Mass. bill would allow videotaping of surgeries –

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 –


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 Partial Nephrectomy Study

Journal of Robotic Surgery, Volume 2, Number 3 / September, 2008

We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.

This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.

Best of AUA Orlando 2008 for Prostate Cancer

Source: Urology Times
Robotic Surgery
Presented by Ashutosh K. Tewari, MD,
Weill-Cornell Medical College, New York.

* Robot-assisted laparoscopic partial nephrectomy is associated with shorter hospital stay and less bleeding, but the warm ischemia time is still around 30 minutes.

* Studies comparing robot-assisted laparoscopic cystectomy and open radical cystectomy show similar oncologic outcomes. At a high-volume tertiary care center, the robotic technique was more cost-efficient, but that finding needs to be confirmed at other centers. Other remaining issues regarding the robotic procedure include the need to define how the reconstruction should be performed, the extent of the lymphadenectomy, and ensuring clear margins at lateral areas.

* A study of almost 4,000 patients reaffirms the safety of robotic-assisted laparoscopic prostatectomy (RALP). Rates of major surgical, major medical, and minor medical complications were all ≤0.7%, and the rate of minor surgical complications was 3.3%.

* Studies comparing open and RALP show the surgeon is the most important variable in determining outcome.

* Extended lymph node dissection should be performed in high-risk prostate cancer patients, and can be done with RALP.

* A total reconstruction procedure including anterior and posterior restoration of the vesicourethral junction is associated with early return to continence and improvement in overall continence rates.

Some of the highlights from the AUA
Of interest is the growing application of robotic surgery for smaller kidney cancers (partial nephrectomy) and bladder cancer, which I have been performing since 2005 myself.

The other very important adaption is the posterior and anterior reconstruction of the urinary tract during robotic prostatectomy, which I have performing for over a year after attending Dr Tewari’s conference.

New for kidney cancer: robotic surgery

Source: Washington University Website

“Robotic surgery is more efficient and precise than either open or laparoscopic surgery for tumors confined to the kidney,” says Bhayani, assistant professor of surgery and a leader in the field of robotic surgery. “Rather than operate with two hands, I can simultaneously control four robotic instruments with mechanical “wrists” that rotate more than 360 degrees, giving me far greater maneuverability than human hands or laparoscopic instruments.” Bhayani led a team at Washington University to develop the procedure for kidney tumors.

Dr Bhayani is a friend and excellent surgeon. Check out his website for a video clip of the partial nephrectomy. I was recently invited as a guest faculty at his conference (First Annual World Robotic Renal Symposium) and had the privilege of watching him perform 2 live surgeries, a robotic nephrectomy and a robotic partial nephrectomy. Both went very well.

Newer Prostate Cancer Treatment Similar to Traditional Surgery

From Washington

“This reaffirms what many other manuscripts have shown, if you go to an individual who has experience, who does this on a consistent basis, your outcomes will be better,” said Dr. Ihor S. Sawczuk, chief of urologic oncology for the Cancer Center at Hackensack University Medical Center, in New Jersey. “If you go to someone who does 20 to 50 procedures a year, that’s better than somebody who only does two to three a year.

I agree with Dr. Sawczuk, a friend and colleague, that more experienced surgeons are more likely to have better results. The surgeon is important, probably more so than the technique. I think the best way to analyze this would have been to set up a study looking at high volume robotic vs. lap vs. open surgeons and having a 3rd party analyze the results. I do not think this is something that would ever be done.

My feeling after performing many open prostate cancer surgeries, a few laparoscopic ones, and over 400 robotic ones is that robotics gives me the ability to perform more accurate surgery, and the difference is more pronounced with more difficult cases.
Being able to remove the catheter within 3 days routinely without needing X-Rays would be difficult for me to achieve with open or laparoscopic surgery.

Positive margins and their significance

UroToday – Prognostic Significance of Location of Positive Margins in Radical Prostatectomy Specimens

In the 201 men with a single positive SM, it was found in the apex in 75 men (37%), posterolateral in 70 men (35%), bladder neck in 20 men (10%), anterior in 25 men (12%), posterior in 11 men (5%), and in no men was a single positive SM found in the seminal vesicle. The positive SM rate decreased with time, from 18% in the early cohort versus 10% in the late cohort. Those with a positive SM had a 1.4 fold greater risk of progression than those with a negative SM (HR 1.39). In the multivariable analysis, significant differences were found between the effects of different sites of a positive SM on disease progression. A positive SM at the posterolateral or posterior regions significantly increased a patients’ risk of progression for a positive SM versus no SM at these sites. The authors attribute the posterolateral and posterior positive SM rates to neurovascular bundle preservation and an inherent risk of a nerve sparing operation.

This study out of Memorial Sloan Kettering reveals that there is a 40% increase in the recurrence rate of prostate cancer after surgery for a positive margin. The worst positive margins are in the area where the nerve bundles are.

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.

Sex After Robotic Prostatectomy: Penile Rehabilitation

I have previously written about sexual function and how it changes after prostate cancer surgery.

As men are being diagnosed with prostate cancer at a younger age and at an earlier stage, the preservation of erectile function and the ability to maintain satisfactory erections has become more important. My partners and I offer a variety of options to assist in the recovery of erections including having a vacuum device specialist come in to the office once a month, teaching patients how to give penile injections and intra-urethral suppositories, and prescribing viagra, levitra, and cialis on a maintenance, preventative basis.

One of the most frustrating things is insurance companies not paying for maintenance medicines even though most urologists feel these medicines help erections return sooner and possibly more fully. There was an excellent review of the literature by Dr. McCullough of NYU that I read this weekend. He is one of the world’s authorities on erectile dysfunction.

This is a great source of information for urologists who can receive 1.5 CME credits.
I will start giving this link out to patients with a letter to see if it helps get them at least partial payment from insurance companies.
I hope patients report any positive experiences with insurance companies paying for their PDE5 inhibitors after surgery.

I have been personally prescribing 1/2 of a pill of the maximum strength to be taken on Mon, Wed, and Friday evenings.

My Robotic nephrectomy on you tube?

As my friends and readers know, in May of 2007 I performed a live right kidney and adrenal gland removal for intuitive surgical. This was telecast to the AUA conference in Anaheim. My hospital helped me edit the video which I did a voice-over for and made into a nice 7 minute piece. I was told it was going on our hospitals website.

I then received an email that it was put on you tube. I am not sure how I feel about this. Exposure is good, but is this the correct forum? I have personally put videos on google video before, but not you tube.

I think the piece is pretty neat and can be viewed below.

I welcome comments about using youtube or other media to promote work. I think surgeons can learn by watching this piece and will find it interesting, but I wonder how it will be perceived.
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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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