Surgical robotic systems: What we have now? A urological perspective

Abstract Introduction The coming decade will see the emergence of many surgical robotic systems that need to prove their cost‐effectiveness and clinical usability to gain the trust of robotic surgeons worldwide. Herein, we provide a concise review of the currently available robotic systems. Since the da Vinci Surgical System's patent expired and its market monopoly ended, many robotic surgical systems have, and will continue to, enter the market. Central to this is the challenge of gaining the trust of robotic surgeons in a cost‐effective manner. However, the cumulative robotic surgical experience of Intuitive Surgical over these years—which has proven itself clinically and technically—is a great challenge for new surgical robots. Methods This was a non‐systematic review of the literature, conducted through the PubMed search engine, using the following words: “Da Vinci,” “robotic surgical system,” and “new robotic surgical device.” Further information was obtained from the robotic system companies’ official websites and press releases. Conclusions The open robotic market carries great challenges for new robotic surgical systems, especially when following well‐established da Vinci Surgical System. Surgeons’ trust, clinical publications, technical support, and market distribution all represent separate challenges that require address.


| ME THODS
A thorough non-systematic literature review was performed using the PubMed electronic search engine. The following words were searched: "Da Vinci robot system" (n = 990), "robotic surgical system" (n = 6,303), and "new robotic surgical device" (n = 950). Study selection criteria were review articles, preclinical studies, and first clinical trials of these robotic surgical systems. Additional information was obtained from each robotic system company's official website and from press release articles. The included figures were sourced from pictures previously published in medical journals. This review focuses on robotic systems that have urological or other potential applications.

| ROBOTI C SURG IC AL SYS TEMS
The robotic systems are summarized in Table 1.

| DA VIN CI SURG I C AL SYS TEM
The introduction of the da Vinci surgical system revolutionized many surgeries over many surgical specialties. The da Vinci system also created a new surgical history milestone: from open surgery, to laparoscopic and endoscopic surgery, to robot-assisted surgery. The adoption of robotic surgery has grown rapidly over all surgical specialties (Figure 1). 11 The long surgical innovation patency period gave intuitive surgery and elevated stature in the robotic surgical system market.
Many surgical platforms were developed, as was trust from surgeons, patients, and health authorities. Additionally, there have been extensive clinical publications on top of a strong marketing strategy with well-distributed distributors across the globe. Over the last 20 years, approximately five million surgeries have been performed with da Vinci Robots, 12 which has given them a massive cumulative experience and competitive advantage.
The Da Vinci surgical system solved several challenges of standard laparoscopic surgery including improved 3D/HD vision, better dexterity, seven degrees of motion (DOF) by the EndoWrist system, and effective simulation training software. Intuitive surgery brought to surgeons da Vinci S, Si, Xi, X, and the gamechanger of their SP (single port) da Vinci Robotic system ( Figure 2). 13

| Senhance (Telelap ALF-X)
The recently (approved October 2017) FDA-approved ALF-X (Senhance; Trans-Enterix®, Morrisville, USA) is a new multiport robotic system. Fanfani et al reported 80 hysterectomy cases from October 2013 to May 2014 with the ALF-X system. 14 For urology, a porcine model of robot-assisted partial nephrectomy has been reported. 15 It has the advantage of totally independent surgical arms, haptic feedback, and eye tracking systems. 16,17 Because of independent surgical arms, this system requires a spacious operative room.

| Revo-i®-
Revo-i® (Mere company Inc., Yongin, South Korea) is the first Korean robotic system, and received Korean FDA approval for clinical use in August 2017. Revo-i® has a control console, a four-arm robotic cart, a vision cart with HD quality, and multi-use endoscopic instruments ( Figure 3). 13,18,19 It has a design similar to that of the da Vinci Si robot.

| Micro Hand S
The Micro Hand S first Chinese robotic system was developed by Tianjin University in collaboration with Central South University in 2013. 21 It is similar to the da Vinci Si robot ( Figure 4). 22 In 2014, the first clinical trial was reported by Yi et al, who treated patients with gastric perforations and two patients with acute appendicitis. 22

| SPORT
The Single Port Orifice Robotic Technology (SPORT) was developed by the Titan Medical Company (Toronto, Canada). 23 It has an open console system that supports HD/3D vision with a multi-articulated robotic instrument. SPORT has been used to perform robotic single-port partial nephrectomy using an animal model, 10 but has not been used in human clinical studies. The company will have a challenging market, as the SP da Vinci Robot has already launched in multiple countries and was featured in a handful of clinical publications.

| Versius
Versius (Cambridge Medical Robotics, Cambridge, UK) was created following the idea of independent robotic arms with separate functional units. 24 It has an open console design. The robotic arm consists of three joints which act as the shoulder, elbow, and wrist.
These joints provide a more human-like range of arm movements.
The creators of Versius also introduced a haptic feedback system.
The company adopted a different marketing strategy in the form of a managed-service contract system. 25 without an upfront capital payment. This should attract mid-range to small hospitals to add robotic surgeries to their existing services.

| Medicaroid
Medicaroid (Kobe, Japan) was introduced in 2016. It was developed by a company in Silicon Valley consisting of a collaborative group of Sysmex and Kawasaki. 30,31 Medicaroid is another table-mounted robot that consists of three arms and an operating console. 10 We are still waiting for their clinical trials to begin.

| PROCEPT
Aquablation (Aquatic ablation therapy) is one of the first endoscopic robots to perform surgery on its own, with the help of live ultrasound guidance. It was developed by the PROCEPT Company 36 and rendered treatment of benign prostatic hypertrophy (BPH) a daycase procedure, possible even in outpatient setups, with proven efficiency in short-and long-term follow-up. Its mechanism of action depends on the aqua beam system software with a surgeon's predefined contour, assisted by ultrasound-calculated length, depth, and width of the planned resection. 37 The WATER study showed that Aquablation therapy results were as effective as the gold standard transurethral resection of the prostate (TURP). 38

| EMARO
EMARO is the first pneumatically powered endoscopic manipulator robot with an air-pressure system ( Figure 5). 13,39 It was developed by a Japanese company based in Tokyo. The operator drives the robot with the help of a head sensor. 39, 40 We await more information on its clinical application and studies.

| Avicenna Roboflex
Avicenna Roboflex (Elmed, Ankara, Turkey) was introduced for intrarenal surgery using a robotically driven flexible ureterorenoscope. 41 It is an tool set unlike any tools that proceeded it. 25 Urologists exhibited precedent adoption of robotic surgery, especially for prostatectomy and partial nephrectomy. 43 Even endourology had demonstrated growing use of robotic endourological surgeries. 42 The intuitive surgery monopolized the surgical robot market over more than a decade, which gave the first systems a considerable competitive advantage. This advantage was the result of a strong market, trust of the surgical community, accumulative technical experience, and-last but not least-the numerous high-quality clinical studies which have supported robotic systems and surgeries. 10 As the patent rights expire, the robotic F I G U R E 5 EMARO robot 3,7 surgery market will be increasingly competitive, thus raising the bar for all robotic companies.
Although the da Vinci system propelled many robots to market, there has been no significant improvement in the console. The closed console system compromised the surgeon's awareness of his/her surroundings in the operative theater. In contrast, the ALFX system offers an open console system, which is a move in the right direction. 6 Haptic feedback is a particularly important feature that is lacking in the current da Vinci system, while the Telelap ALF-X took the initiative step of providing haptic feedback with their robots. 6,16 Given the emerging surgical trends of single-site and natural orifice surgeries, we expect that robotic surgery will revolutionize these types of surgeries through the development of advanced surgical robots and minimally invasive technologies. 43,44 Many companies are currently developing their own surgical robots; however, many of these projects are confidential at this moment. This list of available surgical robots is non-exhaustive, with each day bringing newly developed technology.

| CHALLENG E S TO NE W ROBOTI C SYS TEMS
New robotic companies face many challenges. The open surgical robot market is competitive, and cost is a significant factor in the success or failure of any one system. Companies whose robots are priced similar to existing trusted and tested robots may fail to sell their product. Unfortunately, the development of new, high-quality technology is costly. Future studies on robot pricing are needed.
Another challenge is where to sell the robots. Currently, most high-volume robotic surgery centers have reached their operative room capacity for accommodating robots. When new robotic companies target mid-to-small range hospitals, they do so at the risk of potentially disappointing initial clinical results, which may further reduce their market value.
Additionally, how will health insurance providers consider new surgical robots? Will these novel systems be covered by insurance? Will insurance companies classify all robotic surgery systems as "robotic," regardless of the robot used, or will their classification schemes vary relative to the robot that is used? Many health insurance providers still do not cover robotic surgery by the da Vinci system, even given their long history in the field. Also, how will surgical robots affect medical

| CON CLUS ION
This new era of robotic-assisted surgery attracts both surgeons and patients. Robotic surgery has reshaped our surgeries over the last two decades, and robots are now used in almost in every surgical field. Still, as surgeons, we continue to look-with great interest-to new robotic companies that may be able to provide better robots in a more cost-effective manner. Future studies that compare individual robotic systems are needed to further evaluate the strengths and weaknesses of each system, with an eye on the continued improvement of robotic surgery technology.

CO N FLI C T O F I NTE R E S T
None.