What’s New in Minimally Invasive Surgery for Urology Ho Siew Hong Consultant Urological Surgeon S H Ho Urology and Laparoscopy Centre

Introduction – Basic Qualifications MBBS (S’pore)1993 FRCS (Edin & Glas) 1998 FAMS (Urol) 2002 Consultant Urologist at Changi General Hospital

MBBS (S’pore)1993

FRCS (Edin & Glas) 1998

FAMS (Urol) 2002

Consultant Urologist at Changi General Hospital

Introduction – Subspecialty training Fellowship in Endourology & Laparoscopy in Westmead Hospital, Sydney (1999-2001) - Andrew Brooks, Howard Lau Attachment at Institut Mutualiste Monstsouris, Paris, France (2004) - Guy Vallencian

Fellowship in Endourology & Laparoscopy in Westmead Hospital, Sydney (1999-2001) - Andrew Brooks, Howard Lau

Attachment at Institut Mutualiste Monstsouris, Paris, France (2004) - Guy Vallencian

Minimally invasive surgery Avoids open, invasive surgery Achieving similar, if not better results than open surgery Less pain and morbidity Quicker recovery and ‘down-time’ Cosmesis

Avoids open, invasive surgery

Achieving similar, if not better results than open surgery

Less pain and morbidity

Quicker recovery and ‘down-time’

Cosmesis

Minimally Invasive Surgery Laparoscopy Endoscopy Percutaneous surgery ESWL

Extracorporal Shockwave Lithotripsy (ESWL) ‘ A thousand grains of sand pass through the eye of a needle before a single pebble’ W. Spencer

ESWL Initially developed by aviation company, Dornier Shock waves generated by a spark Transmitted via water Energy absorbed by acoustic surface (stone) Stone shatters and fragments drained by urine

Initially developed by aviation company, Dornier

Shock waves generated by a spark

Transmitted via water

Energy absorbed by acoustic surface (stone)

Stone shatters and fragments drained by urine

Development of ESWL Available since 1980s Treatment of choice for kidney stones up to 2cm diameter ureter stones up to 1cm diameter Minimal complications [hematuria, colic, hematoma (2%), no association with long term renal failure ]

Available since 1980s

Treatment of choice for kidney stones up to 2cm diameter

ureter stones up to 1cm diameter

Minimal complications [hematuria, colic, hematoma (2%), no association with long term renal failure ]

What is new in ESWL ? From water bath to water cushion

From water bath to water cushion

What is new in ESWL ? GA to sedation Day surgery, quicker return to work Larger choice of manufacturers & machines Spark gap technology to electromagnetic / piezoelectric technology Stone localized with fluoroscopy / ultrasound Lower cost per machine, per treatment

GA to sedation

Day surgery, quicker return to work

Larger choice of manufacturers & machines

Spark gap technology to electromagnetic / piezoelectric technology

Stone localized with fluoroscopy / ultrasound

Lower cost per machine, per treatment

What is new in ESWL ? Treatment for stones in kidney and entire ureter Success rates kidney: 80-90% upp ureter: 70% low ureter: 50%

Treatment for stones in kidney and entire ureter

Success rates kidney: 80-90% upp ureter: 70% low ureter: 50%

Endoscopy in Urology (endourology) Cystoscopy TURP / transurethral resection Ureteroscopy

What is new in endourology ? Improvement in technology - better optics, light source, video - miniaturization of instruments - fiber optic, flexible instruments

Improvement in technology - better optics, light source, video - miniaturization of instruments - fiber optic, flexible instruments

TURP Transurethral resection of prostate ‘ gold standard’ Indicated for ARU, complicated BPH, BPH not responding to medical treatment

Transurethral resection of prostate

‘ gold standard’

Indicated for ARU, complicated BPH, BPH not responding to medical treatment

What is new in TURP ? TURP is shrinking ! Improvement in medical therapy Highly selective alpha blockers e.g. Xatral, Hytrin 5 alpha reductase inhibitors e.g. Avodart Greater awareness, early intervention before complications

TURP is shrinking !

Improvement in medical therapy

Highly selective alpha blockers e.g. Xatral, Hytrin

5 alpha reductase inhibitors e.g. Avodart

Greater awareness, early intervention before complications

What is new in TURP ? Safe surgery with few complications Transfusion rate < 5%, TURP syndrome 1%, sepsis <5% Short hospital stay, 1-2 nights Good results (even for at long term, re-treatment rates at 10 years 20%) No actual age limit for TURP

Safe surgery with few complications

Transfusion rate < 5%, TURP syndrome 1%, sepsis <5%

Short hospital stay, 1-2 nights

Good results (even for at long term, re-treatment rates at 10 years 20%)

No actual age limit for TURP

What is new in TURP ? Standard ‘loop’ TURP using monopolar current Bipolar TURP with normal saline Laser resection, vaporization TUNA, TUMT, HIFU

Standard ‘loop’ TURP using monopolar current

Bipolar TURP with normal saline

Laser resection, vaporization

TUNA, TUMT, HIFU

Bipolar TURP Avoids risks associated with monopolar current Avoids use of glycine, allows use of isotonic normal saline wash-out solution Better hemostasis Minimal increase in cost Tried as ‘day surgery’ TURP

Avoids risks associated with monopolar current

Avoids use of glycine, allows use of isotonic normal saline wash-out solution

Better hemostasis

Minimal increase in cost

Tried as ‘day surgery’ TURP

Laser TURP Ablation of prostate tissue PVP, holmium, diode lasers Better hemostasis Day procedure No tissue for histology Cost of fibres Less suitable for larger prostates Long term results are not available, yet

Ablation of prostate tissue

PVP, holmium, diode lasers

Better hemostasis

Day procedure

No tissue for histology

Cost of fibres

Less suitable for larger prostates

Long term results are not available, yet

Endoscopic ureter procedures Ureterorenoscope Revolutionized treatment of pathologies in the entire ureter, up to renal pelvis Benefited from technological advances Day surgery procedures Mainstay of treatment

Ureterorenoscope

Revolutionized treatment of pathologies in the entire ureter, up to renal pelvis

Benefited from technological advances

Day surgery procedures

Mainstay of treatment

Ureteroscopy for stones Treatment of choice for lower ureter stones > 5mm Good alternative for upper ureter stone > 5mm Lithotripsy – laser, ultrasound, EHL, pneumatic

Treatment of choice for lower ureter stones > 5mm

Good alternative for upper ureter stone > 5mm

Lithotripsy – laser, ultrasound, EHL, pneumatic

Ureteroscopy for stones Laser lithotripsy

Percutaneous surgery

Percutaneous surgery Small puncture made on skin overlying kidney Tract dilated Access to kidney developed for - removal of stones - ablation of tumour (radio frequency, cyro)

Small puncture made on skin overlying kidney

Tract dilated

Access to kidney developed for - removal of stones - ablation of tumour (radio frequency, cyro)

PCNL (percutaneous nephrolithotomy) Small hole for big stones Very large stones can be fragmented with laser and removed via small skin puncture More than 1 puncture can be made General anaesthesia, surgery duration 1-3 hours, hospital stay 3 days

Small hole for big stones

Very large stones can be fragmented with laser and removed via small skin puncture

More than 1 puncture can be made

General anaesthesia, surgery duration 1-3 hours, hospital stay 3 days

Laparoscopic surgery

Laparoscopic surgery Key hole surgery Latest development in urology Obvious advantages over conventional open surgery Smaller wound Less pain Quicker recovery, discharge, return to work

Key hole surgery

Latest development in urology

Obvious advantages over conventional open surgery

Smaller wound

Less pain

Quicker recovery, discharge, return to work

Challenges of laparoscopic surgery Technically, more demanding Specialized team Slightly more expensive, use of consumables Advantages outweigh challenges

Technically, more demanding

Specialized team

Slightly more expensive, use of consumables

Advantages outweigh challenges

What is new in laparoscopy in urology? Almost all urological procedures can be done laparoscopically Reproducible, similar if not better results than open surgery What is the standard of care ?

Almost all urological procedures can be done laparoscopically

Reproducible, similar if not better results than open surgery

What is the standard of care ?

Laparoscopic urological surgeries Procedure Standard of care Current opinion Laparoscopic radical nephrectomy Yes Proven long term results for tumour upto 7cm Laparoscopic radical nephroureterectomy Yes Replaces open Laparoscopic marsupilazation of kidney cyst Yes Replaces open Laparoscopic adrenalectomy Yes Replaces open Laparoscopic pyeloplasty Not yet Very promising, awaiting long term results

Laparoscopic urological surgeries  Procedure Standard of care Current opinion Laparoscopic radical prostatectomy No Divided (laparoscopic, robotic assisted laparoscopic, open) Laparoscopic varicocelectomy No Divided (open microscope) Laparoscopic extra peritoneal herniorraphy No Promising, awaiting long term results Laparoscopic ureterolithotomy No Advantage over open, but other options available Laparoscopic partial nephrectomy No At best, similar to open Laparoscopic radical cystectomy No At best, similar to open Laparoscopic retroperitoneal lymp node dissection No Promising, development stage Laparoscopic reimplatation of ureter No Early development stage Laparoscopic augmentation cystoplasty No Early development stage

Laparoscopic Nephrectomy

Laparoscopic nephrectomy Benign, non functioning kidney Renal cell carcinoma - almost all tumours can be removed laparoscopically

Benign, non functioning kidney

Renal cell carcinoma - almost all tumours can be removed laparoscopically

Laparoscopic Prostatectomy 5 small incisions Completely mimick all the principles of open surgery Extraperitoneal approach, avoiding contact with intestine

5 small incisions

Completely mimick all the principles of open surgery

Extraperitoneal approach, avoiding contact with intestine

Laparoscopic Prostatectomy 4-5 hours surgery Less blood loss, minimal blood transfusion requirement Magnification allowing more accurate dissection and preservation of continence and erection Hospital stay of 2 nights, early removal of urinary catheter

4-5 hours surgery

Less blood loss, minimal blood transfusion requirement

Magnification allowing more accurate dissection and preservation of continence and erection

Hospital stay of 2 nights, early removal of urinary catheter

Radical Prostatectomy

Laparoscopic Extraperitoneal Radical Prostatectomy - Our Initial Experience Siew Hong Ho, Li-Tsa Koh , Sam Peh Department of Urology Changi General Hospital Winner of 2 nd best presentation in International College Of Surgeons Meeting, 2006

Laparoscopic Prostatectomy Largest experience in Singapore Follow up of 3 years More than 30 cases (3 in GEH)

Largest experience in Singapore

Follow up of 3 years

More than 30 cases (3 in GEH)

Laparoscopic prostatectomy v/s robotic prostatectomy Assistance from robot in suturing 3D view High capital and recurring cost

Assistance from robot in suturing

3D view

High capital and recurring cost

Tactile feed back Technically more demanding – training and experience critical Extraperitoneal, avoiding contact with intestine Allows for dissection of lymph nodes if necessary Lower cost (by at least $10K) Laparoscopic prostatectomy v/s robotic prostatectomy

Tactile feed back

Technically more demanding – training and experience critical

Extraperitoneal, avoiding contact with intestine

Allows for dissection of lymph nodes if necessary

Lower cost (by at least $10K)

Summary Surgery is moving towards minimally invasive ESWL, endoscopy, percutaneous & laparoscopy More than one or a combination of MIS modalities may be used

Surgery is moving towards minimally invasive

ESWL, endoscopy, percutaneous & laparoscopy

More than one or a combination of MIS modalities may be used

Thank you