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 Joey Wahler (Host): It's improving how a number of conditions are treated. So, we're discussing Urology and Robotics. Our guest is Dr. Benjamin Larson. He's a urologist with Southwest Healthcare. This is Southwest Health Talk with Southwest Healthcare, building relationships that touch the heart. Thanks for joining us.

I'm Joey Wahler. Hi there, Dr. Larson. Welcome.

Benjamin Larson, MD: Thank you. Thanks for having me.

Host: Great to have you board. Appreciate the time. So first, what do we mean in a nutshell by robotics in Urology, and how would you say is the main manner in which it differs from those traditional Urology Surgery techniques of years gone by?

Benjamin Larson, MD: There are a couple of robotic platforms that we are using in Urology, but the primary one is the da Vinci system by intuitive, which allows us to do major surgeries through small incisions, using small instruments with precise control, allowing us to have better visualization and being able to cure a number of diseases from cancer to anomalies that people are born with, with quicker recovery, less downtime, less injury or risks, and improve outcomes overall.

Host: We had touched on it there. What are some of the other common urological conditions that are treated using robotics these days?

Benjamin Larson, MD: Robotic surgery is used in treatment of multiple types of cancer; kidney cancer; bladder cancer, in severe cases; prostate cancer, as well as other deformities that people are born with; scarring that prevents drainage from the kidneys to the bladder, and that could be from things they're born with or other injuries from other surgeries or other conditions; and then, as well as some other issues that can happen, especially in women where there are prolapse of organs and other issues that arise.

Host: So, this is helping to treat women as well.

Benjamin Larson, MD: Correct. And a lot of Urology, even though we do deal with the prostate, which is only men have prostates, everyone has kidneys, everyone has a bladder, and everyone has the need for that urine to get out of the body. 

Host: Absolutely. Perhaps that sometimes gets lost in the context of this type of discussion because urologists are often so much more associated with treating men, aren't they?

Benjamin Larson, MD: Correct. But we do see almost 50 50 men and women patients, and the needs arise from both.

Host: Interesting. You mentioned the da Vinci system. That's kind of the gold standard, if you will, for this type of procedure from an equipment standpoint, right? 

Benjamin Larson, MD: Correct. It's the first in the market for robotic-assisted, not meaning that the robot does the surgery. It just allows us as surgeons to manipulate and finely tune those instruments and control them in more degrees of freedom, whether it's angles and finite movements than we would traditionally with other instruments previously before that.

Host: And speaking of which, it's important to note, isn't it, that the term robotic surgery sometimes throws people that are unfamiliar because it's not as though robots have taken over the OR, right? We still have human doctors like yourself. And so, give people an idea maybe of the training that's involved in using this type of equipment.

Benjamin Larson, MD: Yeah. At this point, in Urology training, I finished my training about 10 years ago. It was still, and it was heavily integrated into that. I would say the majority of doctors' training are now hands-on with it from day one. That involves computer simulations, workshops, using it in other animal labs or other things. And then, slowly learning and seeing and doing in actual human patients.

There are still surgeons who have never used robotic surgery who are taking courses and being proctored or mentored by other surgeons to introduce that into their skills. But as far as Urology goes, we are one of the first fields that use this platform. And so, it's been integrated since day one, I would say, from here on out. 

Host: Gotcha. And so, how would you say robotic Urology improves patient outcomes compared to conventional surgical procedures?

Benjamin Larson, MD: Well, I have a unique advantage of that being a second generation urologist, and my dad was a urologist also before the robotic system came into play. Prior to what we are doing now with the da Vinci system, patients had to be admitted before surgery. They were worked up and prepared. They had large incisions done, sometimes injury nerves and muscles to allow access to those organs. And then, they usually would stay in the hospital even up to a week or so after surgery to control pain and make sure things were healing. Now, those same surgeries, patients are coming in that morning of the surgery. Their surgery is performed in about a relatively same amount of time in the operating room, but some are going home the next day, some even the same day. And much improved outcomes, as well as just the ease of getting back to normal. You're not having to wait months and months for wounds to heal and muscles to regain their strength. You're getting back to normal in a couple weeks or even within a month.

Host: And how important is that to patients, those last few things you mentioned, like being able to get in and out faster and reducing recovery time, et cetera?

Benjamin Larson, MD: Yeah, I think, you know, people don't want to have to lose too much. They're already losing or having a significant risk factor to their health and their lifespan. They're not wanting to have this be a major event in their life. You know, they want to deal with it and want to be able to move past it, which is the goal as a doctor also to help them get through that.

So, being able to be in and out of a hospital where there's other sick people or other infectious diseases is very important. Being able to just return to daily life as quick as possible. We've seen better improvements in outcomes, and avoiding those secondary things that happen from having to be in bed for a couple months while other issues can arise from that. So, this kind of gets people past all those other risks and then back to their normal life as fast as possible.

Host: I'm sure that's very comforting for people to hear. How about the preciseness improvement when using this technology. We hear so much about that being a big advantage for doctors, for surgeons, not just in Urology, but really in all areas of Medicine where this is used. How much of an advantage is that for you and yours and why?

Benjamin Larson, MD: Yeah. It's great because prior to using these modalities with cameras and instruments brought in and right up to the target of the surgery, we would have to make big incisions. We would have to position ourselves in uncomfortable positions to reach and be able to visualize parts in the body. And then, we still were, you know, working with rudimentary instruments to the best of our ability. But there's limits to how big our hands can fit into small spaces. And so, having more smaller instruments that allow us to manipulate them more precisely. So for an example, with this da Vinci surgical platform, we pass the instruments in, position them right next to the organ of interest. And while I sit at the control console and move my hands and wrist, it will scale down to make even finer movements at the tips of the instruments. And that mimics my movement. So, I'm controlling everything. But my movements are even more precise because of the robotic assistance there.

Host: That sounds very cool. How cool is it to use?

Benjamin Larson, MD: It's pretty fun. I've even had my young kids try out demonstration once and they take to it right away, because they're just used to that kind of hand-eye coordination on a screen. But it really allows you to feel like you're right at the problem, getting a good look at everything around, and really know exactly what you're doing with the best precision you can.

Host: Do you ever kind of take a step back and think, "Boy, it's amazing that this kind of technology exists"?

Benjamin Larson, MD: It is. You're sitting there saying, "I'm fixing something so small, but I'm seeing it on a full screen or an immersive eyepiece where it's in three dimensions to my view." And that's much easier than shrinking me down and putting me inside of someone's body. So, it is very cool in that sense. 

Host: That's great. Naturally, most any medical procedure comes with some degree of risks. How about the potential risks of using robotic technology in Urology?

Benjamin Larson, MD: You know, most of the risks that exists are present with any surgery, whether it's this modality open or other approaches, so those are fairly standardized risks for bleeding and infections and, you know, injury to other organs. With robotic surgery, luckily, the software, the hardware, rarely do we have any issues with that that does cause harm. But there always introduces some risk when you're reliant on technology or other instruments that have room for that. But so far, things have been fairly routine, very reliable. And that's what it takes to bring these things to market and then have them introduced, and used in mainstream medical care.

Host: A few other things. How about advancements that have been made recently in robotic systems for Urology? And any idea what's on the horizon in the near future, and how all of that may continue to help to improve that precision and recovery time, et cetera, that you've discussed? 

Benjamin Larson, MD: Sure. So, the intuitive Da Vinci platform has continued to release updated instruments, updated entire platforms that just provide either more compatibility and interoperability. They make it easier in the OR for the staff there to get it all positioned and stuff. So, some of that has just been more improvements on efficiency.

Other things that we've recently introduced at Southwest is another separate robotic system called the Aquablation, which we use for prostate enlargement in men who have difficulty urinating. And that uses ultrasound and high-pressured water to open up a nice big channel through the prostate so men can urinate better. It's an evolution of existing modalities that we've used before, but it's just kind of the newest guided, planned with the robotic assistant, and kind of controlled that way that we've had great success with.

As far as future things, there is new device by da Vinci where it still uses the robotic instruments, but they're all introduced through a single incision, instead of having four or five smaller incisions. That one is currently being used in some locations for Urology, and we'll see how that keeps developing and being applied more to urologic field.

Host: How about the way in which a general practitioner should advise patients considering robotic surgery in Urology? What do you want GPs to know about this?

Benjamin Larson, MD: I think it's being able to tell them that your surgeon is the one using this tool and controlling it. So, there's no need, you know, fear for us pushing a button and going off and getting some coffee. That's not the fear. And otherwise, just to tell them, "Hey, this is the standard of care. This is the way these things should be done." And you want to seek out a urologic surgeon who is doing those and is implementing the latest technology on their behalf. 

Host: And then, finally, we've saved the best for last here in that Rancho Springs Hospital has been designated a Center of Excellence in Robotic Surgery. So, what does that mean to you and your colleagues? That's exciting, right?

Benjamin Larson, MD: Yeah, it was great. It was a long process of documenting the robotic surgeries that we've done, the surgeons who do it, and making sure everyone meets, you know, strict criteria. As that program director, I was involved in getting all those forms and just presenting our data, our safety records, to demonstrate to those certifying bodies that we meet those criteria. And it's something we always knew we were. But it's nice to be recognized and to have that reinforcement, and let patients know, "Hey, this is how well we do things here. And you know, you should be aware."

Host: Well, congratulations on that honor.

Benjamin Larson, MD: Thank you.

Host: And folks, we trust you are now more familiar with Urology and Robotics. Dr. Benjamin Larson, keep up this great cutting edge work. And thanks so much again.

Benjamin Larson, MD: You're welcome. Thank you for having me. 

Host: For more information, please visit swranchosprings.com/services/surgery/roboticsurgery and southwesthealthcaresystem.com. .

Keep in mind, physicians or independent practitioners who are not employees or agents of Southwest Healthcare. The hospital shall not be liable for actions or treatments provided by physicians. If you found this podcast helpful, please do share it on your social media. Thanks again for being part of Southwest Health Talk with Southwest Healthcare, building relationships that touch the heart.

 Michael Smith, MD (Host): Welcome to the Southwest Health Talk Podcast with Southwest Healthcare System. I'm your host, Dr. Mike. My guest today is Dr. Gerald Oh, a Neurosurgeon with Southwest Healthcare System. Today, we're going to be discussing spine and back pain. Dr. Oh, welcome to the show.

Gerald Oh, MD: Thank you. Pleasure to be here.

Host: Let's start off. Let's get right into this. What are the most common causes, spine and back issues that people have? And how are patients typically presenting with that?

Gerald Oh, MD: I would say the vast majority of patients present with degenerative spine. And I would say that's the most common cause of back pain. And, there's different presentations. Some people present very acutely, meaning they're doing something, they get injured, they herniate their disc, and then they show up in the ER.

And then they have severe pain just radiating down the leg, you know, they'll come and they say, I can't walk, my leg is numb. So, at that point, we will get an MRI and evaluate them.

Host: So when you talk about degenerative issues, we're talking about arthritis, good fashioned arthritis for most people. There may be other reasons for that. What's really going on? What's causing the pain, though? Why do we feel that pain going down our leg, for instance?

Gerald Oh, MD: Right. I mean, so, I do want to add the vast majority of patients don't have this acute pain. A lot of times it's more of a chronic type of pain. So, it's something that happens over years. And I think that's where we have to kind of go back and see, okay, so what are the pain generators in the spine?

So in the spine, you have the vertebrae, and then you have the discs in between the vertebrae. You have these facet joints, which are the joints that lock one level to the next. And all those can be pain generators. So, you know, it's one of those things where if someone comes in and they're saying, you know, I've had this pain for years and, the pain's just progressively getting worse, then, it's more of an insidious process.

And we have to look back and again, get some imaging and, look at where exactly the pain is being generated from. So, there's something called discogenic pain. There is pain that could come from micro instability. So maybe the facets, pain can come from the facets. Pain can come from the muscles and those are the things where at times it's very difficult to try to tease out and see where the pain's coming from.

Host: Yeah, so it's like, is it a muscle issue, a tissue issue, an actual spinal nerve issue? These are the things you kind of have to work through. Let me ask you this. I'll give you my story and you tell me if this is common, Dr. Oh. So for me, I started getting dull, kind of pain in my lower back. Let's say this was going on for maybe five, six, seven years, nothing crazy, right?

It wasn't so bad. But maybe take ibuprofen. Once in a while, I was fine. And then one day, get into my mid 50s, I'm playing pickleball with my sisters, and went for a shot, stepped wrong, and then there was intense pain down my leg. And then I went in and realized I had bad arthritis in my spine. Is that common?

Gerald Oh, MD: That, is also common. We also see that a lot. So, it could be from pickleball or it could be from a car accident. Right? So, they've had arthritis for a long time, and then all of a sudden something happens, some kind of an acute event or trauma, and now all of a sudden, they're having this horrible back pain.

But again, these patients might show up in the hospital, and they're in this acute type of inflammation or flare up. And we have to take a step back and just evaluate the whole picture and see, okay, is this an acute disc herniation? And that's something called neuropathic pain. When basically something has herniated out, it's compressing the nerve root and then you get this sharp, what most patients, think of as sciatica is where you get this sharp pain that radiates down the leg. But the vast majority of patients, I would say, present with like I said before, more of an insidious type of back pain that's been going on for years, maybe progressing, they've tried the physical therapy, they've tried some injections, it's not working. And that's the point where they would come back and see us and try to get a more, see what other options are.

Host: Yeah, so you're a Neurosurgeon, your expertise is actually in surgery. How do you decide between somebody who, yeah, this person needs that surgery or this person maybe can go down the medical route of therapy?

Gerald Oh, MD: So, again, it goes back to how long they've had the symptoms for. We kind of divide, you know, acute and chronic symptoms. Anything, I would say, less than six weeks, we would consider acute. Anything more than three months I would say is chronic. I would not operate on anyone who's had back pain for less than six weeks.

But, anyone who comes to me and says, I've had pain for more than three to six months, it's horrible, it's severe, it's debilitating. It's affecting my quality of life. I've been sent to the physical therapist and the pain doctors. I've had injections, multiple injections, and nothing seems to be helping.

That's the point where I would start to consider doing surgery. The other consideration is if there are red flag symptoms. So, those are patients who come in with bowel bladder dysfunction, saddle area numbness. They have a motor deficit, so they get a foot drop all of a sudden, or they're numb down the leg.

So those would be patients where I would say, okay if I saw them in the hospital, I would do the surgery immediately. So, that's a different bucket that I would put the patients in, but the vast majority of patients, I would definitely try non operative management for at least six weeks, maybe even three months or so before considering surgery.

Host: You mentioned physical therapy, so I would assume, the non surgical side of this might include a lot of physical therapy. How does that compare to surgical interventions, maybe medical interventions in managing the pain?

Gerald Oh, MD: I mean, you're asking a surgeon. So for me, surgery is a cure for everything, right? I'm totally kidding. But there is some bias there because every patient that I see in the clinic, they've already been through the physical therapy and most of the patients will tell me physical therapy has not been very helpful.

This is from my perspective. I think, generally speaking, if you look at the literature, physical therapy is very effective. And this was proven in one of the biggest landmark papers in spine it's called the SPORT study. And they followed these patients for many years and they found that for these lumbar disc herniations whether they had surgery or didn't have surgery; their outcomes were pretty similar. The patients who had surgery did a little bit better in almost every category. But really, that proves that physical therapy is very effective and that even with pretty large sizable disc herniations, people can do pretty well without the surgery, but it's very tough for some of these patients because they're in so much pain during that time, they just cannot tolerate it.

Host: Right, understood. So there is a place for it, but from your perspective, surgery, as you said, had better outcomes in many different measurements, so let's get into the surgical part of this. What are some of the latest advancements in surgical treatment.

Gerald Oh, MD: So there are a lot of advancements these days. It's more along the route of minimally invasive surgery. Minimally invasive surgery has been around for a long time. We've been doing discectomies through a tube for a while. Now there's endoscopic surgery. People are getting more into robotics. So there has been a lot of advancements, but at the same time in neurosurgery, I think we're still doing the vast majority of surgeries the more traditional way. And I think there are many reasons for this. Obviously the brain and spine are very sensitive areas to be operating in. So it's, at times difficult to be super innovative and take these chances on your patients. You know, and the other part of that is a lot of neurosurgery is performing decompressions and stabilizations.

So, minimally invasive surgery is great, but a lot of times you just have to get in there and take a look yourself, and do a direct decompression. You have to get in there and take the pressure off the nerve root. And a lot of times when you do minimally invasive fusions, you're doing more of an indirect decompression where you're putting spacers in there to give it some more room, but you're not really taking a good look inside.

So I think there's a place for MIS surgery. I also do that as well, but still, I think, in the field of neurosurgery and spine surgery, the developments are very gradual.

Host: Right. Understood. Yeah, but maybe there's still some hope in the minimally invasive. Overall, I think as a surgeon, you agree that the less invasive you can be, you see that's a pretty good thing. But we understand you're dealing with, as you said, brain and nerves, very delicate. You have to be careful how you use those advancements.

What about recovery? Are there any advancements there? Is there anything new going on there? So maybe people can get back to their, as best they can, their normal functional life?

Gerald Oh, MD: Yeah, I mean, as far as recovery, we try to get patients on their feet as soon as possible. So now, we're pushing patients to be up on their feet and work with a physical therapist day zero, post op day zero. And then we try to get them to be as active as possible. Obviously when there's different types of surgeries. I mean, we can do discectomies where patients go home the same day and they're at home the same day.

But when we're doing these longer segment fusions, obviously we want to be more careful, not to push them too early, but at the same time kind of want them to get up and, be as active as possible without hurting themselves or disrupting the construct.

Host: So let's talk a little bit about some of the general practitioners because a lot of people that's their first step, right? That's who they're seeing is their family doctor, their internist, what have you. How can those kind of doctors best support their patients in managing chronic back issues outside of seeing someone like you?

Gerald Oh, MD: Right. I think really it goes back to the basics. I mean, there are so many fancy things that patients hear about nowadays and, stuff that I don't really want to mention, but they come in and they ask me about these different treatments or, you know, medications and things like that. But it, always goes back to the basics, you know, healthy lifestyle, healthy diet, keeping the weight off.

And people talk about exercising your core and I think that's very important, but when people say core, they always think it's just the abdomen, but it's really your back muscles, like getting on the Roman chair and doing like those reverse sit up type of activities. I always tell my patients, that seems to work best for back pain. So, for me, I think that's what the primary care doctors, that's the way they can really contribute to this back pain epidemic and help their patients out. Secondly, I think, you know, before they send their patients to the specialist, just being able to order the right tests, MRIs, bending x-rays, send them to the physical therapist, send them to the pain doctors, make sure they get at least six to eight weeks of these non operative treatments. And by the time they see us, then these patients will be ready for the next step. So that would also be very helpful as well.

Host: Dr. Oh, as you know, in today's world there is a doctor called Dr. Google which people go online and ask questions and with AI, it's even exploding. Are you worried about certain myths and stuff kind of getting out there in the general population about back pain? What are some of those myths you're a little concerned about when people are out there kind of trying to, I guess self-diagnose these days.

Gerald Oh, MD: I think the biggest thing for me is I want the patients to make sure that they're doing the right thing, right? And what I mean by that is they're not going on bed rest or avoiding the activities that they enjoy doing, because they think that they're somehow handicapped or they shouldn't be doing these things because they're going to be hurting their back.

I think in general, that does more harm than good when patients just stop being active, they stop exercising, they're on bed rest. Now, sometimes you can't help it because they're in so much pain, but a lot of times that just leads to this kind of downward spiral where they're inactive, they gain weight, the more weight they gain, the more back pain they have.

And then, the less active they become and the more weight they, you know, so I think it's one of those things where if that's what's going on, then, go see your doctor, get the imaging that you need to get, and that way you'll have the peace to go out and live your life and do what you need to do.

And, if you can't do that, then that's when you need to go see a surgeon, right? If, I'm not advocating surgery within the first six weeks or even six months, but if it's one year, two year, and you're really starting to lose your quality of life, then I think at that point you need to consider it.

Host: Dr. Oh, you've made it very clear that there are therapeutic steps that can be taken first before surgery. And I think that's important. And as far as the trends and Dr. Google and all that kind of stuff, if you see, like for me, as I, if you see something that's interesting, talk to your doctor first, right? Just have a conversation and see if that's going to work. So Dr. Oh, let's end this. And, I always kind of like to end this way, by the way, what's the take home message you would like the listeners to know about neck, spine, back pain?

Gerald Oh, MD: I would say the take home message is, I always tell my patients, I would like them to live healthy and try to avoid surgery if possible. That's my first priority. But you know, like I said, if there's real pathology there and it's causing true disability, then go see your surgeon and see what your options are.

But make sure you know all your options, right? There are surgeons who only do certain types of surgeries and don't be pigeonholed into only that type of surgery. So make sure you know all of your options. I don't think, you know, searching on YouTube or Google is a bad thing. I think there's a lot of good information there, but make sure, you confirm that information with a doctor that you trust.

And I do want to say that just in this area, we, serve mainly the Temecula Murrieta area, and I'm in a practice here with two other neurosurgeons who collectively have about 50 years of experience and pretty much any kind of spine pathology you know, we can handle in this area.

So, it's a pretty exciting time. The population is growing here, and we're in the midst of basically, trying to get a advanced certification for our hospital. So, that's my plug for our, our hospital system here. So.

Host: Yeah. Fantastic, Dr. Oh. Thanks for coming on today. This is a really great conversation.

Gerald Oh, MD: Thank you for having me. I enjoyed it.

Host: For more information, please visit swhealthcaresystem.com. That's SWhealthcaresystem.com. Physicians are independent practitioners who are not employees or agents of Southwest Healthcare System. The hospital shall not be liable for actions or treatments provided by physicians. I'm Dr. Mike. Thanks for listening.