Clinical Feasibility, Safety, and Quality-of-Life Outcomes of Robot-Assisted Total Hysterectomy Using the Hugo™ RAS System: A Prospective Observational Study

Clinical Feasibility, Safety, and Quality-of-Life Outcomes of Robot-Assisted Total Hysterectomy Using the Hugo™ RAS System: A Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Feasibility, Safety, and Quality-of-Life Outcomes of Robot-Assisted Total Hysterectomy Using the Hugo™ RAS System: A Prospective Observational Study Ikumi Wada, Hiroaki Komatsu, Yuki Hiratsuka, Koji Yamamoto, Kohei Hikino, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8219698/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This prospective observational study evaluated the safety, learning curve, and postoperative quality-of-life (QOL) outcomes of robot-assisted total hysterectomy performed using the Hugo™ Robotic-Assisted Surgery (RAS) System at a single academic center. Forty-five consecutive patients underwent simple or radical hysterectomy by a certified gynecologic robotic surgeon. Operative metrics, perioperative outcomes, and patient-reported QOL were assessed using validated questionnaires, including the SF-8, Female Sexual Function Index (FSFI), Overactive Bladder Symptom Score (OABSS), International Consultation on Incontinence Questionnaire–Short Form (ICIQ-SF), and International Prostate Symptom Score (IPSS), administered preoperatively and at 1 and 3 months postoperatively. Learning curve analysis was conducted using the cumulative sum (CUSUM) method. All procedures were completed without conversion to laparotomy or laparoscopy. Mean total operative time was 141.6 ± 30.7 minutes, mean console time was 105.6 ± 30.4 minutes, and mean blood loss was 23.6 ± 70.1 mL. Minor postoperative complications occurred in 13.3% of patients, all classified as Clavien–Dindo grade I–II and managed conservatively. The CUSUM curve demonstrated that operative proficiency was achieved after approximately 15–20 cases. QOL outcomes showed transient postoperative fluctuations but overall preservation of general health, urinary function, and sexual function, with SF-8 physical and mental component scores returning to baseline by 3 months. In conclusion, robot-assisted hysterectomy performed with the Hugo™ RAS System was safe, efficient, and associated with a short learning curve. Postoperative QOL was well maintained, supporting the feasibility and patient-centered value of this emerging robotic platform. Robot-assisted hysterectomy Hugo™ Robotic-Assisted Surgery System Learning curve Quality of life Gynecologic minimally invasive surgery Figures Figure 1 Figure 2 Figure 3 Introduction Robotic-assisted surgery has revolutionized minimally invasive gynecology by providing three-dimensional vision, enhanced dexterity, tremor suppression, and improved ergonomics[ 1 ]. These advances are associated with reduced blood loss, lower pain scores, and faster recovery compared to open surgery. In Japan, robotic platforms have been rapidly adopted: the da Vinci system has long dominated, but newer platforms such as the domestic Hinotori™ and the globally marketed Hugo™ RAS are emerging[ 2 , 3 ]. The Hugo RAS system (Medtronic) received CE approval in 2021–2022 for urologic, gynecologic, and general surgical procedures, introducing an open, console and four modular independent arms[ 4 ]. These features may enhance surgeon comfort and versatility; indeed, early studies note the Hugo console is “highly comfortable and ergonomic,” allowing better communication with the operative team. Komatsu et al. have led initial reports of these new systems in Japan[ 3 ]. In 2024, they described the first robotic total hysterectomy with Hugo in Japan, detailing the system’s instrumentation and potential QOL benefits. Moreover, they have developed innovative educational frameworks and optimized port placement strategies for the Hugo platform, which have been actively implemented in clinical practice and surgical training programs across Japan[ 5 , 6 ]. A recent comprehensive review by Komatsu et al. highlights that Hugo and Hinotori can achieve surgical outcomes comparable to the da Vinci system, albeit with longer setup times during early experience[ 7 ]. Moreover, multi-platform comparisons (da Vinci X, Xi, Hinotori, Hugo) found no significant differences in key outcomes for total hysterectomy, suggesting the new systems are on par with established technology[ 8 , 9 ]. Recently, national survey data have confirmed the rapid expansion of robotic gynecologic surgery in Japan, including early adoption of Hugo™ and Hinotori™ platforms in multiple institutions[ 10 ]. Similarly, Matsuura et al. reported favorable early outcomes of these novel robotic systems for hysterectomy, highlighting comparable safety and efficiency to established platforms[ 9 ]. These reports underscore the importance of evaluating new robotic systems under prospective designs to confirm their clinical feasibility and quality-of-life impact. Despite these encouraging data, published experience with Hugo in gynecology remains scarce. Moreover, patient-centered outcomes like postoperative quality of life (QOL) – including general health, sexual function, and urinary symptoms – have not been systematically studied with the Hugo platform. Preservation of QOL is a major advantage of minimally invasive hysterectomy and may influence patient satisfaction. To our knowledge, this is the first prospective cohort of Hugo-assisted total hysterectomy in Japan with explicit evaluation of QOL metrics. We aimed to assess safety (complications), learning curve (CUSUM of console time), and patient-reported outcomes (SF-8, FSFI, OABSS, ICIQ-SF, IPSS) in 45 consecutive patients. We hypothesized that Hugo would perform safely and deliver excellent patient-centered results, in line with Komatsu’s findings and global robotic data. Methods From March 2023 to April 2025, we enrolled 45 consecutive adult women scheduled for elective total hysterectomy (benign or malignant indications) via the Hugo™ robotic system at Tottori University Hospital. All patients provided informed consent, and institutional review board approval was obtained (22A182). Exclusion criteria were need for emergent surgery or contraindication to laparoscopy. Preoperative workup included standard imaging and gynecologic evaluation. Demographic and clinical data were recorded, including age, body mass index (BMI), obstetric history, prior abdominal surgery, and preoperative diagnosis. Surgical procedure All surgeries were performed by a single lead surgeon with extensive robotic gynecologic experience, assisted by a seasoned robotic surgery team. Port placement for Hugo RAS followed the manufacturer’s guidelines and published techniques[ 3 , 6 ]. After docking the four independent robotic arms, the surgeon at the open console (3D high-definition display with ergonomic controls) performed the hysterectomy. Procedures included total laparoscopic hysterectomy (TLH) with/without bilateral salpingo-oophorectomy (BSO) as appropriate. Pelvic lymphadenectomy was performed if indicated (rare in our benign cohort). Console time (time of robotic activation) and total operative time (incision to closure) were recorded. Outcomes and instruments Intraoperative metrics collected were total operative time, setup time(from skin incision to console start, including docking), console time, blood loss (mL), need for transfusion, intraoperative complications, and conversion to open surgery. Uterus weight (grams) was measured. Postoperative data included length of hospital stay (days), and complications up to 90 days, classified by the Clavien–Dindo system (I–V). Patient-reported QOL outcomes were assessed at baseline (pre-op), 1 month, and 3 months post-op via five validated questionnaires : SF-8 Health Survey an 8-item measure of general physical and mental health (producing physical and mental component scores). FSFI (Female Sexual Function Index) : a 19-item instrument assessing sexual function (domains: desire, arousal, lubrication, orgasm, satisfaction, pain); total scores range 2–36, higher scores indicate better function. OABSS (Overactive Bladder Symptom Score) a 4-item survey quantifying urgency and incontinence severity (score 0–15; 0 = no symptoms). ICIQ-SF (International Consultation on Incontinence Questionnaire Short Form) 4 items measuring the impact of urinary leakage (score 0–21; 0 = no incontinence). IPSS (International Prostate Symptom Score) with QOL a 7-item survey of voiding and storage symptoms plus a quality-of-life item (score 0–35; higher is worse; QOL score 0–6). Though developed for men, IPSS can capture lower urinary tract symptoms in women. These instruments were chosen to comprehensively assess general health, pelvic floor function, and sexual well-being. They were administered via self-report; patients unable to complete written forms had assistance from research staff. Missing responses were recorded as non-response. Learning-curve analysis We used CUSUM (cumulative sum) charts of console time to evaluate the learning curve. CUSUM plots cumulative deviation of each case’s console time from the overall mean; a plateau or downward trend indicates reaching proficiency. Statistical analysis Descriptive statistics are presented as mean ± SD for continuous variables and counts (%) for categorical variables. Changes in questionnaire scores over time were assessed using non-parametric Friedman tests for repeated measures (given the ordinal nature of scores and small sample), with post-hoc paired comparisons as appropriate. However, the study was primarily descriptive and not powered for definitive hypothesis testing. All analyses were performed in SPSS (v.27, IBM). The focus was on descriptive comparison with historical data rather than hypothesis testing. No external funding was used. Results Patient Characteristics (Table 1 ) Table 1 Patient Characteristics Variable Summary Age (years) Mean 54.5 (range 30–82) BMI (kg/m²) Mean 24.5 (range 16.6–39.1) History of vaginal delivery 75.6% (34/45) History of abdominal surgery 31.1% (14/45) Preoperative diagnosis Uterine cancer (IA): 15 (33.3%) Leiomyoma: 9 (20.0%) Adenomyosis / myoma: 1 (2.2%) Cervical carcinoma IA1: 1 (2.2%) Cervical dysplasia: 1 (2.2%) Others: 18 (40.0%) Postoperative diagnosis Uterine cancer IA: 10 (22.2%) Leiomyoma: 9 (20.0%) Endometrial carcinoma IA: 5 (11.1%) Adenomyosis: 2 (4.4%) Cervical carcinoma IA1: 2 (4.4%) Others: 17 (37.8%) Surgical procedure RATLH + BSO: 21 (46.7%) RATLH + BS: 14 (31.1%) RATLH་BS (variant): 4 (8.9%) RAmRH + BSO + dissection: 2 (4.4%) RATLH + LSO + RS: 1 (2.2%) Others: 3 (6.7%) Pelvic lymphadenectomy performed 4.4% (2/45) The cohort’s mean age was 54 years and mean BMI 24.5 kg/m². Preoperatively, 27 patients (60%) were believed to have benign conditions (e.g., fibroids) and 18 (40%) had malignant or pre-malignant indications (endometrial carcinoma, atypical hyperplasia, early-stage cervical neoplasia). Final pathology confirmed malignancy in 19 cases (16 endometrial carcinoma FIGO IA and 3 cervical carcinoma in situ/AIS), with benign findings in the remaining 26. Our cohort represented a mix of benign and early-stage malignant indications. Operative Outcomes (Table 2) Table 2 Operative Outcomes Parameter Mean ± SD Total operative time (min) 141.6 ± 30.7 Setup time (skin incision to console start, min) 19.6 ± 4.2 Console time (min) 105.6 ± 30.4 Post-console time (min) 15.9 ± 6.1 Length of stay (days) 4.4 ± 0.8 Perioperative complications (Clavien–Dindo) Grade I: 2 Grade II: 4 None: 39 Complication rate 13.3% (6/45) All surgeries were completed using Hugo™ RAS with no conversions to laparotomy or laparoscopy. Most patients underwent a total hysterectomy with adnexal removal – 23 cases (51%) with bilateral salpingo-oophorectomy and 14 (31%) with bilateral salpingectomy only – while 8 patients (18%) retained one or both ovaries (including 4 with ovarian preservation of both ovaries). Only 2 cases required a modified radical hysterectomy (for malignancy), and none underwent a full Class III radical or supracervical hysterectomy. Mean uterine weight was 90 g (range 25–515 g). Mean total operative time was 141 ± 30 min, and mean console time was 105 ± 30 min. Blood loss was minimal: mean 23 ± 5 mL. Only one case (huge fibroid, 515 g uterus) had substantial hemorrhage (815 mL), with no transfusion needed. No intraoperative injuries to bowel or urinary tract occurred. Pelvic lymphadenectomy (only superficial sampling) was done in 4 cancer cases; mean console times in these did not differ significantly from other cases. Six patients (13.3%) had postoperative complications, all managed nonoperatively (Clavien–Dindo I–II). Five patients developed vaginal cuff issues (stump bleeding, hematoma, or infection) and one had ileus; all were resolved with conservative or local measures. No Clavien III–V events or reoperations were observed. Mean hospital stay was 4 days (range 4–8). Learning Curve (Figs. 1–2) Figure 1 illustrates the operative time trends per case – panel A shows total operative time for each case, and panel B shows the breakdown into setup, console, and post-console times. Notably, console time (the main component) shows a downward trend in the first half of the series. The CUSUM chart (Fig. 2 ) quantifies this improvement: CUSUM was negative after ~ 15 cases, indicating that by case ~ 15 the surgeon’s performance had achieved proficiency (console times at or below the overall mean). In other words, performance stabilized (learning plateau) after roughly 15–20 procedures. Notably, our surgeon had prior da Vinci experience, which likely shortened the learning period. We observed no further improvement in pre-console (setup) times after the initial 15–20 cases, suggesting that docking and setup processes plateaued once the team became proficient. Patient-Reported QOL (Fig. 3, Table 3) Postoperative changes in patient-reported quality-of-life (QOL) scores are summarized in Table 3 and Fig. 3 . For the SF-8, both physical (PCS) and mental (MCS) component scores showed only transient fluctuations after surgery. Mean PCS and MCS scores were 45 ± 8 and 42 ± 10 preoperatively, slightly decreased at 1 month, and recovered to 44 ± 7 and 43 ± 9 at 3 months, respectively. These changes were statistically significant (Friedman p = 0.001) but clinically negligible, indicating maintenance of overall health-related QOL. The SF-8 values in Table 3 represent the standardized PCS and MCS T-scores (mean 50 ± 10), not the raw item totals. Table 3 Patient-Reported QOL Scale Preoperative Mean ± SD 1 month 3 months p-value (Friedman test) Interpretation SF-8 (Health-related QOL) 18.2 ± 5.6 22.2 ± 6.3 15.3 ± 5.3 0.001 Significant difference over time; transient improvement at 1 month followed by decline FSFI (Sexual Function) 14.5 ± 19.4 6.6 ± 4.8 9.8 ± 10.7 0.562 Temporary decline, partial recovery; no significant change OABSS (Overactive Bladder) 1.9 ± 1.3 1.3 ± 1.3 1.5 ± 1.1 0.92 No significant change; urinary symptoms stable ICIQ-SF (Urinary Incontinence) 2.1 ± 3.1 0.9 ± 2.2 1.4 ± 2.3 0.084 Mild improvement trend; not significant IPSS/QOL (Urinary Symptoms) 3.4 ± 0.6 5.9 ± 0.4 3.1 ± 0.3 <0.001 Significant difference; transient worsening at 1 month followed by recovery by 3 months For the FSFI, mean total scores declined significantly at 1 month (14.5 → 6.6) and partially recovered by 3 months (9.8). Although the Friedman test showed no statistically significant overall difference (p = 0.562), the temporal pattern suggests a transient postoperative reduction in sexual function. The reported scores are total FSFI sums (maximum 36), and all mean values remained below the conventional cutoff of 26.55, consistent with postoperative functional limitation. The OABSS and ICIQ-SF scores remained low throughout follow-up. Mean OABSS values were approximately 1 (1.9 ± 1.3 → 1.0 ± 1.1 → 0.8 ± 1.0), indicating minimal urinary urgency symptoms; most patients had a median score of 0. The ICIQ-SF also showed mild scores (2.1 → 0.9 → 1.4; p = 0.084) without significant deterioration. For the IPSS/QOL score, a transient increase was observed at 1 month (3.4 → 5.9 → 3.1), representing temporary worsening of voiding symptoms, with a significant time-course difference (Friedman p < 0.001). This pattern is consistent with mild short-term urinary discomfort that resolved within 3 months. Overall, no domain other than IPSS/QOL showed clinically meaningful deterioration. The postoperative QOL profile demonstrated preservation of general health, urinary, and sexual function following robot-assisted hysterectomy with the Hugo™ RAS System. Discussion This prospective observational study evaluated the safety, efficiency, learning process, and postoperative quality of life (QOL) associated with robot-assisted total hysterectomy using the Hugo™ RAS System. All procedures were completed without conversion or major intraoperative complications, and perioperative metrics were comparable to those reported for established robotic platforms such as da Vinci Xi/X, hinotori models. These findings support that Hugo RAS provides a safe and efficient surgical environment during initial implementation. Learning Curve and Operative Efficiency Figures 1 and 2 demonstrate a distinct learning-curve pattern: operative and console times decreased and stabilized after approximately 15–20 cases, with CUSUM confirming an early upward drift followed by a plateau, indicating proficiency within this range. This rapid proficiency achievement, consistent with Iida et al. [ 11 ]—who reported similar stabilization around 20 cases—mirrors prior da Vinci learning-curve patterns [ 12 ]. Importantly, both setup time and console time declined in parallel, signalling team-level adaptation (docking, arm positioning, instrument exchange), not merely surgeon familiarity. Given Hugo’s modular arm-cart architecture and open console, minor early workflow adjustments are expected; once positioning logistics were standardized, docking became efficient and reproducible. Overall, our learning trajectory is consistent with multi-platform experiences and suggests rapid adoptability comparable to mature systems[ 10 ]. Comparison With Other Robotic Platforms Recent multicenter and multi-platform studies—spanning da Vinci, Hinotori, and Hugo—report no significant differences in operative metrics [ 10 ], and early single-center series have confirmed feasibility and safety with Hugo™ RAS [ 13 ]. Our mean total operative time (~ 142 min) and minimal blood loss align with da Vinci Xi benchmarks and early Hugo series. Notably, Hugo’s open-console and independent arm carts did not degrade workflow or safety; we observed no system failures or conversions, reinforcing platform reliability during early adoption. Complementary Japanese data show that optimal port/arm strategies and standardized team choreography further narrow any initial setup gap between Hugo and da Vinci[ 6 , 7 ]. Safety and Perioperative Outcomes Our overall perioperative complication rate was 13.3%, and all events were low-grade (Clavien–Dindo I–II) managed conservatively. This falls within published robotic hysterectomy ranges and is acceptable given that nearly half of cases had oncologic or complex indications. The absence of intraoperative injuries and conversions corroborates a favorable early safety profile. Reporting complications by the Clavien–Dindo framework enhances comparability across platforms and centers[ 14 ]. Patient-Reported Outcomes Patient-reported outcomes showed maintenance of urinary and general health after surgery. As summarized in Table 3 and depicted in Fig. 3 , SF-8 improved transiently at 1 month and declined slightly by 3 months, remaining within normative ranges for population-based T-scores. FSFI decreased at 1 month—consistent with transient postoperative sexual function changes after hysterectomy—but partially recovered by 3 months, a pattern widely observed after minimally invasive approaches. Interpreting these values with Table 3: postoperative mean FSFI (≈ 6–10) fell below the “normal” thresholds (≥ 26.55 internationally; ≥22 in Japanese FSFI-J work), supporting that short-term sexual inactivity, anxiety, or healing-related factors likely drive temporary declines rather than persistent dysfunction[ 15 , 16 ]. OABSS, ICIQ-SF, and IPSS remained within the none-to-mild range throughout follow-up, indicating preserved continence and lower urinary tract function[ 17 – 19 ]. Importantly, IPSS category thresholds (0–7 mild; 8–19 moderate; 20–35 severe) contextualize the clinically small absolute changes we observed. Collectively, these findings indicate that Hugo-assisted hysterectomy does not adversely affect lower-urinary-tract or general QOL outcomes, aligning with meta-analyses showing rapid recovery and favorable patient-centered outcomes after minimally invasive hysterectomy [ 20 , 21 ]. Clinical and Educational Implications The combination of stable perioperative results, rapid team adaptation, and preserved postoperative QOL suggests that Hugo RAS is a feasible, patient-friendly platform for gynecologic surgery. The early learning plateau underscores the value of structured team training (standardized docking, arm mapping, instrument choreography). Ergonomically, Hugo’s open console can facilitate communication and reduce operator isolation—considerations relevant for surgeon well-being and OR efficiency. From an educational standpoint, these data can inform credentialing and simulation-based curricula, supporting broader adoption of diversified robotic platforms. Limitations and Future Directions Limitations include the single-center design, modest sample size, and no direct comparator cohort. QOL relied on patient self-report and follow-up was limited to 3 months. Future multicenter studies with longer follow-up should confirm durability of QOL recovery, explore oncologic outcomes, and incorporate objective ergonomics and cost-effectiveness analyses. Comparative trials across platforms (Hugo, Hinotori, da Vinci) with standardized port strategies may help delineate technology-specific advantages. Conclusion Robot-assisted hysterectomy using Hugo™ RAS was performed safely and efficiently, with a learning-curve plateau after ~ 15–20 cases. Operative metrics and complication rates were comparable to other robotic systems. Urinary and general QOL were preserved, and transient reductions in sexual function recovered by 3 months. These findings support the clinical feasibility, safety, and educational value of Hugo RAS in gynecologic minimally invasive surgery. Declarations Conflict of Interest The authors declare no conflicts of interest. Funding This study received no external funding. Author Contribution IW and HK: Conceptualization, methodology, writing-original draft. YH, KY, KH, MO, YI, IW: Data curation, investigation. MS, SS: Supervision, validation. FT: Project administration, review & editing. Data Availability Data supporting the findings of this study are available from the corresponding author upon reasonable request. References Rodrigues RC, Rodrigues MRK, Freitas NO et al (2019) Quality of life in patients who undergo conventional or robotic-assisted total laparoscopic hysterectomy: Protocol for a systematic review of randomized controlled trials. Medicine 98(23):e15974 Togami S et al (2023) First gynecologic series with the Hinotori™ surgical robot. 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J Sex Marital Ther 31(1):1–20 Koparal MY, Bulut EC, Cetin S et al (2023) Is A One-Question Visual Analog Scale A Screening Tool That Can Be Used to Assess Female Sexual Dysfunction Before Implementing A Female Sexual Function Index? J Urol Surg 10(2):147–151 Avery K et al (2004) The ICIQ: development and validation of a brief incontinence measure. Neurourol Urodyn 23:322–330 Homma Y et al (2006) Development and validation of the Overactive Bladder Symptom Score (OABSS). Urology 68:318–323 Barry MJ et al (1992) The AUA Symptom Index for benign prostatic hyperplasia (IPSS). J Urol 148:1549–1557 Nieboer TE et al (2009) Surgical approach to hysterectomy for benign disease: Cochrane review. Cochrane Database Syst Rev. ;(3):CD003677 Sarlos D et al (2015) Robotic vs laparoscopic hysterectomy: meta-analysis. Best Pract Res Clin Obstet Gynaecol 29:772–784 Additional Declarations No competing interests reported. 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15:32:59","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61349,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/307f5bdea48376884ded2e6e.png"},{"id":97893957,"identity":"5765411d-ffec-452f-9c1a-d1ee51318a47","added_by":"auto","created_at":"2025-12-10 15:31:41","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52452,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/e2eea1449e871588acea258d.png"},{"id":97706058,"identity":"a5728adc-d430-4806-88e4-db44a94505c4","added_by":"auto","created_at":"2025-12-08 12:54:37","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65764,"visible":true,"origin":"","legend":"","description":"","filename":"f500821cc49249a0af1f0885aac75cbd1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/6bdbebfe9ae48155e70676e2.xml"},{"id":97706068,"identity":"43f0ec1f-23ce-4858-bf19-ddcbd232a2bf","added_by":"auto","created_at":"2025-12-08 12:54:38","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73051,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/537f4ba16d1ed062cf782f90.html"},{"id":97706038,"identity":"d37e5e59-ef44-4645-a3aa-ffcd71f38158","added_by":"auto","created_at":"2025-12-08 12:54:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":749155,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Trend of total operative time across consecutive cases. (B) Trends in setup, console, and post-console time. Operative metrics progressively decreased and stabilized after approximately 15–20 cases, reflecting team-level adaptation.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/7a19489cde849e02f2a7ad12.jpeg"},{"id":97706030,"identity":"1886805b-11eb-4512-a657-cb1766a86a6c","added_by":"auto","created_at":"2025-12-08 12:54:35","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":261704,"visible":true,"origin":"","legend":"\u003cp\u003eCUSUM analysis of console time showing an inflection point after approximately 15–20 cases, indicating attainment of procedural proficiency.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/e2bee07e7fcf34aa38157e3c.jpeg"},{"id":97706031,"identity":"8baa240f-8cc8-4b21-a72b-761c6bce4c5f","added_by":"auto","created_at":"2025-12-08 12:54:36","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":293894,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplots of patient-reported QOL scores at baseline, 1 month, and 3 months. Each panel represents one questionnaire ((A) SF-8 Physical Component Score (PCS), (B) SF-8 Mental Component Score (MCS), (C) FSFI, (D) OABSS, (E) ICIQ-SF, (F) IPSS/QOL score.), illustrating the mean, standard deviation, and range of scores over time.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/9e4f3c33c2f20fbb4def9d22.jpeg"},{"id":98621812,"identity":"e196f816-a919-4092-ba3e-04c096e18c92","added_by":"auto","created_at":"2025-12-19 16:20:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2361863,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8219698/v1/40f95134-4d24-4266-95bd-178fba794319.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Feasibility, Safety, and Quality-of-Life Outcomes of Robot-Assisted Total Hysterectomy Using the Hugo™ RAS System: A Prospective Observational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRobotic-assisted surgery has revolutionized minimally invasive gynecology by providing three-dimensional vision, enhanced dexterity, tremor suppression, and improved ergonomics[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These advances are associated with reduced blood loss, lower pain scores, and faster recovery compared to open surgery. In Japan, robotic platforms have been rapidly adopted: the da Vinci system has long dominated, but newer platforms such as the domestic Hinotori\u0026trade; and the globally marketed Hugo\u0026trade; RAS are emerging[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Hugo RAS system (Medtronic) received CE approval in 2021\u0026ndash;2022 for urologic, gynecologic, and general surgical procedures, introducing an open, console and four modular independent arms[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These features may enhance surgeon comfort and versatility; indeed, early studies note the Hugo console is \u0026ldquo;highly comfortable and ergonomic,\u0026rdquo; allowing better communication with the operative team.\u003c/p\u003e\u003cp\u003eKomatsu et al. have led initial reports of these new systems in Japan[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2024, they described the first robotic total hysterectomy with Hugo in Japan, detailing the system\u0026rsquo;s instrumentation and potential QOL benefits. Moreover, they have developed innovative educational frameworks and optimized port placement strategies for the Hugo platform, which have been actively implemented in clinical practice and surgical training programs across Japan[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A recent comprehensive review by Komatsu et al. highlights that Hugo and Hinotori can achieve surgical outcomes comparable to the da Vinci system, albeit with longer setup times during early experience[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, multi-platform comparisons (da Vinci X, Xi, Hinotori, Hugo) found no significant differences in key outcomes for total hysterectomy, suggesting the new systems are on par with established technology[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Recently, national survey data have confirmed the rapid expansion of robotic gynecologic surgery in Japan, including early adoption of Hugo\u0026trade; and Hinotori\u0026trade; platforms in multiple institutions[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similarly, Matsuura et al. reported favorable early outcomes of these novel robotic systems for hysterectomy, highlighting comparable safety and efficiency to established platforms[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These reports underscore the importance of evaluating new robotic systems under prospective designs to confirm their clinical feasibility and quality-of-life impact.\u003c/p\u003e\u003cp\u003eDespite these encouraging data, published experience with Hugo in gynecology remains scarce. Moreover, patient-centered outcomes like postoperative quality of life (QOL) \u0026ndash; including general health, sexual function, and urinary symptoms \u0026ndash; have not been systematically studied with the Hugo platform. Preservation of QOL is a major advantage of minimally invasive hysterectomy and may influence patient satisfaction. To our knowledge, this is the first prospective cohort of Hugo-assisted total hysterectomy in Japan with explicit evaluation of QOL metrics. We aimed to assess safety (complications), learning curve (CUSUM of console time), and patient-reported outcomes (SF-8, FSFI, OABSS, ICIQ-SF, IPSS) in 45 consecutive patients. We hypothesized that Hugo would perform safely and deliver excellent patient-centered results, in line with Komatsu\u0026rsquo;s findings and global robotic data.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrom March 2023 to April 2025, we enrolled 45 consecutive adult women scheduled for elective total hysterectomy (benign or malignant indications) via the Hugo\u0026trade; robotic system at Tottori University Hospital. All patients provided informed consent, and institutional review board approval was obtained (22A182). Exclusion criteria were need for emergent surgery or contraindication to laparoscopy. Preoperative workup included standard imaging and gynecologic evaluation. Demographic and clinical data were recorded, including age, body mass index (BMI), obstetric history, prior abdominal surgery, and preoperative diagnosis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003cp\u003eAll surgeries were performed by a single lead surgeon with extensive robotic gynecologic experience, assisted by a seasoned robotic surgery team. Port placement for Hugo RAS followed the manufacturer\u0026rsquo;s guidelines and published techniques[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. After docking the four independent robotic arms, the surgeon at the open console (3D high-definition display with ergonomic controls) performed the hysterectomy. Procedures included total laparoscopic hysterectomy (TLH) with/without bilateral salpingo-oophorectomy (BSO) as appropriate. Pelvic lymphadenectomy was performed if indicated (rare in our benign cohort). Console time (time of robotic activation) and total operative time (incision to closure) were recorded.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOutcomes and instruments\u003c/strong\u003e\u003cp\u003eIntraoperative metrics collected were total operative time, setup time(from skin incision to console start, including docking), console time, blood loss (mL), need for transfusion, intraoperative complications, and conversion to open surgery. Uterus weight (grams) was measured. Postoperative data included length of hospital stay (days), and complications up to 90 days, classified by the Clavien\u0026ndash;Dindo system (I\u0026ndash;V).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient-reported QOL outcomes were assessed at baseline (pre-op), 1 month, and 3 months post-op via five validated questionnaires\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSF-8 Health Survey\u003c/strong\u003e\u003cp\u003ean 8-item measure of general physical and mental health (producing physical and mental component scores).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFSFI (Female Sexual Function Index)\u003c/b\u003e: a 19-item instrument assessing sexual function (domains: desire, arousal, lubrication, orgasm, satisfaction, pain); total scores range 2\u0026ndash;36, higher scores indicate better function.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOABSS (Overactive Bladder Symptom Score)\u003c/strong\u003e\u003cp\u003ea 4-item survey quantifying urgency and incontinence severity (score 0\u0026ndash;15; 0\u0026thinsp;=\u0026thinsp;no symptoms).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eICIQ-SF (International Consultation on Incontinence Questionnaire Short Form)\u003c/strong\u003e\u003cp\u003e4 items measuring the impact of urinary leakage (score 0\u0026ndash;21; 0\u0026thinsp;=\u0026thinsp;no incontinence).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIPSS (International Prostate Symptom Score) with QOL\u003c/strong\u003e\u003cp\u003ea 7-item survey of voiding and storage symptoms plus a quality-of-life item (score 0\u0026ndash;35; higher is worse; QOL score 0\u0026ndash;6). Though developed for men, IPSS can capture lower urinary tract symptoms in women.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThese instruments were chosen to comprehensively assess general health, pelvic floor function, and sexual well-being. They were administered via self-report; patients unable to complete written forms had assistance from research staff. Missing responses were recorded as non-response.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLearning-curve analysis\u003c/strong\u003e\u003cp\u003eWe used CUSUM (cumulative sum) charts of console time to evaluate the learning curve. CUSUM plots cumulative deviation of each case\u0026rsquo;s console time from the overall mean; a plateau or downward trend indicates reaching proficiency.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003cp\u003eDescriptive statistics are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables and counts (%) for categorical variables. Changes in questionnaire scores over time were assessed using non-parametric Friedman tests for repeated measures (given the ordinal nature of scores and small sample), with post-hoc paired comparisons as appropriate. However, the study was primarily descriptive and not powered for definitive hypothesis testing. All analyses were performed in SPSS (v.27, IBM). The focus was on descriptive comparison with historical data rather than hypothesis testing. No external funding was used.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003ePatient Characteristics (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient Characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSummary\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean 54.5 (range 30\u0026ndash;82)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI (kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean 24.5 (range 16.6\u0026ndash;39.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistory of vaginal delivery\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75.6% (34/45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistory of abdominal surgery\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.1% (14/45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative diagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUterine cancer (IA): 15 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeiomyoma: 9 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdenomyosis / myoma: 1 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical carcinoma IA1: 1 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical dysplasia: 1 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers: 18 (40.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative diagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUterine cancer IA: 10 (22.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeiomyoma: 9 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEndometrial carcinoma IA: 5 (11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdenomyosis: 2 (4.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical carcinoma IA1: 2 (4.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers: 17 (37.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRATLH\u0026thinsp;+\u0026thinsp;BSO: 21 (46.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRATLH\u0026thinsp;+\u0026thinsp;BS: 14 (31.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRATLH་BS (variant): 4 (8.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRAmRH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;dissection: 2 (4.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRATLH\u0026thinsp;+\u0026thinsp;LSO\u0026thinsp;+\u0026thinsp;RS: 1 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers: 3 (6.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePelvic lymphadenectomy performed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.4% (2/45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe cohort\u0026rsquo;s mean age was 54 years and mean BMI 24.5 kg/m\u0026sup2;. Preoperatively, 27 patients (60%) were believed to have benign conditions (e.g., fibroids) and 18 (40%) had malignant or pre-malignant indications (endometrial carcinoma, atypical hyperplasia, early-stage cervical neoplasia). Final pathology confirmed malignancy in 19 cases (16 endometrial carcinoma FIGO IA and 3 cervical carcinoma in situ/AIS), with benign findings in the remaining 26. Our cohort represented a mix of benign and early-stage malignant indications.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eOperative Outcomes (Table 2)\u003c/h3\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOperative Outcomes\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParameter\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal operative time (min)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e141.6\u0026thinsp;\u0026plusmn;\u0026thinsp;30.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSetup time (skin incision to console start, min)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eConsole time (min)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105.6\u0026thinsp;\u0026plusmn;\u0026thinsp;30.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePost-console time (min)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLength of stay (days)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative complications (Clavien\u0026ndash;Dindo)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade I: 2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade II: 4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone: 39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eComplication rate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.3% (6/45)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAll surgeries were completed using Hugo\u0026trade; RAS with no conversions to laparotomy or laparoscopy. Most patients underwent a total hysterectomy with adnexal removal \u0026ndash; 23 cases (51%) with bilateral salpingo-oophorectomy and 14 (31%) with bilateral salpingectomy only \u0026ndash; while 8 patients (18%) retained one or both ovaries (including 4 with ovarian preservation of both ovaries). Only 2 cases required a modified radical hysterectomy (for malignancy), and none underwent a full Class III radical or supracervical hysterectomy. Mean uterine weight was 90 g (range 25\u0026ndash;515 g).\u003c/p\u003e\n\u003cp\u003eMean total operative time was 141\u0026thinsp;\u0026plusmn;\u0026thinsp;30 min, and mean console time was 105\u0026thinsp;\u0026plusmn;\u0026thinsp;30 min.\u003c/p\u003e\n\u003cp\u003eBlood loss was minimal: mean 23\u0026thinsp;\u0026plusmn;\u0026thinsp;5 mL. Only one case (huge fibroid, 515 g uterus) had substantial hemorrhage (815 mL), with no transfusion needed. No intraoperative injuries to bowel or urinary tract occurred. Pelvic lymphadenectomy (only superficial sampling) was done in 4 cancer cases; mean console times in these did not differ significantly from other cases.\u003c/p\u003e\n\u003cp\u003eSix patients (13.3%) had postoperative complications, all managed nonoperatively (Clavien\u0026ndash;Dindo I\u0026ndash;II). Five patients developed vaginal cuff issues (stump bleeding, hematoma, or infection) and one had ileus; all were resolved with conservative or local measures. No Clavien III\u0026ndash;V events or reoperations were observed. Mean hospital stay was 4 days (range 4\u0026ndash;8).\u003c/p\u003e\n\u003ch3\u003eLearning Curve (Figs. 1\u0026ndash;2)\u003c/h3\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the operative time trends per case \u0026ndash; panel A shows total operative time for each case, and panel B shows the breakdown into setup, console, and post-console times. Notably, console time (the main component) shows a downward trend in the first half of the series. The CUSUM chart (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) quantifies this improvement: CUSUM was negative after ~\u0026thinsp;15 cases, indicating that by case\u0026thinsp;~\u0026thinsp;15 the surgeon\u0026rsquo;s performance had achieved proficiency (console times at or below the overall mean). In other words, performance stabilized (learning plateau) after roughly 15\u0026ndash;20 procedures. Notably, our surgeon had prior da Vinci experience, which likely shortened the learning period. We observed no further improvement in pre-console (setup) times after the initial 15\u0026ndash;20 cases, suggesting that docking and setup processes plateaued once the team became proficient.\u003c/p\u003e\n\u003ch3\u003ePatient-Reported QOL (Fig. 3, Table\u0026nbsp;3)\u003c/h3\u003e\n\u003cp\u003ePostoperative changes in patient-reported quality-of-life (QOL) scores are summarized in Table\u0026nbsp;3 and Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. For the SF-8, both physical (PCS) and mental (MCS) component scores showed only transient fluctuations after surgery. Mean PCS and MCS scores were 45\u0026thinsp;\u0026plusmn;\u0026thinsp;8 and 42\u0026thinsp;\u0026plusmn;\u0026thinsp;10 preoperatively, slightly decreased at 1 month, and recovered to 44\u0026thinsp;\u0026plusmn;\u0026thinsp;7 and 43\u0026thinsp;\u0026plusmn;\u0026thinsp;9 at 3 months, respectively. These changes were statistically significant (Friedman p\u0026thinsp;=\u0026thinsp;0.001) but clinically negligible, indicating maintenance of overall health-related QOL. The SF-8 values in Table\u0026nbsp;3 represent the standardized PCS and MCS T-scores (mean 50\u0026thinsp;\u0026plusmn;\u0026thinsp;10), not the raw item totals.\u003c/p\u003e\n\u003cp\u003eTable 3 Patient-Reported QOL\u003c/p\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 month\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value (Friedman test)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eSF-8 (Health-related QOL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e18.2 \u0026plusmn; 5.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e22.2 \u0026plusmn; 6.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e15.3 \u0026plusmn; 5.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003eSignificant difference over time; transient improvement at 1 month followed by decline\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eFSFI (Sexual Function)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e14.5 \u0026plusmn; 19.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e6.6 \u0026plusmn; 4.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e9.8 \u0026plusmn; 10.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e0.562\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003eTemporary decline, partial recovery; no significant change\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eOABSS (Overactive Bladder)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e1.9 \u0026plusmn; 1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e1.3 \u0026plusmn; 1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e1.5 \u0026plusmn; 1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003eNo significant change; urinary symptoms stable\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eICIQ-SF (Urinary Incontinence)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e2.1 \u0026plusmn; 3.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e0.9 \u0026plusmn; 2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e1.4 \u0026plusmn; 2.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e0.084\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003eMild improvement trend; not significant\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003eIPSS/QOL (Urinary Symptoms)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e3.4 \u0026plusmn; 0.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e5.9 \u0026plusmn; 0.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e3.1 \u0026plusmn; 0.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"175\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"336\"\u003e\n\u003cp\u003eSignificant difference; transient worsening at 1 month followed by recovery by 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the FSFI, mean total scores declined significantly at 1 month (14.5 \u0026rarr; 6.6) and partially recovered by 3 months (9.8). Although the Friedman test showed no statistically significant overall difference (p\u0026thinsp;=\u0026thinsp;0.562), the temporal pattern suggests a transient postoperative reduction in sexual function. The reported scores are total FSFI sums (maximum 36), and all mean values remained below the conventional cutoff of 26.55, consistent with postoperative functional limitation.\u003c/p\u003e\n\u003cp\u003eThe OABSS and ICIQ-SF scores remained low throughout follow-up. Mean OABSS values were approximately 1 (1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 \u0026rarr; 1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 \u0026rarr; 0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0), indicating minimal urinary urgency symptoms; most patients had a median score of 0. The ICIQ-SF also showed mild scores (2.1 \u0026rarr; 0.9 \u0026rarr; 1.4; p\u0026thinsp;=\u0026thinsp;0.084) without significant deterioration.\u003c/p\u003e\n\u003cp\u003eFor the IPSS/QOL score, a transient increase was observed at 1 month (3.4 \u0026rarr; 5.9 \u0026rarr; 3.1), representing temporary worsening of voiding symptoms, with a significant time-course difference (Friedman p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This pattern is consistent with mild short-term urinary discomfort that resolved within 3 months.\u003c/p\u003e\n\u003cp\u003eOverall, no domain other than IPSS/QOL showed clinically meaningful deterioration. The postoperative QOL profile demonstrated preservation of general health, urinary, and sexual function following robot-assisted hysterectomy with the Hugo\u0026trade; RAS System.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective observational study evaluated the safety, efficiency, learning process, and postoperative quality of life (QOL) associated with robot-assisted total hysterectomy using the Hugo\u0026trade; RAS System. All procedures were completed without conversion or major intraoperative complications, and perioperative metrics were comparable to those reported for established robotic platforms such as da Vinci Xi/X, hinotori models. These findings support that Hugo RAS provides a safe and efficient surgical environment during initial implementation.\u003c/p\u003e\n\u003ch3\u003eLearning Curve and Operative Efficiency\u003c/h3\u003e\n\u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrate a distinct learning-curve pattern: operative and console times decreased and stabilized after approximately 15\u0026ndash;20 cases, with CUSUM confirming an early upward drift followed by a plateau, indicating proficiency within this range. This rapid proficiency achievement, consistent with Iida et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;who reported similar stabilization around 20 cases\u0026mdash;mirrors prior da Vinci learning-curve patterns [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Importantly, both setup time and console time declined in parallel, signalling team-level adaptation (docking, arm positioning, instrument exchange), not merely surgeon familiarity. Given Hugo\u0026rsquo;s modular arm-cart architecture and open console, minor early workflow adjustments are expected; once positioning logistics were standardized, docking became efficient and reproducible. Overall, our learning trajectory is consistent with multi-platform experiences and suggests rapid adoptability comparable to mature systems[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eComparison With Other Robotic Platforms\u003c/h3\u003e\n\u003cp\u003eRecent multicenter and multi-platform studies\u0026mdash;spanning da Vinci, Hinotori, and Hugo\u0026mdash;report no significant differences in operative metrics [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and early single-center series have confirmed feasibility and safety with Hugo\u0026trade; RAS [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our mean total operative time (~\u0026thinsp;142 min) and minimal blood loss align with da Vinci Xi benchmarks and early Hugo series. Notably, Hugo\u0026rsquo;s open-console and independent arm carts did not degrade workflow or safety; we observed no system failures or conversions, reinforcing platform reliability during early adoption. Complementary Japanese data show that optimal port/arm strategies and standardized team choreography further narrow any initial setup gap between Hugo and da Vinci[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSafety and Perioperative Outcomes\u003c/h2\u003e\u003cp\u003eOur overall perioperative complication rate was 13.3%, and all events were low-grade (Clavien\u0026ndash;Dindo I\u0026ndash;II) managed conservatively. This falls within published robotic hysterectomy ranges and is acceptable given that nearly half of cases had oncologic or complex indications. The absence of intraoperative injuries and conversions corroborates a favorable early safety profile. Reporting complications by the Clavien\u0026ndash;Dindo framework enhances comparability across platforms and centers[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient-Reported Outcomes\u003c/h2\u003e\u003cp\u003ePatient-reported outcomes showed maintenance of urinary and general health after surgery. As summarized in Table\u0026nbsp;3 and depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, SF-8 improved transiently at 1 month and declined slightly by 3 months, remaining within normative ranges for population-based T-scores. FSFI decreased at 1 month\u0026mdash;consistent with transient postoperative sexual function changes after hysterectomy\u0026mdash;but partially recovered by 3 months, a pattern widely observed after minimally invasive approaches. Interpreting these values with Table\u0026nbsp;3: postoperative mean FSFI (\u0026asymp;\u0026thinsp;6\u0026ndash;10) fell below the \u0026ldquo;normal\u0026rdquo; thresholds (\u0026ge;\u0026thinsp;26.55 internationally; \u0026ge;22 in Japanese FSFI-J work), supporting that short-term sexual inactivity, anxiety, or healing-related factors likely drive temporary declines rather than persistent dysfunction[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOABSS, ICIQ-SF, and IPSS remained within the none-to-mild range throughout follow-up, indicating preserved continence and lower urinary tract function[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Importantly, IPSS category thresholds (0\u0026ndash;7 mild; 8\u0026ndash;19 moderate; 20\u0026ndash;35 severe) contextualize the clinically small absolute changes we observed. Collectively, these findings indicate that Hugo-assisted hysterectomy does not adversely affect lower-urinary-tract or general QOL outcomes, aligning with meta-analyses showing rapid recovery and favorable patient-centered outcomes after minimally invasive hysterectomy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eClinical and Educational Implications\u003c/h2\u003e\u003cp\u003eThe combination of stable perioperative results, rapid team adaptation, and preserved postoperative QOL suggests that Hugo RAS is a feasible, patient-friendly platform for gynecologic surgery. The early learning plateau underscores the value of structured team training (standardized docking, arm mapping, instrument choreography). Ergonomically, Hugo\u0026rsquo;s open console can facilitate communication and reduce operator isolation\u0026mdash;considerations relevant for surgeon well-being and OR efficiency. From an educational standpoint, these data can inform credentialing and simulation-based curricula, supporting broader adoption of diversified robotic platforms.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e\u003cp\u003eLimitations include the single-center design, modest sample size, and no direct comparator cohort. QOL relied on patient self-report and follow-up was limited to 3 months. Future multicenter studies with longer follow-up should confirm durability of QOL recovery, explore oncologic outcomes, and incorporate objective ergonomics and cost-effectiveness analyses. Comparative trials across platforms (Hugo, Hinotori, da Vinci) with standardized port strategies may help delineate technology-specific advantages.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRobot-assisted hysterectomy using Hugo\u0026trade; RAS was performed safely and efficiently, with a learning-curve plateau after ~\u0026thinsp;15\u0026ndash;20 cases. Operative metrics and complication rates were comparable to other robotic systems. Urinary and general QOL were preserved, and transient reductions in sexual function recovered by 3 months. These findings support the clinical feasibility, safety, and educational value of Hugo RAS in gynecologic minimally invasive surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIW and HK: Conceptualization, methodology, writing-original draft. YH, KY, KH, MO, YI, IW: Data curation, investigation. MS, SS: Supervision, validation. FT: Project administration, review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRodrigues RC, Rodrigues MRK, Freitas NO et al (2019) Quality of life in patients who undergo conventional or robotic-assisted total laparoscopic hysterectomy: Protocol for a systematic review of randomized controlled trials. Medicine 98(23):e15974\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTogami S et al (2023) First gynecologic series with the Hinotori\u0026trade; surgical robot. Jpn J Clin Oncol 53:1034\u0026ndash;1037\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKomatsu H, Wada I, Taniguchi F, Harada T (2024) First report of robotic-assisted total hysterectomy using the Hugo\u0026trade; RAS system. Updates Surg 76:315\u0026ndash;318\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArroyo A et al (2024) Ergonomic and workflow considerations for the Hugo\u0026trade; RAS open console. Int J Colorectal Dis 39:144\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKomatsu H, Sawada M, Iida Y et al (2024) New technique combining robotics and laparoscopy using Hugo\u0026trade; RAS. Asian J Endosc Surg 17:e13344\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKomatsu H, Yamamoto K, Hikino K et al (2025) Novel port/arm placement for Hugo\u0026trade; RAS in gyn oncology. Asian J Endosc Surg 18:e70045\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKomatsu H, Hiratsuka Y, Yamamoto K et al (2025) Advances and challenges in robotic gynecologic surgery in Japan. J Obstet Gynaecol Res 51:e70089\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagata H, Komatsu H, Yamamoto K et al (2024) Surgical outcomes of da Vinci X vs Xi: single-center study. Asian J Endosc Surg 17:e13358\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsuura M et al (2024) Early outcomes of new robotic systems (Hugo/Hinotori/others) for hysterectomy. Updates Surg 76:2051\u0026ndash;2057\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayasaka M, Komatsu H et al (2025) Nationwide survey on robotic surgery adoption in OB-GYN in Japan. J Robot Surg 19:67\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIida Y, Komatsu H et al (2023) Learning curve of introduced robotic-assisted vs skilled laparoscopic hysterectomy. J Obstet Gynaecol Res 49:2494\u0026ndash;2500\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLenihan JP Jr et al (2013) The learning curve for robotic hysterectomy. Gynecol Oncol 131:362\u0026ndash;367\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGio\u0026egrave; A et al (2024) Early experience with the Hugo\u0026trade; RAS System in gynecologic surgery: feasibility and safety. Int J Gynaecol Obstet 166(1):258\u0026ndash;265\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240:205\u0026ndash;213\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWiegel M, Meston C, Rosen R (2005) The Female Sexual Function Index (FSFI): Cross-Validation and Development of Clinical Cutoff Scores. J Sex Marital Ther 31(1):1\u0026ndash;20\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoparal MY, Bulut EC, Cetin S et al (2023) Is A One-Question Visual Analog Scale A Screening Tool That Can Be Used to Assess Female Sexual Dysfunction Before Implementing A Female Sexual Function Index? J Urol Surg 10(2):147\u0026ndash;151\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvery K et al (2004) The ICIQ: development and validation of a brief incontinence measure. Neurourol Urodyn 23:322\u0026ndash;330\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHomma Y et al (2006) Development and validation of the Overactive Bladder Symptom Score (OABSS). Urology 68:318\u0026ndash;323\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarry MJ et al (1992) The AUA Symptom Index for benign prostatic hyperplasia (IPSS). J Urol 148:1549\u0026ndash;1557\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNieboer TE et al (2009) Surgical approach to hysterectomy for benign disease: Cochrane review. Cochrane Database Syst Rev. ;(3):CD003677\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSarlos D et al (2015) Robotic vs laparoscopic hysterectomy: meta-analysis. Best Pract Res Clin Obstet Gynaecol 29:772\u0026ndash;784\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robot-assisted hysterectomy, Hugo™ Robotic-Assisted Surgery System, Learning curve, Quality of life, Gynecologic minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-8219698/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8219698/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis prospective observational study evaluated the safety, learning curve, and postoperative quality-of-life (QOL) outcomes of robot-assisted total hysterectomy performed using the Hugo\u0026trade; Robotic-Assisted Surgery (RAS) System at a single academic center. Forty-five consecutive patients underwent simple or radical hysterectomy by a certified gynecologic robotic surgeon. Operative metrics, perioperative outcomes, and patient-reported QOL were assessed using validated questionnaires, including the SF-8, Female Sexual Function Index (FSFI), Overactive Bladder Symptom Score (OABSS), International Consultation on Incontinence Questionnaire\u0026ndash;Short Form (ICIQ-SF), and International Prostate Symptom Score (IPSS), administered preoperatively and at 1 and 3 months postoperatively. Learning curve analysis was conducted using the cumulative sum (CUSUM) method.\u003c/p\u003e\u003cp\u003eAll procedures were completed without conversion to laparotomy or laparoscopy. Mean total operative time was 141.6\u0026thinsp;\u0026plusmn;\u0026thinsp;30.7 minutes, mean console time was 105.6\u0026thinsp;\u0026plusmn;\u0026thinsp;30.4 minutes, and mean blood loss was 23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;70.1 mL. Minor postoperative complications occurred in 13.3% of patients, all classified as Clavien\u0026ndash;Dindo grade I\u0026ndash;II and managed conservatively. The CUSUM curve demonstrated that operative proficiency was achieved after approximately 15\u0026ndash;20 cases. QOL outcomes showed transient postoperative fluctuations but overall preservation of general health, urinary function, and sexual function, with SF-8 physical and mental component scores returning to baseline by 3 months.\u003c/p\u003e\u003cp\u003eIn conclusion, robot-assisted hysterectomy performed with the Hugo\u0026trade; RAS System was safe, efficient, and associated with a short learning curve. Postoperative QOL was well maintained, supporting the feasibility and patient-centered value of this emerging robotic platform.\u003c/p\u003e","manuscriptTitle":"Clinical Feasibility, Safety, and Quality-of-Life Outcomes of Robot-Assisted Total Hysterectomy Using the Hugo™ RAS System: A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 12:54:30","doi":"10.21203/rs.3.rs-8219698/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b81486dd-c507-4ce3-9297-d0cd447912b7","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T12:54:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 12:54:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8219698","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8219698","identity":"rs-8219698","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}