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.

Partial Nephrectomy Offers Better Renal Preservation, Survival – Renal and Urology News

The median follow-up for patients still alive at the last follow-up was 8.3 years. The estimated overall survival rates at 10 and 15 years were 69% and 53%, respectively, for RN compared with 80% and 74%, respectively, following PN. Compared with PN-treated patients, patients who underwent RN were 75% more likely to die from any cause and more than four times more likely to develop stage IV chronic kidney disease, after adjusting for covariates, according to findings published online in European Urology. All of these differences between the RN and PN group were significant.

via Partial Nephrectomy Offers Better Renal Preservation, Survival – Renal and Urology News.

There have been several studies that concluded that patients that have kidney tumors and have only part of their kidney removed (partial nephrectomy) vs. the entire kidney removed (total or radical nephrectomy) have less kidney problems in the future.  They patients with nephron sparing surgery (partial) lived longer as well.

Not all patients are candidates for removing only part of the kidney, but most with tumors under 4cm and most with tumors not in the middle of the kidney should have a partial nephrectomy as a consideration.

At Newark Beth Israel, I have been performing robotic partial nephrectomy since 2005.  In 2007 I started using intraoperative renal ultrasound to better show the kidney anatomy.  In 2012 I started using firefly to help me perform more accurate kidney surgery for suspected kidney cancer.

Saint Clare’s Hospital Celebrates Facility Opening – Hopatcong, NJ Patch

Additionally, real-time integrated video and communications systems from Black Diamond Video will place Saint Clare’s in the company of renowned health care organizations with the same technology, such as Cleveland Clinic, Duke, Mass General and Yale, among other select hospitals nationally.

via Saint Clare’s Hospital Celebrates Facility Opening – Hopatcong, NJ Patch.

 

I have been performing robotic surgery at Saint Clare’s for 5 years.  I am fortunate to work with a dedicated team of nurses and anesthesiologists and my partner, Dr Alex Gelllman when I perform my robotic prostatectomies there.  I was very pleased to learn about the upgrade to the davinci Si platform and the new operating rooms.  This should be a benefit to Dr Gellman’s and I andn our patients.

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?

Laparoscopic nephroureterectomy for TCC of the ureter or renal pelvis

This review of an article by one of the founders of laparoscopic urology shows that with one of the common laparoscopic method to remove a kidney, ureter, and bladder cuff for transitional cell caner of the upper urinary tract lining there seems to be a higer recurrence rate and positive margins.
Our current technique is a robotic approach to remove the whole specimen intact with 2 robotic operations at the same setting. Prior to this I usually would remove the kidney with the laparoscope and then the ureter and bladder cuff with an open incision. Without robotic surgery, I never felt that I would obtain as good a specimen as with open surgery for the bladder part of the operation. With the robotic nephroureterectomy, I think the specimen is equal and there is no need to make a large incision or to open up the bladder like I did in open surgery.

clipped from www.urotoday.com

Oncologic Outcomes of Extravesical Stapling of Distal Ureter in Laparoscopic Nephroureterectomy

The local recurrence rate (17% vs. 0%) and the bladder recurrence rate (50% vs. 33%) were higher in the laparoscopic stapled group (p = 0.090)

Of note there were 3 patients (25%) with a positive margin in the laparoscopic group vs. none in the open group.

To be sure, as a frequent user of the stapler to remove the ureteral cuff, I have over the years altered my technique in order to improve removal of a larger cuff of bladder along with the entire ureteral tunnel:

blog it

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.

3 experts discuss their experience with robotic surgery

Symposium: Robotic surgery in urology: Hype, hope, and reality – Modern Medicine

Community urologists who want to learn this must have an adequate volume of cases, at least 20 prostatectomies a year, and it probably will take 20 or 30 procedures before they are comfortable. For someone doing less than 20 cases a year, it doesn’t make much sense. You have to do this procedure with some regularity to keep up your skills.

Pruthi: I hesitate to suggest a number because of the different issues we have mentioned. In the Henry Ford experience, when they looked at complications, the learning curve was 200 cases.

2 At Vanderbilt, the surgeon-reported learning curve was 250 cases.

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