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Melanie Cole (Host):  Welcome. I’m Melanie Cole. And today, we’re discussing Robotic Urologic Surgery Program at UF Health Shands Hospital. We’re going to examine how advancements in instrumentation and the rapid adoption of robotic surgery in urologic surgery is changing the landscape of urologic surgeries. We’ll touch on the advantages of robotic surgery over conventional open and laparoscopic surgery and how the multitude of urologic surgical procedures that robotic surgery is applied to include those applied to oncologic procedures, female urology and reconstructive surgery. Here to tell us about all of that today is Dr. Li-Ming Su. He’s a David A. Cofrin Professor of Urologic Oncology and the Chairman in the Department of Urology at UF Health Shands Hospital.

Dr. Su, it’s a pleasure to have you with us today. what was previously done for urologic issues and how have as I said in the intro, advancements in instrumentation given birth to this era of robotic surgeries? When was it first introduced into the field of urology?

Li-Ming Su, MD (Guest):  Very good. Melanie, first of all, thanks for giving me this opportunity to be part of this podcast. I’m very excited to have this opportunity to speak on behalf of my team and the extraordinary changes that we’ve seen in our department and also nationwide with regards to the use of robotics in urologic surgery.

Really, if you look back over the last decade and a half, we’ve seen the implementation of robotic surgery in the field of urology. And in my career of almost two decades; this has probably been the most transformative change in our field with the rapid infusion of robotic surgery that in many ways has supplanted what we used to do by open surgery and even laparoscopic surgery. Whereby over 90% of surgeries at least the major operations we used to perform were by open surgical techniques; we’ve now seen in many different arenas within urologic surgery; this change to robotics because of advances of minimally invasive surgery.

Host:  It is an exciting time to be in urologic surgery. Dr. Su, tell us about the new Da Vinci Surgical System and how it’s going to change the landscape of urologic surgeries that you are doing at UF Health Shands Hospital. What are you doing there and what conditions can you use it for?

Dr. Su:  Absolutely. Our program in robotic surgery in our department at UF Health Shands Hospital began in 2007. And during that period of time, the most common operation that robotic surgery was applied to was that for prostate cancer and this is robot assisted laparoscopic radical prostatectomy. And this still remains the most common operation that we use the robot for, however, we have now seen expansion of robotic surgery into many different areas of cancer surgery specifically whether it’s the robotic partial nephrectomy or radical nephrectomy for kidney cancer, also radical cystectomy for bladder cancer. That is complete removal of the bladder and reconstructing a new urinary system.

So, I think that the robotic interventions have had it’s most significant impact in the area of cancer surgeries and really what this has translated to is much less invasive incisions but as good in some ways more precise surgical interventions done through tinier incisions leading to less transfusions, faster patient recovery and certainly patient satisfaction and outcomes.

But in addition to the cancer arena, we’re seeing a huge wave of interest in using robotic surgery for more advanced reconstructive procedures for both men and women.

Host:  Well that certainly is exciting. So, as we’re speaking about the advantages over standard or laparoscopic surgery; what will it enable you to do? How is it different for the surgeon than performing these procedures using traditional surgical methods and while you’re telling us about that; speak about the learning curve a little bit.

Dr. Su:  Sure. So, there are advantages to the surgeon, but there are also advantages to patients that I touched on briefly. For the surgeon, really this is a happy marriage in my mind between traditional open surgery and conventional laparoscopic surgery. And what I mean by that is urologic surgeons now can perform very complex operations within the human body without making a big incision. So, through small incisions, we can place robotic instruments that are essentially miniaturized wrists that we can then articulate, dissect, and retract in a very similar manner to what we would do in an open surgery but through eight millimeter instruments. So, you can imagine the size of your pinky finger having a very sophisticated terminal instrument that has the same maneuverability as the human wrist.

So, on top of that, so it’s an advantage of using both open surgical concepts and how we operate but with a minimally invasive approach as we see in laparoscopy but even beyond laparoscopy, we have three dimensional visualization and high definition images so that’s again, an advantage over conventional laparoscopy. So, it’s really a marriage of both techniques.

So, also, I can’t say enough about the magnification that is offered by robotic surgery being 12 to 15x greater than what we can see with our naked eye. And so a surgeon then is able to see the nuances of tissues and diseased versus normal tissues and making critical decisions while performing these complicated operations whether it’s a cancer operation or reconstructive operation.

For the patient, I alluded to the fact that smaller incisions equates to less pain, faster recuperation and back to the nuance of better visualization we are also seeing less blood loss because we can prospectively identify vessels and manage them, cauterize them or suture them before bleeding is encountered and thus reducing overall blood loss during the operation.

Host:  Well thank you for that very comprehensive answer. Dr. Su, as we are talking about oncologic procedures, female urology, reconstructive surgery; does patient selection play a role in who can receive surgical procedures with robotics and who is it indicated for and why is that important?

Dr. Su:  Absolutely. There are certain patients that are perhaps not well suited for robotic intervention and these are patients that have had very, very complex intraabdominal or pelvic surgeries where there’s a lot of scar tissue that would make establishment of a robotic environment with what’s called pneumoperitoneum, inflating the abdomen with carbon dioxide and placing our small instruments through our keyhole incisions very complicated. However, on the other hand, there are patients that we are able to do robotically that would be complicated if done by an open surgical technique. For instance, morbidly obese patients and we are unfortunately in our society, we are seeing that our body mass index has grown considerably year by year. Traditional open surgery can be a very morbid operation in those that are of high body mass index. They have higher complication rates, wound infection rates, and blood loss et cetera. But if we can do that surgery through smaller incisions; then we can steer clear of some of those associated morbidities that are encountered through open surgical incisions in these unique patient sets.

So, on one hand, patient selection is important and is limited by patients that have complex prior abdominal surgery or radiation treatments that would make scar tissue a problem. But it’s also opened up the opportunity to treat other patients that would be difficult through an open approach.

Host:  Do you have any technical considerations or issues you’d like other providers to know when they are considering robotic surgery for urologic issues?

Dr. Su:  Well I think as anything, this is all about experience. Just as we – as any surgeon learns a technique, it does require time, experience and exposure to a variety of different anatomic circumstances to really excel at what we do. What’s really unique about robotic surgery is the skill set is very, very different than open surgery and laparoscopy and even though as I said before, it’s a marriage of both techniques and taking advantage of the unique nature of each type of intervention. What different that we do robotically is no longer do we have tactile feedback as we perform these robotic surgeries.

And because of that, we have to rely more on our visualization to be able to appreciate the unique tissue planes as we do these operations. So, in many senses, we are relying upon a different sense, human sense if you will to perform these complex operations that we would otherwise have in open surgery which is tactile feedback. So, the analogy of that is you always hear about people that are born with one sense missing whether it’s the sense of sight for instance, but their other senses tend to take over. So, their sense of hearing may be better. Similarly here, is we do not have tactile feedback but then our visual sense is augmented by the 12-15X magnification and high definition quality images and so we are able to see those tissues and therefor perform as good and, in some ways better than open surgery because of that unique skill set.

Host:  Very well explained. Dr. Su, as we wrap up, please tell other providers what you’d like them to know about the Robotic Urologic Surgery Program at UF Health Shands Hospital, when you feel it’s important that they refer and go ahead and tell us about your team.

Dr. Su:  Absolutely. So, if I look at globally what’s happening at UF Health Shands Hospital, we have an extraordinary group of bright and talented robotic surgeons in many different disciplines, not only urology. Also gynecology, thoracic surgery, general surgery, ear, nose and throat surgeons as well and so we have – and colorectal surgery. So, we have a very multidisciplinary team involved in robotics. We have four Da Vinci Robotic Surgical Systems that have dual console capability and simulation for training of our residents, fellows and novice surgeons.

From a urologic standpoint, I’m proud to say that we have nine extremely well-trained and talented urologic surgeons. We began our program in 2007. We cover the disciplines of oncology, in that we perform robotic prostatectomy, partial nephrectomy, radical nephrectomy, cystectomy and then from a reconstructive standpoint; we do a lot of pelvic organ prolapse repair for female urology prolapse and incontinence work. We do pyeloplasty’s for kidney and ureteral obstruction and also, we are now delving into more complex urologic reconstructions that may involve substitution of the intestinal segments for bypassing ureteral strictures or some of the latest advances of using buccal mucosa as a platform to augment a repair for ureteral strictures.

So, I think the opportunities for robotics continues to challenge urologists and provide great opportunities to be very, very creative and we’re very excited about the future of robotics in urology and I’m proud to have a group of nine surgeons that offer a whole range of these types of operations for our patient population.

With regards to our urologic robotic team here at UF Health Shands Hospital, we have one of the most experienced programs here in the southeastern section of the United States. Certainly, with regards to our robotic prostatectomy and kidney cancer work, especially partial nephrectomy work; we perhaps have one of the highest volume practices in the state of Florida. As these cases can be very challenging and require a great deal of experience, for physicians who encounter cases that perhaps can be done robotically yet they don’t have those years of experience; we are happy to provide a second opinion and see these patients in our clinic. We are able to turn around our visit times quite rapidly as we have a very established nurse navigator approach to intake of our new patients coming in for evaluation. And even those that need a multidisciplinary approach to the cancer care; we have established clinics with medical oncology and radiation oncology as well as review of their pathology and radiology reports.

So, we are available to the community and the region and our referring physicians and we are happy to provide this service to these individuals.

Host:  Well thank you so much Dr. Su for joining us today. What a fascinating topic. Thank you for sharing your expertise. And that wraps up this episode of UF Health MedEd cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates, please follow us on your social channels. I’m Melanie Cole.