Robotic Surgery in Urology

Dr. Wong Wai Sang

FRCS, FRACS, FHKAM, FRACS(Urology)
Urological Surgery in The Last Century
Open surgery – 100 years
Urological Surgery in The Last Century
Open surgery – 100 years
Urological Surgery in The Last Century
Open surgery – 100 years
Urological Surgery in The Last Century
Open surgery – 100 years
Urological Surgery in The Last Century
TURP – 50 years
Urological Surgery in The Last Century
URS, PCNL – 20 years
 Urological Surgery in The Last Century
Laparoscopic surgery – 10 years

Urological Surgery at The Turn of The Century

Robotic Surgery
 Minimally Invasive Surgery
Laparoscopic 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 Surgery
Advantages
• 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 Surgery
Disadvantages

decreased surgeon’s dexterity, control, precision

more 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 System
Surgical 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 System
Human eye vision and beyond
• Double lenses laparoscope
• 3D, high definition, binocular view
• 10-15X magnification
 Da Vinci Surgical System
Human 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 System
Short 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
 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) (%) (%)
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
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 >24 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 >700 days NA 0.5
Detectable PSA 15% 1 0.5

M Menom UCNA 2004

Da Vinci Surgical System
 Robotic Surgery
PWH
(Nov 2005 – Nov 2006)

Urology Paediatric Surgery

 radical prostatectomy 17  reimplantation of ureter 8
 radical cystectomy 3  pyeloplasty 6
 partial nephrectomy 3  excision of ureterocele 2
 ureterocalycostomy 2
 pyeloplasty 1 Upper GI
 ureteroureterostomy 1  wedge excision of stomach 3
 fundoplication 1
Lower GI  Heller cardiomyotomy 1
 APR 1
Cardiothoracic Surgery
Gynecology  thymectomy 1
 hysterectomy 2
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 Surgery
HKSH
March 2007 – July 2007
• Radical prostatectomy 29
• Partial nephrectomy 2
• Pyeloplasty 1

• Hysterectomy
2
• Tubal reanastomosis
2
 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