I was recently faced with a case of a right sided UPJ stenosis with good renal preservation and two 5 mm stones in the upper pole. Having done at least a half dozen robotic pyeloplasties I felt that that would be the appropriate treatment for the UPJ but was not sure how to address the stones. I did not want to leave them in place and have to address them later. A separate percutaneous nephrostolithotomy seemed like overkill for the size of the stones. A PNL could be combined with an antegrade endopyelotomy, but the stones were in upper pole calyces and the combined procedure might require two separate entry points for adequate access (lower pole entry point to reach the upper-pole and a mid- or upper-pole entry point to reach the UPJ).

I am at a point in my career that has not afforded the experience of younger surgeons in laparoscopy so some of this I have to make up as I go along. I placed the three ports in the standard fashion for a pyeloplasty (we have only a 3-arm, not 4-arm, system). I had a 10mm port above the umbilicus on the midline for the assistant and during the case we placed a 5mm below the umbilicus and to the right of the midline. Once the renal pelvis was open and the stenotic portion excised I held the kidney in position with the two working arms and stepped away from the console. The arms, of course, locked into position. I then passed a flexible cystoscope through the 5mm port and, using the image on the da Vinci room monitor directed the tip into the open pelvis. At that point I visualized the two stones with the scope's optics and, using a zero tip Nitinol basket, extracted the two stones in sequence from the upper pole calyces. They just fit through the port. I could have used the 10mm port for a larger stone but the placement of the 5mm port provided a direct shot at the upper pole. A ureteroscope could, of course, been substituted for the cystoscope but the anatomy did not appear to require it.

I then returned to the console and completed the anastomosis.

Several thoughts come to mind:
1) How large a stone would one be willing to approach in this manner?
2) If a stone or fragment were to go astray in the retroperitoneum or peritoneum and could not be located, what, if any, are the consequences?
3) Would anyone consider this approach a replacement for PNL for treatment of some larger stone burdens?

Posted by Dale Russell M.D. | Permalink | Comments (1) | TrackBacks (0)

The most cited drawback of robotic surgery is the loss of fine feeling of the instruments on tissue.

The other drawbacks are the expense of the surgical system and the need for precise positioning of the robotic arms to provide for a full range of motion without repositioning the arms.

Haptics refers to the feedback of moving the robotic controls on the surgeon.

The current version of the da Vinci robotic surgical system does not have haptics Incorporated into the system. I admit it would be nice for the next version of the system to have haptics and enable the surgeon to feel the tension on sutures, as well as the tension of instruments on tissue.

The robotic radical prostatectomy procedure is a delicate urologic procedures that is a good one to use in discussing haptics.

In my opinion, the loss of feedback is not a major or significant drawback. Although I think it will make the robot easier to use and possibly a little safer, the 10 times magnification more than makes up for this shortfall. We have different senses that are used to some extent in surgery. The sense of sight allows us to see tension in tissue and sutures. As long as the instruments are kept in the field of view, the loss of fine sense of feel is not a problem for me.

There is a limited sense of feel with the da Vinci. When instruments have tension, eventually it will be felt in the instruments. When I am retracting the prostate with my left hand, I feel the tension when it gets to a certain level, granted not as soon as I would with me hands. When I lift on the vas and seminal vesicles with my 4th arm, I can feel the tension in the instrument. If my instruments are colliding with each other, or with the bony side wall, or with a laparoscopic instrument the instruments don't move as smooth as usual.
To date I have performed 65 robotic operations and 49 prostate operations and have not had any complications related to lack of haptics. I haven't had any vessel or bowel injuries.

I find the argument used by other surgeons amusing. When laparoscopy first was used, open surgeons would criticize that there was poor feel from the laparoscopic instruments. I agreed with this as well back then, but with care this was not a major issue. Now the laparoscopic surgeons with the straight instruments that are controlled at a distance with a fulcrum at the port site use the same argument that was used against them against robotics.

The open surgeons sometimes say that they need to use their hands to feel things that I cant even see well at 10 times magnification. I perform a fair amount of major open surgery and personally cant feel things that well through 2 sets of gloves.

Another endpoint could be the quality of nerve sparing or the margin status. My nerve sparing looks better and less traumatic with the robotic approach and my margin rate is improved with robotics as compared to open, which I discussed on a recent blog entry.

I do have my own questions regarding robotics for more delicate operations such as pyeloplasties in young children and will ask a friend and experienced robotic pediatric urologist, Dr. Jeffrey Stock, to comment on this if he would.

I will also attempt at suturing with very small needles the next time I get a chance to practice on the robot, which may be next week when we have a demo for local high school students.

Posted by Domenico Savatta, M.D. | Permalink | Comments (1) | TrackBacks (0)

A presentation at the AUA Western section meeting was reviewed in the Urology Times November 2005 issue:

UT article: Smokers face higher risk of TCC after radiation

Patients that have a history of smoking are 13 more likely to get bladder cancer (transitional cell cancer) after radiation as compared to patients who get radiation and have not smoked.

This was an interesting study that adds to the known literature involving long term effects of radiation for the treatment of prostate cancer.

There was a retrospective review performed by Nancy Baxter, MD, PhD, from the University Of Minnesota Cancer Center that revealed an increase of 70% in the risk of rectal cancer following radiation therapy for prostate cancer (click for abstract).
This led to a recommendation to screen every radiation patient with endoscopy every 5 years.

Physicians: Medscape offers CME credits for learning about Baxter's study.

The current study is from the Mayo Clinic College of Medicine in Rochester Minnesota with lead author Kristin Chrouser, MD. I will await the publishing of their results to comment on their study, but this study is a meaningful reminder that although radiation is relatively effective in treating prostate cancer, it does have sidel effects on nearby organs.

We will have to see if the newer ways that are being developed to target tissues with radiation will lead to less of these problems in the future.

Domenico Savatta, MD

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1. What does an operating room need to house a da Vinci robot?

2. What staff are required?

The only requirement for the operating room is the operating room size. The unit consists of a console that the surgeon sits at and the robot that needs to be wheeled in towards the patient. These pieces cant be too close while the patient is entering the OR suite as you need to have freedom for people to walk around.

The other components for the operation are components you would need for all surgery or laparoscopic surgery.

Laparoscopic equipment: TV monitors for the assistant and nurses, air insufflator, light source.

Standard equipment: cautery generators, suction canisters, anesthesia setup.

In our hospital there is only 1 room that is large enough for the robot to work in. The robot, although weighing in excess of 1000 pounds (I think) is relatively easy to move around. We move it to other parts of the operating room to practice with it and easily move it around the room between cases if we are doing 2 different operations that day.

Our hospital is building 3 state of the art laparoscopic suites which should have all the screens and lap equipment hanging from the ceiling. I m told there will a 42 inch plasma on the wall for everyone in the OR to see. Teleconferencing will also be available and my expectation is to have surgeons from all over the country and world come learn how to do some of the advanced robotic procedures we are doing at NBI currently.

I am hoping that the next generation of robots will be integrated into the operating theaters and will need less space.

What staff are required?
The main difference between this surgery and previous surgeries is that the surgeon is not at the field. I am currently performing surgeries with another urologist, but plan on hiring and training a physician assistant or nurse first assist to help. 90% of the operations can be just as safely, quickly, and precisely performed with a qualified non-physician assisting after the learning curve has been passed.

The anesthesia requirements are the same as any surgery except a full general anesthetic is needed (not a spinal). The blood loss is much less, as are the fluid shifts as compared to open surgery, so I would consider most cases low stress for the anesthesiologist.

The scrub nurse is the same as any operation. She does much less work than open once there is an experienced robotic team since the amount of instrument changes, sutures, etc. is less as compared to open surgery.

The circulating nurse is also necessary, as we sometimes use different devices from special clips or staples depening on the anatomy.

The only time that additional people are nice to have in the room is the setup and docking of the robot and the removal of the robot. We have developed several ways to remove steps to make this process as streamlined as possible.

Compared to open or lap surgery, the staff requirements are similar. The room size is the only difference with a large room needed for robotics.

Posted by Domenico Savatta, M.D. | Permalink | Comments (2) | TrackBacks (0)

We started our robotic surgery program at Newark Beth Israel Hospital on Dec. 13th, 2004.

Our 9 man group decided to let one person do all of the robotic surgery. Since I had the best combination of open and laparoscopic surgical skils, as well as strong cancer training from a 6 year residency at Indiana University, I had the fortune of being the person.

We did 2 cases in Dec, 2004 (both prostates). We did between 1 (Feb 05) and 7 cases per month from Jan to Sep 0f 2005 for a total of 42 operations (including 32 prostates).

We then jumped to 13 operations (10 prostates) in Oct 2005 and should do about that many in Nov and Dec of 2005.

I project I will do 200 operations (150 prostates) in 2006.

Why?

When we first started we had several hurdles.

Our practice is based in West Orange, about 1 mile from Saint Barnabas Medical Center. There was no robot there and no intention of getting one due to the cost. After visiting the AUA in May of 2004 and listening to my mentor from Indiana switch from open to robotics and listening to the advantages, I knew I had to get into it. I decided to go to Newark Beth Israel, also in the Saint Barnas Health Care System.
I met with the CEO of NBI and the rest is history. I did have a problem from bringing patients from the suburbs into the city.

The learning curve. The first 10 cases were scheduled as all day events. The times quickly went down from 10 hours, to 7 hours, to 5 hours. Given how far it was from our office in midday traffic and that we didn't have enough equipment for 2 cases, we could only do 1 a day and usually didn't schedule office hours afterwards. This was a major money loser.

The perceived learning curve. Amazingly to me, until we had done about 30 operations people still thought we hadn't done enough and often went elsewhere.

What changed.
1) Currently, most people that need surgery understand we are the leaders in this and stay with us. We do the most difficult robotic surgery in the state including dvP in patients up to 300 pounds (I probably would go heavier, but my heaviest patient was 290 pounds.
2) I am getting referrals from PMDs that I did not know until I did surgery on one of their patients and now they know about me and send patients with blood in the urine or elevated PSAs.
3) I am getting many 2nd opinions for robotic surgery for patients with known problems.
4) I am getting referrals from the internet and from friends of friends that know what I am doing.
5) I am the only one in the state doing things such as robotic partial nephrectomies and robotic cystectomies. I think my complex robotic surgery ability ranks well nationally.
6) Some procedures that I once did laparoscopically I now do quicker and safer robotically. This includes pyeloplasties and nephrectomies. My last 2 of each went home the following day.

What do the hospitals think?
SBHCS- The system is delighted. They own both hospitals.

NBI- The robot collected dust except for a cardiac surgeon who used it about once a month and a pediatric urologist (The guy is world class- If your child needs urologic surgery, he is worth the trip) who used it 2-3 months.
Since my arrival, the general surgeons and gynecologists have come aboard.
There is strong talk of getting a 2nd robot for the hospital and 3 state of the art laparoscopic rooms are almost finished getting built.

SBMC- They have chosen not purchase a da Vinci at this time. If new procedures are done routinely with the robot, then I think they will reconsider. I think the next big procedure will be the robotic hysterectomy.

Posted by Domenico Savatta, M.D. | Permalink | Comments (0) | TrackBacks (0)

For all the advanced features for the da Vinci surgical system it is surprisingly reliable.

Dr Ahlering at University of California Irvine wrote a review article for the AUA Update series where he commented that his first 200 cases had 5 problems. 4 cases were delayed because of software problems that were easily fixed. There was one case that involved a power outage when the backup battery was not charged and he finished the case laparoscopically.

I have performed 62 robotic operations with only 2 problems.
One day we arrived at the operation and had a wire to our 4th arm severed.
We did the operation with only 3 arms the way lots of places that don't have the 4 arm machine do it, with 3 arms- a camera and 2 instruments.
Our other problem was a faulty connection between the left arm and the instrument. We had to put it on and off a few times before it would engage. It delayed us a few minutes. If it didn't engage, we would have redocked the robot with only 3 arms.

If I had a complete failure, I would have the option of finishing the operation laparoscopically or open. It would depend on the patients anatomy and if I thought I could do it laparoscopically or open better. I think this would be a rare event.

Domenico Savatta, M.D.

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This is one of the most common questions I am asked.

Patients want to know if their surgeon is qualified to do a procedure.

I always answer this question honestly and to the best of my knowledge. With robotic cases I keep accurate data on outcomes and can answer this precisely.

I then add "How many is enough to know how to do the procedure?"

I explain that I was trained as an open cancer surgeon first and have taken out over 200 prostates. As a resident in Indiana I performed lots of open prostate surgeries, a few laparoscopic prostatectomies, and a lot of laparoscopic nephrectomies.

I knew enough about lap prostates that I couldn't justify performing lap prostates- my results for continence and erections wouldn't be as good until I had done 50-100 of them.

Prior to performing a dvP, I already had 4 scheduled. Each man knew we hadn't done any yet. I knew the operation would be similar or better than open surgery.

Our first guy took 10 hours, but he went home in a day and a half and is now completely continent and has a PSA <0.1 1 year after surgery.

Our 3rd guy took 5 hours, went home the next day, had his catheter out in 6 days and went to work, regained his erections within 2 weeks, and went skiing in 3 weeks.

By the 8th case we were under 4 hours including set up time.

I think somewhere between 20-30 cases I far surpassed what I could do open.

I did my first under 2 hour prostatectomy with pelvic lymph node dissection (of any type) with my 42nd case.

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Dr. Smith at Vanderbilt offers a concise review of the current literature on robotic assisted prostatectomy. Click for abstract.

Laparoscopic (with a focus on Robotic-assisted) vs. open RRP was reviewed.

The key findings in the review of the literature were
1) Similar postoperative pain in open vs. robotic prostatectomy in one prospective series.
Most urologists including myself feel that our robotic patients have significantly less pain.

I discharge most of my patients within 24 hours and do not give narcotic pain pills at discharge.

2) Operative times are similar after the learning curve has been passed.

I agree with this. In my experience we achieved similar operating times for non-complicated robotic prostatectomies by 30 operations. After 40 operations the times have been quicker than open.

3) Less bleeding with the robotic approach.

This is almost universally accepted.
We have not transfused a patient to date and have stopped having our patients donate blood after the first 4 operations.

4) Hospital stay - slightly better for robotic, although open series also have short hospital stays.

I think the robotic patients more easily leave the hospital after 24 hours, and some patients are being discharged the same day.

5) Urinary continence- No good studies showing a benefit.

The author pointed out that the method to evaluate continence is highly variable in series.
Our experience is that patients are having return of continence quicker. Some are continent within a week or two, but most are continent within 3 months. The improved visualization has allowed for a more precise dissection to leave the urinary sphincter intact with out compromising our apical margin rate.

6) Erectile dysfunction- Similar to incontinence, there are no good studies for this.

The author points out that the principles and anatomic dissection for nerve sparing is the same regardless of the approach. I disagree with this. My technique for the robotic approach involves finding the prostate at the base, away from where the nerves attach. I believe this allows me to spare the nerve bundle more completely and with less trauma.
4 of my first 20 patients with a bilateral nerve sparing procedure with good erectile function preoperatively have had intercourse within 3 weeks or surgery. This is much rarer with open surgery. I am collecting accurate data by patient questionnaire to follow this more thoroughly.

7) Oncological outcomes- Similar in large series with experienced surgeons.

I agree with this, but I personally feel much more comfortable with a magnified, robotic approach in getting very close to the prostate and sparing the nerves for erection and muscles for urinary continence.
My last 20 dvPs have a 5% positive margin including all 17 with T2 prostate cancer being negative and 2 of 3 with T3 disease being negative.
This has allowed me to spare more nerves than I would feel comfortable with in open surgery.

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I use the da Vinci hot shears in my dominant (right) hand. I find it useful to take down adhesions from the sigmoid to the pelvis by cutting.

It provides excellent hemostasis by using cautery for the bladder neck or seminal vesicles, and is an excellent scissor to open the endopelvic fascia and to release the neurovascular bundle.

The only negative is the increased production of smoke that happens with this instrument compared to the hook.

For non-nerve sparing procedures, I still use the hook cautery.

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