DEPARTMENT OF UROLOGY
I INTRODUCTION I SERVICES I RESEARCH / TRAINING I
Research

To do research in various urological disease such as bladder cancer, prostate cancer, urethral stricture and urinary calculi


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ROBOTIC WORKSHOP MARCH 2006: A REVIEW
Azlin Azali, Sahabudin Raja Mohamed
Department of Urology, Hospital Kuala Lumpur


INTRODUCTION

Robotic surgery was first started in the Department of Urology, Hospital Kuala Lumpur in April 2004. To date we have done 130 cases of robotic surgery. Majority of cases were radical prostatectomies. The experience with first fifty cases of robotic radical prostatectomy was published in the World Journal of Urology (Would J. Urol May 2006). In order to expand the robotic surgery to other areas of urologic surgery, we held a live-surgery workshop with the urologists from Vattikuti Institute headed by Professor Dr. Mani Menon.

WORKSHOP

The robotic workshop was held at the Urology and Nephrology Institute (IUN) from 15th to 31st of March 2006. It was a collaboration between IUN and Vattikuti Institute of Urology, Detroit. In the conjunction with this workshop, we also held an international conference from the 25th to 26th of March 2006. It was officiated by the Minister of Health, Dato' Chua Soi Lek on the 25th of March, 45 cases were performed during the two-week workshop, varying from stone surgery to hernia repair.

Two years ago, Dato' Dr Sahabudin and Professor Mani Menon conceived the idea of robotic stone surgery during a meeting in Egypt. Since then both parties have been working towards making it a reality. 70 cases were initially selected; these cases were then presented to Professor Ashok Hemal during his brief visit to KL prior to the workshop. Renal stone which were large and confined to the renal pelvis were selected. Most of the cases were seen in the HKL clinic and a few others were referred from other hospitals.

For the first time in Asia, the surgeons also performed robotic nephrectomy for donor kidneys, non-functioning kidneys and renal cell carcinoma. Eight patients underwent robotic nephrectomy; three patients were donor for renal transplant and five more had non-functioning kidneys. There were two renal cell carcinoma cases, one patient underwent nephroureterectomy while the other underwent partial nephrectomy. The average duration of surgery was about four hours. All the patients had uneventful recovery.

There were challenges in gathering enough cases for the workshop, specifically for stone surgery. For stone surgery patients required investigations, such as urine culture, CT urography and DTPA scan. As they came from all over the country, it was time-consuming to get these investigations for them. Among those who had had these investigations done, there was a few candidates who were deemed unsuitable for the robotic stone surgery due to the unfavourable stone location (calyceal stones) were not included for robotic surgery instead were given an option for PCNL.

The workshop was run by a team of 12 surgeons and anesthesiologist from Detroit as well as the local consultants, specialists and anaesthesiologists. Cases were predetermined by the operating surgeons. The progress was monitored on a daily basis when the patients were still hospitalized. Patients were discharged on the 2nd or 3rd post operations day. Depending on the type of robotic surgery performed, the follow-up ranged from 10 to 14 days after patients were discharged.

The pre and post operative protocol contained pre-emptive analgesia, instructions on bowel preparation and diet on the two days preceding the surgery, pre-operative antibiotics, intravenous fluid regime and investigations (blood and urine). Post-operative protocol includes deep vein thrombosis prophylaxis, urinary catheter care and routine blood investigations. Meanwhile, for other cases (stone surgery, hernia and vesico-vaginal fistula repairs, etc.), some adjustments had to be made to accommodate the pre- and post-operative care (e.g. choice of antibiotic).

Post-operative pain control was achieved mostly with patient-controlled analgesia(PCA). Pre-emptive analgesia using COX-2 inhibitor helped to reduce post-operative pain. Patients were encouraged to use incentive spirometry and saline nebuliser to minimise atelactasis.

Patients who underwent robotic stone surgery and pyeloplasty had their ureteric stents removed 2 weeks after their respective surgeries. Patients with vesico-vaginal fistula and prostate cancer had to undergo pericathetogram to ensure there was no anstomotic leak.

Most cases had uneventful recovery. In one particular case, a patient developed fever and abdominal distension secondary to transperitoneal urinary leak from stone surgery. Retrograde Pyelogram showed blocked stent with urinary leak from lacerated lower pole calyx. The blocked ureteric stent was changed and she was treated with intravenuous antibiotic. She recovered fully from the surgery. One other patient who underwent stone surgery also developed abdominal distension and fever from prolonged ileus. One radical prostatectomy case had persistent urinary leak on pericathetogram up to one month after the surgery.

The 45 cases of robotic surgery performed during the workshop are listed below:
  • Nephrectomy (5)
  • Partial nephrectomy (1)
  • Nephroureterectomy (2)
  • Pyeloplasty (3)
  • Pyelolithotomy (14)
  • Ureterolithotomy (1)
  • Donor nephrectomy (3)
  • Prostatectomy (11)
  • VVF repair (1)
  • Hernia repair (1)
  • Cystectomy (3)
Patients who underwent robotic stone surgery will be followed-up with intravenous urography to be performed six months after their surgery to rule out pelvic stricture. With the good outcome of robotic pyeloplasty we recommend that a randomised study to compare the advantages of robotic pyelolithotomy over percutaneous nephrolithotripsy has been proposed. we hope to undertake this project in February 2007.