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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

The University of Alabama at Birmingham, one of the nation’s leading hospitals in robotic surgery volume is enhancing its work in the field. Here to discuss the new single port robot as it relates to urology surgeries are my guests, Dr. Soroush Rais-Bahrami and Dr. Jeffrey Nix, and they are both urologists at UAB Medicine. Dr. Rais-Bahrami, I’d like to start with you. What was previously done for urologic issues? How have advancements in instrumentation given birth to the era of robotic laparoendoscopic single site techniques?

Soroush Rais-Bahrami, MD (Guest): So, there has been a clear progression from open surgical techniques to laparoscopic minimally invasive approaches and then with the advent of robotic technologies, robot assisted laparoscopic techniques and now with the newest single port robotic platform; we’ve minimized the number of incisions and the size of the overall incision burden to achieve the robotic approach to achieve a lot of the surgeries that classically would be done through larger incisions and open approaches when the patients are appropriately selected for these cases.

Host: And we’re going to discuss patient selection but before we do that, Dr. Nix, tell us about the new DaVinci SP single port surgical system. How is it going to change the landscape of urologic surgeries that you are doing at UAB and why the need for this?

Jeffrey Nix, MD (Guest): So, I think what you see with the single port system is a continued evolution of minimally invasive surgery. To piggyback onto what Dr. Rais-Bahrami has said, basic laparoscopic surgery in its inception was an incredible progress over open surgery but was very difficult to teach, very difficult to do, the instruments were unwieldy. This single degrees of freedom, very basic instruments have now progressed even in those approaches, but the technology has gotten better. Things have gotten smaller. The ability to minimize things has made trocars, our port, our incision site that might have been an inch before; now we can do them as small as five millimeters in terms of multiport incisions.

But still, if you were going to have a gallbladder removed; you might have three or four small incisions. If you were going to have your prostate removed; you might have four, five or even six small incisions. And so, you have a minimally invasive approach, but you still have multiple different wounds to heal from. So, the single port platform can take that down to one or two small incisions and again, for cancer surgeries like a lot of the procedures that Dr. Rais-Bahrami and I are doing; we are taking out tissue at the end of the case.

So, as an example, the single port platform fits through about a one inch incision. So, I can hide that incision in the belly button, and I can still get out the prostate through that one inch incision and minimize the morbidity to our patients. So, the biggest quest in terms of minimally invasive surgeons as an overarching theme, is can we do the same operation that classically would have been done through a large open incision, but can we do that through these small tiny incisions that maximize recovery for patients and minimize their morbidity.

So, we are trying to do the same operation or even do it better but doing it through less morbidity and so I think that’s what you see with this single port approach is another step in that evolution towards less and less invasivity as we improve our patient outcomes in terms of short term outcomes like time back to work.

Host: Dr. Rais-Bahrami, then tell us about patient selection and how important that is for this particular type of procedure. Who is it indicated for and who might it not be?

Dr. Rais-Bahrami: Well, currently in urologic surgery this has been used for a multitude of different surgical techniques. The single port robotic platform has been FDA approved first in urologic surgeries and has also been recently approved for transoral surgeries by our ENT colleagues nationwide as well.

In urology specifically, this new robotic platform has been used for cancer surgeries as well as noncancer surgeries done by urologic surgeons. I’d say at UAB, the majority of single port robotic cases have been done as prostate surgeries for an indication of prostate cancer or kidney surgeries with an indication of either kidney tumors being removed, kidney cancers being treated or in cases of urinary tract blockage where reconstructive surgeries have been done on the urinary tract between the kidney and the bladder along the ureters drainage tube.

Host: Dr. Rais-Bahrami so, what you were just speaking of is that what it is now, as of now FDA approved for and do you see that changing in the future?

Dr. Rais-Bahrami: As with the evolution of surgical technologies and surgical techniques that Dr. Nix nicely reviewed; as the robotic platform gets further tested and expanded, I do envision that the indications and the approvals will likely expand. Urology has been a leader among surgical specialties in terms of progressive minimally invasive surgeries and endoscopies historically and I think it is very fitting that the single port robotic platform which has a small profile entrance at the incision level but can reach into deep structures of the pelvis for example, things like prostate surgery or deep bladder or ureter surgery in the pelvis, it really provides an advantage.

That’s also seen by the second FDA approval for our ENT colleagues that do limited space surgery through a transoral approach that the single port robotic platform really allows us access to a small field that may be otherwise difficult and challenging to access. As Dr. Nix also mentioned, the conventional laparoscopy through multiple ports or even the robot assisted laparoscopy through multiple ports really requires triangulation and sometimes a different amount of space to actually access a focal point where we are operating deep either in the pelvis or our colleagues may be operating in the deep oropharynx or deep throat region.

So, this technology may really fit a niche that was otherwise very challenging even with other robotic and laparoscopic devices.

Dr. Nix: And I would like to jump in and add. There’s also the surgeon discretion to use these agents off label for indications that seem appropriate where the FDA has not yet approved specifically for an indication. We see that already in urologic surgeries. I mean when you have expert robotic surgeons using a platform that they are now very comfortable with; we see an evolution of that really quickly to using it for off label procedures like partial nephrectomies, removing a part of the kidney that has become cancerous which is not currently FDA indicated, but is an easy sort of way for us to innovate and use this in an off label indication for a tool that we have begun to master based on our use for other procedures.

Host: So, Dr. Nix, based on what Dr. Rais-Bahrami said, do you feel it hasn’t gained or has gained widespread acceptance and as he was mentioning, adequate triangulation and bedside assistant, wrist articulation. There’s all these technical considerations. What do you feel other providers are thinking of this particular type of procedure? And what about the learning curve? Is there a difficult learning curve for the use of the newer robots?

Dr. Nix: Yeah, I think you are going to see a cycle of innovation like you do with any new product. So, you are going to have early adopters that are going to come well before the remainder of the field, and I think that’s what you see at UAB. I mean, there are currently about 15 platforms in existence in the US and in our utilization here, I’m one of the highest volume users in the world. So, we are early adopters of this technology. It is a different tool and it does have a learning curve associated with it and we’ve been, Dr. Rais-Bahrami and I have been involved in testing this tool at different trips out to the corporate headquarters for well into six to eight months before the platform ever became available.

So, in lots of different ways, you are going to see interest grow in our field as this becomes more mainstream and this is what if you go back and look at the history of multiport robotic surgery; it’s what you saw in that as well. You have early adopters and then you have the rest of the field take off. What I will tell you and what Dr. Rais-Bahrami I hope would echo, is that this is a very, very good technology. And when you see tools like this as early adopters come out that are good, then you know the rest of the field will eventually adopt it. It’s just a matter of time.

An example of where that wasn’t necessarily the case is with single incision laparoscopic surgery or SILS, there were different mnemonics for this but when that came out when Dr. Rais-Bahrami and I were both in training; it was incredibly difficult, incredibly arduous to use and it died out pretty quickly. So, those early adopters who were involved in single incision laparoscopic surgery without the advent of all the technology that we have now with the robotics; you saw this die out pretty quickly because it wasn’t – it just wasn’t ready.

What we’re dealing with here and this technology is technology that has evolved significantly to allow the user to adapt it pretty quickly to their expertise and to their comfort level from the previous surgical platforms. And so I think you will see this continue to evolve as hospitals become more and more interested.

Host: Dr. Rais-Bahrami, are there still clinical questions surrounding its use and is this technology superior to another? Does it improve clinical outcome compared with standard laparoscopy? Kind of summarize it for us and what you guys are seeing as outcomes now.

Dr. Rais-Bahrami: I think those are very valuable questions and questions that Dr. Nix and I and the rest of our clinical research team in the department of urology are actually investigating as we speak. As we have developed the program for the single port robotic surgical techniques in our department; we are actively acquiring data on out clinical outcomes and comparing them not only to historic data but our own series of multiport robotic procedures as well as laparoscopic and even open procedures that have been historically understood to have a certain rate of complications or a certain rate of hospital stays postoperatively as patients recover to try to evaluate just those questions. To see if this is improving overall patient outcomes from a population standpoint.

Now, from personal anecdotal experience, and I believe Dr. Nix has seen the same thing; this has really provided a lot of patient satisfaction where patients and their families are astounded by the fact that perhaps a radical prostatectomy can be done through an inch long incision that significantly can be hidden within the patient’s umbilicus or belly button with perhaps one additional small incision for a laparoscopic trocar site for our bedside assistant.

A number of patients have mentioned after their procedures as they have come back for postoperative follow-up checks how straightforward the recoveries have been and how minimal narcotic or other pain medicine requirements they’ve had since the surgery and how quick their recovery has been. We recognize that this is all anecdotal, but we are currently investigating on sort of methodical way whether or not this proves to be the same or significantly better compared to our standard approaches that we had before we adopted this technique.

Host: Thank you for clarifying that. This is such an interesting topic and an interesting time to be in your field. So, Dr. Nix last word to you here. Tell other physicians what you would like them to know about what you are doing there at UAB, when you feel it’s important to refer and maybe where you see this field going, what you see going on in the next ten years.

Dr. Nix: Yeah, I think the overarching theme I’d like to sort of express is our continued continuous continual desire to evolve surgery. We won’t rest. We won’t stop. We want to continue to do the best thing possible for patients and part of that requires a constant desire for innovation. So, the field of robotic surgery or minimally invasive surgery will only grow more complex and there will be more players in the field with more different opportunities. And so, we need to be at the front edge of that curve, trying to figure out where the innovation exists and where wasted resources exist.

And so, that’s what we are trying to do. So, I think our desire here is to really, really move the needle forward in terms of how we respect patients and their outcomes. We want to be able to continue to provide great quality cancer outcomes in terms of the classic traditional things that we are looking for, but we really are focused on our patients here and trying to get the best we can as the technologies are available and we want to continue to be at the leading edge of that curve. And I think that’s what referring providers should notice about this or the next thing. Because this won’t be the last opportunity for innovation.

Host: Dr. Rais-Bahrami have anything to add?

Dr. Rais-Bahrami: I absolutely want to just second Dr. Nix’s opinion that we want to forge forward the field of surgery, the field of urology and ultimately keep our patients as our number one goal and try to optimize their outcomes while maintaining the standards of therapy that we’ve always achieved while again, minimizing discomfort and minimizing the duration until they convalesce to full activity, return to work and comfort after their procedures.

Host: Thank you so much gentlemen for coming on in this panel discussion today and sharing your expertise. What an exciting time to be in your field. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.

That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician. If you as a provider, found this podcast as informative, as I did, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.