robotic radical prostatectomy (RALP) with pre-existing inflatable penile prosthesis (IPP): technical innovations to improve safety and outcomes.

Robotic-assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical approach for treatment of prostate cancer. Prostate cancer is often comorbid with erectile dysfunction (ED), and a small subgroup of men undergoing RALP have an indwelling inflatable penile prosthesis (IPP). In men with IPPs, we perform two techniques at the time of RALP to preserve the pelvic reservoir. In the No Touch Technique, we leave the pseudocapsule of the reservoir intact, electing to dissect the pelvic sidewall and lateral prostatic attachments away from the pseudocapsule. In the Safe Mobilization Technique, we sharply open the pseudocapsule overlying the reservoir and relocate the reservoir out of the pelvis. We retrospectively analyzed 155 cases (Group IPP) from a cohort of 1000 men who underwent RALP. These cases were compared to a randomly selected control group comprising 455 men with PCa who underwent RALP without prior IPP placement (Group NoIPP). We compared perioperative and functional outcomes. The overall incidence of positive surgical margins (PSM) did not significantly differ between the groups (14% in Group IPP and 12% in Group NoIPP, p = 0.4). Furthermore, there was no statistically significant difference in the incidence of PSM at the bladder neck between Group IPP (5.3%) and Group NoIPP (3.4%), p = 0.1. Binomial logistic regression analysis did not find prior IPP placement to be a significant predictor of continence at 3 and 6months or for BCR. All patients in Group IPP were able to successfully cycle their devices postoperatively and there were no reported device infections. The No Touch Technique and Safe Mobilization Technique are easy to perform and safe adjunct procedures at the time of RALP in men with pre-existing IPP.