Dr. Viterbo presents updates on Surgery for Bladder, Kidney and Prostate Cancer during COVID-19.
Yes. Again. Perfect. All right. And I apologize for these technical delays. But as we know, this is what the pandemic has forced us to kind of do. We do it with our patients and we try and make the best of it. So I apologize. And as you know, this pandemic has constantly forced us to think and rethink reassess and assess what seems to be always a rapidly changing situation. And then if we kind of stop and think about everything that we've gone through, as far as a community, you know, what was going on 10 months ago, what was going on a couple of months ago and what has been going on through this resurgence or even tonight? Um it leaves us spinning, you know, as a global community and as our patients look to us for answers amidst this pandemic, we consider some of the surgical implications and special considerations in trying to provide the best urological oncological care. We can we think about the biology of the cancer and it's kinetics the aggressive itty and maybe how that cancer affects progression or worsening overall outcome in. Can we delay treatment And as it's safe to delay treatment um at a time where we're trying to decrease exposures and best guide our patients next slide. Please. There are unique set of circumstances around surgery. You know, and as we um consider um you know, operating during covid we know as doctor could've caused discussed earlier, there is an increased risk of viral pneumonia. I see you admission and even mortality and there's special things that we should be doing when we are operating. Um you know, trying to use a negative negative pressure room when intubating and ex debating our patients trying to decrease our energy instruments to kind of decrease the potential aerosolization of possible viral particles in our surgical smoke. And there has been some controversies regarding should we even do minimally invasive surgery? Is the CO. Two or the air within the abdomen carry increased risk of viral particles. And are we exposing our staff and our ourselves and has forced us to even reconsider you know, some of our filtering systems. In fact some of the relief money has been used to, you know, reevaluate what kind of filtration we're using in our in our patients and try and integrate this into our intelligent platforms uh you know, robotic platforms and so on. Um Next slide please. And so surgery during covid 19 has required us to think about, can we delay care? Should we delay care and then? Which cancers? Can we do that safely? And uh in the beginning of the pandemic it was left to our discretion to kind of think of, you know which disease can be delayed maybe for three months or six months or can we look at other options and has also given us time to pause and think about. Can we do this differently? Um How can we decrease exposure to our patients And if we take patients to surgery, how do we take care of them post operatively? And does this necessitate uh further visits to the hospital? And can we actually examine incisions through tele visits and face time and you know what impact this has on patients during their recovery. With a strict no visitor policy and so on. So as we look at you know, urologic cancer, this this situation has definitely necessitated us to kind of re examine the diagnosis and treatment of different urologic cancers. Next slide please. So can we do this better so that we decrease exposure, manage staff exposure and explore how technology can actually help us take better care and even control of our patients during this pandemic. Just wanted to highlight some of the technology that has proven to be very useful for bladder cancer diagnosis. Blue lights. This tosca p. With this view has made a significant change you know potentially decreasing um um multiple visits and helping us consolidate care briefly helps us maybe decrease on the morbidity of some of the procedures and maybe helping us realize um possible bladder sparing um surgery and for prostate cancer. Uh We've kind of looked at our technology and we have acquired a powerful um um micro ultrasound that has also helped us in taking care of our patients. Again decreasing um patient visits and better utilization of some of the technology that we have um moving from a trans rectal to a transparent needle biopsy for the detection of prostate cancer and again using air minimally invasive platforms to help again impact decreased length of stay utilization of hospital resources and again decreased exposure both to our patients and to our staff and for kidney cancer being aggressive with utilization of renal biopsy to help us um you know better manage our patients and um um use uh aggressive active surveillance schemes and continue to use minimally invasive approaches. So just to to to to go back to bladder cancer. Um So during covid, I think Dr koop Kulikov had mentioned some of this. We see we saw initially some delay in he material work up. Next slide please. We saw patients who came to our office with larger tumors, partly because their reluctance to see the physician. Um and maybe to the reluctance of doctors to really be seeing patients. So we saw some larger tumors in our office when patients presented with the mature area and as patients presented with later stage disease Blue lights to Skopje with this, if you continue to be to be an invaluable tool, um larger tumors um and tumors that had um uh progressed um could really benefit from this technology. Next slide please. And for those of you who are not familiar with blue lights, Sista Skopje, it is a technology that helps us visualize tumors in a better sense. Using a Sista scope that is equipped with both white and blue lights um for visual inspections inside the bladder and what we do. Next slide please. We instill this this view. Hex so mean alive, you know, hex Vicks dye into the bladder one hour prior to a procedure and then we take the patient back to the operating room and we inspect the bladder and typically we would remove any lesions that would see. And with this type of technology there would be tumors that we may miss, we otherwise miss. And this technology has really helped us kind of consolidate care and um um helped us uh diagnosed patients even though uh you know with multiple tumors and again decrease multiple visits to the hospital. Next slide, please. And can also kind of prove to help us carry out bladder sparing procedures which can translate again into um decreased length of stay, improved quality of life and um better utilization of resources, decreasing potential exposures and risks during covid. Next classes. So to recap with bladder cancer surgery, some of the updates during the pandemic that has been have been utilized effectively was the use of blue light Sista Skopje with this view versus white light Sista Skopje. Um And for a treatment better utilization of bladder sparing techniques through partial suspect me and for muscle invasive bladder cancer. Continued um use of both open and robotic platforms that can help us during this pandemic translate through uh patient benefits with decrease length of stay essential. Um You know for patients with a strict no visitor policy and decrease in blood loss and potential decreased visits uh post operatively to the hospital for prostate cancer. The pandemic has also forced us to re think and re examined some emergent technology especially in the diagnosis and treatment. Next slide please. There was initial concerns regarding diagnosis of prostate cancer. Should we delay prostate biopsy? Is there potential of um air civilization of the virus through fecal contamination? Should we be delaying biopsies for three months, six months? Can we better utilize resources? There was delayed in getting images with M. R. I. S. And diagnosing these lesions. And so we kind of re examined of what what can we do, what other technology is available to us and how do we triage patients? Um Two more aggressive active surveillance schemes. Next slide please. And so early in the pandemic were very aggressive about delaying prostate biopsies. And you can see here a schema of you know what our criteria now that you know some of the recommendations have relaxed but maybe again getting stricter during this resurgence. We are happy to have recently acquired um this um powerful ultrasound technology. Next slide please. Um The exact view micro ultrasound. This is a powerful tool in which we typically use a traditional um ultrasound to carry our prostate biopsies which uses like a 6 to 12 megahertz transducer. This uses a 29 megahertz transducer which improves visualization of uh suspicious lesions in the prostate by 300 times. It can not only allow us to visualize but target in real time, cutting down multiple patient visits. It also has helped us carry out more transparent neal versus trans rectal biopsies which has helped us move the needle towards a potentially safer procedure with decreased fecal aerosolization safety to the patient and decreased infections next time, please. And here are a couple of pictures of um our initial use of the exact view ultrasound initially being used at Fox Chase in the O. R. And Dr Koloskov. And uh some of us are now transitioning to office based procedures uh to better care for our patients. Next slide please. Yeah this is a buy. This is a picture. It's a video. I don't know if you can run that but in the right lower hand corner you can see um what looks to be a suspicious lesion. You can see it in real time and what you saw there is the needle going right through the lesion. This has saved this patient a trip to the M. R. I. Then um a trip here and um really has helped us to consolidate care and also has decreased the anxiety of these patients waiting for um um A diagnosis next slide please. The ultrasound has also proved to be invaluable in the detection of other lesions. This was borrowed from the website but you can see here the technology is so powerful you can visualize the bladder and um a polyp within the bladder. The patient had originally presented with the manchuria and an elevator elevated psa. And here you can see a bladder pile that is so nicely visualized. Next slide please. And again here are some nice examples of some lesions on the left, a suspicious prostatic lesion at the apex of the prostate and to the right the needle going through that lesion. Next slide please. And these are some images of transparent real ultrasound guided biopsy is traditionally prostate biopsies are performed trans directly and there's been a slow movement for transparent real one for an increased safety to the patient, decreased infection rate as the needle goes through the perineum instead of through the rectum there's been um reap and the literature increase um um detection rates and also targeting of more clinically significant cancers unless so of lower risk cancers. Next slide please. Here you can see um a schematic of how this transparent cell biopsy is done typically can be done with M. R. I. Fusion but now with an ultra with an ultrasound with such clarity and detail you can see how this can be formed without the need of potentially an M. R. I. Next slide please. And here are different applicators used to perform those transparent real biopsies. And even though the probe is in through the rectum, those biopsies are taking place through the perineum next slide please. And this is a schematic of a typical transparency a biopsy next slide please. And for kidney cancer, as I mentioned before for diagnosis, continued use of renal biopsies to help better triage patients aggressive use of active surveillance and continued a blade of treatment with both cryo uh and radio frequency ablation and continued use of different sparing surgery and minimally invasive platforms. Next slide please and again um you know this pandemic has made us more sensitive not only to patient anxiety next slide please but also to physician anxiety and um made us realize you know things that we need to pay attention to risk of staff exposure, personal exposure, how we treat our patients post operatively is a fever really a fever from U. T. I. Wound infection or covid complications. These are all considerations as a surgeon and um, for a surgical patients to uh, to consider as we continue to move through this pandemic next slide, please. And this is just a brief recap of some of what I discussed. Thank you. Next slide, please. And I apologize for the technical errors and happy to answer any questions.