Les Assises de la cancérologie publique. Robotisation. Hôpital Henri Mondor. Les Assises de la cancérologie publique 29 & 30 mars 2012

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1 Les Assises de la cancérologie publique 29 & 30 mars 2012 Robotisation en chirurgie cancérologie CC Abbou PUPH Hôpital Henri Mondor

2 Laparoscopic p surgery AUA Abstracts LN LRP <'

3 2000

4 Robotics Exposure 2000 INSTRUMENTS REVOLUTION

5 Robot assisted laparoscopic prostatectomy (RALP) was first performed in 2000 by Binder et al in Frankfurt, Germany [2], and by Abbou et al in Creteil, France [1]. References [1] Abbou CC, Hoznek A, Salomon L, et al. Remote laparoscopic radical prostatectomy carried out with a robot. Report of a case. ProgUrol 2000;10:520 3 [2] Binder J, Kramer W. Robotically assisted laparoscopic radical prostatectomy. BJU Int Les 2001;87: Assises de la cancérologie publique 29 & 30 mars 2012

6 Retropubic, laparoscopic, and robot assisted radical prostatectomy: a critical review of outcomes reported by high volume centers. Coelho RF, Rocco B, Patel MB, Orvieto MA, Chauhan S, Ficarra V, Melegari S, Palmer KJ, Patel VR.J Endourol Dec;24(12): Review Mondor Series RALP RALP LAP TOTAL RoboticAssistance Nb of patient/year World experience

7 da Vinci Surery Impact Datas de la robotique 1850 systèmes da Vinci 330 en Europe 54 en France (17en 2011) Indications: en France: 25% cancer de la Prostate (50% IDF) (vs 15% en célioscopie et 60% en laparotomie) USA: 87% Cancer de la Prostate aux US, dans les pays nordiques et quelques zones Euro comme Genève 66% des indications Cancer de l'utérus aux US 33% des indications bénignes de l hystérectomie aux US

8 da Vinci Surery 1 Datas Monde, 4ème trimestre 2011 : Urologie: Gynécologie: Digestif,cardiovasculaire,ORL: i France: 4ème trimestre 2011:3000 Urologie: 2100 Gynécologie: 500 Digestif,cardiovasculaire,ORL: 400

9 Cout par intervention Montant 9000 Fixe/Variable par procédure Part Variable Part Fixe Nbre procédures

10 Robotic urology 2011 Pubmed All specialties 885 Urology 529 Prostate t 300 Nephrectomy 141 Partial 103 Radical 32 Cystectomy 81 Adrenalectomy 16 16

11 Centralisation of Care after Robotic Introduction ti 35% of hospitals that owned a robot performing: 85% of all cases 9% of hospitals performing : 57% of all cases Questions: Iscentralization of care resulting inbetter outcomes, as was previously demonstrated with RALP and radical cystectomy data: Morbidity and oncologic outcomes? Am J Med Qual Dec 28. Allareddy V, Ward MM, Wehby GL, Konety BR Robotic Prostatectomy: The Rise of the Machines or Judgment Day Joshua J. Meeks, James Les A. Assises Eastham de.msc la cancérologie publique 29 & 30 mars 2012 Published online 5 January 2012

12 KIDNEY

13 MANAGEMENT OF RENAL TUMORS 100 (JOHNS HOPKINS) ORN 80 OPN LRN LPN % PATIENTS LRA PRA PEMPONGKOSOL, BJU Int 98:751, 2006

14 MAINTAIN OF THE KIDNEY FUNCTION SURVIVAL

15 Is RAPN better than LPN? All series Since LPN55 RAPN44 OT 182mn 150mn P<.001 WIT 15.3mn 13.3mn P<.001 ELB 206cc 118cc P=.005 N: 150 LPN 102 RAPN 152 OT mean 193mn 152mn P<.001 WIT 18mn 14mn P<.001 ELB 245cc 122cc P=.001 Urology Oct;78(4): BradyUrological Institute, Johns Hopkins University, USA. Robotic assisted versus traditional Les laparoscopic Assises de cancérologie partial nephrectomy: publique 29 comparison & 30 mars 2012 of outcomes and evaluation of learning curve. Pierorazio PM, Patel HD, Feng T, Yohannan J, Hyams ES, Allaf ME.

16 Is «O» Ischemia possible? 2 WARM ISCHEMIA

17 Micro dissection Of renal artery branches

18

19 PROSTATE

20 REGISTRIES SERIES

21 Perioperative Outcomes of Robot Assisted Prostatectomy Compared WithOpen Radical Prostatectomy: Results Fromthe Nationwide Inpatient Sample Between October 2008 and December 2009 Within the NIS (the Nationwide id Inpatient tsample) patients underwent LRP, RARP or ORP 61.1% underwent RARP, 38.0% underwent ORP, 0.9% underwent LRP.

22 Outcomes of Robot Assisted Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample Open, n = 7389 Robotic, n = 7598 Robotic vs open, odds ratio (95% CI) Homologous blood transfusion, n (%) 572 (7.7) 184 (2.4) 0.30 ( ) <0.001 Intraoperative 73 (1.0) 33(0.4) 044( ( ) 0 < Postoperative complication, * n (%) Overall 823 (11.1) 705 (9.3) 0.82 ( ) <0.001 Cardiac 96 (1.3) 68 (0.9) 0.69 ( ) Respiratory 191 (2.6) 105 (1.4) 0.53 ( ) <0.001 Vascular 45 (0.6) 30 (0.4) 0.65 ( ) Operative wound 48 (0.6) 35 (0.5) 071( ( ) 1) Genitourinary 86 (1.2) 90 (1.2) 1.02 ( ) Miscellaneous medical 459 (6.2) 432 (5.7) 0.91 ( ) Miscellaneous surgical 121 (1.6) 122 (1.6) 0.98( ) Length of stay >2 d, n (%) 2923 (39.6) 1105 (14.5) 0.26( ) <0.001 In hospital mortality, n (%) 6 (0.1) 1 (0.0) 0.16 ( ) 0.092

23 Discrepancies EXPERTS SERIES

24 Which one is better? N articles RRP 30 LRP 14 RALP 14 Transfusion % 20.1% 3.5% 1.4% Complications % 10.3% 11% 10.3% PM+ 24% 21.3% 13.6% 12 m Continence 79% 84.8% 92% 12 m Potency 1 NSS 43% 31% 60% 12 m Potency 2 NSS 61% 54% 93.5% Retropubic, laparoscopic, and robot assisted radical prostatectomy: a critical review of outcomes reported by high volume centers. Coelho RF, Rocco B, Patel MB, Orvieto MA, Chauhanh S, Ficarra V, Melegari is, Palmer KJ, Patel VR. J Endourol Dec;24(12):

25 COMPLICATIONS

26 Complications ,6 10,3 6,6 7,1 6,2 1, ,7 6,4 Clavien overall(%) Clavien grade Clavien grade 3+4(%) 1+2(%) Robotic Laparoscopic open RP Roboticprostatectomy: a review of outcomescompared compared with laparoscopic and open approaches. Berryhill R Jr, Jhaveri J, Yadav R, Leung R, Rao S, El Hakim A, Tewari A.Urology Jul;72(1):15 23

27 CANCER CONTROL

28 PSM ,22 18,3 10,3 30,4 28,1 38,9 PSM pt2 (% ) PSM pt3 (% ) Robot Lap Ouvert Roboticprostatectomy: a review of outcomescomparedcompared with laparoscopic and open approaches. Berryhill R Jr, Jhaveri J, Yadav R, Leung R, Rao S, El Hakim A, Tewari A.Urology Jul;72(1):15 23

29 HOW TO PROGRESS?

30 Surgical anatomy Intra Fascial and Inter Fascial intrafacial i Endopelvic fascia Prostatic fascia Denonvilliers Prerectal Fat Pinterfacial PROSTATE Pelvic Floor NV Bundle Les Assises RECTUM de la cancérologie publique 29 & 30 mars 2012

31 Eur Uro Jan 2012 Anatomic Grading of Nerve Sparing During Robot Assisted Radical Prostatectomy Oscar Schatloff a, Sanket Chauhan a,b,, Ananthakrishnan Sivaraman a, Darian Kameh a, Kenneth J. Palmer a,b, Vipul R. Les Patel Assises a,b,* de la cancérologie publique 29 & 30 mars 2012

32 Complete Periprostatic AnatomyPreservation During Robot Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex Sparing Technique Euro UrolVolume 58, issue 3, pages e29 e38, September 2010 Anastasios D. Asimakopoulos a, Filippo Annino b, Alejandro D Orazio c, Clovis Fraga T. Pereira d,camille Mugnier c, Jean Luc Hoepffner c, Thierry Piechaud c, Richard Gaston c.

33 RESULTS

34 Complete PeriprostaticAnatomyPreservation DuringRobot Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex Sparing Technique Eur Urol Sep;58(3): Epub2010 May 18. Complete periprostatic anatomy preservation Les Assises during de la robot assisted cancérologie laparoscopic publique 29 radical & 30 mars prostatectomy 2012 (RALP): the new pubovesical complex sparing technique. Asimakopoulos AD, Annino F, D'Orazio A, Pereira CF, Mugnier C, Hoepffner JL, Piechaud T, Gaston R.

35 NEW WAYS

36

37 New.. And New.. Tools New and New Cost? 8mm optic EndoGIA Endobulldog Harmonic Seal and Cut Vascular fluorescence Laser Ultrasound

38 PATIENT OPINION

39 Patient reported body image and cosmesis outcomes following kidney surgery: Assuming equivalent surgical risk ikpreference for future LESS, 39% laparoscopy, 33%, open surgery 4%, Astheoretical risk ofless was raised, preference for 1. LESS decreased, 2. whereas preference for laparoscopy and open surgery increased. Eur Urol Nov;60(5): Epub 2011 Aug 12. Park SK, Olweny EO, Best SL, Tracy CR, Mir SA, Cadeddu JA. Department of Urology, University Les Assises of Texas de la Southwestern cancérologie Medical publique Center, 29 & 30 Dallas, mars TX , USA

40 Quo Vadis? Vdi?

41 Augmented Reality

42 Mentoring Network

43 Remote Surgery Clinical Training

44 Isaac Animov One of the "Big Three" science fiction writers Predicted the routine use of robots

45 From Robotic assistance to Active Robotic Systems Ingredients for ARS are progressively developed : 1. Huge experience in the industry 2. Standardization of the surgical techniques 3. Refinement of the image (patient specificity : CT, MRI ): Anatomic recognition 4. Augmented reality 5. Software for guidance (GPS like)

46 Minimally Invasive & Open Surgery MIS OS CC Abbou EAU Congress Debate in Stockholm 1999 M Marberger

47 Minimally Invasive & Open Surgery MIS OS P E A C E