Alternative set up strategies for upper tract robotic surgery with the Hugo RAS – experience from an early adopter institution

The Hugo RAS (Medtronic) represents a growing alternative to the DaVinci robotic platform, featuring a distinctive modular arm-cart design that may pose challenges for surgeons transitioning from established systems. Arm-cart positioning, restricted assistant access, and risk of personnel injury have been identified as barriers to adoption. Following FDA approval for urological procedures in 2025, optimizing a standardized, ergonomic set-up for upper tract cases is essential to facilitate broader uptake. A retrospective analysis of a prospectively maintained database was performed at a single robot-naïve institution. All patients undergoing Hugo RAS upper tract procedures - including robot-assisted partial nephrectomy (RAPN), radical nephrectomy, pyeloplasty, and nephroureterectomy - from January 2024 to May 2025 were included. Perioperative outcomes, set-up times, intraoperative events, and arm-cart repositioning requirements were recorded. A unilateral, four posterior arm-cart configuration with a linear or "W" port arrangement was employed in all. 54 upper tract procedures were performed across two expert robotic surgeons. No cases required intraoperative arm-cart repositioning. Median set-up time for RAPN improved by 8 min between the first and last quartile of cases (15 to 7 min). One additional port was required in a nephroureterectomy case. One minor assistant injury occurred. One case required open conversion for vascular bleeding. RENAL nephrometry scores ranged from 4 to 11 (median 7), with 44% classified as moderate-to-high complexity. A unilateral posterior arm-cart configuration with linear port placement is feasible, reproducible, and familiar to DaVinci-experienced surgeons, improving ergonomics, workflow, and set-up efficiency for Hugo RAS upper tract procedures.