I don't use Ryan a little bit. So Ryan, J. Ryan Mark is a man with three first names, no last name James Ryan Mark. I told him, he came over. I was like, you gotta get a last name. So, uh, but he goes by Ryan and, uh, Ryan is, you know, sort of a staple of Philadelphia trained here, uh, did a fellowship, uh, down in the Carolinas and came back and it's been a Jefferson for 89 years, 78. So and then, you know, we've been talking for the last few years and it was. Opportunity and we're proud to have him be on our team. He's a guru in robotics open surgery laparoscopy. I mean a really a very well rounded, uh, urologic oncologist. He, uh, anchors our team at Chestnut Hill, uh, and he will talk to you about some technology where he is the, uh, number one, number one, single port, uh, surgeon in the mid-Atlantic, um, and so he, you know, it's a really unique skill set that he will speak to you about. Thanks, um, so yeah, so. Whenever uh you're talking to a room, particularly a room that has a lot of medical oncologists in it, um, when you're presenting surgical data, it's, it's not quite as, quite as high level data as, uh, what they're used to seeing. So hopefully the videos will kind of. Kind of cover that um and make it a little bit interesting anyways um in terms of disclosures this have disclosed I have been a proctor for intuitive in the past um. So what is the Da Vinci SP platform? So the Da Vinci SP is sort of in. Improvement technology to try and make surgery more minimally invasive was approved back in 2018. Um, it has all the, the same kind of bells and whistles as the multi-port system um but everything goes through a single incision that ranges from about 2.5 centimeters to 4. Application I was like, and the surgeons in the room, they may have a friend who's used it before, you know, this thing came out in 2018, but you haven't seen a whole lot of it done, um. In the clinic patients aren't following up having had a lot of single port surgery. It's been very slow, um, for it to adopt, um, particularly because of some of the challenges with the, uh, platform which we'll talk about, but a lot of people have kind of been wondering if this is the future of robotic surgery. Are we gonna have this dystopian Blade Runner type future where we're all struggling to do more challenging cases on this new system or we have this nice sort of, uh, pretty future ahead. So what have been some of the challenges? Well, when this thing initiated, um. The surgeons were finding the the the grip of the instruments was a lot weaker. Uh, we're used to this cross screen retraction where we use an arm to lift everything out of the way, get really big exposure. Um, the lateral retraction of the instruments are weakened because they don't come in from the side. You're kind of flexing. Um, the. Because the instruments flex, if you're using an assistant, it ricochets all over the place, um, and despite the fact that it looks a lot like the robot we're all used to, it's very different in terms of technique, um. And if you look at sort of what the surgeons experience, uh, when they first start using this, what you really see is the workload even after 20 cases remains pretty high um and so a lot of people have found it very frustrating to get used to, um, and this particular group, they'd performed over 3000 radical prostatectomies and even after 20 with the single port system they were finding they were still having difficulty, um. Now, when you look at trying to train on it, what you find is experienced surgeons have problems with suturing, dissection. Cutting basically the the list is everything that you do during surgery um and so because of some of these challenges um in the past it's really something that people's kind of been scared of, um, and haven't used a lot, but the instruments have continued to improve when I got started on it, I was using the 3rd generation instrumentation, which really was pretty frustrating. Um, and during that time, the grip strength got better, the arms became more flexible. Simple fixes such as increasing the thickness of the sheath that goes on the arm made the arms more rigid and allowed you to do more, um, and you're starting to see that adoption is really increasing and so this is something you guys are gonna see, uh, a lot more of in the future. Um, a couple of years ago we had about 13 systems, um, in the mid-Atlantic region. Um, And it's, it's projected there's going to be somewhere between 5 to 7 more systems kind of in our area, uh, coming up in the next 2 years. And if you look at the amount of publications that have been um written uh over the last like 5 years or so, you really kind of see uh where a lot of the interest lies in using the system at least in terms of urology um and you can see that there's been a steady increase overall, um, when you kind of look at the, the total, um. Sort of just body of literature about it. Um, we'll review some of it. It's not super high impact literature, um, as you'll see. So what can we use this robot for prostate cancer? So one of the nice things about this robot for prostate cancer is it's really widened what we can do to access the patient's prostate. Um, open surgery was done for years either through the perineum, which could be done with this robot, or through a lower midline incision in the retro pubic space. You're seeing a lot of surgeons now go back to that retropubic approach to get to the prostate using this robot just through a much smaller incision. You can go in the way we traditionally go in with the multi-port system up above the umbilicus and into the peritoneum. You can approach it completely posterior and aorexia sparing approach. You can actually go directly into the bladder to get to the prostate, and you can really tailor your approach for your, your patient based off of what their anatomy is, what you're trying to accomplish, and particularly what their surgical history is, um, so the extra peritonealadical prostatectomy is basically a robotic version of the old radical retropubic, um. When you compare this to a multi-port procedure, like most of these slides, the data is really just gonna show you that the outcomes are basically the same as if you were doing it with multi port, so we're not losing any ground with this system and as you start to gain experience, the operative times are the same, the margin rates are the same, um, the patients have similar recovery, um, and this approach is very familiar and easy way to get started. It's basically like doing an anterior approach with the multi port but you don't have to drop the bladder. What would be the advantage of this? Well, you're not getting into the abdomen, um. If someone's had previous abdominal surgery, it doesn't matter you're not there um you're working in a confined space, um, a big thing that you'll see when we kind of look at positioning these patients are positioned completely flat, um, so there's none of the extreme positioning that we do, uh, to put patients in extremereellenberg position. Um, and you can complete the entire procedure, and there are some benefits realized to that approach. Transvesical approach is, is a unique way, uh, to, to do radical prostatectomy now. Um. Something that hasn't really people tried it with the multi port, but um it wasn't really all that feasible. With this procedure, you make the incision below the umbilicus with the bladder full and enter the bladder directly. Um, and essentially start with incision around the underside of the bladder neck and you start approaching the prostate almost like you were beginning the posterior dissection as you come through the bladder neck in a regular prostate procedure. So it's, it sounds like it might be really foreign but once you get started, um, the, the landmarks are very much the same. and one of the benefits of this, um, you see is because you're not mobilizing the bladder, um, it, you have very similar results to what you would see with the res sparing prostatectomy where the, the urinary continence mechanisms are better preserved, um, because the bladder is left in place, you're not violating the space and moving the bladder around, um. The group of Cleveland Clinic that's really kind of pioneered this, uh, approach, they leave their catheters in now for 3 or 4 days, um, so the patients are getting their catheters out, um, and again it doesn't really matter what surgical history the patient has, you're going directly into their bladder as long as that space hasn't been violated, um, you're, you're doing surgery, um, and the patients do well. So those are kind of two unique approaches to getting to the prostate, um, treatment of kidney cancer is another area where I think this, uh, system excels without the large instrumentation and the cross screen retraction, radical prostatectomies have been done, but generally it's not gonna be anything that you see this system having a major benefit for, uh, just because you're any, you know, the footprint of this robot is smaller, so you're really talking about working in smaller spaces. So anytime you're having to do a larger procedure, um. You're not, I don't think you're gonna be as satisfied with it, um, but it is something that has been done, um, and the outcomes are roughly the same. Partial nephrectomy is a really big area where I found this system to kind of quickly become my favorite out of the two, compared to multi-port, um, the one downside, particularly because of some of the instrumentation with the clips and the way we do the reories you'll see longer warm warmer, longer warm ischemia times. Um, but they didn't exceed over 30 minutes in these studies and all the other outcomes are the same. Um, and what's particularly unique about this approach is now, um, To do these robotically we'd be coming in through the abdomen or we're doing retroperineal procedures in from the side which require us to have the patients in a full flank position. You can now take a patient, have them positioned completely supine, so the anesthesiologist has access to their their chest if they need to for some reason their arms are out so that the a line's not working. It's right there. They're positioned in a very familiar way for the anesthesiologist. And we make a small incision just right here over on the side and get into the preperitoneal space and then roll the peritoneum over and then we're in the retroperitoneum and from there you can get up to the kidney um as urologists we are retroperitoneal surgeons at heart um and this kind of gets us back in the home territory um and some of the benefit here is. If anyone's ever managed a renal trauma patient, you know, the kidney can be shattered, and the plan is not open to space. If if your organ remains in the rech perineum, things like leaks and bleeds are much better temporized. Small leaks may not even become symptomatic. Um, and so the, the recovery process is a lot easier. Also because you're making just one single incision, you have the opportunity to provide local anesthesia to that area. And these patients wake up with significantly less pain because they're, they're laying flat, um, and they have this one incision. Um, I've done up to 6 centimeter tumors this way, um, and as long as you're kind of choosing your patients appropriately, you can approach the the kidney and do anything you do with the multi port through this incision. Um, anterior tumors, if you just tilt the patients so the bowels go out of the way, you can get to the anterior part of the kidney. The posterior part of the kidney is, is there, the lower part of the kidney is right in your face. The only tumors that you might worry about are ones that are challenged with the multi-port system as well, which is just right at the top of the kidney. Um, where you really need a little more space to roll things around, um. Ethelial cancer is also um. Very accessible, uh, with this system, particularly when you're dealing with the upper tract, uh, nephroureterectomy has been done, a multitude of ways. The early reports, the patients were in flank positions, um, here they have a plus one port, um, and they approached the, the kidney in a retrooneal space through more of the flank, um, and with the system the way it pivots around, you can get access, um, above the kidney down to the, the bladder, um, and you see that outcomes are basically the same when compared to a multi-port. But that anterior approach is also possible, um. So You no longer have to really get into the abdomen to do this multi-quadrant, uh, procedure. The patient can be laying completely flat, um, and particularly if the patient doesn't have a particularly fat, um, grodas around the kidney to where you're gonna make a larger incision to extract the kidney, you can basically do the entire procedure through that incision and maybe extend a little bit to get your specimen. You've got access to the entire nodal chain, um. And the, the visibility of the, the ureter down of the bladder cut is, um, just like a delight, uh, something we struggle with sometimes with multiport to really get access, um. The procedure here in the video, um, is a, is a distal ureterectomy and a lady who had had a, a previous colon resection. She was elderly, um, about 83, she had a recurrent high grade tumor, um, in her distal ureter and Through that incision, I was able to go in, remove the distal ureter, check for margins. They were negative, reimplant the ureter. Um, and she went home the next day. I mean, she looked good enough to send home the same day but, you know, being as old as she was, we kept her around, um. Radical cystectomy, they've been done um. It's probably not an area where this system excels in. This is just a slide to show that it's possible. Um, there are some kind of unique thoughts with how this might um make things cosmetically a little bit better. Um, my opinion is it doesn't really add a whole lot. Um, I don't have a cystectomy video because I didn't think it would really benefit patients too much, um, when I was doing these, you know, the, the one thing that people talk about is putting a port in where you put the stoma and then kind of decreasing the level of incisions, but I'd be worried about peristomal hernias. And then anytime you're working with the bow you're gonna need staplers, and so you're gonna have to put in extra ports, um, and anyone who's worked with bowel on a robot knows that it can be pretty fiddly and so having all your instruments in this one small area, um, I, I think you're gonna see that this is something that people do to do it, um, but you're not gonna see it, um, become very popular. Um, so here you can see kind of just more of this distal ureterectomy. Um, penile cancer. Um, there are only about 2 reports out there for penile cancer. Um, as someone who's done a lot of robotic and little node dissections, um, I look forward to using the system on there. Um, it's, I think the perfect, uh. Basically the perfect footprint for getting into someone's groin, um, so how does it optimize surgery if the outcomes are the same as multiport generally? Well, obviously cosmesis, um, if you ask patients about their incisions, um, basically the they report improved satisfaction with the size of the scar, the way that it looks, they're not bothered. Do incisions really matter all that much, um. To patients they do, um, exactly how they matter would surprise you. Um, so in considering who to select for this, uh, sort of approach, if you're thinking of cosmesis, the patients are happiest with, uh, umbilical incisions, um. But if you really start to like research it, you'll find that the Incisions whether or not people worry about incisions is not gender specific, um, and you know if someone has prior abdominal surgery they generally don't care um and where you put the incision doesn't matter to them too much, um, and so it probably wouldn't put as much weight on cosmesis, um, as a lot of people would think. I think the biggest advantage is positioning of the patient, um, I think. People who have been researching this system and the various techniques I think have struggled to uh clearly define a major advantage of this system compared to the old system because I mean you guys have seen postoperative multi port patients before they do very well, um, you're able to get them home same day or next day a lot of the time um there is just a little difference that you see in these patients it's hard to characterize and that's one of the things I'm kind of racking my brain to try and figure out, um, because I think you'll see that. There's, if I could figure out what the physiological marker is that kind of accounts for the fact that the patient isn't upside down on their head for extended periods of time and they're not laying on their flank, um, they're just in a nice comfortable operative position, um, you see it in the patients in terms of their recovery, um. the fire alarm. That's it. And the same day discharge, they happen. I do want to share one slide that's pretty wild. Um, I was up in Cleveland Clinic recently and, uh, Doctor Kayu showed a picture of him holding a prostate, showing a patient. Um, their prostate. As they were having surgery, um, and so you're able to do radical prostatectomies with an epidural with this system if you needed to, um, which I think kind of goes to show how little trauma is being done to the body if you just numb it up below the waist you're able to get in and do radical surgery and send those patients on the same day, um. So I mean like what is the, how do you optimize. Cancer care with this system, um, you know, when you, you can make the argument, how is it better than multiport, um. I think that At least my thought is it's just as good as multi port. There's a big push, um, and you see a lot of new technologies that are coming out trying to be minimally invasive, and we argue about whether or not um those treatments are adequate for some of these cancers focal therapy for prostate cancer and things like this. With this, you're getting the same surgery you were getting before, the same amount of tissue, um, but you're doing it with the smaller footprint and patients are recovering just a little bit faster, um, and I can't. Tell you how many times we've been in one of our multidisciplinary meetings where there's that lymph node that somebody wants and it's in the retroperitoneum and nobody can get it safely. I mean, your access to the the vasculature is there and you're doing it through an incision like this and so it doesn't seem like a big get, particularly if someone's had that cystectomy or that big open nephrectomy ahead of time. So.
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