Robotic Surgery in Urology

Dr. Wong Wai SangFRCS, FRACS, FHKAM, FRACS(Urology)

Urological Surgery in The Last CenturyOpen surgery – 100 years

Urological Surgery in The Last CenturyOpen surgery – 100 years

Urological Surgery in The Last CenturyOpen surgery – 100 years

Urological Surgery in The Last CenturyOpen surgery – 100 years

Urological Surgery in The Last CenturyTURP – 50 years

Urological Surgery in The Last CenturyURS, PCNL – 20 years

Urological Surgery in The Last CenturyLaparoscopic surgery – 10 years

Urological Surgery at The Turn of The CenturyRobotic Surgery

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

Laparoscopic SurgeryAdvantages

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

Open Nephroureterectomy

Laparoscopic Nephroureterectomy

Laparoscopic Radical Prostatectomy

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)

Laparoscopic SurgeryDisadvantages

decreased surgeon’s dexterity, control, precisionmore surgeon’s fatigue and tiredness

very difficult in operating complex surgery

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

Robotic Surgical Systems

• To overcome the problems from complex surgery

meticulous dissection

suturing

knots tying

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

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, <1% of the radical prostatectomy were done by

robots in 2001, >40% of the radical prostatectomy were done by robots in 2006

Da Vinci Surgical SystemHuman eye vision and beyond

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

Da Vinci Surgical SystemHuman hand dexterity and beyond

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

Da Vinci Surgical System• Improved dexterity• Better control• Better precision

• Improved ergonomics – decreased fatigue and strain

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 prostatectomyImproved cancer controlIncreased continenceEnhanced sexual potency

V Patel J Endourol 2005T Ahlering ART 2006

M Menom UCNA 2004

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%

Operative parameters for conventional, laparoscopic & robotic radical prostatectomy

OT blood loss catheter complications +ve margin

(min) (ml) (day) (%) (%)

RRPLepor 131 820 7-14 6.6 17

Catalona217 1395 7-14 10 21

LRPMontsouris 217 345 6.6 13.3 17

Abbou 271 NA 9 11.7 18.1

RAPMenon 160 153 7 5 6

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 0.91Blood loss 910 ml 0.42 0.10Positive margin 23% 1 1Complication 15% 0.67 0.33Catheter time 15.8 days 0.5 0.44Hospital >24 hours 100% 0.35 0.07Postop pain score 7 0.45 0.45

(0-10)Mean time to continence 160 days 1 0.28Mean time to erection 440 days NA 0.4Mean time to intercourse >700 days NA 0.5Detectable PSA 15% 1 0.5

M Menom UCNA 2004

Da Vinci Surgical System

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

Robotic Radical Prostatectomy

Robotic Radical Cystectomy+ Intracorporeal Ileal Conduit

Robotic Ureterocalycostomy

Da Vinci S Surgical System• Fast foolproof setup• Rapid instrument exchange• Multi-quadrant access• Interactive video display

Robotic SurgeryHKSH

March 2007 – July 2007

• Radical prostatectomy 29• Partial nephrectomy 2• Pyeloplasty 1

• Hysterectomy2

• Tubal reanastomosis2

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