Dr. PETER BIRO

How the Vision DUO Transformed Neuromuscular Monitoring in Urologic Surgery

I first came across the device—then known as the TOFcuff—in 2018, during a desperate search for a neuromuscular transmission (NMT) monitor (also known as relaxometer) that could deliver reliable measurements across the full range of neuromuscular blockade intensities. I wasn't disappointed as soon as I found TOFcuff by RGB Medical Devices, Madrid.

My need for a device with high precision and good data resolution in values and timing, particularly during deep blockade, stemmed from a new responsibility: heading anesthesia for urologic surgeries at my longtime workplace in the University Hospital Zurich, Switzerland. At that time, the department of Urology had just started performing robot-assisted prostatectomies, which require a consistently deep neuromuscular blockade throughout the pneumoperitoneum period. The device from RGB Medical in Madrid, equipped with compressomyographic (CMG) technology, not only met this need—it also proved completely resistant to artifacts caused by electrical or mechanical interference, which are common in surgical environments. Another major advantage of the cuff-based technology was that it didn’t require manual access to the sensor—crucial during these procedures, where the patient’s arms are positioned and tightly wrapped along the body.

During the long hours of robot-assisted surgeries, it became clear that even with carefully fine-tuned dosing, it was not easy to consistently maintain the neuromuscular blockade within the target range of 1 to 3 post-tetanic counts (PTC). As soon as a maintenance dose was administered, metabolism and elimination would immediately begin to weaken the relaxant’s effect. This made it a major advantage that the Vision DUO could detect and alert us to any early signs of an undesired return to lighter levels of blockade. Thanks to this capability, we were able to maintain the required depth of blockade during 75% of the pneumoperitoneum phase, effectively preventing risky spontaneous movements in patients who were not unnecessarily deeply sedated. In the remaining cases, a loss of effect could be detected and corrected before the blockade lightened to a PTC of 6.

I quickly came to appreciate several other features as well, like the AI-driven "autopilot" mode, which automatically selects the next stimulation mode, and its adequate timing based on previous results. This removes the need for manual adjustments during monitoring. From induction to emergence, the device continuously performs the appropriate assessments and displays both current values and the trend of the blockade, keeping the anesthesiologist fully informed about the patient’s relaxant needs. This, in turn, makes medication planning much easier, helping to avoid both over- and underdosing, and effectively preventing residual blockade after anesthesia ends. It also promotes the economic use of NMT blockers and reversal agents and significantly reduces the risk of postoperative complications related to residual blockade.

Through my frequent and critical use of the device—later renamed Vision DUO—I was able to provide the manufacturer with practical, real-world suggestions for improvements. This was a rare and positive experience, as manufacturers don’t often incorporate clinical feedback so readily—or so quickly. Thanks to this collaboration, several enhancements were introduced, particularly aimed at improving usability in day-to-day clinical practice. Nowadays, the Vision DUO is an outstanding fully developed NMT monitoring system, essentially a device that would top any anesthesiologist’s wish list.