What Is Radical Cystectomy. Radical cystectomy is the surgical removal of the entire bladder and is the standard treatment for muscle-invasive bladder cancer and high-risk non-muscle invasive disease that does not respond to other treatments. The operation also requires creating a urinary diversion, most commonly an ileal conduit, which uses a segment of small intestine to route urine out of the body through an abdominal stoma.
The Case for Robotic Surgery. Open radical cystectomy has historically been associated with significant blood loss, prolonged recovery, and notable complication rates. Robot-assisted radical cystectomy (RARC) has demonstrated comparable oncological outcomes with the potential for less blood loss, faster recovery, and fewer perioperative complications compared to open surgery, particularly when the urinary diversion is performed entirely inside the body (intracorporeally).
The Hugo RAS System. The Hugo RAS system (Medtronic) is a relatively new robotic surgical platform that has been evaluated across several urological procedures. Unlike the more established da Vinci system, Hugo uses a modular arm architecture and a distinct operating room setup. Its performance had been demonstrated in partial nephrectomy, radical prostatectomy, and other procedures, but radical cystectomy with intracorporeal diversion had not previously been reported for this platform.
Study Goal. This video section report describes the first series of robot-assisted radical cystectomies with intracorporeal ileal conduit urinary diversion performed using the Hugo RAS system, providing detailed information on surgical setup, trocar placement, docking, and early outcomes to guide other centers considering adopting this platform for bladder cancer surgery.
Patient Selection. Two male patients underwent surgery at Fundació Puigvert in Barcelona. The first was a 71-year-old with very-high-risk non-muscle-invasive bladder cancer that warranted radical surgery. The second was a 64-year-old with T2 high-grade bladder cancer, representing muscle-invasive disease where cystectomy is the standard of care.
Trocar and Arm Configuration. The surgical team used a four-arm Hugo RAS configuration with established docking angles developed and previously described by the same group. Two additional trocars were placed for the bedside assistant: one 12-mm port and one 5-mm port. This setup allows the robot arms and assistant to access the pelvis and abdomen without conflicts during the extended operative sequence.
Intracorporeal Ileal Conduit. In both cases, the urinary diversion was constructed entirely inside the body without exteriorizing the bowel. A Wallace type-1 uretero-enteric derivation technique was used, which joins both ureters to one end of the isolated ileal segment before connecting it to the abdominal wall. Performing the entire procedure intracorporeally is technically demanding but may reduce complications related to bowel exposure.
Why Intracorporeal Diversion Matters. Extracorporeal diversion (bringing the bowel out through a larger incision to construct the conduit) negates many minimally invasive benefits and increases wound-related complications. Intracorporeal diversion requires advanced robotic skills but preserves the minimal access advantages throughout the entire procedure, which this report demonstrates is feasible on the Hugo platform.
Operative Times. The first case required 360 minutes (6 hours) and the second required 420 minutes (7 hours) of total operative time. Robot docking took 12 minutes in the first case and 9 minutes in the second, reflecting the time required to position and connect the modular arm system before surgery could begin. These times are within the range reported for RARC with intracorporeal diversion on other robotic platforms.
Blood Loss and Intraoperative Safety. Estimated blood loss was 200 mL in the first patient and 400 mL in the second. No intraoperative complications occurred in either case. The absence of intraoperative events is particularly important for complex pelvic surgery where unexpected bleeding or bowel injury would require conversion to open surgery or cause significant morbidity.
Postoperative Course. The second patient developed an ileus (temporary cessation of bowel function) on postoperative day 4, classified as a Clavien-Dindo grade 2 complication, meaning it required pharmacological treatment but no reoperation or invasive intervention. The first patient had an uncomplicated recovery. Ileus is a known complication of bowel manipulation during ileal conduit construction.
Oncological Outcomes. No positive surgical margins were recorded in either patient, indicating complete removal of the cancer without leaving microscopic disease at the resection boundaries. During follow-up, neither patient experienced cancer recurrence or disease progression, suggesting adequate oncological control in these early cases.
Platform Feasibility Confirmed. The successful completion of two technically demanding cases demonstrates that the Hugo RAS system is capable of supporting radical cystectomy with intracorporeal urinary diversion. The learning curve for new platforms is steep, and reports from experienced robotic surgeons establishing feasibility are essential for guiding other centers through initial adoption.
Modularity as a Feature. The Hugo system's modular arm architecture offers different positioning flexibility compared to conventional robotic systems. Understanding how to configure arm angles and operating room setup for complex pelvic procedures -- which require extensive working space for bowel manipulation and pelvic dissection -- is critical knowledge that this report provides to potential adopters.
Expanding Access to Robotic Cystectomy. Bladder cancer is underserved by robotic surgery in many centers because of the high cost and learning curve of radical cystectomy. The availability of an alternative robotic platform with comparable performance could increase competition and reduce barriers to adoption, potentially bringing minimally invasive cystectomy to more patients globally.
Limitations of Early Series. With only two patients, no statistical conclusions can be drawn about safety, efficiency, or outcomes compared to other platforms or open surgery. The report serves as a proof-of-concept and surgical guide rather than a definitive comparative study. Larger prospective series are needed to formally evaluate the Hugo system against established alternatives for radical cystectomy.
First Report of Its Kind. This represents the first published description of robot-assisted radical cystectomy with intracorporeal ileal conduit performed using the Hugo RAS system. Establishing this precedent is important for the field, as it confirms the procedure is technically executable on this platform and provides a reproducible surgical template for other teams.
Potential for Wider Adoption. Detailed documentation of surgical settings, arm configurations, trocar placement, and docking procedure reduces the uncertainty that prevents centers from attempting new robotic platforms. By providing this information in combination with a surgical video, the authors create a practical resource for urologists considering adopting the Hugo system for bladder cancer treatment.
Next Steps. Future work should include larger patient series with longer follow-up to assess oncological outcomes, quality of life, complications, and functional results of the urinary diversion. Comparative studies between the Hugo system and established robotic platforms for radical cystectomy will be needed to definitively establish where each system offers advantages.