Medical Education Programmes
Robotic Prostatectomy in the USA
by Prasanna Sooriakumaran, Specialist Registrar in Urology, Guy's Hospital, London
With a PhD in prostate cancer and my specialist registrar training in urology, I have seen robotic prostatectomy in action in the UK and I was interested to see how it might differ in the top US institutions. Thanks to The Urology Foundation, I was given the opportunity to find out on a short visit to the USA, visiting Vip Patel, the world’s most prolific robotic prostatectomist, who has performed well over 3000 cases, and Ash Tewari, who performs over 650 cases per year currently and has over 2000 cases under his belt.
Global Robotics Institute, Florida
Dr Patel’s unit in Florida was simply mind blowing. The common entrance to two parallel theatres functioned as an observation area, with big screen monitors and consoles outside each theatre. Six robotic radical prostatectomies are done per day between the two theatres from 7am to 4pm. This works so smoothly not simply because of the skill of Dr Patel, who performed 12 cases without any significant blood loss, but also because of the skills of the fellows, nurses, physician assistants, and anaesthetists. All members of the team were highly proficient, highly motivated, extremely helpful to me in explaining their role within the team, and determined to do their best to make everything run like clockwork. I was thoroughly impressed by them all, and it taught me how to run an efficient robotic service.
I had the opportunity to learn specific technical points from Dr Patel himself, to make the operation more successful, such as his method of nerve sparing to preserve potency. I was also shown around the training lab, which again was simply awesome. The facilities, which include three robots with porcine models for training, are staffed all day Monday to Friday. I was able to practise my suturing, dissection, and knot-tying skills using a da Vinci robot, being trained by one of the lab managers.
I started my days at 6am with the fellows and Dr Patel (they meet every morning in the gym at 5am but that was too much for me!) on the ward round where I watched Dr Patel telling each patient how the procedure went. Not one of the 12 patients was in hospital for more than 24 hours, and not one was unable to mobilize because of pain by the 6am ward round the next day. I had the opportunity to speak to the nursing sister who explained to me how they managed these patients postoperatively, in terms of their fluids, oral intake, and mobilization, and again, I was very impressed by the quality of their work.
Finally, I met up with the research fellows and the database manager who records Dr Patel’s results without his input to avoid reporting bias, and I was taken through Dr Patel’s impressive cancer cure, potency, and continence outcomes. This visit has shown me that success is a result of a top-notch surgeon combined with a top-notch team. I now understand why such surgeons bring their own team with them when performing live surgery at visiting locations.
Cornell University, New York
I then flew from the Disney-hysterical Orlando to the hustle and bustle of downtown New York. Cornell University’s hospital is the New York Presbyterian Hospital, ranked the best hospital in New York. Dr Ash Tewari and his tremendous team of fellows, nurses, and physician assistants have one operating theatre and they perform three cases per day. Dr Tewari also starts operating by 7am, finishes by 3 to 4pm, and manages to see patients in their clinic rooms between cases. Again, Dr Tewari’s operating skills and clinical results were impressive, and I picked up yet more pointers.
Even when the operating finishes at 4pm, the day is far from over, as Dr Tewari then meets up with his research fellows and the research day begins! I listened to his fellows update him on how the research was going, discuss any stumbling blocks, and seek Dr Tewari’s input on how to overcome them. I also saw an interview with him by ABC (one of the biggest US television networks) talking about robotic prostatectomy and, perhaps more impressively, witnessed a consultation with a patient’s relative who had flown in from India to have Dr Tewari perform his surgery. Despite working from 6am to 8pm all day both Dr Patel and Dr Tewari make time to see their patients and their relatives daily.
I was left feeling highly motivated by this visit. Not only did I pick up even more tips on how to perform the surgery, but I learnt how to successfully build up a robotic prostatectomy service, as well as how to juggle academia with clinical expertise. In the UK it often seems like a choice between becoming a top surgeon or a top researcher, but both Dr Patel and Dr Tewari are among the world’s best at both.
Too often in UK training we talk about competence, whereas in those two centres competence is not the aim, expertise is. I have been motivated by my visit to strive to bring that sort of care to prostate cancer patients in the UK, and now I know that it can be done and how it can be done. It will take work but patients deserve it!
I thank The Urology Foundation for sponsoring this visit; especially in these troubled economic times where funding is hard to come by, the need for donations becomes yet more important. I hope that The Urology Foundation will continue to receive funds so that they can continue to support UK Urology in the future.
