Endoscopic simple prostatectomy – Abstract

Endoscopic simple prostatectomy – Abstract.

This review looked at minimally invasive treatments for patients that have urinary obstruction from very large patients.

Traditionally open surgery was done since procedures done through the natural urinary opening often did not have goo long term results.

Laparoscopic adenomectomy (LA) and robotic-assisted simple prostatectomy (RASP) have been performed for about 10 years.  I started performing these operations in 2005 and have one of the worlds largest experiences in removing the middle part of the prostate robotically.  I disagree that the learning curve is short.  It is important to be in the correct plane in the prostate which is often more difficult to find with robotic or laparoscopic surgery than traditional open surgery.

Most of my patients are able to go home the day after surgery when I perform this operation robotically.

 

An interview with MD Advisor

I recently gave an interview to the MD Advisor. We discussed some of the recent safety concerns with robotic surgery and the daVinci robot.

Some of the important points that we discussed are:

Robotic surgery is performed by a surgeon and is not automated.
Experienced surgeons have less complications that inexperienced surgeons.
Robotic surgery magnification can lead to a more precise surgery, but the magnification will lead to instruments not being in the surgeons filed of view which is similar to laparoscopy.

You can view the article on page 11 of the Fall issue of MD Advisor.

Safe removal of the urethral catheter 2 days following laparoscopic radical prostatectomy – Abstract | Prostate Cancer | UroToday | Urology Information

Results:Of the 114 patients who underwent laparoscopic prostatectomy, 64 56% were deemed suitable for removal of catheter on second postoperative day prior to discharge. The first 20 patients selected for early removal of urethral catheter were covered with a suprapubic catheter inserted at the time of surgery. Out of 64 patients deemed suitable for early removal of urethral catheter, 53 83% were able to pass urine without complication. 11 patients 17% developed urinary retention that necessitated recatheterisation. In all cases, reinsertion of catheter was performed easily and successfully without the need for cystoscopic guidance or adjuncts.

via Safe removal of the urethral catheter 2 days following laparoscopic radical prostatectomy – Abstract | Prostate Cancer | UroToday | Urology Information.

 

This study looked at patients who were deemed suitable to have their catheters removed after 2 days of laparoscopic prostatectomy.  This was not done robotically, which makes the skill of the surgeons in accurate suturing very impressive.  They had a relatively high re-cathetrization rate of 17%.  I wonder if these patients were still in the hospital on day number 2.  Urinary retention is a bigger deal if the patient is at home and has to come to the office or emergency room for catheter reinsertion.

I did not read the paper, just the abstract, but I assume they did not perform any reconstructive techniques that I have been performing since 2007.  This reconstructive work makes the bladder neck more fixed and I have not seen very much retention (2-3%) when I have removed catheters after 2-3 days after dvP.

Mass. bill would allow videotaping of surgeries – BostonHerald.com

BOSTON – Massachusetts lawmakers are considering a bill that would give patients the right to have their operations videotaped if they pay for it.

The measure would let licensed medical videographers tape the procedures. They would not have to be in the operating room at the time. A copy of the surgery would be given to the hospital for its records. Hospitals that refused would face a $10,000 fine.

The bill is scheduled for a Statehouse hearing Tuesday before the Public Health Committee.

Another bill set to be heard at the same time would create a special commission to investigate the use of robotic surgery in Massachusetts and develop a training protocol.

via Mass. bill would allow videotaping of surgeries – BostonHerald.com.

 

Two interesting bills are going to be voted on in Massachusetts according to this article.

 

The first would allow the taping of any surgery.  This would be paid for by the patient.  I have given patients videos of their robotic surgeries when they are recorded and come out OK on the DVD.  I also have had relatives of patients in the operating room at certain times, but I think most surgeons would not support this bill.

Surgery is rarely a “perfect” with fluid and bleeding obscuring view.  I do not think a lay person would be able to understand and would be concerned about the implications in a malpractice case.  I would recommend these videos by non-admissible in any legal proceedings, although I would be open to allowing expert witnesses testify to what they saw.

 

The second case involves the training and credentialing of robotic surgery.  I am very interested to see why robotic surgery is different than other forms of surgery.  In my opinion, laparoscopic surgery was harder to learn originally than robotic surgery is today and this was never subjected to additional legislation.

I do think that the individual medical societies that the surgeons participate in and hospitals that have robotic systems have specific training protocols which should try to be standardized.

Robotic prostate surgery: a health care conundrum

Story by:
ROD MICKLEBURGH
VANCOUVER— From Friday’s Globe and Mail
Published Thursday, Dec. 09, 2010 8:54PM EST

Just six weeks ago, Rob Lucy had his cancerous prostate gland removed by a surgeon-controlled robot at Vancouver General Hospital. It cost him nothing.

If his operation had been booked for the new year, however, Mr. Lucy would have had to shell out more than $2,800 from his own pocket for exactly the same procedure.

via Robotic prostate surgery: a health care conundrum – The Globe and Mail.

The above was the story describing an upcoming charge for patients undergoing robotic prostate surgery in Vancouver. Below is an excerpt from an article in the vancouver Sun.

The health authority has cast these fees as being in the same category as other elective upgrades that patients are asked to pay for now, such as lighter fibreglass casts.

It argues that patients can choose conventional surgeries at no cost if they prefer, as required under the Canada Health Act.

But this justification depends on two conditions: first that there is no therapeutic advantage to the robotic procedures and second, that there is, in fact, a real choice.

It’s not clear whether the first condition has been met. Sun health reporter Pamela Fayerman reports that while the ultimate outcome is no different, patients who choose the robotic route need less blood during operations, need less hospital time and recover more quickly.

If those benefits are expected to outweigh the costs for individuals who can afford the robotic route, they should also be enough to qualify for public funding, especially as we expect there is still a research value attached to exploring mechanically assisted surgery.

The question of real choice is equally problematic.

via Charging patients for robotic surgery breaks new ground.

The Canadian system of healthcare offers equivalent care for all which the government pays for (Through a tax).  Robotic surgery is more expensive in Vancouver and patients are being asked to pay part of the cost.

The reporter brings up the dilemma that if the robotic surgery is better, than it should be paid for.  If it is not better, then it shouldn’t be performed.  Robotic surgeons typically perform more surgeries than conventional surgeons at specialty centers.  This may mean someone would need to pay extra for the more experienced surgeon.

These are interesting issues to consider as our health care system in the US is heading towards more governmental involvement. Is healthcare a right and should it be paid for by the government for all through taxes? If we think that it should be paid for for all patients as it is in Canada, can we afford to give every patient the best care?

Robotic surgery summary- October/November 2007

In October and November I performed 46 robotic surgeries, including 35 dvPs, 4 partial nephrectomies, 2 nephrectomies, 2 radical cystectomies including a bladder replacement in a woman, 1 simple prostatectomy, a stone procedure to remove a large left kidney stone, and a removal of a piece of ureter and re-implant for ureteral cancer.
The most important operation was the anterior exenteration (removal of bladder) and bladder replacement in a female, the first operation to be done completely robotic for me of this type.

One nice trend I have been noticing is a significant improvement in the recovery of urinary control with the reconstruction sutures I have added to the robotic prostatectomy. Most patients are having decent control by 4-6 weeks. I will be looking at the data in more detail in a few months to see how much of an improvement the addition of these sutures has added.

Robotic failure during surgery

Robot failure during radical prostatectomies is ‘extremely rare’ – Failure rates will continue to shrink as technology advances – UrologyTimes

The study team recorded critical failures in 20 cases (0.3%) leading to the cancellation of 10 procedures and conversion to laparoscopic in one case and to open procedure in nine cases. Recoverable failures were more frequent, occurring in 124 instances (1.9%). The most common malfunctions or failures occurred in the optical system and in the surgical arms. Failure of the master system or power system was less common.


Dr. Patel did not ask me to be in this studay, but my experience is simlar. I have 2 failures during my robotic surgery cases. 1 was during a kidney removal operation and we converted to laparoscopy.

The other was during a prostate removal when we brough in one of the other 2 robots. Thats 2 in almost 500 operations.

We also had 1 cancellation, 1 delayed start, and 2 other cases that were done with only 3 arms.

I would call that 2 major problems and 4 minor problems.

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