Urologic robotic surgery in Korea: past and present

Since 2005 when the da Vinci surgical system was approved as a medical device by the Korean Ministry of Health and Welfare, 51 systems have been installed in 40 institutions as of May 2015. Although robotic surgery is not covered by the national health insurance service in Korea, it has been used in several urologic fields as a less invasive surgery. Since the first robotic-assisted laparoscopic radical prostatectomy in 2005, partial nephrectomy, radical cystectomy, pyeloplasty, and other urologic surgeries have been performed. The following should be considered to extend the indications for robotic surgery: training systems including accreditation, operative outcomes from follow-up results, and cost-effectiveness. In this review, the history and current status of robotic surgeries in Korea are presented.

Standardized analysis of complications after robot-assisted radical cystectomy: Korea University Hospital experience

Purpose

To analyze the complications after robot-assisted radical cystectomy (RARC) by use of a standardized reporting methodology by a single surgeon.

Materials and Methods

We prospectively reviewed a maintained institutional database of 52 patients who underwent RARC to manage bladder cancer and were followed up in 3 months by a single surgeon at Korea University Medical Center from 2007 through 2014. All complications within 90 days of surgery were defined and categorized into 5 grades according to the Clavien-Dindo classification. Logistic regression analysis was used to identify predictors of complications.

Results

Fifty percent of patients (26 of 52) experienced a complication of any grade <90 days after surgery, and 11 patients (21.2%) experienced a major complication. Complications were grouped in systems-based categories. Fifty complications occurred in 52 patients and hematologic complication (transfusion) was the most common (13 of 52). Wound dehiscence, anastomotic leakage, urinary tract obstruction, mechanical obstruction, and thromboembolism occurred as major complications. Mean estimated blood loss (EBL) was 247 mL and mean total operative time was 496 minutes. The mean number of lymph nodes harvested was 24.6, with 30.5 for extended dissection. EBL (over 300 mL), operative time, and method of urinary diversion were significant negative predictors of minor complications, whereas EBL (over 300 mL) was a significant negative predictor of major complications (p<0.05).

Conclusions

The present results show that the complication rate reported by use of a standardized methodology after robotic radical cystectomy is still considerable although comparable to that of contemporary robot series. EBL, operative time, and diversion methods were predictors of complications.

Initial experience of robot-assisted radical cystectomy with total intracorporeal urinary diversion: comparison with extracorporeal method

PURPOSE

To report our surgical technique and initial experience with robot-assisted laparoscopic radical cystectomy (RARC) with total intracorporeal urinary diversion compared with an extracorporeal method.

SUBJECTS AND METHODS

In total, 42 patients underwent RARC by a single surgeon at our institute for clinically localized bladder cancer. Among these, 4 patients underwent RARC with complete intracorporeal urinary diversion. An ileal conduit was achieved in 3 patients, and an orthotopic neobladder was created in 1 patient. Our surgical technique is presented in detail, and the intracorporeal cases were compared with 38 previous extracorporeal diversion cases for perioperative outcome, postoperative oncologic outcome, and complications.

RESULTS

Three men and 1 woman underwent complete intracorporeal urinary diversion. In patients receiving ileal conduits the mean total operative time was 510 minutes, and the estimated blood loss was 400 mL. In the patient receiving an ileal neobladder the total operative time was 585 minutes, and the estimated blood loss was 500 mL. Mean time to flatus was 60 hours, and no intraoperative or postoperative major complications occurred. Surgical margins were negative with no positive lymph nodes. Compared with extracorporeal cases, the mean total operative time for RARC was significantly longer, but perioperative outcomes of estimated blood loss, time to flatus, and postoperative oncologic outcomes were not significantly different.

CONCLUSIONS

Our initial experience showed that RARC with complete intracorporeal urinary diversion is feasible based on perioperative data and oncologic features. However, in this small case series, we observed no definite benefits associated with intracorporeal urinary diversion over extracorporeal urinary diversion except for better cosmesis. Long-term, large-scale, prospective comparative studies will be needed to demonstrate the benefit of intracorporeal urinary diversion.

Robot-assisted radical cystectomy and pelvic lymph node dissection: a multi-institutional study from Korea

PURPOSE

To report short-term retrospective perioperative and pathologic outcomes of the first robot-assisted radical cystectomy (RARC) series in Korea.

PATIENTS AND METHODS

Between April 2007 and August 2009, 104 nonconsecutive patients, including 22 women, underwent RARC across seven institutions. We evaluated the outcomes in these cases, including operative variables, hospital recovery, pathologic outcomes, and complication rate.

RESULTS

The mean age of all patients was 63.6 years (range 39-82 years), and the mean body mass index was 23.6 kg/m(2) (range 16.0-31.8 kg/m(2)). Among the 104 patients, 60 had an ileal conduit and 44 had an orthotopic neobladder. The mean total operative time was 554 minutes, and the mean blood loss was 526 mL. The time to flatus and bowel movement was about 3 days, and the time until hospital discharge was about 18 days. The mean number of lymph nodes removed were 18, and 10 patients had node metastatic disease on final pathologic evaluation. Postoperative complications occurred in 28 (26.9%) patients.

CONCLUSIONS

Our initial experience with RARC appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. The current series suggests that RARC is becoming more prevalent, not only in Western countries, but also in Asian countries, just as robot-assisted radical prostatectomy has also gained widespread acceptance. Data from long-term, large, prospective, multicenter, ideally randomized comparative studies with open radical cystectomy are needed to confirm the outcome of the novel operation reported here.

Initial experiences with robot-assisted laparoscopic radical cystectomy

PURPOSE

Robot-assisted laparoscopic radical cystectomy (RLRC) is a new option for the treatment of muscle-invasive bladder cancer, and case series for RLRC have been increasing recently. We report our operative technique and initial experiences with RLRC with extracorporeal urinary diversion.

MATERIALS AND METHODS

Between October 2008 and November 2009, 17 consecutive patients with muscle-invasive bladder cancer underwent RLRC, pelvic lymph node dissection, and extracorporeal urinary diversion. Urinary diversion included 13 ileal conduits and 4 orthotopic neobladders (Studer method). Data were collected prospectively on patient demographics, intraoperative parameters, pathologic staging, and postoperative outcomes.

RESULTS

The mean patient age was 63.7 years. The mean body mass index was 22.6 kg/m(2). No patients had a history of previous abdominal surgery. The mean operative time was 379.1 minutes, including 32.6 minutes for pelvic lymph node dissection, 185.2 minutes for RLRC, and 159.4 minutes for urinary diversion. The mean estimated blood loss was 210.5 ml. The mean hospital stay was 20.7 days and the mean time to oral intake and ambulation was 5.0 and 1.3 days, respectively. There were no major perioperative complications. The pathologic reports showed urothelial cell carcinomas in all cases.

CONCLUSIONS

Our initial clinical experiences indicate that RLRC with pelvic lymph node dissection and extracorporeal urinary diversion is a safe and feasible procedure with minimal blood loss and rapid recovery. Long-term follow up in a larger patient population is needed to determine the true oncological and functional benefit of this procedure.