Urologic Surgery in Motion

davinci-robotInside a ballroom of the Chicago Sheraton Wednesday morning, an unusual live event was taking place. As a few dozen people looked on with intent interest, an abstract mix of watery reds, fluffy yellows and pulsating browns filled a giant projection screen. Swooping above and into this mixture were what looked like two metallic alligator heads, joined occasionally by various other silver creatures to help lift, cut and suction the material below. Through the whole process, the operator of these tools offered audio narration from halfway across the country, conversing casually with a panel of experts in the ballroom.

The strange screening was a live surgical broadcast, one of many offered at the 2010 World Congress on Endourology held last week. Dr. Steven Shichman, a urologic surgeon from Connecticut, was performing a robotic partial nephrectomy – removing a tumorous mass from the top of a 70-year-old man’s kidney. Despite the large remote audience, Shichman went about his work with calm professionalism, slowly and methodically clearing tissue until the kidney, tumor, and important blood vessels took shape within what looked like (to the non-surgical observer) an impossible mess. After carefully clamping the major blood vessels to the kidney, Shichman deftly removed the bulbous tumor and sutured the organ surface, completing those time-sensitive tasks in a brisk 11 minutes. Hundreds of miles away from his operating room, he received a round of applause.

Endourologists concern themselves with fixing or removing the kidney, prostate, and bladder, but the live surgery revealed the meeting’s emphasis on a different organ: the eyes. Like any medical conference, there were plenty of data, numbers, and graphs to pore over about the effectiveness of established and experimental surgeries. But the main purpose of the meeting, which attracted over 900 urologists from 50 different countries, was the sharing of surgical techniques and strategies, an information exchange of a sort that would be familiar to craftsmen of any field.

“We will cover 1,300 abstracts, and I am sure that all of us can learn from each other,” said Arieh Shalhav, professor of surgery at the University of Chicago Medical Center and the President of this year’s World Congress.

Sharing knowledge is essential in a field that has advanced quickly over the last two decades, first with the introduction of laparoscopic, minimally-invasive procedures in the 1990’s and lately with the use of surgical robots such as the da Vinci system. The new technology and methods have changed major surgeries requiring large abdominal incisions to intricate procedures that leave behind only a few marks mere millimeters in diameter. The role that urologic surgeons have played in pushing forward the boundaries of minimally-invasive surgery was underlined by Jeffrey Matthews, professor and chair of surgery at the Medical Center, in his welcoming remarks.

“We’re looking to you not only for leadership in urology and urological disease, but also leading all of surgery in your approaches to innovation and minimally invasive techniques and other advances,” Matthews said.

Interestingly, some of the discussion Wednesday at the conference engaged over just how hard to keep pushing the boundaries of minimally-invasive surgeries given the field’s recent successes. A new technique known as LESS – Laparoendoscopic Single Site Surgery – was the floor topic for one such debate, between Matthew Gettman of Mayo Clinic and Stuart Wolf from the University of Michigan.

In the LESS procedure, the three or four holes used in laparoscopic surgery are reduced to a single hole, typically placed in the belly-button of a patient. Gettman argued that “LESS is Best” for patients concerned about the cosmetic after-effects of surgery, saying that the technique wins “the battle of Band-Aids.” But Wolf countered that studies have yet to prove that LESS procedures show enough benefits over traditional minimally-invasive procedures to outweigh the additional skill required to operate via a single incision. Wolf proposed his own acronym: SLIP, for Small and Strategic Lap Incision Placement. The small incisions needed for laparoscopic surgery can easily be “hidden” behind a patient’s natural and unnatural landmarks, Wolf said, showing a picture of a patient with a tattoo across his entire stomach of an eagle gripping the U.S. and Mexico flags.

“We used his body art to his advantage, hiding some of our incisions,” Wolf said to a chuckling audience. “Thank you sir, very kind of you.”

Even if it gains acceptance, LESS surgeries might only be a stop along the way to the ultimate goal: NOTES, surgeries using “natural orifices” such as the urethra or the vagina instead of incisions to do internal surgical procedures. Two talks presented what may soon be possible with the technique, including complicated procedures such as prostate removal and kidney surgery.

“This is very, very impressive work,” Shalhav said. “Some people before were called crazy for these ideas, but it’s going somewhere.”

But as with the meeting’s presentations, seeing makes a big difference for urologic surgeons. Improving how a surgeon visualizes a tumor and the important landmarks surrounding it was the aim of several research presentations, with authors trying everything from high-resolution confocal microscopy to 3-D imaging to GPS location finders to help reduce the guesswork in cutting cancerous tissue away from healthy tissue. Inderbir Gill, a USC surgeon, highlighted the GPS method, showing how pre-operative MRI scans can be “painted” onto live ultrasound images used during surgery with similar technology to the Garmin found in your car.

Coloring the tumor neon purple with GPS might dilute some of the mystery of the live surgery demonstration held later that morning. But even the most experienced surgeons need to occasionally ask for directions, and at least at this meeting, they seemed eager to learn and try out new tricks in their own operation rooms. Through debate, live video, poster presentations, and perhaps a little bit of socializing, the World Congress on Endourology demonstrated a field that wasn’t happy to stand still.

About Rob Mitchum (523 Articles)
Rob Mitchum is communications manager at the Computation Institute, a joint initiative between The University of Chicago and Argonne National Laboratory.
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