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Review

Early Clinical Outcomes of the Novel Hinotori Robotic System in Urological Surgery—A Review of Existing Literature

1
Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
2
Department of Urology, National University Hospital, Singapore 117074, Singapore
*
Author to whom correspondence should be addressed.
Soc. Int. Urol. J. 2025, 6(4), 56; https://doi.org/10.3390/siuj6040056
Submission received: 11 March 2025 / Revised: 22 July 2025 / Accepted: 1 August 2025 / Published: 19 August 2025

Abstract

Robotic-assisted surgery has gradually established its role in uro-oncological cases that demand a high level of precision, optimising surgeon ergonomics and decreasing fatigue whilst maintaining optimal clinical outcomes. With the novel Hinotori surgical robot (Medicaroid Corporation (Kobe, Hyogo, Japan)) launched in Japan back in 2019, it has now demonstrated its use case across various clinical series of different surgeries. We sought to narratively synthesise the initial feasibility of the Hinotori robotic system in urology. A systematic, comprehensive literature search was conducted across various databases from September 2024 to October 2024. Relevant keywords within the scope of this study were generated for a more accurate search. After exclusion and removal of duplicates, a total of nine articles were included for review. Among the included studies, one study reported data solely on radical prostatectomy for prostate cancer, two studies reported on robotic-assisted nephroureterectomy for renal tumours, two studies reported on partial nephrectomy performed for renal masses, two studies reported on radical nephrectomy carried out for renal malignancies and one study reported on robotic-assisted adrenalectomy for adrenal cancer. Lastly, one study collectively reported on outcomes pertaining to partial nephrectomy, partial nephrectomy, vesicourethral anastomosis and pelvic lymph node dissection in a porcine model, as well as partial nephrectomy, radical prostatectomy and pelvic lymph node dissection in cadavers. The current literature supports its non-inferiority to the well-established Da Vinci system, with no major drawbacks or concerns identified when comparing parameters such as intraoperative time, estimated blood loss (EBL), perioperative events (transfusions, conversion to open surgery), length of hospital stay and major postoperative complications. Future studies involving larger cohorts and more complex surgical cases are essential to further evaluate the efficacy and safety of the Hinotori system. The new Hinotori robotic system offers unique three-dimensional features as a non-inferior robotic platform alternative that has proven clinically safe thus far in its use. Larger scale studies and randomised trials are eagerly awaited to assess and validate more holistically its clinical utility.

1. Introduction

Urology has welcomed its era of minimally invasive surgery in the recent decade—with the shift from traditional open surgeries to laparoscopic and robotic-assisted surgeries, cases with complex anatomy requiring sophisticated planning are made less challenging. The Da Vinci Robotic System developed by Intuitive Surgical Inc. (Sunnyvale, CA, USA) has been one of the pioneers and remains highly utilised to date. Yet, with the introduction of other newer and novel robotic systems on the market, they could potentially be equally as efficacious with features such as modular designs, open access consoles, haptic feedback, smaller instruments, and machine learning [1]. Although uncommon, complications pertaining to Da Vinci have been reported in the form of morbidity- and mortality-related events [2,3]. Healthcare technology companies hence continue their efforts in refining the existing robotic platforms in attempts to account for these shortcomings. Within the region of Asia, the Hinotori robotic system produced by Medicaroid Corporation (Kobe, Japan) has primed itself as one of the rising competitors in robotic surgery. Officially approved for clinical use in August 2020, the Hinotori has successfully witnessed its application in routine surgical practice. Features that set it apart from current robotic platforms in the market include an additional axis of motion (eight axes of motion), while maintaining its compactness and minimising interference between working arms. It also features a docking-free design, which confers increased flexibility of the robotic arm once the dedicated surgical instrument is attached. This reduces extra-corporeal interference within the operating field. Owing to its relative nascency, the Hinotori platform has only been formally utilised in Japanese cohorts. The aim of this study is to narratively synthesise the literature reporting on the Hinotori to date and summarise the clinical outcomes associated with its initial years of application.

2. Materials and Methods

A systematic search was carried out across Pubmed from December 2023 to February 2024, with the search terms ‘‘Hinotori’’, ‘‘Urological Robotic Surgery,’’ ‘‘Robotics’’ and other terms deemed relevant to the scope of the study. An initial number of 10 articles were included in the initial search. Duplicates were excluded and articles were screened. Studies that focused on other novel robotic platforms were excluded. After exclusion, a total of nine studies were finalised for review (Figure 1). Among the included studies, one study reported data solely on radical prostatectomy for prostate cancer, two studies reported on robotic-assisted nephroureterectomy for renal tumours, two studies on partial nephrectomy performed for renal masses (either benign or malignant), two studies on radical nephrectomy carried out for renal malignancies and one study on robotic-assisted adrenalectomy for adrenal cancer. Lastly, one study collectively reported on outcomes pertaining to partial nephrectomy, partial nephrectomy, vesicourethral anastomosis and pelvic lymph node dissection in a porcine model, as well as partial nephrectomy, radical prostatectomy and pelvic lymph node dissection in cadavers.

3. Results

Baseline characteristics of all studies, including peri-operative indicators and follow-up outcomes post-surgery, are detailed in Table S1. In-depth parameters of partial or radical nephrectomies such as preservation of renal function and achievement of trifecta outcomes are provided in Table S2.

3.1. Robotic-Assisted Partial Nephrectomy (RAPN)

RAPN has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses [4]. In recent years, RAPN has developed to become a safe technique that reduces warm ischemia time (WIT) in comparison to the laparoscopic approach [5]. Currently, the utility of robotic-assisted partial nephrectomy has been well established with the Da Vinci robotic surgical system as the primary platform. Since the advent of the Hinotori in Japanese institutions, the novel system has been validated in its use within both the pre-clinical and clinical context. Three studies have been published on RAPN outcomes using the Hinotori system, with Motoyama et al.’s study acting as a primary comparison with the Da Vinci system and Hinata et al.’s being a cadaveric one [6,7]. Motoyama et al. published the first clinically matched prospective cohort study, looking at patients with small renal masses (SRM) that underwent RAPN with either the Da Vinci or the novel Hinotori system. Perioperative and oncological outcomes were non-inferior in the Hinotori group, with no significant differences in operative duration and ischemic time seen and no major complications as well. Negative surgical margins were also achieved in all patients. “Trifecta” outcomes were also attained in 100% of patients operated with the Hinotori system and postoperative renal function changes were comparable to that of the Da Vinci cohort. Similar findings were corroborated in a separate study by Miyake et al., who also sought to prospectively evaluate 30 cases of RAPN with the Hinotori robotic system [8]. Zero major complication rates and no positive surgical margins were encountered, alongside full achievement of trifecta parameters as well. Interestingly, the Hinotori has been used for all patients with small renal tumours undergoing RAPN, even those with complex tumours—50% had renal tumours corresponding to complex tumours characterised by cT1b, completely endophytic, hilar and/or cystic tumours. This is comparable to tumours similar to or even more complex than characteristic tumours usually operated on using Da Vinci system.

3.2. Robotic-Assisted Radical Nephrectomy (RARN)

Two studies by Motoyama were published on RARN, with one study performed with direct comparison to the Da Vinci system and the other focusing on a select group of two patients requiring RARN and inferior vena cava (IVC) tumour thrombectomy (IVCTT) with the novel Hinotori system [9,10]. In the former study, a total of 34 patients (13 Hinotori, 21 Da Vinci) patients underwent RARN as a retrospective case series across both platforms. Both platforms achieved satisfactory peri-operative and postoperative outcomes—no significant differences were found in parameters such as operative duration, estimated blood loss, major complication rates and postoperative length of stay. Negative surgical margins were attained in both groups as well. The RARN/IVCTT study comprised 2 patients with clear cell renal cell carcinoma (RCC), pT3b, World Health Organization International Society of Urological Pathology (WHO ISUP) Grades 3 and 4, with the other radical nephrectomy (RN) study focusing on local renal tumours in a larger sample size of 13 patients. Despite the relative anatomical complexity in tackling Level I and II IVC thrombi, the Hinotori system provided optimal outcomes as well, reporting zero major complication rates with any need for intra-operative blood transfusion or conversion to open RN.

3.3. Robotic-Assisted Nephroureterectomy (RANU)

The use of RANU is becoming increasingly prevalent [11]. Two studies have been published to date on RANU using the Hinotori system. In Shimizu et al.’s study, a case series of four cases is discussed and in Motoyama et al. study, their experience in eight patients is described. In the former study, outcomes were compared in retrospect to their Da Vinci cohort as well, which demonstrated no significant differences between both groups. There was one Clavien–Dindo Grade 3 complication in the Da Vinci group. In terms of trocar placement, an 8 mm robotic port was placed two finger widths below the costal margin at the lateral edge of the rectus muscle, the third arm was placed as close to the midline as possible and the camera and additional robotic arm ports were placed 7 cm apart from each robotic arm port. The 12 mm assistant port was placed at least 5 cm median from the camera port.
In Motoyama’s study, three patients underwent RANU for renal pelvic tumours and the remaining five patients for lower ureteral tumours [9]. The surgical steps are described as follows: firstly, a nephrectomy starting out from the renal hilum, proceeding onwards to lymph node dissection, vesico-ureteric junction and ureteric dissection, distal ureterectomy, bladder cuff excision, cystostomy and the eventual en bloc removal of the specimen. Trocar placement was described as a 12 mm camera port (#1), two 8 mm ports for a robotic arm on each side—right (#2) and left (#3), two 12 mm ports for assisting (#4 and #5) and a final port for liver traction (#6) at the kidney direction stage. At the bladder direction stage, the 3rd and 4th ports are switched. Hence, the 8 mm robotic port is placed inside the 12 mm port for the left arm and one of the 8 mm assisting ports is converted to a 12 mm port for assisting. Median operating time was 230 min, estimated blood loss was 23 mL and mean hospital stay was 10 days. There were no postoperative complications. When this was compared to four patients who received RANU using Da Vinci, their operative time was 211 min and estimated blood loss was 35 mL with no major complications, and mean hospital stay was 12 days. The difference in operating time may be accounted for as the Hinotori required undocking when moving from the kidney to bladder direction phase to re-determine trocar positioning. These outcomes were comparable to other studies focusing on RANU using the Da Vinci robotic platform. In study of five RANUs performed, operative time was 160–240 min, estimated blood loss was 100–200 mL and days of hospital stay were 3–7 [12]. Morizane’s study of nine cases undergoing RANU describes the following perioperative outcomes: a mean operative time of 323 min, mean EBL of 55 mL, and a mean length of hospital stay of 12 days. No patients experienced major complications after surgery [13].

3.4. Robotic-Assisted Adrenalectomy (RAA)

Most RAAs have substantial evidence for the use of the Da Vinci system, but the use of the Hinotori platform in adrenalectomy still has limited evidence. Adrenalectomy is considered a challenging procedure, and the laparoscopic approach is widely accepted traditionally when compared to open surgery [14]. However, conversion to a robotic approach has gained traction in recent years, and has proven to be highly effective and safe [15,16,17]. In a meta-analysis by Argusa, robotic-assisted surgery (RAS) is considered superior to a laparoscopic approach due to shorter hospital stay and lesser blood loss [18,19]. The initial and only study of the Hinotori system by Motoyama discusses a case report of six cases where adrenalectomy was performed for adrenal tumours using the Hinotori compared to five patients using the Da Vinci system [20]. In all 11 patients, they underwent the transperitoneal approach, with no differences in surgical procedures, including the port replacement. In terms of trocar placement, three trocars were used as robotic arms and one to two additional trocars for assisting. This includes AirSeal iFS (CONMED Japan KK, Tokyo, Japan) in patients with left adrenal tumours, or to lift a last trocar to perform the liver lift in patients with right adrenal tumours.
Both groups had similar perioperative outcomes, with a median operative time of 119 min, estimated blood loss of 8 mL, and length of hospital stay of 7 days. No patients experienced major perioperative complications. The Hinotori group had slightly longer operative times, owing to larger adrenal tumours. Additionally, the Hinotori group had perioperative outcomes like those of other institutions using the Da Vinci system. A study by Francis et al., reported on outcomes of 37 patients who underwent RAA, with a mean operative time of 213 min, EBL of 74 mL and an average length of stay of 1.4 days [15]. Four patients experienced postoperative complications that resulted in unplanned hospital readmissions and there was one mortality.

3.5. Robotic-Assisted Radical Prostatectomy (RARP)

Robotic surgery has revolutionised radical prostatectomies in urology, establishing its use as a superior approach to laparoscopic surgery [21,22]. Two studies are published on RARP using the Hinotori system. In Yamamoto’s study, 93 patients were included, with two groups, one group using the Da Vinci system and the other group using the Hinotori system [23]. For the Hinotori group, the median operative time was 343 min and median blood loss was 180 mL, with median console time of 271 min. There was one perioperative complication of common bile duct stone in this group. When compared to the Da Vinci group, the median operative time was 334 min and median blood loss was 172.5 mL, with median console time of 254 min. There were two perioperative complications of common bile duct stone and pulmonary embolism in this group. Regarding trocar placement, it is performed similarly to conventional port placement with four robotic arms and two assisting ports.
Another study by Hinata reports on RARP performed in 30 patients with localised prostate cancer [7]. Male patients had a pre-operative PSA of 7.6 ng/mL. The following outcomes of median console time and blood loss were 165 min and 162.5 mL, respectively. Significantly, four (13.3%) recoverable errors were observed due to longer operation time because of equipment malfunction, which necessitated recovery time during the operation. Compared to the Da Vinci system, there is a failure rate of 0.5% due to device failure when evaluating over 800 RARPs in a prospective study by Zorn KC et al. [24]. Three major perioperative complications (Clavien–Dindo ≥ 3) were reported, including anastomotic leakage, paralytic ileus, and pulmonary embolism. Postoperatively, positive margins were observed in 2 out of 26 cases (7.7%) for pT2 diseases and in two out of four cases (50%) for pT3 cancers. Trocars included three ports for robotic arms, one camera port, and two assisting ports. Compared to other robotic systems such as Revo-i, a study of 17 patients reported median docking time, console time, ureterovesical anastomosis time and EBL of 8 min, 92 min, 26 min and 200 mL, respectively [25]. There were three blood transfusion events—one intra-operatively due to a blood loss of 1 500 mL and two patients postoperatively. There were no other major complications. The median hospital stay was 4 days. At 3 months, four patients had positive surgical margins, one patient had biochemical recurrence (BCR) and fifteen patients achieved continence.
In another institution, using the Da Vinci system, RARP was performed in 66 patients with prostate cancer [12]. Lymph node dissection was also performed in 35 patients, and 12 (18.2%) had positive lymph node disease. Median operative time was 210 min, console time was 130 min and EBL was 200 mL. Median hospital stay was 7 days. Postoperatively, 23 patients (34.8%) had positive surgical margins.

4. Discussion

Overall, robotic-assisted surgery has shown benefits such as shorter length of stay, lesser blood loss and fewer complications, with specific benefits such as shorter WIT in renal surgeries compared to traditional open surgery or laparoscopic surgery [26,27]. Comparing the Hinotori to the pre-existing well-acclaimed Da Vinci system already on the robotic market, both perioperative and postoperative findings revealed favourable outcomes which were non-inferior to that of the Da Vinci. This reviewed parameters such as intraoperative time, estimated blood loss (EBL), perioperative events (transfusions, conversion to open surgery), length of hospital stay, as well as major postoperative complications. Considering these encouraging findings, the Hinotori presents an innovative perspective with favourable outcomes and similar safety profiles. On the international stage, the Hinotori has since been approved for use in Singapore in September 2023. In November 2024, the first overseas surgery was performed here in Singapore, a robot-assisted radical prostatectomy using the Hinotori system. Alongside the nine studies discussed above, in 2024, Nakayama et al. reported a nonrandomised study comparing 97 RARPs performed with the Hinotori robot to 40 Da Vinci RARP cases that showed overlapping perioperative outcomes [28].
The benefits that the novel Hinotori system has to offer are largely advantageous, including increased flexibility of robotic arm movement with eight axes of movement range which simultaneously inhibits interference between multiple robotic arms. This has specifically been designed to realise accurate and minute manipulations in each surgery. Other technical aspects such as software calibration of trocar position without docking arms results in the provision of a large space in a clean field and protects against collisions between arms outside the body. This, in conjunction with the flexibly positioned 3D viewer mounted in the surgeon’s cockpit brings greatly desired convenience and reduces fatigue for the surgeon. Such benefits allow a great range of urological surgeries to be performed, showing extreme significance and importance in challenging, complex surgeries such as IVCTT. Both systems may have a similar difficulty of learning curve as well, demonstrated in a study of the Hinotori system in other types of surgery—gastric, pancreatic and rectal [29]. This is further reinforced by Nakayama’s study, where two surgeons were compared—one who had performed 40 RARP procedures and another surgeon with >100 RARP procedures performed. There were no statistically significant differences in time using the Hinotori [28]. In terms of oncological outcomes, both the Hinotori and Da Vinci systems provide similar perioperative outcomes. In a recent systematic analysis of six studies and 904 patients, there was no statistical difference in positive surgical margin rate (PSM) and BCR between the two groups [30].
However, there are limitations as well. In the same study, the Da Vinci group had significantly shorter operating time and robotic intervention time [30]. In terms of device error, device errors were detected in 4 of 30 (13.3%) surgeries, related to updating of the control programs [31]. This was decreased from an initial 16.1% as reported in the preclinical phase. Conversely, the Da Vinci reports device failure in 0.4–0.5% of cases, with robotic surgeries converted to open [24,26,32]. As the Hinotori system is relatively new, these device errors are anticipated, and accepted as below the preset 15%. However, as the system matures and more users are able to report feedback, improvements can be made to reduce this error rate. The main challenge in evaluating the Hinotori remains that there is a paucity of literature, and the sample size is extremely small. This is also due to the Hinotori being a new system, and long-term data is not available yet to evaluate the outcomes of surgery performed using this system.
Another drawback highlighted in Motoyama’s paper on RANU is that RANU could be completed without re-docking with the Da Vinci but not using the Hinotori. This is particularly during movement from kidney to bladder direction to determine the trocar position by software-based calibration. The study acknowledged that this may contribute to differences in perioperative outcomes. Most importantly, there is still limited literature on comprehensive studies comparing the Hinotori robotic system to the Da Vinci robotic system, and distinct differences cannot be thoroughly evaluated. Moreover, such studies with early experience also have the potential to be subjected to concerns such as patient selection bias. As a result, it remains largely speculative whether this novel system is truly non-inferior. However, such comparative studies are crucial to provide valuable insight into this product.

5. Conclusions

The rapid adoption of the Hinotori system since its induction in 2019 in Kobe, Japan, underscores its expansive potential in advancing minimally invasive urological surgeries. This innovative system offers substantial advantages in enhancing surgical precision and patient outcomes, positioning it as a strong contender in the field of precision-based surgery. Unsurprisingly, its success extended beyond Urology to other surgical specialties. The current literature supports its non-inferiority to the well-established Da Vinci system, with no major drawbacks or concerns identified. Future studies involving larger cohorts and more complex surgical cases are essential to further evaluate the efficacy and safety of the Hinotori system. Longer term data is required to evaluate prognostic outcomes and long-term outcomes. Such research will be crucial for establishing its role in the global landscape of urological surgery.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/siuj6040056/s1.

Author Contributions

All named authors have contributed significantly to the conceptualisation, conduct and writing of the paper. All authors have fulfilled the Committee on Publication Ethics (COPE) requirements for authorship. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analysed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Prisma flowchart of methods.
Figure 1. Prisma flowchart of methods.
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MDPI and ACS Style

Ong, S.M.; Peng, H.M.; So, W.Z.; Tiong, H.Y. Early Clinical Outcomes of the Novel Hinotori Robotic System in Urological Surgery—A Review of Existing Literature. Soc. Int. Urol. J. 2025, 6, 56. https://doi.org/10.3390/siuj6040056

AMA Style

Ong SM, Peng HM, So WZ, Tiong HY. Early Clinical Outcomes of the Novel Hinotori Robotic System in Urological Surgery—A Review of Existing Literature. Société Internationale d’Urologie Journal. 2025; 6(4):56. https://doi.org/10.3390/siuj6040056

Chicago/Turabian Style

Ong, Simone Meiqi, Hong Min Peng, Wei Zheng So, and Ho Yee Tiong. 2025. "Early Clinical Outcomes of the Novel Hinotori Robotic System in Urological Surgery—A Review of Existing Literature" Société Internationale d’Urologie Journal 6, no. 4: 56. https://doi.org/10.3390/siuj6040056

APA Style

Ong, S. M., Peng, H. M., So, W. Z., & Tiong, H. Y. (2025). Early Clinical Outcomes of the Novel Hinotori Robotic System in Urological Surgery—A Review of Existing Literature. Société Internationale d’Urologie Journal, 6(4), 56. https://doi.org/10.3390/siuj6040056

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