What is New In Minimally Invasive Surgery for Urology


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Dr Ho Siew Hong gave a series of Continous Medical Education lectures to doctors of Gleneagles, Mount Elizabeth and East Shore Hospitals on the latest in Urology surgery

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
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    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner. For more information please visit http://www.neurosurgeonindia.org/
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  • What is New In Minimally Invasive Surgery for Urology

    1. 1. What’s New in Minimally Invasive Surgery for Urology Ho Siew Hong Consultant Urological Surgeon S H Ho Urology and Laparoscopy Centre
    2. 2. Introduction – Basic Qualifications <ul><li>MBBS (S’pore)1993 </li></ul><ul><li>FRCS (Edin & Glas) 1998 </li></ul><ul><li>FAMS (Urol) 2002 </li></ul><ul><li>Consultant Urologist at Changi General Hospital </li></ul>
    3. 3. Introduction – Subspecialty training <ul><li>Fellowship in Endourology & Laparoscopy in Westmead Hospital, Sydney (1999-2001) - Andrew Brooks, Howard Lau </li></ul><ul><li>Attachment at Institut Mutualiste Monstsouris, Paris, France (2004) - Guy Vallencian </li></ul>
    4. 4. Minimally invasive surgery <ul><li>Avoids open, invasive surgery </li></ul><ul><li>Achieving similar, if not better results than open surgery </li></ul><ul><li>Less pain and morbidity </li></ul><ul><li>Quicker recovery and ‘down-time’ </li></ul><ul><li>Cosmesis </li></ul>
    5. 5. Minimally Invasive Surgery Laparoscopy Endoscopy Percutaneous surgery ESWL
    6. 6. Extracorporal Shockwave Lithotripsy (ESWL) ‘ A thousand grains of sand pass through the eye of a needle before a single pebble’ W. Spencer
    7. 7. ESWL <ul><li>Initially developed by aviation company, Dornier </li></ul><ul><li>Shock waves generated by a spark </li></ul><ul><li>Transmitted via water </li></ul><ul><li>Energy absorbed by acoustic surface (stone) </li></ul><ul><li>Stone shatters and fragments drained by urine </li></ul>
    8. 8. Development of ESWL <ul><li>Available since 1980s </li></ul><ul><li>Treatment of choice for kidney stones up to 2cm diameter </li></ul><ul><li>ureter stones up to 1cm diameter </li></ul><ul><li>Minimal complications [hematuria, colic, hematoma (2%), no association with long term renal failure ] </li></ul>
    9. 9. What is new in ESWL ? <ul><li>From water bath to water cushion </li></ul>
    10. 10. What is new in ESWL ? <ul><li>GA to sedation </li></ul><ul><li>Day surgery, quicker return to work </li></ul><ul><li>Larger choice of manufacturers & machines </li></ul><ul><li>Spark gap technology to electromagnetic / piezoelectric technology </li></ul><ul><li>Stone localized with fluoroscopy / ultrasound </li></ul><ul><li>Lower cost per machine, per treatment </li></ul>
    11. 11. What is new in ESWL ? <ul><li>Treatment for stones in kidney and entire ureter </li></ul><ul><li>Success rates kidney: 80-90% upp ureter: 70% low ureter: 50% </li></ul>
    12. 12. Endoscopy in Urology (endourology) Cystoscopy TURP / transurethral resection Ureteroscopy
    13. 13. What is new in endourology ? <ul><li>Improvement in technology - better optics, light source, video - miniaturization of instruments - fiber optic, flexible instruments </li></ul>
    14. 14. TURP <ul><li>Transurethral resection of prostate </li></ul><ul><li>‘ gold standard’ </li></ul><ul><li>Indicated for ARU, complicated BPH, BPH not responding to medical treatment </li></ul>
    15. 15. What is new in TURP ? <ul><li>TURP is shrinking ! </li></ul><ul><li>Improvement in medical therapy </li></ul><ul><li>Highly selective alpha blockers e.g. Xatral, Hytrin </li></ul><ul><li>5 alpha reductase inhibitors e.g. Avodart </li></ul><ul><li>Greater awareness, early intervention before complications </li></ul>
    16. 16. What is new in TURP ? <ul><li>Safe surgery with few complications </li></ul><ul><li>Transfusion rate < 5%, TURP syndrome 1%, sepsis <5% </li></ul><ul><li>Short hospital stay, 1-2 nights </li></ul><ul><li>Good results (even for at long term, re-treatment rates at 10 years 20%) </li></ul><ul><li>No actual age limit for TURP </li></ul>
    17. 17. What is new in TURP ? <ul><li>Standard ‘loop’ TURP using monopolar current </li></ul><ul><li>Bipolar TURP with normal saline </li></ul><ul><li>Laser resection, vaporization </li></ul><ul><li>TUNA, TUMT, HIFU </li></ul>
    18. 18. Bipolar TURP <ul><li>Avoids risks associated with monopolar current </li></ul><ul><li>Avoids use of glycine, allows use of isotonic normal saline wash-out solution </li></ul><ul><li>Better hemostasis </li></ul><ul><li>Minimal increase in cost </li></ul><ul><li>Tried as ‘day surgery’ TURP </li></ul>
    19. 19. Laser TURP <ul><li>Ablation of prostate tissue </li></ul><ul><li>PVP, holmium, diode lasers </li></ul><ul><li>Better hemostasis </li></ul><ul><li>Day procedure </li></ul><ul><li>No tissue for histology </li></ul><ul><li>Cost of fibres </li></ul><ul><li>Less suitable for larger prostates </li></ul><ul><li>Long term results are not available, yet </li></ul>
    20. 20. Endoscopic ureter procedures <ul><li>Ureterorenoscope </li></ul><ul><li>Revolutionized treatment of pathologies in the entire ureter, up to renal pelvis </li></ul><ul><li>Benefited from technological advances </li></ul><ul><li>Day surgery procedures </li></ul><ul><li>Mainstay of treatment </li></ul>
    21. 21. Ureteroscopy for stones <ul><li>Treatment of choice for lower ureter stones > 5mm </li></ul><ul><li>Good alternative for upper ureter stone > 5mm </li></ul><ul><li>Lithotripsy – laser, ultrasound, EHL, pneumatic </li></ul>
    22. 22. Ureteroscopy for stones Laser lithotripsy
    23. 23. Percutaneous surgery
    24. 24. Percutaneous surgery <ul><li>Small puncture made on skin overlying kidney </li></ul><ul><li>Tract dilated </li></ul><ul><li>Access to kidney developed for - removal of stones - ablation of tumour (radio frequency, cyro) </li></ul>
    25. 25. PCNL (percutaneous nephrolithotomy) <ul><li>Small hole for big stones </li></ul><ul><li>Very large stones can be fragmented with laser and removed via small skin puncture </li></ul><ul><li>More than 1 puncture can be made </li></ul><ul><li>General anaesthesia, surgery duration 1-3 hours, hospital stay 3 days </li></ul>
    26. 26. Laparoscopic surgery
    27. 27. Laparoscopic surgery <ul><li>Key hole surgery </li></ul><ul><li>Latest development in urology </li></ul><ul><li>Obvious advantages over conventional open surgery </li></ul><ul><li>Smaller wound </li></ul><ul><li>Less pain </li></ul><ul><li>Quicker recovery, discharge, return to work </li></ul>
    28. 28. Challenges of laparoscopic surgery <ul><li>Technically, more demanding </li></ul><ul><li>Specialized team </li></ul><ul><li>Slightly more expensive, use of consumables </li></ul><ul><li>Advantages outweigh challenges </li></ul>
    29. 29. What is new in laparoscopy in urology? <ul><li>Almost all urological procedures can be done laparoscopically </li></ul><ul><li>Reproducible, similar if not better results than open surgery </li></ul><ul><li>What is the standard of care ? </li></ul>
    30. 30. 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
    31. 31. 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
    32. 32. Laparoscopic Nephrectomy
    33. 33. Laparoscopic nephrectomy <ul><li>Benign, non functioning kidney </li></ul><ul><li>Renal cell carcinoma - almost all tumours can be removed laparoscopically </li></ul>
    34. 34. Laparoscopic Prostatectomy <ul><li>5 small incisions </li></ul><ul><li>Completely mimick all the principles of open surgery </li></ul><ul><li>Extraperitoneal approach, avoiding contact with intestine </li></ul>
    35. 35. Laparoscopic Prostatectomy <ul><li>4-5 hours surgery </li></ul><ul><li>Less blood loss, minimal blood transfusion requirement </li></ul><ul><li>Magnification allowing more accurate dissection and preservation of continence and erection </li></ul><ul><li>Hospital stay of 2 nights, early removal of urinary catheter </li></ul>
    36. 36. Radical Prostatectomy
    37. 37. 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
    38. 38. Laparoscopic Prostatectomy <ul><li>Largest experience in Singapore </li></ul><ul><li>Follow up of 3 years </li></ul><ul><li>More than 30 cases (3 in GEH) </li></ul>
    39. 39. Laparoscopic prostatectomy v/s robotic prostatectomy <ul><li>Assistance from robot in suturing </li></ul><ul><li>3D view </li></ul><ul><li>High capital and recurring cost </li></ul>
    40. 40. <ul><li>Tactile feed back </li></ul><ul><li>Technically more demanding – training and experience critical </li></ul><ul><li>Extraperitoneal, avoiding contact with intestine </li></ul><ul><li>Allows for dissection of lymph nodes if necessary </li></ul><ul><li>Lower cost (by at least $10K) </li></ul>Laparoscopic prostatectomy v/s robotic prostatectomy
    41. 41. Summary <ul><li>Surgery is moving towards minimally invasive </li></ul><ul><li>ESWL, endoscopy, percutaneous & laparoscopy </li></ul><ul><li>More than one or a combination of MIS modalities may be used </li></ul>
    42. 42. Thank you