Fellowship in Laparoscopic and Robotic Urology

Royal Adelaide Hospital, Adelaide, Australia

Supervisor : Mr Peter Sutherland

Introduction

In February 2008 I started a Urological fellowship at the Royal Adelaide Hospital specialising in Laparoscopic, Robotic and Pelvic Oncology. This year represents the sixth and final year of Urological training that I have undertaken as a specialist registrar in the South Thames region.

The Royal Adelaide hospital is the largest teaching hospital in South Australia, it is the regional trauma centre for the state and offers all services on site except paediatrics. It has a local referral population of over 1 million but covers a tertiary referral area including Darwin, Alice Springs and the whole of the Northern Territory. A region over 3000 km end to end.

The Royal Adelaide Hospital

The Royal Adelaide Hospital

The Royal Adelaide Hospital

The Urological department consists of 7 full time and 2 part time consultants (headed by Professor Villus Marshall and Mr Peter Sutherland), 2 middle grades (myself as the fellow and a junior registrar), and one specialist nurse. The department has a large Oncological practice but covers all areas including stone, BPH, female, trauma and reconstruction.
My timetable consists of eight sessions a week in theatres and 2 sessions in outpatients, running a “week on/week off” 1 in 2 on call rota.
Working in a high volume centre spending the time predominantly in theatre has, after six months, already given me great experience, learning new techniques more quickly than would be possible in the UK.

 Timetable

  • Morning ward rounds 7.30am
  • Four full days a week in theatres plus one additional half day every other week
  • A day and a half in the robot theatre a week
  • 1 ½ clinics a week

Logbook for the year

  • 672 procedures performed
  • 130 robotic prostates
  • 45 laparoscopic procedures, 38 nephrectomy’s
  • 17 Cystectomy’s
  • 71 TURP’s

Robotic Radical Prostatectomy

Robotic assisted laparoscopic surgery for localised prostate cancer has become increasingly popular around the world. With over 500 robots now in the US and over 60% of radical prostate operations being done robotically there, it is inevitable that this technique would become the standard of care worldwide for organ confined disease. Uptake within the UK has been slow due to the costs of the machines (around 1.5 million pounds per robot) hence training opportunities within the UK are currently limited. The benefits of this surgery include lower morbidity, reduced blood loss and hence lower transfusion rates, shorter hospital stay and earlier return to normal daily activities. The robot itself offers greatly magnified 3D vision, scaled motion of its fine instruments, which mimic the movement of the surgeons hands thereby helping the surgeon to be more precise and delicate when dissecting the prostate. Reconstruction of the bladder to the urethra is also greatly facilitated by the robot, thereby reducing complications such as urine leaks and anastomotic strictures.

It was for this reason that I wanted to learn this technique on my fellowship and be able to offer it as a fully trained robotic surgeon on my return to the UK, hence I chose the Royal Adelaide because of the high volume of robotic work that passes through the department.

The robotic unit was set up by Mr Peter Sutherland, head of the Urology department at the Royal Adelaide Hospital in November 2004, after installation of the standard 4 arm Da Vinci robot. He has subsequently built up an expert robotic team around him within theatres, all who play a vital role in keeping the service running. It was the second robot installed in Australia and is still the only public robot in the country, therefore we are able to offer this service to both public and private patients. To date over 600 cases have been performed here with Mr Sutherland having performed over 500.

As the Urology Fellow I was the first Fellow to be trained in Robotic Surgery in the department so we devised a structured, modular and fully mentored training programme for the year with the goal of being able to complete the operation completely in under 3 hours.

Firstly I had an introductory session to the robot and the console, to learn how to move the arms, dock and undock from the patient and how to use the console.

I performed 20 hours of “drylab work”, leaning how to control the robot, handle the instruments, practice suturing and perform 20 timed urethral anastomoses on a latex bladder model. I was allowed free access to the robot out of hours for practice purposes, also helped by supportive theatre staff.

Concurrently I assisted and observed 20 cases before being allowed on the console. This observation was complemented by DVD recordings of the operation performed by both Mr Sutherland and Dr Vip Patel, who demonstrated cases at the Royal Adelaide, a useful way to understand the complexities of the operation.

Once I completed this initial learning phase I started operating on patients. We divided the operation into 10 steps, learning one step at a time. The robotic system aids training with the mentor being able to clearly see what the trainee is doing and step onto the console and take over at anytime. We tried to perform each step around 5 times before moving on to the next. Once I had completed all the steps a number of times I performed my first case in around 3 hours, 7 months into the fellowship and 5 months ahead of schedule. By the end of the year I had had experience in over 120 cases and had been on the console for half of these. I have performed 20 complete cases to date, a number needed by Intuitive Surgical to be recognised as fully robotically trained. A goal that I felt would have been difficult to achieve a year earlier.

Laparoscopic Surgery

Performing a Laparoscopic Nephrectomy (left), with the Registrar Dr Kevin Bax (right)

Performing a Laparoscopic Nephrectomy (left), with the Registrar Dr Kevin Bax (right)

Throughout my training in London I have gained experience with laparoscopic or “keyhole” techniques for the surgical management of kidney diseases particularly renal cancer. I intended for my fellowship year to spend time in a high volume centre building on the skills already acquired and graduate to a fully independent laparoscopic surgeon. Within the department at the RAH there is only one trained laparoscopic surgeon who has been very helpful in letting me perform these cases independently. Throughout the year we have performed 40 laparoscopic nephrectomy’s and a handful of pyeloplasty’s and operations for renal cysts, more than any other hospital in South Australia. We have been performing these cases on a weekly basis. Almost all cases have been performed without senior cover in theatres and only a junior registrar to assist. I have been performing these cases both via the transperitoneal and by the extraperitoneal route, a technique not previously done in Adelaide before. Operating in this environment, being given this responsibility, has been a good stepping stone to life as a Consultant back in the UK. I was able to present work on the experience I had with Laparoscopic renal cryotherapy at St.Georges Hospital in London, at the state Urological meeting.

I have also helped train both the registrar and a Consultant in laparoscopic surgery, hopefully leaving them fully proficient in this area.

Pelvic Oncology

To complement the uro-oncology surgery performed with the robot and laparoscope, the Royal Adelaide has given me a huge experience in complex open pelvic surgery and reconstruction techniques, again helping bridge the gap between registar training in the UK and becoming a Consultant. We have performed 17 cystectomy’s this year including 3 pelvic exenturations in conjunction with the General Surgeons and/or Gynae Oncologists, and I have been performing these without Consultant supervision for the last six months.

There is also a high volume of general urology practiced at the RAH in particular BPH and complex stone work which I have also been involved in.

Australia has a high incidence of urological stone disease, a lot of which present as complex stone disease. I have also had experience in performing many ureteroscopies, both flexible and rigid, and PCNL’s with the Holmium laser. One technique that I have been shown this year and performed a lot of, which is not commonly practised in the UK is supine percutaneous nephrolithotomy, this offers many advantages to the patient and is a technique rarely used for stone surgery elsewhere.

Since the introduction of Holmium laser to the RAH we have been performing Holmium Laser Enucleation of the prostate for men with BPH. I have already had some experience with this technique in the UK and have built on these skills, increasing the number of operations performed. Again this is a technique that I would like to use to benefit patients on my return to the UK. While in Adelaide I had the opportunity to see Peter Gilling, a world expert in this technique demonstrate the operation, and talk on it at the state meeting, a useful adjunct to my training.

Conferences and Clinical visits

  • June 2008 – BAUS, Manchester. With the help from Prostate UK I was able to fly back for BAUS
  • August 2008 – Prostate Cancer Symposium, Melbourne Cricket Ground. This exceptional meeting was organised by Professor Tony Costello and included live Robotic Surgery performed by Dr Vip Patel.
  • November 2008 – HOLEP masterclass with Peter Gilling, Repatriation Hospital, Adelaide
  • March 2009 – USANZ national meeting, Gold Coast, Queensland. I will be presenting two robotic abstracts.
  • March 2009 – Clinical visit, Epworth Hospital, Melbourne. This has been arranged to watch Professor Tony Costello and Mr Justin Peters perform Robotic assisted radical prostatectomy surgery, the first centre to perform this in Australia.

Research

Presentations at the Urological Society of South Australia and Northern Territory, Barossa, November 20081. Robotic assisted Radical Prostatectomy, A series of 400 patients with 6 month follow up.

Eddy B.A., Kiss G.G, Wilson A., Sutherland P.D,

2. Laparoscopic renal cryotherapy. Initial results from a UK series

Eddy B, Anderson C

Presentations at World Congress of Endourology, Shanghai, December 2008

1. Robotic Assisted Radical Prostatectomy. An Australian series of 400 cases with minimum 6 month follow up.Eddy B, Kiss G, Wilson A, Sutherland P

2. Experience matters in robotic radical prostatectomy, comparison of the first and last 50 cases in a series of over 400 patients.

Kiss G, Eddy B, Wilson A, Sutherland P

Presentations accepted for USANZ, Gold Coast, March 2009

1. Robotic assisted radical prostatectomy. Surgical outcome from 400 cases with a minimum 6 months follow up.Eddy B, Kiss G, Wilson A, Sutherland P

2. Experience matters in robotic assisted radical prostatectomy: Comparison of the first and last 50 cases in a single surgeon series of 400 patients

Kiss G, Eddy B, Wilson A, Sutherland P

Presentations accepted for BAUS, June 2009

1. What can be achieved in a 1 year fellowship. A review of a fully mentored, modular training programme with initial surgical outcome.Eddy B.A, Kiss G, Sutherland P.D.

2. Experience matters in Robotic Assisted Radical Prostatectomy: comparison of consecutive sets of 50 cases in a single surgeon series of 500 patients.

Eddy B.A. Kiss G, Sutherland P.D.

Other presentations where Prostate UK has been referenced include medical school lectures to 4th and 5th year students on BPH, Haematuria, Renal Cancer and Prostate Cancer.

Sir Donald Bradman Statue, Adelaide Oval.

Sir Donald Bradman Statue, Adelaide Oval.

While we are here we have taken the opportunity to explore Adelaide and South Australia. The state offers both a great beach lifestyle and stunning countryside only minutes out of town. The state is best known for its wine regions and wine making seems to part of the culture here with 4 world recognised regions only a short drive away. The Barossa has 88 wineries to choose from and is only 1 hour away, McLaren Vale and the Adelaide Hills regions are within 20 minutes, we have made the most of our free time in visiting these wineries and tasting some world class wines. The local sport over the winter is Aussie rules football and Cricket in the summer. Famous for Sir Donald Bradman, South Australia has a good cricketing history. The Adelaide Oval is a world class ground and I have been able to watch state and international cricket here.

I have also travelled with my family, both within the state and around the country and have been able to see some beautiful parts of Australia including the sunshine coast in Queensland, Sydney, Melbourne and the Great Ocean road, a spectacular 5 day drive between Melbourne and Adelaide. I also took the opportunity to dive with South Australia’s most talked about inhabitants, the great white sharks.

I have currently extended my Fellowship while suitable jobs become available in the UK, so being able to increase the number of Robotic operations performed, however on my return I would gladly present my fellowship to Prostate UK.

Once again I would like to offer my thanks to Brigadier John Anderson, Amanda McLean, Professor Roger Kirby and Prostate UK for their support of what has been a truly excellent fellowship year. Support that will hopefully benefit patients with prostate and other urological diseases on my return to the UK.

Ben Eddy

Laparoscopic and Robotic Fellow
Royal Adelaide Hospital
Adelaide
South Australia