Robotic Surgery in Urology Dr' Wong Wai Sang FRCS, FRACS, FHKAM, FRACSUrology

1
Robotic Surgery in UrologyDr. Wong Wai
SangFRCS, FRACS, FHKAM, FRACS(Urology)
2
Urological Surgery in The Last CenturyOpen
surgery 100 years
3
Urological Surgery in The Last CenturyOpen
surgery 100 years
4
Urological Surgery in The Last CenturyOpen
surgery 100 years
5
Urological Surgery in The Last CenturyOpen
surgery 100 years
6
Urological Surgery in The Last CenturyTURP 50
years
7
Urological Surgery in The Last CenturyURS, PCNL
20 years
8
Urological Surgery in The Last CenturyLaparoscopi
c surgery 10 yearsUrological
Surgery at The Turn of The CenturyRobotic Surgery
9
Minimally Invasive SurgeryLaparoscopic Surgery

• Muhe performed the first laparoscopic
  cholecystectomy in 1985 but rejected by the
  German Surgical Society
• Mouret performed the first laparoscopic
  cholecystectomy in 1987
• Perissat demonstrated the technique of
  laparoscopic cholecystectomy at the Society of
  American Gastrointestinal Surgeons Meeting in
  Louisville in 1989
• Spread rapidly all over the world
• First laparoscopic cholecystectomy done in HK in
  1990

10
Laparoscopic SurgeryAdvantages

• Decreased pain
• Shorter hospital stay
• Rapid return to work
• Smaller scars
• Less infection
• Less bleeding

11
Open Nephroureterectomy
12
Laparoscopic Nephroureterectomy
13
(No Transcript)
14
Laparoscopic Radical Prostatectomy
15
Laparoscopic Radical Prostatectomy

• Schuessler (1997) had no advantages over open
  surgery because of the difficulties and long
  hours of the operation
• Vallancien (1999), Abbou (2000) laparoscopic
  radical prostatectmy was feasible
• Ahlering (2003) learning curve for
  laparoscopically naïve surgeon was 80-100 cases,
  learning curve for skilled laparoscopic surgeon
  was 40-60 cases
• (median number of radical prostatectomy
  performed by US urologists was 7 per year)

16
Laparoscopic SurgeryDisadvantagesdecre
ased surgeons dexterity, control, precisionmore
surgeons fatigue and tirednessvery difficult in
operating complex surgery
17
Means to Overcome Decrease Dexterity

• Clip
• Haemolock
• Stapler
• Endoloop
• Extracorporeal knot tying
• Ligasure
• Harmonic scalpel
• Argon beam coagulator
• To escape from the difficulties in suturing and
  knots tying

18
Robotic Surgical Systems

• To overcome the problems from complex surgery
• meticulous dissection
• suturing
• knots tying

19
Da Vinci Surgical SystemSurgical robot

• Robot a mechanical device incorporated with a
  computer
• Master-slave system the surgeon directly
  initiates all the movements of the robotic
  instruments in real time
• Robotic radical prostatectomy robotic assisted
  laparoscopic radical prostatectomy
• retain the advantages of minimally invasive
  surgery
• overcome the drawbacks of conventional
  laparoscopic surgery

20
Da Vinci Surgical System

• The prototype was developed by Stanford Research
  Institute in 1980s, funded by US Army, to perform
  battlefield surgery remotely by a surgeon in the
  safe rear
• FDA approved in human operations in 2000
• Targeted at the heart, but hit the prostate
• By the end of 2006, 559 robots have been
  installed worldwide, 392 robots were in US
• In 2006, over 70,000 robotic surgery were
  performed
• Over 30,000 robotic surgery were for prostate
  cancer
• In US, lt1 of the radical prostatectomy were done
  by robots in 2001, gt40 of the radical
  prostatectomy were done by robots in 2006

21
Da Vinci Surgical SystemHuman eye vision and
beyond

• Double lenses laparoscope
• 3D, high definition, binocular view
• 10-15X magnification

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
Da Vinci Surgical SystemHuman hand dexterity and
beyond

• Endowrist instruments have 6 degrees of freedom
• Filtering off hand tremor
• Scaling down movements 1-5X

26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
Da Vinci Surgical System

• Improved dexterity
• Better control
• Better precision
• Improved ergonomics decreased fatigue and strain

30
Da Vinci Surgical SystemShort learning curve
better results

• Ahlering - surgeons with experience in open
  techniques but no laparoscopic experience, the
  results of after performing 8 - 12 robotic
  radical prostatectomy were comparable to those of
  skilled laparoscopists who had performed more
  than 100 laparoscopic radical prostatectomy
• T Ahlering J Urol 2003
• Robotic radical prostatectomy vs open radical
  prostatectomy
• Improved cancer control
• Increased continence
• Enhanced sexual potency
• V Patel J Endourol 2005
• T Ahlering ART 2006
• M Menom UCNA 2004

31
Experience of robotic radical prostatectomy from
different centers in the world

• patients OT blood loss hospital
  stay catheter ve margin
• Binder 10 450 mins - - 18 days 30
• Rassweiler 6 315 mins - - 7.3 days 0
• Bentas 40 8.3 hrs 570 ml - - -
• Ahlering 60 231 mins 103 ml 25.9 hrs 7
  days 16.7
• Menon 40 274 mins 256 ml - - 18
• Menon 200 160 mins 153 ml 1.2 day 7 days 6

32
Operative parameters for conventional,
laparoscopic robotic radical prostatectomy

• OT blood loss catheter complications ve
  margin
• (min) (ml) (day) () ()
• RRP
• Lepor 131 820 7-14 6.6 17
• Catalona 217 1395 7-14 10 21
• LRP
• Montsouris 217 345 6.6 13.3 17
• Abbou 271 NA 9 11.7 18.1
• RAP
• Menon 160 153 7 5 6

33
Odd ratio for important outcomes for
laparoscopic, robotic radical retropubic
prostatectomy performed at the Vattikuti Urology
Institute

• Variable open laparoscopic robotic
• (reference value) (odd ratio) (odd ratio)
• Operating time 163 mins 1.51 0.91
• Blood loss 910 ml 0.42 0.10
• Positive margin 23 1 1
• Complication 15 0.67 0.33
• Catheter time 15.8 days 0.5 0.44
• Hospital gt24 hours 100 0.35 0.07
• Postop pain score 7 0.45 0.45
• (0-10)
• Mean time to continence 160 days 1 0.28
• Mean time to erection 440 days NA 0.4
• Mean time to intercourse gt700 days NA 0.5
• Detectable PSA 15 1 0.5
• M Menom UCNA 2004

34
(No Transcript)
35
Da Vinci Surgical System
36
Robotic SurgeryPWH (Nov 2005 Nov 2006)

• Urology
• radical prostatectomy 17
• radical cystectomy 3
• partial nephrectomy 3
• ureterocalycostomy 2
• pyeloplasty 1
• ureteroureterostomy 1
• Lower GI
• APR 1
• Gynecology
• hysterectomy 2

• Paediatric Surgery
• reimplantation of ureter 8
• pyeloplasty 6
• excision of ureterocele 2
• Upper GI
• wedge excision of stomach 3
• fundoplication 1
• Heller cardiomyotomy 1
• Cardiothoracic Surgery
• thymectomy 1

37
Robotic Radical Prostatectomy
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
Robotic Radical Cystectomy Intracorporeal Ileal
Conduit
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
Robotic Ureterocalycostomy
48
(No Transcript)
49
Da Vinci S Surgical System

• Fast foolproof setup
• Rapid instrument exchange
• Multi-quadrant access
• Interactive video display

50
Robotic SurgeryHKSHMarch 2007 July 2007

• Radical prostatectomy 29
• Partial nephrectomy 2
• Pyeloplasty 1
• Hysterectomy
• 2
• Tubal reanastomosis
• 2

51
Robotic Surgery in The Future

• All complex laparoscopic surgery will be done by
  robots
• All laparoscopic surgery will be done by robots
  if the cost can come down
• Further improvement of technology
• smaller robot, flexible laparoscope and
  instruments
• Telesurgery