Joey Wahler (Host): It's an advancement that's becoming more widespread throughout the medical world. So, we're discussing the use of robotic-assisted surgery in urologic care. Our guest, Dr. Stephen Mannas, he's a urologist at San Juan Health Partners Urology.

Host: This is Celebrate health, a podcast from San Juan Regional Medical Center. Thanks for listening. I'm Joey Wahler. Hi, Dr. Mannas. Thanks for joining us.

Stephen Mannas, MD: Hi, there. Not a problem.

Host: Great to have you with us. So first, can you tell us a bit about where you're from originally and what road you traveled to wind up in your current position?

Stephen Mannas, MD: Yeah, absolutely. first off, thanks for having me. I think this is great that we're able to do this. So, I grew up in a small town in Oklahoma called Ardmore, kind of right between Oklahoma City and Dallas. And I kind of always knew I wanted to be in medicine and ended up going to Notre Dame for undergrad and then back to Oklahoma City at OU for both medical school as well as residency. And then, I've got some family that are all originally from Oklahoma, but have kind of moved out this direction to New Mexico, in the Four Corners area. So, I had family close by and ended up here this past summer. So, that's kind of how we got here.

Host: And doctor, you've also got your brother, Daniel, who's a urologist, and your wife Maureen, who's a general surgeon, all of you working at San Juan Regional Medical Center. What's it like having it all in the family, literally?

Stephen Mannas, MD: Oh, it's certainly very interesting. You know, my brother being out here for the last seven years along with our third partner, Chris Taylor, was a big reason why we ended up here in Farmington. And then, yeah, having a wife in surgery as well is great. You know, it means I do my own laundry. But aside from that it's been great. We're always on the same page. We've met in med school and has kind of gone through this path together. So, I think it's been good for the community, but it's been certainly wonderful for us.

Host: That's awesome. Now, is your brother a surgeon or just your wife?

Stephen Mannas, MD: Both of them. So yeah, Daniel's a urologic surgeon like myself and then, Maureen, of course, is a general surgeon.

Host: So, three surgeons in the immediate family, which begs the obvious biggest question of all, doc, which of the three of you has the steadiest hand in the OR?

Stephen Mannas, MD: If I was going for just steadiest hand, probably my oldest brother, Jonathan, who's a neurosurgeon in Lubbock. So, there's unfortunately a fourth.

Host: Unfortunate for no one. That's even more awesome. You've got a brain surgeon as well. Any rocket scientists in the family?

Stephen Mannas, MD: Fourth is an engineer. But I think he stopped just short of rocket scientist, unfortunately.

Host: Wow. Well, I think the Mannas parents and extended family have an awful lot to be proud of there.

Stephen Mannas, MD: Well, we did all right.

Host: So, a Notre Dame grad and with all the hitting the books that a future doctor must do, did you have much time to go and see some Notre Dame football?

Stephen Mannas, MD: Yeah, absolutely. I made plenty of time for football. A lot of great memories there. And, you know, my senior year was actually the year we got absolutely trounced by Alabama in the championship game, so really good year up to that point, but definitely a lot of great memories.

Host: Well, that's okay because Bama coach, Nick Saban, will never be able to practice medicine, so I think you got the last laugh.

Stephen Mannas, MD: Yeah, maybe in that regard.

Host: In any event, how about for those unfamiliar, can you explain why robotic surgery is so beneficial to both the patient and for doctors like you as well?

Stephen Mannas, MD: So, there's a lot of different reasons for the patient. Basically, I think to understand why it's so beneficial, may help to kind of back up and explain exactly what robotic surgery is and how it works. Basically, it's kind of an advanced form of laparoscopic surgery. So instead of making a big open incision like we used to, we make several very small incisions. And we put ports through those incisions, we fill the abdomen up with air, and then we're able to go in with a camera and instruments to do the surgical work. The difference between laparoscopic surgery and robotic surgery is that, from that point, it's actually a robot that's controlling the instruments locally with the patient, whereas the surgeon is at a separate console in the same room controlling the robot. So, there's kind of an added step there. But what that allows for is better visualization. We have 3D visualization in the console as well as much improved kind of manipulation and dexterity with the instruments from a robotic standpoint.

So with all that in mind, what that means is it's much less invasive surgery for patients. So, it's less pain, shorter hospital stays, quicker recovery. And most importantly, it often means a better quality surgery. So, you know, I always tell my patients the best surgery is the one that your surgeon is most comfortable with. And certainly this younger generation, especially of urologists, we're trained almost exclusively on the robot. And that's where we're comfortable and that's where, you know, if we're removing a cancer, for example, we have the most confidence that we're going to get everything out and give you the best possible procedure. That's the patient's standpoint.

From a surgeon's standpoint, all those benefits are kind of what I already touched on. It's what we're comfortable with for training. It's what we have better dexterity with. And that leads into, I think, a third benefit, you know, patient surgeon, but also I think a broader benefit to the community, especially here in Farmington. Because what it means is Farmington and San Juan are going to stay competitive in recruiting young physicians going forward that are trained on this technology and practice in the way they were trained. So, it means getting to do these bigger surgeries here in our community, not having to send those off elsewhere, being able to continue to recruit young physicians moving forward.

Host: Gotcha. So, I'm going to ask you about particular procedures that you apply this to in a moment. But first, just to follow up on one or two things you mentioned a moment ago, you talked about some of the benefits of robotic-assisted surgery. How about being able to be more precise? I always hear surgeons like yourself talk about that as such a big advantage from your standpoint, and then of course, through osmosis, for the patient as well. Why is that so important?

Stephen Mannas, MD: Because what we do is inherently very high risk. You know, we do it a lot, we have excellent training, so we're very confident in what we do. By the time we get to this point, I think everything's very safe. But the robotic improvements certainly contribute to that safety.

We're going to talk about specific surgeries it sounds like here in a little bit, but just to kind of briefly touch on that, there are times where maybe an adrenal tumor or a kidney tumor where it's really important that you don't get into that tumor and they're very sensitive. And if you just kind of look at them wrong, they might rupture or spill tumor, things like that. It's very important that you have good dexterity and that your instruments do exactly what you want them to do. You always hear about surgeons talking about like, "Oh, you can't shake and be a surgeon." And to an extent that's true, but everyone has some degree of a tremor. And if you've, you know, had a long night on call and you're drank a little coffee, doing a big open surgery, that can contribute.

One of the things about the robot is it eliminates any tremor. It negates that. And then, you're, again, working on a much smaller scale, even though it's significantly magnified, so it doesn't feel like that. So, working around tumors, working around big blood vessels, those are high risk things that can be dangerous. So, to know that you have absolute control over what's going on provides us with a lot of confidence and obviously contributes to patient safety.

Host: Wow. So, it actually eliminates tremors so that if you have one, it's really like you don't, huh?

Stephen Mannas, MD: Oh yeah, it's kind of like cheating.

Host: It sounds like it. So, let's get to some of those procedures. In urology, where are you and yours using robotic assist the most?

Stephen Mannas, MD: So, I think the single most significant surgery that it's revolutionized within urology is for prostate removals, specifically for prostate cancer. And that's because you can imagine the prostate is located just beneath the bladder, it kind of wraps around the urethra. Well, that's really deep in the pelvis. You know, that's basically an area that's very small. It's surrounded in the bony pelvis. So, the old days where you're doing surgery, that's a really hard area to access. And moreover, when you remove it, you have to sew the urethra back to the bladder, which is a very intricate procedure. So, doing that when you're kind of working in a hole, it's a challenge. With the robot, the camera's pushed right up to where you're working, it's magnified, again, the instruments that you work are on a smaller scale, so it's a huge benefit in that regard.

But then also, we do different procedures for like kidney cancers, for example, removing kidneys or removing parts of kidneys. Again, you're working around major blood vessels when you do that, so having that improved visibility, that plays a role there. And then, some other common procedures we do, different reconstructive things like reconnecting the kidney tubes that drain into the bladder to the bladder if there's an obstruction, certain procedures for prolapse in women, those all have a role for the robot certainly.

Host: Now, you're trained in da Vinci robotic-assisted surgery, which is the gold standard equipment-wise, from what I understand, in that industry. So, can you tell us, doc, what that is exactly and what kind of training do you need for it?

Stephen Mannas, MD: So, there's two components to the robot. There's the component that is basically what we call docked to the patient. So, we place ports in the patient like you would for laparoscopic surgery, and then we have this component of the robot that we wheel in and it controls the instruments that are mounted to those ports. It kind of almost looks like big spider arms. It's kind of an interesting looking device because it controls multiple instruments at a time. You know, you're controlling a camera, usually three different instruments beyond that. So, there's that component. But then, there's also a monitor that we kind of put our head into, usually kind of tucked in the corner of the room that gives us that 3D display. And then, you know, there's little hand controls that mimic not only grasping or moving your hand, but also mimic wrist articulation, which when you stop and think about it, your wrist can bend and rotate in all sorts of different manners. So, it being able to replicate that is very important. And then, foot controls for, you know, sometimes you have to burn something or you may have to adjust your camera. And so, you're working with both your hands and feet simultaneously. So as you can imagine, that takes a lot of training, usually done in residency to both understand how to properly use the robot from the console standpoint, but also how to dock it to the patient, set the instruments up in a way that they're spaced appropriately. So, you have good working room. There's just a lot of fine details that go into it that, you know, can take years.

Host: I'm sure. Couple of other things. It's called robotic-assisted surgery, but is it important to note as well that robots haven't exactly taken over our operating rooms here? It's still experienced, well-trained surgeons behind their use, right?

Stephen Mannas, MD: Absolutely. Yeah. The robot's only doing what we-- I don't want to say tell it to do-- but in a sense that, you know, it's mimicking our controls. And interestingly, a lot of the technology was actually developed for the Army basically, so that on a battlefield, that's obviously a dangerous location, you could do surgery on, say, a soldier who's wounded and the surgeon can be somewhere else entirely, some safe environment where they're controlling the robot. And what they found was there's application in that regard, but really this is just a better surgical system for a lot of procedures. Even without the need to be in a separate location, it's still very beneficial. And that's something I stress to my patients, is I'm not right at the patient's side while I'm doing the surgery, but I'm still right there in the room. If there's an issue, the surgeon's in control at all points, a hundred percent for sure.

Host: Definitely an important part of it all to point out right there. Finally, how about if someone listening is considering robotic surgery for a urology condition, what would you tell them?

Stephen Mannas, MD: So, I tell them that we have a lot of evidence for the success at this point. It's cutting edge in the sense that it's still relatively new technology and it's certainly very impressive technology in that sense. But it's got years of training for surgeons at this point. It's very well established. Again, it's pretty much the baseline for training for all urologists going forward, and that's for a reason. It's because we're very comfortable with it. It's very well established. And while it may be something new for patients in a lot of instances, it's not something new to medicine, it's not an experiment and it's something that I think they can be very confident in.

Host: Well, folks, we trust you are now more familiar with robotic surgery in urologic care. Dr. Stephen Mannas, thanks so much again.

Stephen Mannas, MD: Thank you. I appreciate you having me.

Host: Appreciate you being up. And to learn more about the services available at San Juan Health Partners Urology, please call 505-609-6380. Again, 505-609-6380. If you found this podcast helpful, please share it on your social media. And thanks again for listening to Celebrate Health, a podcast from San Juan Regional Medical Center. Hoping your health is good health. I'm Joey Wahler.