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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 53  |  Issue : 6  |  Page : 223-229

The expansion condition of amount and complexity of urologic robotic surgery in 2000 patients: A 13-year experience sharing


1 Department of Surgery, Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan
2 Department of Surgery; Department of Medical Research, Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan
3 Department of Medical Research, Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan
4 Department of Urology, Wan Fang Hospital, Taipei Medical University; Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei; Department of Nursing, Jen-Teh Junior College of Medicine and Management, Hou-Loung Town, Miaoli, Taiwan

Date of Submission22-Jun-2020
Date of Decision16-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication19-Dec-2020

Correspondence Address:
Yu-Ching Wen
Department of Surgery, Taipei Municipal Wanfang Hospital, No. 111, Sec. 3, Xinglong Road, Wenshan District, Taipei City 116
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_101_20

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  Abstract 


Background: Robot-assisted surgeries have been found to possess a number of advantages over conventional surgeries, and these benefits have promoted the expanded use of robot-assisted procedures in recent years, both in the numbers of procedures performed and the types of procedures to which robotic assistance is applied. This study sought to quantify this expanded use of robot-assisted surgeries over a 13-year period at a single surgeon in Taiwan.
Materials and Methods: We retrospectively reviewed a total of 2000 patients who underwent robot-assisted urologic surgeries between December of 2005 and August of 2018. For the purposes of statistical comparison, we divided this 13-year period into four subperiods and classified the surgeries into eight types depending on the body part or parts upon which they were performed.
Results: The total number of surgeries in the first, second, third, and fourth subperiods was 124, 173, 738, and 965, respectively; this represented a significant increase in the total number of robot-assisted urologic surgeries performed across the four subperiods. In addition, there were also significant increases in the numbers of surgeries for seven of the eight categories of surgeries across the four subperiods.
Conclusion: These results show that our institution's experience with robot assistance in urological surgeries from 2005 to 2018 was consistent with the generally expanded use of such assistance documented by earlier studies, with both the numbers and types of robot-assisted surgeries performed increasing significantly over that period.

Keywords: da Vinci robot, partial nephrectomy, radical prostatectomy, urological surgeries


How to cite this article:
Tung MC, Ou YC, Lu CH, Chang YK, Wen YC. The expansion condition of amount and complexity of urologic robotic surgery in 2000 patients: A 13-year experience sharing. Formos J Surg 2020;53:223-9

How to cite this URL:
Tung MC, Ou YC, Lu CH, Chang YK, Wen YC. The expansion condition of amount and complexity of urologic robotic surgery in 2000 patients: A 13-year experience sharing. Formos J Surg [serial online] 2020 [cited 2021 Jan 27];53:223-9. Available from: https://www.e-fjs.org/text.asp?2020/53/6/223/304018




  Introduction Top


Since the introduction of the first surgical robot, the Arthrobot, in 1983, robotic devices have been used for an increasingly wide range of surgical applications from preoperative planning and precise needle placement to robot-assisted stereotactic and laparoscopic procedures.[1] The first robot-assisted urological surgeries were conducted in 1988 using the Probot system,[2] but since the early 2000s, virtually all robot-assisted surgeries have been performed using the da Vinci robotic surgical system manufactured by intuitive surgical.[1] Robot-assisted surgery, whether laparoscopic or otherwise, possesses a number of advantages in comparison to conventional surgery, including reduced bleeding, lower transfusion rates, shorter hospital stays, shorter recovery times, and better cosmetic outcomes, among others.[3]

In the field of urology specifically, prostatectomy for the treatment of localized prostate cancer is among the most commonly performed procedures, with a number of approaches, including radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robot-assisted laparoscopic radical prostatectomy (RALP), having been developed and utilized over the past several decades.[4] The first use of LRP, for example, was performed by Schussler et al. in 1992, with refinements to the technique being reported by Guillonneau et al. in 1999 and 2001.[5],[6],[7] In spite of those refinements, however, proficiency in LRP is regarded as being difficult to obtain, with Guillonneau et al. asserting that a surgeon must perform the procedure at least 60 times to become sufficiently versed in it.[7]

Fortunately, the use of the da Vinci system in RALP provides a number of advantages that make the learning curve for RALP substantially faster than that for LRP, with various studies suggesting that proficiency in RALP can be obtained by performing the procedure anywhere from 12 to 25 times. These advantages include better control and articulation through the use of multiple effector arms, improved visualization via three-dimensional stereoscopic optics, the elimination of tremors, and reduced surgeon fatigue.[4],[8] In terms of outcomes, these advantages of robotic assistance have also been reported to result in various benefits of RALP over both RRP and LRP. For example, one study comparing RALP and RRP found that RALP resulted in lower blood loss, shorter hospital stays, and less patient pain than RRP,[9] while another comparing RALP and LRP found that RALP resulted in shorter operative times, lower intraoperative blood loss, and shorter hospital stays with comparable continence and potency rates.[10]

Robot-assisted surgery has also shown some benefits in comparison to nonrobot-assisted surgery for other types of urological procedures, such as nephrectomy, nephroureterectomy, and cystectomy. For example, one study comparing robot-assisted partial nephrectomy to laparoscopic partial nephrectomy found that the robot-assisted procedure results in shorter hospital stays, lower intraoperative blood loss, and shorter warm ischemia time (WIT).[11] With regard to cystectomy, one systematic review found that while open radical cystectomy and robot-assisted radical cystectomy (RARC) yield similar outcomes in terms of pathological, oncological, functional, and complication outcomes, RARC consistently entails lower blood loss and a decreased need for intraoperative transfusion.[12]

Taken together, such accumulating evidence indicating the benefits of robot-assisted surgery has, in turn, promoted the expansion of the use of robot-assisted procedures in recent years, both in the numbers of different robotic procedures performed and the types of procedures to which robotic assistance is applied. The purpose of the present study, therefore, was to quantify the expanded use of robot-assisted surgery over a 13-year period at a single surgeon in Taiwan.


  Materials and Methods Top


The four-arm da Vinci system (Intuitive Surgical Inc., USA) was first used for a urological surgery at Taichung Veterans General Hospital (TCVGH) in Taichung, Taiwan, in December of 2005. The da Vinci system was applied in surgeries of prostate, kidney, bladder, and other organs in the subsequent years. Our team experiences in robotic assistance surgeries were gradually increased both in numbers and types of procedures. The consistent growing indicating the benefits of robot-assisted surgery. This study was approved by the Institutional Review Board of Tungs' Taichung Metroharbor Hospital (approval number: 109007), and the informed consent was waived by IRB.

For the present study, we retrospectively reviewed a total of 2000 patients who underwent robot-assisted urologic surgeries between December of 2005 and August of 2018 in order to quantify a single surgeon's (YCOU) expanded use of robot-assisted surgery over this approximately 13-year period. During the period of 13-year, Dr. Ou YC used to serve at TCVGH from 2005 to 2017, and as a consultant surgeon of Tungs' Taichung Metroharbor Hospital (TTMHH) (2013–2017), then he has been with TTMHH since August 2017. For the purposes of statistical comparison, we divided this 13-year period into four groups (Group 1 [2005–2007], Group 2 [2008–2010], Group 3 [2011–2014], and Group 4 [2015–2018]). We also classified the surgeries into the following eight types depending on the body part or parts upon which the surgeries were performed: adrenal gland; kidney; ureter; kidney and ureter (combined); prostate; urinary bladder; kidney, ureter, and urinary bladder (combined); and others. We analyzed these patients who received robot-assisted partial nephrectomy by parameters including age, gender, body mass index, American Society of Anesthesiologists, tumor size, renal nephrectomy score, blood loss, da Vinci time, and WIT. We then performed a linear trend test using SAS for Windows, version 9.4 (SAS Institute, Cary, NC, USA), to determine the types of surgeries which were significantly increased in number across the different subperiods. P < 0.05 was considered statistically significant.


  Results Top


Our total sample of 2000 robot-assisted urologic surgeries from December 2005 to August 2018 was divided into the four aforementioned subperiods. The total number of surgeries in the first, second, third, and fourth subperiods was 124, 173, 738, and 965, respectively; this represented a significant increase in the total number of robot-assisted urologic surgeries performed across the four subperiods. There were also significant increases in the number of surgeries for all eight of the aforementioned types of surgeries across the four subperiods, with the exception of surgeries of the kidney, ureter, and urinary bladder (combined). With respect to those eight categories of surgeries, the most common types of procedures were surgeries of the prostate (accounting for 84.4% of the 2000 procedures), followed by surgeries of the kidney alone (4.3%) and surgeries of the kidney and ureter (combined) (3.6%). Moreover, there were also significant increases in the numbers of specific procedures. For example, only 5 partial nephrectomies were performed from 2005 to 2007, whereas 31 partial nephrectomies were performed from 2015 to 2018. Similarly, the number of nephroureterectomies with bladder cuff excision was significantly increased from 1 in the first subperiod to 48 in the fourth subperiod. [Table 1] discloses additional details.
Table 1: Total case numbers and distribution over four time periods

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[Table 2] shows that there was no significant difference in radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, and location relative to polar lines (RENAL) nephrectomy score between the four subperiods but only found a significant in subclassification of nearness (P = 0.015). The WIT was decreased significantly across the four subperiods (P = 0.004). In addition, [Table 3] shows the details regarding the perioperative outcomes of different types of robot-assisted surgeries including conversion rate, transfusion rate, and 30-day and 90-day surgical mortality rate. All of the different types for conversion rate and transfusion rate are <2% and 7%, respectively. Only three patients were died among 90 days after surgery due to acute myocardial infarction, pneumonia, and disease progression, respectively. [Table 4] provides the details regarding the 11 patients in the overall sample upon whom two robot-assisted procedures were performed.
Table 2: Robotic-assisted partial nephrectomy patients

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Table 3: Perioperative outcomes of different robotic-assisted surgeries

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Table 4: Two robotic urologic procedures in the same patients

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In summary, there were significant increases in the numbers of almost all different types of surgeries. This is reflected in the fact that 48.3% of the total samples of 2000 procedures were performed in the fourth subperiod. Similarly, of the 21 different types of surgical procedures performed over the entire study period, only 13 were performed in the first two subperiods, whereas 18 were performed in the latter two subperiods.


  Discussion Top


While robotic assistance was first employed in urology to perform robot-assisted radical prostatectomy (RARP), the benefits provided by such assistance soon. Its use expanded to robot-assisted partial nephrectomy and RARC. The benefits of those procedures, in turn, led surgeons to apply the da Vinci platform in an increasingly wide range of urological procedures, including pyelolithotomy, diverticulectomy, cystectomy, fistula repair, ureterolysis, and varicocelectomy, among others.[1],[13] Consistent with this rapidly burgeoning use of the platform, a 2008 survey of urologic surgeons from 44 countries found that while only 38% of the respondents had actually performed robot-assisted procedures at that time, 61% believed that they would perform such procedures in the future, 78% believed that it was vital or at least beneficial to be trained in robot-assisted surgery, and 61% already viewed RARP as the gold for prostatectomy or felt that it was at least as effective as laparoscopic prostatectomy.[14]

The results of the present study show that our institution's experience with robot assistance in urological surgeries from 2005 to 2018 was quite consistent with the generally expanded use of such assistance both predicted and documented by those earlier studies. For example, a comparison of the results for the 2005–2007 period with those for the 2015–2018 period indicated significantly higher numbers of robotically assisted surgeries of the adrenal gland, kidney, renal pelvis and ureter, and prostate in the latter period. In terms of specific procedures, meanwhile, the results indicated significantly higher numbers of robot-assisted partial nephrectomies, nephroureterectomies with bladder cuff excision, radical prostatectomies, simple prostatectomies, partial cystectomies, radical cystoprostatectomies or cystohysterectomies or cystectomies with ileal conduit (or cutaneous ureterectomies), and bladder diverticulectomies during the latter time period. Relatedly, while there were no robot-assisted partial cystectomies, radical cystoprostatectomies or cystohysterectomies or cystectomies with ileal conduit (or cutaneous ureterectomies), bladder diverticulectomies, pelvic cyst removals, ventral hernia repairs, retroperitoneal tumor resections, varicocelectomies, or retroperitoneal lymph node dissections performed at the hospital from 2005 to 2007, at least one of each of these types of surgeries was performed at the hospital from 2008 to 2018. In short, then, the use of robot-assisted approaches increased over the overall study period both in terms of the types of surgeries and the range body parts to which they were applied, as well as in terms of the raw numbers of specific types surgeries.

In [Table 3], we used the RENAL nephrometry scoring system to analyze the complexity of the renal tumor and found that the subclassification of nearness of tumor to the collecting system or sinus in millimeters was increased significantly in Group 4. The total number of complex cases was also increased in Groups 3 and 4 in comparison with Groups 1 and 2.

Our result revealed that the WIT of Group 4 was significantly shorter than Groups 1, 2, and 3, which means that our surgical technique was progressed. The da Vinci time was not decreased. This might be due to the increased complexity of renal tumor and patient's condition.

In the recent studies, the average blood loss was from 67 to 323 ml, the average tumor size was from 2.4 cm to 5 cm, and the average WIT was from 16 to 27.8 min.[15] In our study, the average blood loss was 232.6 ± 440.9 ml, the tumor size was 3.6 ± 2.0 cm, and the WIT was 18.1 ± 11.7 min in all patients. In Group 4, the average blood loss was 140.3 ± 157.9 ml, the tumor size was 3.1 ± 1.4 cm, and the WIT was 17.6 ± 8.6 min. Our surgical quality is progressing and similar to international standard.

In addition, the results of the present study were also consistent with those of earlier studies in terms of some of the advantages provided by robot-assisted surgeries in comparison to nonrobot-assisted procedures. Specifically, the patient records indicated that the robot-assisted procedures of all types led to shorter hospital stays, shorter docking times, better cosmetic outcomes, reduced postoperative pain, faster returns to normal physical activities, and shorter physician learning curves than the corresponding nonrobot-assisted laparoscopic surgeries.

On the other hand, the data also indicated some disadvantages to robot-assisted surgeries. Specifically, the operating times for the robot-assisted surgeries were longer than those for the corresponding nonrobot-assisted surgeries, and the robot-assisted surgeries were also less cost-effective than the corresponding nonrobot-assisted surgeries. These disadvantages of robot-assisted surgeries were consistent with those noted in some previous studies. For example, a 2004 study comparing the costs of RRP, LRP, and RAP found that RRP and LRP were more cost-effective than the robot-assisted procedure by $1726 and $1239 per case, respectively. As noted in that study, this was likely due in part to the fact that the costs of a new technology – in this case, the robotic platform – are heaviest during the technology's 1st year of use, with the relative cost being reduced as the technology receives greater use over a longer period of time. Nonetheless, more recent studies conducted in 2011, 2012, and 2014, respectively, still showed that the per-patient costs of robot-assisted surgeries were higher than those for comparable nonrobot-assisted procedures, even while also showing that the costs could be reduced by maximizing the number of cases in which the robotic platform is applied.


  Conclusion Top


The results of the present study showed that the numbers and types of robot-assisted surgeries performed at our institution increased substantially from 2005 to 2018. Of course, greater use of the robotic platform should serve to reduce its per-patient cost relative to nonrobot-assisted procedures, but the results of the present demonstrate that hospitals and those paying for the procedures should continue to monitor their costs and outcomes so that the cost-effectiveness of their application can be maximized going forward.

Financial support and sponsorship

This work was supported by grants through funding from the TTMHH (107R0009).

Conflicts of interest

There are no conflicts of interest.



 
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Ou YC, Yang CR, Wang J, Cheng CL, Patel VR. Comparison of robotic-assisted versus retropubic radical prostatectomy performed by a single surgeon. Anticancer Res 2009;29:1637-42.  Back to cited text no. 4
    
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Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: Initial short-term experience. Urology 1997;50:854-7.  Back to cited text no. 5
    
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Guillonneau B, Cathelineau X, Barret E, Rozet F, Vallancien G. Laparoscopic radical prostatectomy: Technical and early oncological assessment of 40 operations. Eur Urol 1999;36:14-20.  Back to cited text no. 6
    
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Guillonneau B, Rozet F, Barret E, Cathelineau X, Vallancien G. Laparoscopic radical prostatectomy: Assessment after 240 procedures. Urol Clin North Am 2001;28:189-202.  Back to cited text no. 7
    
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Bhayani SB. da Vinci robotic partial nephrectomy for renal cell carcinoma: An atlas of the four-arm technique. J Robot Surg 2008;1:279-85.  Back to cited text no. 8
    
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Menon M, Tewari A, Baize B, Guillonneau B, Vallancien G. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: The Vattikuti Urology Institute experience. Urology 2002;60:864-8.  Back to cited text no. 9
    
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Hakimi AA, Blitstein J, Feder M, Shapiro E, Ghavamian R. Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: Single-surgeon experience. Urology 2009;73:119-23.  Back to cited text no. 10
    
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Wilson TG, Guru K, Rosen RC, Wiklund P, Annerstedt M, Bochner BH, et al. Best practices in robot-assisted radical cystectomy and urinary reconstruction: Recommendations of the Pasadena Consensus Panel. Eur Urol 2015;67:363-75.  Back to cited text no. 12
    
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Guru KA, Hussain A, Chandrasekhar R, Piacente P, Hussain A, Chandrasekhar R, et al. Current status of robot-assisted surgery in urology: A multi-national survey of 297 urologic surgeons. Can J Urol 2009;16:4736-41.  Back to cited text no. 14
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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