Research on the Effectiveness and Safety of Remote Control of Domestic Surgical Robot System for Urinary Surgery

Research on the Effectiveness and Safety of Remote Control of Domestic Surgical Robot System for Urinary Surgery

Research on the Effectiveness and Safety of Remote Surgery of Domestic Surgical Robot System for Urinary System Diseases

One-arm clinical trial was adopted in this study. The surgeon performed remote urological surgery for patients through domestically produced "MicroHand" surgical robot system (Shandong Weigao Co., Ltd). The "MicroHand" surgical robot system consists of two physically separated subsystems named the "surgeon console" and "patient side cart". The surgeon console includes a stereo image viewer, two master manipulators, a control panel and several foot pedals. The patient side cart includes a passive arm that can slide in the up-down direction and be adjusted forward and backward, a swivel head that can rotate around the vertical axis, and three slave arms (one for the endoscopic camera and the other two for surgical instruments). The surgeon console (based in Qingdao) takes the surgeon's input and translates manipulation into a control signal. After network transmission, the patient side cart (based in other cities in Shandong Province) translates the control signal into actual instrument manipulation. The 3D images captured by the endoscopic camera were simultaneously sent back to the screen of the surgeon console as visual feedback. Data between the surgeon console and the patient side cart were transmitted through a 5G network. The safety and effectiveness of the robotic system in remote clinical diagnosis and treatment were verified by the main judgment criterion and secondary judgment criterion. Fifty patients with urinary diseases are planned to enroll in the clinical trial. Main judgment criterion: The robot-assisted telesurgery did not transfer to other types of surgery, such as open surgery or normal robot-assisted surgery. Secondary judgment criterion: operative time, blood loss, postoperative pain, preoperative adjusting time and hospitalization time. Patient enrollment: This trial aims to explore the safety and effectiveness of the domestically produced robotic system in remote clinical diagnosis and treatment through 5G network. Fifty patients with urinary diseases are planned to enroll in the clinical trial.

Objective： This clinical trial aims to evaluate the efficacy and safety of telesurgery for patients with tumors of the urinary system using Chinese independently developed "MicroHand" Surgical Robot System through 5G network. Content： One-arm clinical trial was adopted in this study. The product was domestically produced "MicroHand" surgical robot system (Shandong Weigao Co., Ltd). Before entering the clinical study, the patients were fully informed and the written informed consent were signed. According to the inclusion criteria and exclusion criteria, the researchers will conduct a detailed screening to determine whether the patients are suitable for the clinical study. Telesurgery would be conducted for patients who met the inclusion criteria using "MicroHand" surgical robot system. Data between the surgeon console and the patient side cart were transmitted through a 5G network. The safety and efficacy of the robotic system in remote clinical diagnosis and treatment were verified according to the main judgment criterion and secondary judgment criterion. Background：With the combination of robotic and network communication technology, telesurgery has become a reality. On the one hand, telesurgery can conserve and optimize medical resources, providing high-quality medical services to unbalanced areas, such as rural areas, stricken areas and battlefields. On the other hand, telesurgery can reduce the time spent by patients waiting for treatment and thus prevent diseases from worsening. The unbalanced distribution of medical resources has been a prominent problem in China. In addition, the vast territory and relatively lower medical distribution ratio per capita make it difficult for patients to receive timely and high-quality treatment, especially those in remote and underdeveloped areas. Therefore, telesurgery is more significant in China. In recent years, surgical robot systems and network communication technology have experienced breakthroughs. The operation systems of the da Vinci robot in America, the REVO-I robot in South Korea and the ALF-X robot in Italy are more flexible and intelligent, performing well in surgical procedures. The "Micro Hand S" system robot, independently developed in China, represets a new generation of surgical robot systems. In addition to the flexible and intelligent characteristics of traditional robots, the robot has a series of advantages, such as a clear interface, light weight, low cost in terms of use and maintenance, and strong equipment compatibility. After preliminary experiments, the domestically produced robot has been successfully applied in clinical surgery. Meanwhile, in the field of network communication, the emerging 5G mobile communication technology (the 5th generation of wireless systems, 5G technology for short) is the latest generation of cellular mobile communication technology. 5G technology is also an extension of 4G (LTE-A or WiMax), 3G (UMTS or LTE) and 2G (GSM) technology. 5G technology has a high data rate, low latency, high throughput, equipment connection on a large scale, low cost and low energy consumption. The emergence of 5G technology offers more opportunities for the prevalence of telesurgery. In September 2020, our research group carried out the first 5G remote telesurgery using the "Micro Hand S" system robot and a 5G network between Qingdao, Shandong Province, and Xixiu, Guizhou Province, in September 2019 in China (the network communication distance was nearly 3000 km). Specifically, the investigators conducted radical cystectomy on a male patient. The 5G network (Plan A) was used throughout the operation, with an average total delay of 254ms (including an average round-trip delay of 104ms and a packet loss rate of 0%). The operation time was about 5 hours, the intraoperative bleeding was about 200ml, and no intraoperative complications occurred. The patient recovered smoothly after the operation and was discharged on the 18th day. The investigators demonstrated that ultra-remote laparoscopic telesurgery can be performed safely and smoothly under the 5G network using domestically produced equipment. On such basis, our research group planned to carry out this clinical trial with more patients to evaluate the efficacy and safety of telesurgery for patients with tumors of the urinary system using Chinese independently developed "MicroHand" Surgical Robot System through 5G network. Introduction of the "MicroHand" surgical robot： The "MicroHand" surgical robot system consists of two physically separated subsystems named the "surgeon console" and "patient side cart". The surgeon console includes a stereo image viewer, two master manipulators, a control panel and several foot pedals. The patient side cart includes a passive arm that can slide in the up-down direction and be adjusted forward and backward, a swivel head that can rotate around the vertical axis, and three slave arms (one for the endoscopic camera and the other two for surgical instruments). The surgeon console (based in Qingdao) takes the surgeon's input and translates manipulation into a control signal. After network transmission, the patient side cart (based in Anshun) translates the control signal into actual instrument manipulation. The 3D images captured by the endoscopic camera were simultaneously sent back to the screen of the surgeon console as visual feedback. Steps of the procedure： ① The surgeon console was placed in Qingdao, Shangdong Province, while the patient side cart was placed in other cities in Shandong Province. ② Connections between the surgeon console and the patient side cart were established through a public 5G wireless network. Special 5G customer premise equipment (CPE) was used as a signal repeater station and amplifier. Upload and download speed will be tested as network bandwidth. ③ After general anesthesia, the supine position was maintained, the surgical area was disinfected, and pneumoperitoneum was established from the left side of the umbilicus by using a Veress needle. Then, trocars were inserted, and slave arms were delivered. Slave arm A was equipped with robotic grasp pliers, and Slave arm C was equipped with an ultrasonic scalpel (bipolar pliers or electrocautery). Robot-assisted telesurgeries, including adrenalectomy and nephrectomy, were performed by a surgeon from the departments of urology. The surgeon in Qingdao performed the dissection and coagulation of the target organs, while assistants in other cities performed exposure of structures and clip application. Trocar placement and position of the patients were also adjusted in each telesurgery by the assistants if necessary. After completion of the dissection, the target organs were removed by the assistant bedside. Then the pneumoperitoneum was exsufflated and the incisions were closed. Intraoperative network latencies and vital signs were monitored constantly. The master-slave manipulation consistency was assessed subjectively. The operative time, blood loss and complications were recorded.

Patients with upper urinary diseases (renal cell carcinoma, nonfunctioning kidney and adrenal tumor) will be treated by telesurgery.

The success of the telesurgery is the robot-assisted telesurgery did not transfer to other types of surgery， such as open surgery or normal robot-assisted surgery. The number of the success divided by the total number is the success rate.

Mechanical response delay of the robot, endoscope imaging and image processing delay plus video codec delay equals the total delay.

Inclusion Criteria: ASA class I-III BMI: 18-30Kg/m2 patients with Robson Stage I or II renal cell carcinoma that need radical nephrectomy patients with nonfunctioning kidney that need radical nephrectomy patients with adrenal tumor that need adrenalectomy Exclusion Criteria: women during pregnancy or lactation period patients with uncontrolled hypertension patients with a history of epilepsy or psychosis patients with severe cardiovascular disease (NYHA, grade III-IV) patients with cerebrovascular disease (CVD) patients with other diseases that cannot tolerate surgery

Nguan C, Miller B, Patel R, Luke PP, Schlachta CM. Pre-clinical remote telesurgery trial of a da Vinci telesurgery prototype. Int J Med Robot. 2008 Dec;4(4):304-9. doi: 10.1002/rcs.210.

Sterbis JR, Hanly EJ, Herman BC, Marohn MR, Broderick TJ, Shih SP, Harnett B, Doarn C, Schenkman NS. Transcontinental telesurgical nephrectomy using the da Vinci robot in a porcine model. Urology. 2008 May;71(5):971-3. doi: 10.1016/j.urology.2007.11.027. Epub 2008 Mar 4.

Clayman RV. Transatlantic robot-assisted telesurgery. J Urol. 2002 Aug;168(2):873-4. No abstract available.

Marescaux J, Leroy J, Rubino F, Smith M, Vix M, Simone M, Mutter D. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg. 2002 Apr;235(4):487-92. doi: 10.1097/00000658-200204000-00005.

Garcia P, Rosen J, Kapoor C, Noakes M, Elbert G, Treat M, Ganous T, Hanson M, Manak J, Hasser C, Rohler D, Satava R. Trauma Pod: a semi-automated telerobotic surgical system. Int J Med Robot. 2009 Jun;5(2):136-46. doi: 10.1002/rcs.238.

Lefranc M, Peltier J. Evaluation of the ROSA Spine robot for minimally invasive surgical procedures. Expert Rev Med Devices. 2016 Oct;13(10):899-906. doi: 10.1080/17434440.2016.1236680. Epub 2016 Sep 30.

Abdel Raheem A, Troya IS, Kim DK, Kim SH, Won PD, Joon PS, Hyun GS, Rha KH. Robot-assisted Fallopian tube transection and anastomosis using the new REVO-I robotic surgical system: feasibility in a chronic porcine model. BJU Int. 2016 Oct;118(4):604-9. doi: 10.1111/bju.13517. Epub 2016 May 26.

Fanfani F, Monterossi G, Fagotti A, Rossitto C, Gueli Alletti S, Costantini B, Gallotta V, Selvaggi L, Restaino S, Scambia G. The new robotic TELELAP ALF-X in gynecological surgery: single-center experience. Surg Endosc. 2016 Jan;30(1):215-21. doi: 10.1007/s00464-015-4187-9. Epub 2015 Apr 4.

Moglia A, Ferrari V, Morelli L, Ferrari M, Mosca F, Cuschieri A. A Systematic Review of Virtual Reality Simulators for Robot-assisted Surgery. Eur Urol. 2016 Jun;69(6):1065-80. doi: 10.1016/j.eururo.2015.09.021. Epub 2015 Oct 1.

Yi B, Wang G, Li J, Jiang J, Son Z, Su H, Zhu S, Wang S. Domestically produced Chinese minimally invasive surgical robot system "Micro Hand S" is applied to clinical surgery preliminarily in China. Surg Endosc. 2017 Jan;31(1):487-493. doi: 10.1007/s00464-016-4945-3. Epub 2016 May 18.

Yi B, Wang G, Li J, Jiang J, Son Z, Su H, Zhu S. The first clinical use of domestically produced Chinese minimally invasive surgical robot system "Micro Hand S". Surg Endosc. 2016 Jun;30(6):2649-55. doi: 10.1007/s00464-015-4506-1. Epub 2015 Aug 21.