Minimally invasive surgery in urology oncology. Dr. Tongchai Nakamont 23 Jan 2014

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1 Minimally invasive surgery in urology oncology Dr. Tongchai Nakamont 23 Jan 2014

2 Urology oncology Renal cell carcinoma ( RCC) Transitional cell carcinoma (TCC) Kidney Ureter Bladder Prostate cancer

3 Urological Surgery in The Last Century Open surgery 100 years

4 Urological Surgery in The Last Century Open surgery 100 years

5 Urological Surgery in The Last Century Open surgery 100 years

6 Urological Surgery in The Last Century Open surgery 100 years

7 Urological Surgery in The Last Century TURP 50 years

8 Urological Surgery in The Last Century URS, PCNL 20 years

9 Urological Surgery in The Last Century Laparoscopic surgery 10 years Urological Surgery at The Turn of The Century Robotic Surgery

10 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

11 Decreased pain Laparoscopic Surgery Advantages Shorter hospital stay Rapid return to work Smaller scars Less infection Less bleeding

12 Open Nephroureterectomy

13 Laparoscopic Nephroureterectomy

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 cases, learning curve for skilled laparoscopic surgeon was cases (median number of radical prostatectomy performed by US urologists was 7 per year)

16 Laparoscopic Surgery Disadvantages decreased surgeon s dexterity, control, precision more surgeon s fatigue and tiredness very 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 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

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, <1% of the radical prostatectomy were done by robots in 2001, >40% of the radical prostatectomy were done by robots in 2006

21 Da Vinci Surgical System Human eye vision and beyond Double lenses laparoscope 3D, high definition, binocular view 10-15X magnification

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25 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

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29 Da Vinci Surgical System Improved dexterity Better control Better precision Improved ergonomics decreased fatigue and strain

30 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

31 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 Blood loss 910 ml Positive margin 23% 1 1 Complication 15% Catheter time 15.8 days Hospital >24 hours 100% Postop pain score (0-10) Mean time to continence 160 days Mean time to erection 440 days NA 0.4 Mean time to intercourse >700 days NA 0.5 Detectable PSA 15% M Menom UCNA 2004

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33 Da Vinci Surgical System

34 Urology radical prostatectomy radical cystectomy partial nephrectomy ureterocalycostomy pyeloplasty ureteroureterostomy Robotic Surgery PWH (Nov 2005 Nov 2006)

35 Robotic Radical Prostatectomy

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41 Robotic Radical Cystectomy + Intracorporeal Ileal Conduit

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

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47 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