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On November 1, 2022 - The First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU) successfully completed a left radical nephrectomy for renal cancer by transperitoneal approach + para-aortic lymph node dissection with the assistance of Toumai^® Laparoscopic Surgical Robot (“Toumai^®”), and removed the life-threatening risk of the patient diagnosed with a large malignant renal tumor. The surgery was performed under the leadership of Dan Xia and Shuo Wang, directors of the urologysurgery department in cooperation with the anesthesia care team. The case was a highly difficult, challenging and risky surgery in the field of urology assisted by the Chinese-developed four-arm laparoscopic surgical robot, and was the fifth challenging surgery completed within two weeks since the Toumai^® was installed in FAHZU. It not only reflected the sophisticated skills of the Urology Surgery Department of FAHZU in clinical operation and surgical robot application, but also verified the clinical fitness and the accurate performance of Toumai^®, which makes it an ideal assistant for the surgeons in complex surgeries.

The patient in this surgery was a male. Upon admission, Dan Xia and Director Wang Shuo's team conducted a thorough examination and evaluation of the patient's overall condition - the preoperative CT suggested a large tumor volume (11*11*10 cm) and multiple enlarged lymph nodes around the lesion, and the CTA suggested heterogeneous arteries in the renal area, which was considered a possible renal cancer. Besides, the patient suffered from severe intestinal adhesions, as evidenced by the large abdominal wall adhesions to the intestine, which could easily lead to intestinal injury with the potential risk of intestinal fistula during intraoperative operations. After a thorough evaluation, the team decided to perform a radical nephrectomy + abdominal para-aortic lymph node dissection for left-sided kidney cancer via a transabdominal approach with the assistance of a Chinese-developed four-arm laparoscopic surgical robot with the powerful robotic surgical console of the hospital in urologyafter thorough communication with the patient.

The operation went smoothly with the full cooperation from the anesthesia and the nursing teams. Intraoperatively, the huge kidney was seen to be wrapped by abundant trophoblastic vessels, and the abdominal wall was extensively adhered to the colon with unclear anatomical structures. With the 3D high-resolution operation vision offered by Toumai^®, Director Wang remotely controlled the four robotic arms on the patient cart from the surgeon console. The flexible mechanical wrist delicately handled the adhesive part of the intestine by pulling and dissociation, thoroughly bared the multiple renal artery of renal hilum, clipped and cut the exposed arteries and veins of the kidney, and completely removed the swollen lymph glands in the abdominal aorta area. The entire surgery lasted 2 and a half hours, and the procedure perfectly demonstrated the exquisite clinical skills of the surgeon and the precise, flexible and stable performance of the robot.

The installation of Toumai^® was completed in FAHZU on October 16, 2022. The first surgery assisted by Toumai^® was carried out on October 25, and three challenging surgeries were completed on October 27. Within one week, Toumai^® participated in five challenging surgeries led by Director Dan Xia and Director Shuo Wang including three radical prostatectomy via extraperitoneal approach, one partial nephrectomy through retroperitoneal approach and one left radical nephrectomy for renal cancer by transperitoneal approach + para-aortic lymph node dissection.

In the radical prostatectomy, Director Shuo Wang was able to operate Toumai^® and complete a series of complex operations in the narrow pelvic cavity. With the close coordination of the flexible robotic arms, the amount of bleeding was limited, the surgical injury was small, and the blood vessels and nerves around the prostate were preserved to a large extent, which improved the post-operative life quality of the patient, reduced the risk of urologyincontinence, and increased the urologycontinence capability of the patient.

In the partial nephrectomy, Director Dan Xia smoothly removed the tumor with Toumai^®, and the warm ischemia time only lasted 19 minutes. The expectations of the patient for small injury, minimal invasion and quick recovery were fulfilled.

Director Dan Xia has been working on the research of minimally invasive surgery in the field of urologysurgery for a long time, and leads the nation in both the surgery quantity and the surgery quality, especially in the field of robot-assisted laparoscopic surgeries. So far, she has completed over 2,000 robot-assisted surgeries covering radical prostatectomy, nephron-sparing surgery, radical cystectomy, excision of giant pheochromocytoma, vena cava thrombectomy, and the first left renal vein transposition in the country.

Director Shuo Wang has participated in over 8,000 laparoscopic urological surgeries, and personally completed more than 2,000 robot-assisted surgeries, the amount of surgeries ranging top three in the country for five consecutive years. He informatively expanded the scope of indications that may be cured through robot-assisted surgeries, and carried out a series of highly challenging minimally invasive surgeries in the hope of relieving the pain of the patients with urologytract diseases with the minimally invasive surgeries to the largest extent. He has demonstrated operation process in multiple national academic conferences. He also demonstrated operation process and delivered keynote speeches in the 2016 American Robotic Urology Symposium and the 2018 World Robot Conference on behalf of China, winning the recognition of peers across the world.

Director Dan Xia said she has witnessed the rapid development of minimally invasive surgery technologies over two decades of her career. The robotic console integrates a large number of new advanced technologies, and is subject to rapid development and update. The development of science and technologies has significantly driven the booming of minimally invasive surgery. The successful completion of five highly challenging surgeries in a row by Toumai^® in FAHZU is another proof of the maturity of the clinical adaptability and technical level of the Chinese-developed robot.

As Director Shuo Wang said, the technology innovation in the field of surgical robots has become an industry focus with the development of innovative technologies in the medical field. Over the past decade, the surgical robot technologies have gradually expanded into the departments of urologysurgery, Thyroid Dept, gynecology, and orthopedics. The clear vision and accurate operation offered by the surgical robot have made it an ideal substitute for the open surgery. The successful completion of five challenging surgeries by Toumai^® in a row has proven that the Chinese-developed surgical robot has grown mature in performing challenging surgeries. We hope the Chinese-developed surgical robot will further contribute to the development of domestic clinical technologies through continuous technology innovation, and make the Chinese-developed surgical robot popular in the operation room！

The surgeons that participated in this surgery were able to quickly complete multiple challenging surgeries within a short time. There are mainly three reasons. Firstly, as the leading experts in the application of domestic surgical robots in the field of urology, Dan Xia and Shuo Wang havehas extensive clinical experience and have respectively completed over 2,000 robotic surgeries; secondly the stable performance of the MicroPort^® Toumai^® has significantly reduced the learning curve of the surgeons; thirdly, the customized education and training team and the service support team of the MicroPort^® Toumai^® have provided them with professional and systematic training, which ensured the professional operation by the surgeons and the stable performance of the robotic system, thus providing benefits for more patients.

Mr. Yu Liu, Executive Vice President and Chief Commercial Officer of MicroPort^® MedBot ^®, said:“The successful completion of five highly challenging urology surgeries assisted by Toumai^® in FAHZU has not only shown the leading operation skills of directors Dan Xia and Shuo Wang, but also the outstanding and stable performance of Toumai^® in challenging procedures. This means that Toumai^® has made another breakthrough in the clinical application, and also serves as a clinical verification of the advantages of domestic surgical robots in technology innovation. We look forward that Toumai^® will get continuous improvement and optimization through ongoing communication and joint exploration with the experts and surgeons, bring more clinical benefits to the surgeons and patients, and realize the original intention of "Make Surgery Easier, Safer and Less Invasive".