Shape the Future of Urological Surgery

Shape the Future of Urological Surgery THE ROLE OF LAPAROSCOPIC SURGERY IN NEW MILENNIUM Victor Chia-Hsiang Lin, MD Division of Urology, Department of Surgery Chi-Mei Medical Center

MY TALK TODAY IS Minimal Invasiveness in Urological Surgery Endoluminal & Percutaneous & Extraluminal (Laparoscopy) Real Impact of Laparoscopic Surgery on Urology Be the standard of care? The Realm of Laparoscopic S. In Urology Practice patterns in CCF Chi-Mei Experience The Future? Miniaturization Robotic surgery & Telesurgery Endoluminal reconstruction

Trend In Urological Surgery Big surgeons make a big wound?? Minimal Invasiveness Less analgesics Better cosmesis Shorter hospital stay Quicker convalescence

Minimal Invasiveness in Urology This trend is like Industrial Revolution, like Digital Revolution

TERRITORY of UROLOGICAL DISEASE Endoluminal Disease: Most urolithiasis,, benign obstructive stricture, BPH, superficial TCC, Extraluminal Disease: Adrenal tumor, renal cortex tumor, retroperitoneal tumor, whatever outer than urethra and transitional cell epithelial lining

Trend In Urological Surgery: MIS 3 main Strategies from 3 Revolutions: Endoluminal Endoscopic surgery (1960) Percutaneous Manipulation (1970) Extraluminal Endoscopic Surgery (1990) (Lap. S.)

CHANGES OF SURGICAL STRATEGIES IN UROLOGY 1990 2000 Open Surgery Open Surgery Laparoscopic S. Endourol. S. Laparoscopic S. Endourol. S.

MY TALK TODAY IS Minimal Invasiveness in Urological Surgery Endoluminal & Percutaneous & Extraluminal (Laparoscopy) Real Impact of Laparoscopic Surgery on Urology Be the standard of care? The Realm of Laparoscopic S. in Urology Practice patterns in CCF Chi-Mei Experience The Future? Miniaturization Robotic surgery & Telesurgery Endoluminal reconstruction

Besides the minimal invasiveness, Can laparoscopic S. in urology be a new STANDARD OF CARE??? Think More

LAPAROSCOPIC RADICAL NEPHRECTOMY To provide you data as regards: 1) Efficacious 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability Secondary Ports Primary Port Thus to make a determination as to whether or not LRN can be e considered the standard-of of-care today?

FACTORS THAT DETERMINE STANDARD OF CARE STATUS 1) Efficacious(=Effective and Efficiency) 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability

RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY THE CLEVELAND C CLINIC EXPERIENCE Laparoscopic (N=100) Open (N=60) P-value Age 62 63 0.8 O.R. time (hrs) 2.8 3.1 0.9 EBL (ml) 97 370 0.001 Tumor size (cm) 5.0 6.1 0.08 Spec. wt. (gm) 604 637 0.9 Hosp. Stay (d) 1.4 5.8 0.001 Gill et al: Cancer 92, 1843, 2001

RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY THE CLEVELAND CLINIC EXPERIENCE Laparoscopic (N=100) Open (N=60) P-value Narcotics (mg) 14 295 <0.001 Open conversion 2 - Complications 5 (13%) 8 (24%) 0.5 Follow up (mos) 16.1 28.7 <0.001

HOW ABOUT LARGER TUMORS.????

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR TUMORS > 5 cm. IN SIZE: CCF EXPERIENCE LAPAROSCOPY OPEN P-valueP < 5 cm > 5 cm > 5 cm (n=48) (n=28) (n=20) Age (yrs) 59 62 64 0.8 BMI 29 32 28 0.2 ASA Class 2.9 3.3 2.9 0.02 Tumor size (cm) 3.5 7.3 7.3 0.9 Spec. Wt. (gm) 424 686 618 0.2

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR TUMORS > 5 cm IN SIZE: CCF EXPERIENCE LAPAROSCOPY OPEN P-valueP < 5 cm > 5 cm > 5 cm (n=48) (n=28) (n=20) O.R. time (hrs) 2.7 3.0 3.2 0.36 Blood loss (cc) 216 138 337 0.0002 Narcotics (mg) 14.5 14 316 <0.0001 Hosp. Stay (d) 1.7 1.3 6.0 <0.0001 Complic. (%) 21 14 30 0.2 Followup (mos) 10.8 6.1 27.6 <0.0001

HOW ABOUT OLDER PATIENTS.????

LAPAROSCOPIC RADICAL NEPHRECTOMY OCTAGENARIANS & NONAGENARIANS Cleveland Clinic Experience LAPAROSCOPY (n=11) OPEN (n=6) Urology, 53:1121, 1999 P-value Age 87 (80-98) 81 (80-82) 82) 0.006 ASA Class 5.1 (2-8) 5 (3-10) 0.42 Co-morbidities 2 1.5 0.5 O.R. times (hrs) 3.5 3.0 0.1 Hosp. stay (d) 2 (1-7) 6 (6-11) <0.001 Complications (%) 4 (36%) 2 (33%) 0.9 Convalescence (wks) 14 42 < 0.001

FACTORS THAT DETERMINE STANDARD OF CARE STATUS 1) Efficacious 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability

MORCELLATION versus INTACT EXTRACTION

We prefer intact extraction for ALL CANCER adrenal, kidney, bladder, prostate, testis

SPECIMEN RETRACTION

Laparoscopic Radical Nephrectomy Cleveland Clinic Experience (N=100) FOLLOW-UP = 16.1 mos (1-36 mos) Port-site recurrences : 0 Local recurrences : 0 Distant metastases : 2 Mortality : 1 (11mon) Gill et al: Cancer,1843, 2001

LAPAROSCOPIC RADICAL NEPHRECTOMY LONG-TERM CANCER CONTROL Ono, J Urol, 165:762, 2001 SMALL VOLUME DISEASE (<5CM) Median Follow-up: 33 mos Laparoscopy (n=119) Open (n=44) 5-yr disease free 95% 88% 5-yr patient survival 95% 96%

LAPAROSCOPIC RADICAL NEPHRECTOMY LONG-TERM CANCER CONTROL Ono, J Urol, 165:762, 2001 SMALL VOLUME DISEASE ( 5CM)( Median Follow-up: 25 mos Laparoscopy (n=39) Open (n=30) 3-yr disease free 100% 82% 3-yr patient survival 91% 88%

FACTORS THAT DETERMINE STANDARD OF CARE STATUS 1) Efficacious 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability

Retroperitoneoscopic Radical Nephrectomy THE CLEVELAND CLINIC EXPERIENCE INDICATIONS: 2005 All comers with. T1-T3aNoMo renal tumors No evidence of IVC involvement No perirenal invasion

Retroperitoneoscopic Radical Nephrectomy The Cleveland Clinic Experience CONTRAINDICATIONS : 2005 IVC involvement Locally invasive tumors Bulky lymphadenopathy Tumor size?

FACTORS THAT DETERMINE STANDARD OF CARE STATUS 1) Efficacious 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability

WIDESPREAD AVAILABILITY > 3000 cases performed Available in all continents Performed at multiple hospitals by multiple surgeons

FACTORS THAT DETERMINE STANDARD OF CARE STATUS 1) Efficacious 2) Morbidity 3) Oncological adequacy 4) All comers? 5) Widespread availability 6) Financial viability Expensive or Cheap??

LAPAROSCOPIC RADICAL NEPHRECTOMY FINANCIAL ANALYSIS WE COMPARED THE HISTORICAL CHARGES OF Open radical nephrectomy (n=20) (1996 1998) vs. Laparoscopic radical nephrectomy (n=18) (1997 1998) vs. Laparoscopic radical nephrectomy (n=15) (1998 1999)

LAPAROSCOPIC RADICAL NEPHRECTOMY FINANCIAL ANALYSIS Open 1996-98 98 (n=20) Laparoscopic 1997-98 98 (n=18) Laparoscopic 1998-99 (n=15) Age (yrs) 63 59 62 Tumor size (cm) 6.6 5.1 5.4 O.R. time (hrs) 3.0 3.4 2.5 Hosp. stay (d) 5.9 <1 <1

LAPAROSCOPIC RADICAL NEPHRECTOMY FINANCIAL ANALYSIS Open 1996-98 98 (n=20) Laparoscopic 1997-98 98 (n=18) Laparoscopic 1998-99 (n=15) Intra-op $2755 $5565 $3661 Post-op op $2289 $1155 $753 TOTAL $5044 $6721 $4414

LAPAROSCOPIC RADICAL NEPHRECTOMY FINANCIAL ANALYSIS Open 1996-98 98 (n=20) Laparoscopic 1997-98 98 (n=18) Laparoscopic 1998-99 (n=15) Intra-op 1 102% higher 33% higher Post-op op 1 49% lower 67% lower TOTAL 1 33% higher 12.5% lower

LAPAROSCOPIC RADICAL NEPHRECTOMY FINANCIAL ANALYSIS UNDER-ESTIMATED ESTIMATED SOCIO-ECONOMIC VALUE Patient Care: Cost of family care (time, fee ) Postop Recovery: Earlier to resume work Less Morbidity and Complication

Laparoscopic Radical Nephrectomy The Cleveland Clinic Experience Summary In 2005 Cosmetically superior O.R. time same as open surgery (2-2.5 2.5 hrs) Shorter hospital stay (1.4 vs 5.8 days) Quicker recovery; considerably less morbidity Equivalent cancer control Financially 12.5% cheaper than open

If the difficulty is the only excuse of reluctance to laparoscopic radical nephrectomy, laparoscopic radical nephrectomy will be the treatment of choice in the near future!!

QUIZ? So, today If President Chen presents to you With a CT-scan diagnosed 8-10 cm organ-confined Kidney tumor

Should LRNx not be e considered as the standard-of of-care in this kind of VIP -class patient??

MY TALK TODAY IS Minimal Invasiveness in Urological Surgery Endoluminal & Percutaneous & Extraluminal (Laparoscopy) Real Impact of Laparoscopic Surgery on Urology Be the standard of care? The Realm of Laparoscopic S. Practice patterns in CCF Chi-Mei Experience The Future? Miniaturization Robotic surgery & Telesurgery Endoluminal reconstruction

Standard Laparoscopic Surgeries in CCF * indicates till November 30, 2002. 1997 1998 1999 2000 2001 2002* Adrenalectomy Open Lap 15 23 13 38 2 35 9 45 7 40 10 43 Nephrectomy Open Lap 75 10 100 27 71 41 82 63 54 80 68 85 NU Open Lap 17 4 19 17 12 20 13 29 9 12 16 18 Live Donor Nx Open Lap 30 7 31 8 13 17 13 46 2 61 18 54

Advanced Laparoscopic Surgeries in CCF 1997 1998 1999 2000 2001 2002* NSS Open Lap 109 4 133 24 152 19 147 50 184 67 188 115 Prostatectomy Open Lap 176 0 240 0 251 12 134 30 209 91 317 90 Cystectomy Open Lap 54 0 60 0 83 1 18 8 55 6 107 5 * indicates till November 30, 2002.

Open Adrenalectomy Open Nephrectomy Lap Adrenalectomy Lap Nephrectomy 45 40 35 30 25 20 ` 100 90 80 70 60 50 40 15 30 10 20 5 0 1997 1998 1999 2000 2001 2002 10 0 1997 1998 1999 2000 2001 2002 Open NU Lap NU Open LDN Lap LDN 30 70 25 60 20 50 15 40 10 30 20 5 10 0 1997 1998 1999 2000 2001 2002 0 1997 1998 1999 2000 2001 2002

Open RP Lap RP 350 300 250 Open NSS Lap NSS 200 150 200 180 160 140 120 100 80 60 40 20 0 1997 1998 1999 2000 2001 2002 100 50 0 120 1997 1998 1999 2000 2001 2002 Open RC Lap RC 100 80 60 40 20 0 1997 1998 1999 2000 2001 2002

CURRENT STATUS OF LAP. S. IN CCF Feasible Viable alternate Tx of choice Lap. Ad + Lap. RN, NU + Lap DNx + Lap PNx +? Lap RP +? Lap RC +?

Chi Mei Experience in Laparoscopic Urology 1997 ~ 2000: Developing Stage Lap. Adrenalectomy & Simple nephrectomy 2000 ~ 2002: Introduction of Hand Assisted Laparoscopic Surgery 2002 ~ present: The era of pure laparoscopy for all advanced procedures

Tiers of Laparoscopic Urology Where are we now?? 1997 2000 2002 2003 1st Tier Diagnostic laparoscopy UDT Renal cyst 2nd Tier Adrenalectomy Simple Nx Radical Nx,, NU+BCE, Live DNx Pyeloplasty 3rd Tier Ileal ureter Partial Nx Radical prostatectomy Radical cystectomy with ileal conduit, continent pouch, neobladder

I. Laparoscopic Adrenalectomy 20 th Consensus (Bangkok, 2000) in World Congress of Endourology and th World Congress of Endourology and Shockwave Lithotripsy Laparoscopic Adrenalectomy is the Treatment of Choice for Benign Adrenal Tumor.

Adrenal Corticocarcinoma Laparoscopic Right Adrenalectomy Tumor Rt Kidney

Adrenal Corticocarcinoma Laparoscopic Adrenalectomy Surgical Time 5.5 hrs. Adrenal Size - 16 cm Specimen Wt 560 gm Blood Loss - 500 cc Postop Hospital Stay 3 days

Port Configuration & Postop View

Laparoscopic Adrenalectomy Indications Yesterday Conn s adenoma Cushing s s adenoma Non-function Adenoma >4 cm Today Pheochromocytoma Adrenal Ca - if no infiltration Solitary metastasis

Laparoscopic Adrenalectomy Contraindications Yesterday Adrenal Size > 5-65 6 cm Pheochromocytoma Adrenal Cancer Prior Surgery Coagulopathy Poor anesthetic risk Today Large infiltrating adrenal cancer Unacceptable anesthetic risk Coagulopathy Tumor size??

II. From Hand-Assistance to Pure Laparoscopic Nephrectomy Myth or Reality? - hand-assisted assisted laparoscopy decreases operative time?? J Urol, 167: 2387-91, June 2002 TM Complications related to hand-port TM BJU Int., 90(4): 364-7, Sept 2002

Comparison of Purely versus Hand Assisted Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma -Chi Mei Medical Center Experience Annual Meeting of Taiwan Surgical Association March 2004

Comparison of Pure Laparoscopic versus Hand-Assisted Laparoscopic Nephroureterectomy and Bladder Cuff Excision for Upper Tract Transitional Cell Carcinoma Chi Mei Medical Center Experience 14 th Annual Meeting, Taiwan Urological Association, August 2004

Ergonomic

Results (I) Group 1 (pure) Group 2 (hand) No. patients 16 16 p value Mean operative time (mins.) 231 ± 64 256 ± 89 0.787 Mean blood loss (ml.) 166 ± 224 228 ± 251 <0.05 Mean blood transfusion (units of PRBC) Mean specimen wt. (gm.) Duration of Foley indwelling (days) 0.25 ± 1.1 0.9 ± 1.3 <0.05 254 ± 115 152 ± 67 <0.05 4.8 ± 2.5 4.6 ± 2.3 0.789

Mean analgesics (mg. morphine sulfate) Mean days of oral intake (days) Mean days of hospital stay (days) Cost Wound for specimen Results (II) Group 1 (pure) Group 2 (hand) p value 16.6 ± 10.5 47 ± 42 <0.05 2.2 ± 1.3 2.6 ± 0.5 0.108 6.1 ± 2.5 8.6 ± 2.7 <0.05 Hand- port TM (-) Flexible* Hand-port TM (+) Fixed Complication (%) 1/16 (6%) 1/16 (6%) *Gibson, Pfannenstiel incision, old scar, vaginal extraction

Discussions Purely Hand assisted Technique ++-+++ +++ +-++ ++ Ergonomic ++-+++ +++ +-++ ++ Wound complication +-++ ++ ++-+++ +++ Cost +-++ ++ ++-+++ +++ Cosmetic ++-+++ +++ +-++ ++

Conclusion Purely laparoscopic Nx and NxUx as efficacious as HAL in experienced hand offer the advantages flexible choice of wound for specimen extraction ergonomic less cost (without hand-port TM relatively earlier recovery TM ) However, HAL is still essential for neophyte laparoscopists to go through the learning curve

Laparoscopic Radical Nephroureterectomy with Concomitant Radical Cystectomy for Multi-focal Transitional Cell Carcinoma in Uremic Patients Annual Meeting, 19 th Taiwan Surgical Association, March 2005

Drawbacks of traditional open surgery in uremic patients Extremely long incision Increased morbidity Difficulty in postoperative care Prolong postoperative recovery

Case 1 64 y/o, male ESRD under hemodialysis Left ureteral TCC (T1) s/p laparoscopic NxUx + BCx for 3 years (retroperitoneal hand-assisted) assisted) Recurrent bladder TCC (high grade, T2a) s/p TUR-BT Suspicious right renal tumor

Laparoscopic left NxUx + radical cystoprostatectomy Operation time: 260 min Estimated blood loss: 200 ml Post-OP hospital stay: 3 days

Laparoscopic left NxUx + radical cystoprostatectomy

Case 2 64 y/o, male Hemodialysis for 5 years PSVT s/p RF ablation, ASA III Left ureter TCC (T3) s/p laparoscopic NxUx + BCx for 0.5 years (pure trnasperitoneal) Reccrrent bladder TCC s/p TUR-BT (grade II, T1)

Dx: Reccrrent TCC of right ureter and urinary bladder Laparoscopic right NxUx + radical cystoprostatectomy Operation time: 300 min Estimated blood loss: 300 ml Post-OP hospital stay: 6 days

Transitional cell carcinoma, right ureter (T3) Transitional cell carcinoma, urinary bladder (T2)

Vaginal Delivery of Specimen

Conclusion Laparoscopic nephroureterectomy and concomitant radical cystectomy is a minimally alternate for multifocal TCC in uremic patients.

Laparoscopic Radical Prostatectomy - Initial Experience Annual Meeting, 19th Taiwan Surgical Association, March 2005

Rationale of LRP Introduction Minimally Invasiveness under laparoscopic magnification Equivalent oncological control, urine continence and sexual function preservation Pioneering LRP 1997 Schuessler: : 9 pt; 9.4 hrs; 3 complications 1997 Raboy: : 1 case report of Retroperitoneal RP 1999 Guillonneau and Abbou: : the first 2 largest series with promising results

Material and Methods From March 2004 to January 2005 Total 12 patients who were diagnosed as clinically localized prostate cancer underwent transperitoneal LRP The preoperative demographic data and the postoperative outcomes and functional results (continence and sexual function) were analyzed.

Operative data Mean OP time: 418 mins (340-615) Mean estimated blood loss: 204 cc (100-400cc) Blood transfusion: Nil Neurovascular bundle preservation: 8 pts Rt: : 3 Lt: 3 Bil: : 2 Bilateral pelvic node dissection: 2 due to high PSA (13.57 and 15.3 ng/ml) Conversion to open surgery: Nil

Results Oncological control: Organ confined : 11, Extracapsular extension with negative surgical margin: 1 Serum PSA all fell below 0.2 ng/ml Continence: no one need pad protection Sexual preservation: 5 (70%) regained erection 3 (43%) achieved satisfactory vaginal penetration

Ultimate Challenge?? 69 y/o male. PSA: 18 ng/ml ct1c Huge prostate gland (165 gm) with intravesical protrusion Provide LRP or not?? Annual Meeting, 19th Taiwan Surgical Association, March 2005

Critical Procedures

Conclusion Our preliminary results suggest LRP can be performed safely and effectively. Is LRP easier than Open RP due to laparoscopic magnification after learning curve? We believe that LRP will hold promising in Taiwan in the near future.

What Can NOT Be Done Laparoscopically In 2005? 1st Tier Diagnostic laparoscopy UDT Renal cyst 2nd Tier Adrenalectomy Simple, Radical Nx,, NU+BCE, Live DNx Pyeloplasty 3rd Tier Ileal ureter Augmentation cystoplasty Partial Nx Radical prostatectomy Radical cystectomy with ileal conduit, continent pouch, or neobladder Medical contraindication Severe intraabdominal adhesion (No working space) Bulky tumor with local or node infiltration Tumor size??

MY TALK TODAY IS Minimal Invasiveness in Urological Surgery Endoluminal & Percutaneous & Extraluminal (Laparoscopy) Real Impact of Laparoscopic Surgery on Urology Be the standard of care? The Realm of Laparoscopic S. Practice patterns in CCF Chi-Mei Experience The Future? Miniaturization Robotic surgery & Telesurgery Endoluminal reconstruction

MINIATURIATION NEEDLESCOPIC

Mini Minimal Invasiveness Needlescopic vs. Conventional Laparoscopy Traditional Laparoscopic Adrenalectomy ( 6 mos post-op ) Needlescopic Adrenalectomy ( 2 wks post-op )

ROBOTICS (Beyond the Quality of Hand-Made)

ROBOTICS (Beyond the Quality of Hand- Made) DaVinci and Zeus Six degrees of freedom human wrist Filters hand tremor 1:5 motion scaling Full wrist action 12 X magnification True 3D viewing

ROBOTIC PYELOPLASTY: Mayo Clinic Experience: IS IT BETTER? Std. Lap. Robotic Patients 4 4 O.R. time (hrs) 3.9 2.3 Suturing time (hrs) 2.0 1.2 Hosp. Stay (d) 4 4 No long term follow-up data provided. Gettman M. et al: Eur. Urol 42:453,2002

From Lab to Clinical More Investigations Endoluminal plastic technique (e.g. endopyeloplasty) (e.g. endoluminal ureteroplasty)

Fire Continues between Lap. S and Open S. The easier open procedures have obviously been overtaken by MIS The remainings for open S. are the disease with extensive adhesion, complicated reconstruction, huge tumor Open Surgery Laparoscopic S. Endourol. S. Continue to raise the bar? Nerve-sparing radical cystectomy with orthotopic bladder substitute

Many Thanks to the invitation to share my idea my teachers all the patients who trust me

THANKS FOR YOUR ATTENTION!! Victor Chia-Hsiang Lin