Robotic Surgery Advancements in Urology
Dr. Peters discusses the cutting-edge robotic surgery procedures offered to urology patients at Children’s Health.
Featured Speaker:
Dr. Peters is on a mission to make surgery faster, easier and less scary for his patients. He joined Children’s Health in 2015 and spearheaded our robotic surgery program, where doctors use a robotic surgical system to make surgery more accurate and precise. Every surgeon in this program is certified in the da Vinci Robotic Surgical System, which is one of the most advanced robotic systems available today. This minimizes complications and helps many children recover faster.
Dr. Peters and his colleagues perform some of the country’s highest numbers of laparoscopic and robotic surgeries for pediatric urology conditions. Laparoscopic surgery uses tiny instruments and a camera to perform operations through small incisions. This means less-noticeable scars, less pain and a shorter hospital stay.
Dr. Peters has helped define best clinical practices in pediatric urology and led the writing of the most recent guidelines in managing vesicoureteral reflux, a common urological condition in children. He has also been an advisor to the NIH and the American Urological Association. He is also the pediatric editor of the premier Urology textbook.
Dr. Peters earned his medical degree from John Hopkins University. He completed his urology residency at the Brady Urological Institute at Johns Hopkins and did fellowship training at Boston Children’s Hospital and Harvard Medical School.
He lives in Dallas with his wife of 35 years and enjoys cycling vacations with his family.
Craig Peters, MD
Craig Peters, M.D., treats children with urological problems and specializes in urinary tract infections, fetal urology and minimally invasive surgery. He is the Division Director of Pediatric Urology at Children's Health℠ and a Professor of Urology at UT Southwestern Medical Center.Dr. Peters is on a mission to make surgery faster, easier and less scary for his patients. He joined Children’s Health in 2015 and spearheaded our robotic surgery program, where doctors use a robotic surgical system to make surgery more accurate and precise. Every surgeon in this program is certified in the da Vinci Robotic Surgical System, which is one of the most advanced robotic systems available today. This minimizes complications and helps many children recover faster.
Dr. Peters and his colleagues perform some of the country’s highest numbers of laparoscopic and robotic surgeries for pediatric urology conditions. Laparoscopic surgery uses tiny instruments and a camera to perform operations through small incisions. This means less-noticeable scars, less pain and a shorter hospital stay.
Dr. Peters has helped define best clinical practices in pediatric urology and led the writing of the most recent guidelines in managing vesicoureteral reflux, a common urological condition in children. He has also been an advisor to the NIH and the American Urological Association. He is also the pediatric editor of the premier Urology textbook.
Dr. Peters earned his medical degree from John Hopkins University. He completed his urology residency at the Brady Urological Institute at Johns Hopkins and did fellowship training at Boston Children’s Hospital and Harvard Medical School.
He lives in Dallas with his wife of 35 years and enjoys cycling vacations with his family.
Transcription:
Robotic Surgery Advancements in Urology
Bill Klaproth (Host): The Children’s Health Minimally Invasive and Robotic Surgery Center is one of the few centers in the country that uses minimally invasive surgery for complex urology conditions in children. So, let’s learn about the history of robotic surgery in the Urology department, the different types of robotic surgeries performed and why robotic surgery is a value to patients and their families. This is Pediatric Insights Advances and Innovations with Children’s Health where we explore the latest in pediatric care and research. I’m Bill Klaproth. With us to discuss robotic surgery advancements in urology is our expert, Dr. Craig Peters, Division Director of Pediatric Urology at Children’s Health and Professor of Urology at UT Southwestern Medical Center. Dr. Peters, thank you so much for your time. So, I know Children’s Health offers the only dedicated pediatric robotic surgery program in north Texas. Can you talk about the history of robotic surgery in the urology department and when and how it first began?
Craig Peters, MD (Guest): Sure. The hospital acquired one of the Da Vinci systems about eight years ago, so in about 2012 through a very generous grant from the Dekelboum Foundation and since at that point, urology was the principle user in pediatric applications, the pediatric urologists who had done quite a lot of laparoscopy here Dr. Linda Baker, chose to start the program and I actually came here long before I joined Children’s to mentor her in her first cases and help the team get started. So, I came in 2008 and we spend two days doing cases and I was working with Dr. Baker and her team to understand the principles, how the workflow goes, room set up, equipment use and patient positioning and a variety of the other sort of nuances of this since at that point, I’d been doing robotic surgery for about a decade and was asked to do mentoring type visits periodically for programs that were starting up their initiative.
From there, the program continued to grow both with Dr. Baker and subsequently several others of the faculty gained experience with the robot and applied it in a variety of situations which we can talk about later.
Host: So, you’re extremely versed in robotic surgery. So, then what types of robotic surgeries do you offer to urology patients and how do these procedures set Children’s Health apart?
Dr. Peters: At this point, and this has evolved. We started this is 2002, so 18 years. Robotic surgery for pediatric urology really focuses heavily on kidney surgeries. Typically patterns of obstruction or malformation that affect how the kidney can function and drain. We also can do procedures on the bladder and this has to do with either structural abnormalities or functional abnormalities that can create problems with kidney function, drainage or urinary tract infections. We also can do a variety of reconstructive types of procedures in the pelvis which can be very difficult to reach with convention open surgery as well. We’ve done a number of other types of less common procedures in a way to try to figure out what the applications are and where there’s a real advantage.
There are a variety of other smaller things that can be done as well. A number of years ago, we pioneered in children using the robot to actually remove very large kidney stones and this is an uncommon need. But it does happen and for unusual situations, it’s perfectly adapted to particularly the situation where there’s an obstruction of the kidney and subsequent kidney stones.
Host: So, when it comes to robotic surgeries and you were mentioning kidney surgeries, bladder surgeries, reconstructive surgeries; are there any preferred tools or methods specific to the team?
Dr. Peters: There is a nice method that was originally conceived of by Dr. Patricio Gargollo when he worked here. He is now up at Mayo Clinic, where he put the small little incisions through which we place the ports that the instruments and camera go through to go inside the body; and he put them all below the bikini line so it hid the incisions and so he called this the Hides technique for hidden incision for certain types of procedures. This was a kidney procedure.
One of our current faculty members Dr. Jacobs, adapted this to bladder surgeries so after we are done, you wouldn’t see the incisions in someone wearing a bikini. And this has a way of reducing at least the visual impact of any scarring. The other tool that we’ve recently adapted using is a different kind of insufflation which means how we put gas into the abdomen which gives us a working space through which we can do out procedures and this is a common maneuver done for lots of surgeries that are done laparoscopically or with the robot. Many people will be familiar with this through a laparoscopic gallbladder removal. But this insufflation technique which is relatively new and has not been used much in children allows us to maintain the visual field that we need for surgery without posing a significantly high pressure on the abdomen. And it avoids some of the other issues that we sometimes have with this technology including fogging of the lens, or smoke in the field that impairs visualization. So, this technology called the flows AirSeal is a nice adaptation that we’ve recently started using.
Host: So, you were just talking about several techniques and advancements. Can you talk about why you feel robotic surgery is of value to patients and their families?
Dr. Peters: Sure. A lot of people focus on the fairly simplistic concept that it’s small incisions. I think that’s part of it, but it misses some of the key elements, and visualization, I think, is one of those. We can do the sorts of surgery that we are doing robotically through small incisions in children, but you limit your visual field. And one of the key principles of surgery, no matter how you do it, is exposure. If you can’t see where you are working, you run the risk of either missing something that’s relevant, injuring something that you didn’t see or didn’t realize was close by or not being able to really appreciate the pathology that you are trying to repair.
So, the beauty that I see, even in a very small child, and I use the robot in kids as small as five kilograms and you can do even smaller if you need to; I can still see a wide area around the kidney or the bladder or the pelvis so that I have a whole visualization of the context of the operation without making a big incision. And I think, and I certainly have had multiple cases where that has a clear role and a benefit in terms of the outcome of the surgery; allowing me to appreciate differences or variations in the anatomy or the pathology that we’re dealing with.
Host: Always beneficial for sure. So, then can you talk about the outcomes of robotic surgeries at Children’s Health and how you envision robotic surgery evolving in the future and how you and your staff are going to teach this to future generations?
Dr. Peters: Well our outcomes have been consistently good. We do periodically assess them. I think it’s critically important, particularly in the evolution of a new technology, that we know how we’re doing. Patients typically for a kidney operation, go home the next morning. For bladder operations it’s the same thing when usually they would be in the hospital two to three days in the past. The overall results seem to be very good. In our published papers, we shown equivalent results to conventional open surgery that we’ve been doing for decades in terms of success of either correction or obstruction or prevention of infection or correction of a anatomic abnormality.
Parents seem to be very pleased with it. They like the fact that there’s not a big incision. They like the fact that the child can go home relatively quickly and get back to normal activities pretty fast. But most importantly, they want to be reassured that the outcome is going to be equal and it’s hard to prove better because our success rates are in the high 90% for most of these procedures no matter what technique you use. But we’re reducing the morbidity and maintaining the satisfactory outcome.
Now, part of that is looking at evolution of the system just as you mentioned. I think this is in essence, a first generation of robotic surgery. And the directions that I see it going are going to be progressive integration of information. This is a digital platform. Therefore, we can integrate digital information, which is imaging, which is positional location, which is movement, which is pressure, a variety of other ways of interacting with the patient and their tissues and knowing where we are going to be. So, we ultimately, in the future, and this is not something we do regularly now; we should be able to take preoperative imaging and use that to guide where we go, to guide the instrument and to guide our activities.
There is some research being done on supervised autonomous robots so that the robot knows what you want to do and can do it more precisely, potentially more efficiently than the human hand. We’re not there yet. But ultimately, we should be. And we can record all of this and ultimately, I think we need to figure out systems to learn from how we’ve done it so that we continue to improve. And that, being able to see what we’ve done, understand it, register it and improve from it; also integrates with our educational program and that’s something that I fell very strongly about as well. That it is a major obligation of ours to teach our next generation of surgeons about this and to make sure that they continue to improve it as they develop.
And so, we teach this to our Fellows. We have a Fellowship program in pediatric urology here that every year trains a new pediatric urologist and they all get extensive experience on the robotic system and are very comfortable with it. We train the residents, some of whom may go into pediatric urology but others in adult urology use the robot for a variety of surgical procedures. And we’re teaching very delicate reconstructive techniques. We also have other educational programs here at Children’s UT Southwestern including work with the simulation center and then myself and a number of our faculty also teach at both national and I’ve taught at international courses on robotic surgery to teach other practitioners about the basics and further applications and where this ultimately may go.
Host: That is really, really cool. With mentorship from people like you, and continual learning, training and teaching, it sounds like we certainly will equip our future surgeons well. Dr. Peters, this has really been informative. Thank you so much for your time.
Dr. Peters: Surely. Thank you.
Host: That’s Dr. Craig Peters and thanks for listening to Pediatric Insights. For more information, please visit www.childrens.com/discoverurology. And if you found this podcast helpful, please rate and review or share this episode and please follow Children’s Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children’s Health. Thanks for listening.
Robotic Surgery Advancements in Urology
Bill Klaproth (Host): The Children’s Health Minimally Invasive and Robotic Surgery Center is one of the few centers in the country that uses minimally invasive surgery for complex urology conditions in children. So, let’s learn about the history of robotic surgery in the Urology department, the different types of robotic surgeries performed and why robotic surgery is a value to patients and their families. This is Pediatric Insights Advances and Innovations with Children’s Health where we explore the latest in pediatric care and research. I’m Bill Klaproth. With us to discuss robotic surgery advancements in urology is our expert, Dr. Craig Peters, Division Director of Pediatric Urology at Children’s Health and Professor of Urology at UT Southwestern Medical Center. Dr. Peters, thank you so much for your time. So, I know Children’s Health offers the only dedicated pediatric robotic surgery program in north Texas. Can you talk about the history of robotic surgery in the urology department and when and how it first began?
Craig Peters, MD (Guest): Sure. The hospital acquired one of the Da Vinci systems about eight years ago, so in about 2012 through a very generous grant from the Dekelboum Foundation and since at that point, urology was the principle user in pediatric applications, the pediatric urologists who had done quite a lot of laparoscopy here Dr. Linda Baker, chose to start the program and I actually came here long before I joined Children’s to mentor her in her first cases and help the team get started. So, I came in 2008 and we spend two days doing cases and I was working with Dr. Baker and her team to understand the principles, how the workflow goes, room set up, equipment use and patient positioning and a variety of the other sort of nuances of this since at that point, I’d been doing robotic surgery for about a decade and was asked to do mentoring type visits periodically for programs that were starting up their initiative.
From there, the program continued to grow both with Dr. Baker and subsequently several others of the faculty gained experience with the robot and applied it in a variety of situations which we can talk about later.
Host: So, you’re extremely versed in robotic surgery. So, then what types of robotic surgeries do you offer to urology patients and how do these procedures set Children’s Health apart?
Dr. Peters: At this point, and this has evolved. We started this is 2002, so 18 years. Robotic surgery for pediatric urology really focuses heavily on kidney surgeries. Typically patterns of obstruction or malformation that affect how the kidney can function and drain. We also can do procedures on the bladder and this has to do with either structural abnormalities or functional abnormalities that can create problems with kidney function, drainage or urinary tract infections. We also can do a variety of reconstructive types of procedures in the pelvis which can be very difficult to reach with convention open surgery as well. We’ve done a number of other types of less common procedures in a way to try to figure out what the applications are and where there’s a real advantage.
There are a variety of other smaller things that can be done as well. A number of years ago, we pioneered in children using the robot to actually remove very large kidney stones and this is an uncommon need. But it does happen and for unusual situations, it’s perfectly adapted to particularly the situation where there’s an obstruction of the kidney and subsequent kidney stones.
Host: So, when it comes to robotic surgeries and you were mentioning kidney surgeries, bladder surgeries, reconstructive surgeries; are there any preferred tools or methods specific to the team?
Dr. Peters: There is a nice method that was originally conceived of by Dr. Patricio Gargollo when he worked here. He is now up at Mayo Clinic, where he put the small little incisions through which we place the ports that the instruments and camera go through to go inside the body; and he put them all below the bikini line so it hid the incisions and so he called this the Hides technique for hidden incision for certain types of procedures. This was a kidney procedure.
One of our current faculty members Dr. Jacobs, adapted this to bladder surgeries so after we are done, you wouldn’t see the incisions in someone wearing a bikini. And this has a way of reducing at least the visual impact of any scarring. The other tool that we’ve recently adapted using is a different kind of insufflation which means how we put gas into the abdomen which gives us a working space through which we can do out procedures and this is a common maneuver done for lots of surgeries that are done laparoscopically or with the robot. Many people will be familiar with this through a laparoscopic gallbladder removal. But this insufflation technique which is relatively new and has not been used much in children allows us to maintain the visual field that we need for surgery without posing a significantly high pressure on the abdomen. And it avoids some of the other issues that we sometimes have with this technology including fogging of the lens, or smoke in the field that impairs visualization. So, this technology called the flows AirSeal is a nice adaptation that we’ve recently started using.
Host: So, you were just talking about several techniques and advancements. Can you talk about why you feel robotic surgery is of value to patients and their families?
Dr. Peters: Sure. A lot of people focus on the fairly simplistic concept that it’s small incisions. I think that’s part of it, but it misses some of the key elements, and visualization, I think, is one of those. We can do the sorts of surgery that we are doing robotically through small incisions in children, but you limit your visual field. And one of the key principles of surgery, no matter how you do it, is exposure. If you can’t see where you are working, you run the risk of either missing something that’s relevant, injuring something that you didn’t see or didn’t realize was close by or not being able to really appreciate the pathology that you are trying to repair.
So, the beauty that I see, even in a very small child, and I use the robot in kids as small as five kilograms and you can do even smaller if you need to; I can still see a wide area around the kidney or the bladder or the pelvis so that I have a whole visualization of the context of the operation without making a big incision. And I think, and I certainly have had multiple cases where that has a clear role and a benefit in terms of the outcome of the surgery; allowing me to appreciate differences or variations in the anatomy or the pathology that we’re dealing with.
Host: Always beneficial for sure. So, then can you talk about the outcomes of robotic surgeries at Children’s Health and how you envision robotic surgery evolving in the future and how you and your staff are going to teach this to future generations?
Dr. Peters: Well our outcomes have been consistently good. We do periodically assess them. I think it’s critically important, particularly in the evolution of a new technology, that we know how we’re doing. Patients typically for a kidney operation, go home the next morning. For bladder operations it’s the same thing when usually they would be in the hospital two to three days in the past. The overall results seem to be very good. In our published papers, we shown equivalent results to conventional open surgery that we’ve been doing for decades in terms of success of either correction or obstruction or prevention of infection or correction of a anatomic abnormality.
Parents seem to be very pleased with it. They like the fact that there’s not a big incision. They like the fact that the child can go home relatively quickly and get back to normal activities pretty fast. But most importantly, they want to be reassured that the outcome is going to be equal and it’s hard to prove better because our success rates are in the high 90% for most of these procedures no matter what technique you use. But we’re reducing the morbidity and maintaining the satisfactory outcome.
Now, part of that is looking at evolution of the system just as you mentioned. I think this is in essence, a first generation of robotic surgery. And the directions that I see it going are going to be progressive integration of information. This is a digital platform. Therefore, we can integrate digital information, which is imaging, which is positional location, which is movement, which is pressure, a variety of other ways of interacting with the patient and their tissues and knowing where we are going to be. So, we ultimately, in the future, and this is not something we do regularly now; we should be able to take preoperative imaging and use that to guide where we go, to guide the instrument and to guide our activities.
There is some research being done on supervised autonomous robots so that the robot knows what you want to do and can do it more precisely, potentially more efficiently than the human hand. We’re not there yet. But ultimately, we should be. And we can record all of this and ultimately, I think we need to figure out systems to learn from how we’ve done it so that we continue to improve. And that, being able to see what we’ve done, understand it, register it and improve from it; also integrates with our educational program and that’s something that I fell very strongly about as well. That it is a major obligation of ours to teach our next generation of surgeons about this and to make sure that they continue to improve it as they develop.
And so, we teach this to our Fellows. We have a Fellowship program in pediatric urology here that every year trains a new pediatric urologist and they all get extensive experience on the robotic system and are very comfortable with it. We train the residents, some of whom may go into pediatric urology but others in adult urology use the robot for a variety of surgical procedures. And we’re teaching very delicate reconstructive techniques. We also have other educational programs here at Children’s UT Southwestern including work with the simulation center and then myself and a number of our faculty also teach at both national and I’ve taught at international courses on robotic surgery to teach other practitioners about the basics and further applications and where this ultimately may go.
Host: That is really, really cool. With mentorship from people like you, and continual learning, training and teaching, it sounds like we certainly will equip our future surgeons well. Dr. Peters, this has really been informative. Thank you so much for your time.
Dr. Peters: Surely. Thank you.
Host: That’s Dr. Craig Peters and thanks for listening to Pediatric Insights. For more information, please visit www.childrens.com/discoverurology. And if you found this podcast helpful, please rate and review or share this episode and please follow Children’s Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children’s Health. Thanks for listening.