Texas Robotic Surgery

2012-03-25T16:23:00.000-05:00

Over the years, I've had nurses and patients complement me on my attitude and demeanor on the surgical floors. Of course, I've had some complaints and advice given as well. I just read an article going over habits of physicians that resonate with patients. Some I already do, others are new and worth trying out.

Patients appreciate the white coat, despite the rise in blood pressure that comes with the anxiety it also provokes. Sitting down during rounds, which seems inefficient to a surgeon, actually increases the perception that surgeons are listening by over 50%. In addition, it doesn't add extra time and may rest our aging knees!

Having the nursing staff accompany the surgeon during rounds improves patient care and allows the staff to relay concerns and reduce follow-up calls. Keeping the family in the room during rounds achieves a similar effect.

All in all, most of this is common sense, but it doesn't hurt to review and try out new things to improve patient outcome.

Open Source Robotics with the Raven

2012-01-22T20:33:00.000-06:00

I love the term open source; most think of Linux, MySQL, php or other computer science related ideas. Raven is actually an open source platform for software programming a robotic system developed by the University of Washington and UC Santa Cruz.
What does this mean? Well, one example would be doing surgery on a beating heart, but the instruments and camera would move in concert with the heart beat, making the surgeon less distracted during surgery. Maybe it would also bring more innovation to surgery, taking it out of the monopoly situation we are in right now.

Genetic Link for Prostate Cancer

2012-01-13T17:25:00.000-06:00

A homeobox transcription gene in endoplasmic reticulum

With all the controversy regarding prostate cancer screening and the use of PSA, it is good news to hear that research published earlier this year is giving us something similar to BRAC in breast cancer.

Men were 5 times more likely to develop early prostate cancer if they had mutation in the HOXB13 gene. About 3% of men who had early prostate cancer also had the mutation. While this number sounds low, I think it is an important marker, which could help identify patients who should be subject to screening.

In addition, it would be interesting to see if there is anything that could be done to the mutation as a sort of preventive therapy.
In San Antonio, we have seen a definite increase in interest in predictive tests for prostate cancer. A genetic test would be great to help identify patients who would be candidates for treatment with a robotic radical prostatectomy.

Prostate Cancer Survivors Respond to PSA Screening Controversy | The List | a Chron.com blog

2011-10-24T23:13:00.001-05:00

Kirby EagleNation Goman Outwardly super-healthy 51 y.o. has PSA of 20.6. Turns out to be Stage 3, with seminal vesicle involvement and extra-prostatic extensions. Thank God for my surgeon, Naveen Kella of Urology San Antonio. Everyday is a gift.

via blog.chron.com

Thanks for the mention, Mr Goman. I'm going to check out the Blue Cure.

Unleash the Robot Dogs of War

2011-10-24T23:01:00.001-05:00

via bits.blogs.nytimes.com

The intuitive robot is a bit smoother, but this is impressive and a bit intimidating if you are on the wrong side of AlphaDog...

Stanford researchers build transparent, super-stretchy skin-like sensor

2011-10-24T20:43:00.001-05:00

via news.stanford.edu

This kind of skin could be placed on robots-- Imagine placing this on a robotic instrument with a way to pass on the force sensation to the human controlling the motion. Or perhaps creating a emergency stop when parts of the robotic instrument start running into resistance... This technology was created not only at my alma mater, but also by my old chemE department!

PSA controversy

2011-10-15T17:59:00.000-05:00

The controversy around the use of PSA for screening for prostate cancer has existed since the utility of PSA was first discovered. No screening test is perfect. A perfect screening test would identify everyone who has cancer and exclude everyone who does not in a way which is inexpensive and noninvasive way.With an elevated PSA, the patient is in the unfortunate position of having to undergo a biopsy to prove there is cancer. Many biopsies will end up being negative. Approximately 25% will end up being positive for cancer.

These positive biopsies then have to be discussed with the patient. Not every person with prostate cancer should have treatment. One out of six men will be diagnosed with the disease, but not everyone will die of the prostate cancer, even if left untreated.

However, if we examine the pre-PSA era, men routinely walked into a urologist's office with widespread, uncurable disease. Now, it is rare to find such a patient. Mortality has decreased.

While research continues on better screening methods, men with prostate cancer should talk to urologists and get other opinions from trusted medical professionals. Hiding or preventing access to a diagnosis seems heavy-handed...

This statement from the American Urological Association summarizes our official position.

Live surgery with narration

2011-10-15T17:29:00.000-05:00

A lot of patients want to know if they can have a recording of their surgery after its done- it's a social time we live in, after all. While I used to record every case to help with learning, I now only record select cases. Here is a live robotic prostatectomy, which has had minimal edits but shows every step of the procedure. I have included narration and would like to thank Quill for helping support the video. Quill creates a novel suture, which is useful for constructing the urethrovesical anastomosis. They use this video for training. Here is the video:

Go Stanford! Robotic Jedi Light Saber Fight

2011-07-18T22:51:00.001-05:00

Unfortunately, this class didn't exist when I was at Stanford. Using an Xbox Kinect, computing technology, and creativity, this class demonstrates a robotic arm that is able to fight AND defend during a sword fight. Very interesting.

ARTAS Hair Restoration System Receives FDA Approval – Medgadget.com -- Internet Journal of Emerging Medical Technologies

2011-06-27T21:04:00.001-05:00

via medgadget.com

Interesting to see if this will raise the cost of hair transplants significantly... Also, what's the learning curve?

Updates on the Amadeus robot

2011-06-12T14:39:00.001-05:00

via surgrob.blogspot.com

#TitanMedical has announced a board of urological advisors. It will be interesting to see if it is more than smoke and mirrors because the technology sounds impressive. #IntuitiveSurgical definitely needs some competition.

Another Reason to Drink Coffee- Fight Prostate Cancer!

2011-05-20T01:14:00.001-05:00

Six Cups of Coffee a Day Cuts Lethal Prostate Cancer Risk By Over Half

As I sit up late here on my laptop, I fortuitously stumbled on this article. This one is interesting... From US News: "Researchers at the Harvard School of Public Health analyzed data from nearly 48,000 American men who reported their coffee consumption every four years between 1986 and 2008. They found that those who consumed the most coffee—at least six cups a day—were 60 percent less likely to develop lethal prostate cancer than nondrinkers, according to a study published Tuesday in the Journal of the National Cancer Institute. Men who drank one to three cups a day, meanwhile, had a 30 percent lower risk of lethal prostate cancer. The results were similar between men who drank decaf and regular coffee, suggesting caffeine isn't the driving force behind the trend. Rather, coffee could reduce inflammation and affect key hormones that play a role in the disease, the researchers speculate. "If our findings are validated, coffee could represent one modifiable factor that may lower the risk of developing the most harmful form of prostate cancer," study author Kathryn Wilson told CBS."

Obviously, further study is needed. Let's see if Starbucks will sponsor some supporting studies!

Abiaterone for hormone refractory prostate cancer

2011-04-30T17:58:00.001-05:00

I remember first hearing about this drug when it was owned by Cougar. The first thought was that it would be great to have a drug that was a safer form of ketoconazole. Although I don't use ketoconozole because of its risk for adrenal insufficiency due to the effect on cortisol production.

Abiaterone is a newer, safer form of ketoconazole, which attracted J&J's attention enough to merit a 1 billion dollar buyout.

Like its predecessor, abiaterone blocks testosterone synthesis and can even block tumor cells from producing testosterone, which is a mode of resistance being more heralded. Does the drug work any better than ketoconazole? Theoretically yes, but there have been no head to head trials to see if it is clinically significant. What is significant is the difference in price. Ketoconazole 200 mg tid costs approximately $150 monthly. Abiaterone costs nearly $5000 per month.

For now, patients interested in this medication can ask us about clinical studies. Another drug with a similar mode of action is TAK-700. More to come on that one later.

With robotics, Provenge, Abiaterone, and other developments, it is an exciting time in the era of prostate cancer treatment.

Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds

2011-04-29T16:25:00.001-05:00

This article points out the obvious to me. It takes hundreds of cases to reach expert proficiency for a case like a robotic prostatectomy. In Texas, no individual surgeon has done over 2000 cases except right here in San Antonio!

From Bloomberg...

Doctors who perform robotic-assisted prostate cancer surgery aren’t proficient and able to remove all the malignant cells surrounding the tumor until they have done the procedure more than 1,600 times, researchers said.

Results from a study suggest the operations using Intuitive Surgical Inc.’s da Vinci robot are being performed too often at community hospitals by surgeons without enough experience, said Prasanna Sooriakumaran, lead author and urologist at the Weill Cornell Medical College in New York. Doctors have embraced the approach because studies show it can be learned quickly, uses smaller incisions, causes less blood loss and speeds recovery.

More than 90,000 men in the U.S. have their prostate gland removed each year because of cancer, according to the American Society of Clinical Oncology. The surgery is done mainly with robotic technology introduced in 2000 by Sunnyvale, California- based Intuitive Surgical, typically by doctors who perform 100 or fewer procedures annually, Sooriakumaran said.

“The operation is not easy to perform and it takes a lot of experience in order to get the best results for our patients,” he said in a conference call. “The enthusiasm in the United States needs to be tempered in terms of what sort of hospital needs to be purchasing this equipment and what sort of surgeons should be allowed to do these operations.”

The researchers tracked three surgeons learning the technique over a six-year period at high-volume centers at the University of Pennsylvania in Philadelphia, Karolinska Institute inStockholm and Weill Cornell in New York City. Surgery times decreased with each operation, while the doctor’s ability to remove all the cancer increased, Sooriakumaran said.

Removing Cancer Cells

The surgeons needed to perform more than 1,600 operations before they were able to gauge with at least 90 percent accuracy how much tissue surrounding the tumor they needed to remove to get all the malignant cells. Leaving stray cancerous cells in the margins, at the edge of the tissue removed during surgery, can lead to recurrences of the disease.

Every hospital has its own system to train surgeons and it’s not up to the company to determine when the doctors reach proficiency, said Calvin Darling, a spokesman for Intuitive Surgical.

While he hasn’t yet seen the study, the 1,600 number “strikes me as absurd,” Darling said today in a telephone interview.

Training Time

“The average time it takes to get to proficiency as defined by our hospitals in their training protocols is typically mid- double digits,” he said. “This is an order of magnitude higher.”

Intuitive Surgical reported $660.3 million in 2010 sales of the da Vinci system, according to a company filing.

The company’s shares fell $1.20, or less than 1 percent, to $339.99, at 4 p.m. New York time in Nasdaq Stock Market composite trading.

More than 700 operations a year are done in medical centers that specialize in the surgery, compared with just a handful a month for smaller, community-based hospitals, Sooriakumaran said. The procedure needs to be centralized so that surgeons can get the amount of experience needed to gain the best results for their patients, he said.

The results will be presented tomorrow at the Genitourinary Cancer Symposium in Orlando,Florida. The investigators are now gathering information on additional surgeons to expand their findings. It is likely that other doctors, who are in lower- volume medical centers, will take even longer to get the experience they need, Sooriakumaran said. Intuitive Surgical has provided funding for Ashutosh Tewari, an author of the study and a urology professor at Weill Cornell.

Increased Use

Use of robotic technology is growing exponentially, said Nicholas Vogelzang, an oncologist at the Comprehensive Cancer Centers of Nevada in Las Vegas and chair of U.S. Oncology’s developmental therapeutics committee. Doctors need to ensure their abilities are keeping up, he said.

“This data today will make everyone pause,” said Vogelzang, who pointed out that traditional open surgery also requires years of practice. “Maybe it’s time to go a little bit farther before we rush into this surgery. Experience really does matter.”

More proof why robotic experience is important

2011-04-22T14:25:00.001-05:00

via sportsgrindent.com

U Penn engineers were honored with the opening pitch at the Phillies game. Their robot, however, is excellent demonstration that the robot is only as good as the people behind it. Experience is key, no matter who or what throws the pitch! My team and I have done over 2000 robotic cases, making us the most experienced team in Texas.

Meet the TurtleBot!

2011-04-18T21:57:00.001-05:00

via willowgarage.com

A personal robot that can do home surveillance and deliver the donuts! Definitely on my wishlist.

High-end medical option prompts Medicare worries - Yahoo! News

2011-04-04T11:55:00.001-05:00

via news.yahoo.com

Urologists cover many elements of men's health. While there is no "concierge urology" yet, there are some urologists who do not accept government insurance and have patients file their own private insurance claims. Patients coming from South America or Mexico for prostate cancer surgery find San Antonio a comfortable and friendly place to recuperate after surgery. Mexico has a handful of robots for prostate surgery. What is lacking is experience. Dr Kella and Urology San Antonio have the most experience in Texas with over 2000 prostate cancer cases performed. They also have been handling the unique needs of our international patients.

World's Most Expensive Paper Airplane

2011-04-02T16:43:00.001-05:00

This video is interesting as to demonstrating the robot's capability. However, those don't look like training instruments. Looks like a needle driver and a forceps. Estimated cost per use for the pair is $300 to $400...

Video: Da Vinci Surgical Robot Takes A Break to Make, Fly Paper Airplanes | Popular Science

2011-04-02T15:31:00.001-05:00

via popsci.com

Cancer prevention trial (SELECT) comes to a halt - Harvard Health Publications

2011-04-02T11:39:00.001-05:00

Two worrisome — though not statistically significant — trends also emerged: there were slightly more cases of prostate cancer in men taking only vitamin E and slightly more cases of diabetes in men taking only selenium.

via harvardprostateknowledge.org

Take home messages: 1. Supplement research constantly changes from study to study 2. Exercise (reduced belly circumference) reduces aggressive prostate cancer risk 3. Dieting is also beneficial.

Take home messages:

1. Supplement research constantly changes from study to study
2. Exercise (reduced belly circumference) reduces aggressive prostate cancer risk
3. Dieting is also beneficial.

Advanced Prostate Cancer Treatment

2011-03-30T22:08:00.001-05:00

via provenge.com

The Centers for Medicare and Medicaid Services proposed paying for the vaccine, known as Provenge, which costs $93000 a patient. It had to go through further review (due to the expensive cost), which was unique. Usually a drug approved by the FDA is always paid for its indicated use by Medicare.

Flying Robots playing tennis... What's next?

2011-03-29T21:49:00.001-05:00

I love robots, and I love tennis, so this is pretty exciting...

Good foods for prostate health and getting ready for surgery

2011-03-26T13:05:00.001-05:00

In my practice, I inform patients that diet can play a role in helping the body fight prostate cancer. The research is hopeful concerning Japanese and Mediterranean diets. Red meat is mostly absent in these diets. Both are also low in calories and fat.

In the Japanese diet: Green tea, vegetables (not starches), fish and soy.

The Mediterranean diet: fresh fruits and vegetables (watch out for too much fruit with its calories) garlic, red wine, olive oil, and fish.

Ten take home messages:

Eliminate as much red meat and fatty dairy products as possible.
Abdominal circumference has been linked to prostate cancer risk.
Avoid margarines and fried foods.
Fresh fish is good. Omega-3 fatty acids are high in cold water species (salmon, trout, mackerel)
Our ancestors ate a lot of fresh vegetables- the body is used to foods like this and beneficial elements are discovered regularly in vegetables. Cruciferous vegetables such as cabbage, broccoli, and cauliflower are good.
Drink green tea.
Red wine is good
Tomatoes products are very high in lycopene, which may help fight cancer.
Olive oil and avocado oil are good. No to canola, corn and soybean oil, which are high in polyunsaturated fats.
Selenium is potentially helpful.

Robotic-Assisted Prostate Surgery: Experience Matters

2011-03-23T22:02:00.001-05:00

Having done 2000 robotic prostatectomy cases in San Antonio, Texas, I know that experience matters. From http://news.cancerconnect.com/.>
According to the results of a study presented at the 2011 Genitourinary Cancers Symposium, a surgeon may have to perform well over a thousand robotic-assisted prostate cancer surgeries before becoming fully proficient at the procedure.

Treatment options for early-stage prostate cancer include surgery, radiation therapy, and active surveillance (close observation but no treatment until the cancer shows signs of worsening).

Radical prostatectomy refers to the surgical removal of the entire prostate and some surrounding tissue. Prostatectomy may be performed using traditional open surgery, in which the surgeon makes a single, long incision; or through a laparoscopic procedure (sometimes called minimally invasive surgery), in which several small incisions are made. During laparoscopy, the surgeon inserts a small video camera through one of the incisions in order to see inside the abdomen. In a variant of laparoscopic surgery known as robotic-assisted laparoscopic surgery, the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments.

Previous studies of robotic-assisted prostate surgery have suggested that it doesn’t take long for surgeons to learn how to perform the procedure safely. Achieving the best possible cancer outcomes, however, may require a greater amount of experience.

To assess the number of robotic-assisted prostate surgeries that a surgeon must perform before becoming fully proficient, researchers assessed 3,794 patients who were treated by one of three surgeons.

A key outcome that was considered in the study was the rate of positive surgical margins. A positive surgical margin means that cancer is found at the edge of the tissue that was removed during surgery; it may be a sign that not all of the cancer was removed.

The rate of positive surgical margins declined as surgeons gained experience. The lowest rates of positive surgical margins (<10%) came after a surgeon had performed more than 1,600 robotic-assisted prostate surgeries.

In a prepared statement, one of the researchers involved with the study concluded “Even for [surgeons] who do hundreds of cases per year, it takes a long time to get to the stage where they are getting the best possible cancer control results. Our results show that it is possible to get good cancer cure rates and low surgical margins with this operation, but it takes a significant amount of experience.”

Patients who are considering robotic-assisted prostate surgery may wish to seek out a surgeon who has extensive experience with the procedure.

Reference: Sooriakumaran P, John M, Leung R et al. A multi-institutional study of 3,794 patients undergoing robotic-assisted laparoscopic radical prostatectomy to determine the surgical learning curve for positive margins and operating time. Presented at the fourth annual Genitourinary Cancers Symposium; February 17-19, 2011; Orlando, FL. Abstract 102.

Prostate Cancer Surgery for Clippers Coach

2011-03-16T21:59:00.001-05:00

This article was interesting to me becuase it indicates that Coach Hughes paid over $70,000 for his surgery. Our rates in San Antonio are much more competitive. We have a package that covers all the costs for my services, the anesthesiolgist, pathologist as well as the hospital charges for a routine stay. There are few people who have done 2000 cases with the robot. For San Antonio prostate surgery or Mexico prostate surgery, cash paying patients should contact us.

ESPNLosAngeles.com

Former Los Angeles Clippers coach Kim Hughes is used to helping players, but it was players who stepped up for him in his time of need.

In September 2004, while he was a Clippers assistant, Hughes was diagnosed with prostate cancer. He was premed at Wisconsin, so he had an idea what he was up against. His doctor told him that he could wait a few months for surgery, but the team was preparing for training camp and he didn't want to miss a chunk of the season recuperating. So Hughes went for a second opinion and found a doctor who would do the surgery a week later.

"But he wasn't covered under my insurance plan," Hughes told ESPNLosAngeles.com. "We had a certain group of doctors we could go to. So if I elected to use him, it'd be out of my pocket.

"[The Clippers] didn't talk to me directly about it. They told, I believe my agent, that the reason they couldn't pay for the surgery is if they paid for mine, if anybody else had a problem -- head coach, secretary, assistant coach -- if they paid for mine, the onus would be on them for everybody else.

"I said, 'That's fine. I choose to try and save my life, and if I have to pay for it myself, I will.'"

Then coach Mike Dunleavy, who had recommended the new doctor, mentioned Hughes' plight to some players.

Several players on that team -- including Corey Maggette, Chris Kaman, Elton Brand and Marko Jaric -- offered to help.

"Kim was one of our coaches and he's a really good friend of mine, too," Maggette said, according to the Journal Times of Racine, Wis. "He was in a situation where the Clippers' medical coverage wouldn't cover his surgery. I thought it was a great opportunity to help someone in need, to do something that Christ would do.

"It shows your humanity, that you care for other people and not just yourself. Kim was in a life-and-death situation."

Hughes' desire to get the surgery over with quickly proved to be a smart move. The cancer had progressed and was threatening other parts of his body.

"Normally it's a very slow-growing cancer," Hughes told ESPNLosAngeles.com, adding that his father and twin brother also had prostate cancer. "It's one of the slowest, but mine was caused by genetic factors and it was a very aggressive and fast-spreading cancer."

Hughes had his entire prostate removed and didn't miss training camp, thanks to the players.

"Those guys saved my life," Hughes said, according to the Journal Times. "They paid the whole medical bill. It was like $70,000 or more. It wasn't cheap.

"It showed you what classy people they are. They didn't want me talking about it; they didn't want the recognition because they simply felt it was the right thing to do."

Maggette, who now plays for the Bucks, said that Hughes thanks him every time they see each other.

"I've said to him, 'Kim, come on. You don't have to do that. You're good,'" Maggette said, according to the newspaper. "It just shows you what kind of person he is, to keep thanking me all the time for that. Like I said, it was just my time to serve another human being.

"I think if anyone on my team is in that kind of situation, I would try to help him out if I could. That's just the person I am. I was raised that way."

Hughes, who took over for Dunleavy last season but was not brought back by the Clippers, said that the players showed that you can't judge an NBA player by the flashy exterior.

"Corey is perceived by some people as not being a good person because he seems to be aloof and arrogant," Hughes said, according to the newspaper. "But they don't know him. He's a good man; he's a great man.

"You can have all the money, all the success, all that stuff, all those so-called important things in life, but in the end, you're judged by what you did for your fellow man. Corey will always be an important part of my life. What he and those other guys did for me put things in perspective."

The Clippers did not immediately respond to a request for comment on Hughes' situation.

ESPNLosAngeles.com's Ramona Shelburne contributed to this report.