Surgeons: Vipul Patel and Simone Crivellaro

Moderators: Jihad Kaouk, Jean Joseph, Mutahar Ahmed and Jeffrey Nix


Vipul Patel, MD, FACS completed his medical school education at Baylor College of Medicine in Houston, TX. He then completed his residency and fellowship training at the University of Miami in Florida. Dr. Patel served as director of the Robotic Surgery Program at The Ohio State University in Columbus, Ohio, prior to joining Advent Health Celebration.
Dr. Patel is board certified by the American Urological Association and is the medical director of the Global Robotics Institute at Advent Health Celebration and medical director of the Advent Health Cancer Institute Urologic Oncology Program. He is a professor of Urology at the University of Central Florida College of Medicine in Orlando, Florida, and a clinical associate professor of Urology at Nova Southeastern University, also in Orlando.
He serves as an honorary professor at the University of Milan, Korea University and Ricardo Palma University in Lima, Peru, and was recently made an honorary professor of the Russian Academy of Science.
He is the founder of the International Prostate Cancer Foundation (IPCF) and a founding member of the Society of Robotic Surgery. He is the editor emeritus of The Journal of Robotic Surgery and editor of the first-ever robotic urology textbook.
Dr. Patel is world-renowned for his contribution to the field of robotic surgery and prostate cancer. Dr Patel is the most experienced robotic surgeon in the world and has personally performed over 13,500 robotic prostatectomies for the treatment of prostate cancer.
He currently serves as president of the Florida Urologic Society and Past president and Managing Director of the Society of Robotic Surgery.

Dr. Crivellaro completed his medical training at University of Torino (Italy), and his residency between University Hospital of Novara in Italy, Lahey Clinic in Boston and Harper Hospital in Detroit. He also completed a fellowship in minimally invasive and reconstructive urology at Wake Forest University (NC). Dr. Simone Crivellaro practices in the Department of Urology at University of Illinois at Chicago where he specializes in robotic, minimally invasive procedures to treat urologic conditions. He is leading the Urology Robotic Program in a very well known institution for robotic surgery such as UIC. He is a pioneer of the Single Port Robotic Surgery and he has been one of the first surgeon worldwide to offer single-incision robotic urological procedures, allowing him to deliver excellent clinical outcomes in an extremely minimally invasive way. He is an expert in uro-oncology and reconstructive urology via laparoscopic and robotic procedures, and he has published multiple scholarly articles on minimally invasive surgery, reconstructive urology, and related areas.


Jihad Kaouk, MD FACS, FRCS (Glasgow) is an American Board certified Urologist and the Director of the Center for Advanced Robotic and Image Guided Surgery at the Cleveland Clinic Glickman Urological and Kidney Institute. He also serves as a Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, the Vice Chair of Enterprise Surgical Operations and the chair holder for the Zegarac-Pollock Endowed Chair in laparoscopic and robotic surgery. Dr Kaouk also serves as the President of the Society of Urologic Robotic Surgeons (SURS) and Editor-in-Chief of Urology Video Journal (UVJ).
In Innovations, he has performed several first ever done surgical procedures, including the first Robotic single port surgery through the belly button in 2008, the first completely transvaginal kidney removal in 2009, and the first robotic perineal prostatectomy in 2014 Dr. Kaouk holds 2 USA patents for medical devices used mainly during partial nephrectomy and in robotic surgery.
Since 2005, Dr. Kaouk has served on committees at the national and local levels. From 2005-2008, he belonged to the American Urological Association’s Urologic Diagnostic and Therapeutic Imaging Task Force, and from 2006-2010 he was on the Guidelines for the Management of small Renal Masses committee. Currently Dr Kaouk Chairs the AUA Laparoscopic, Robotic and New Technology committee.
Dr Kaouk have lectured in 145 scientific meetings, chaired 26 urologic meeting and performed live surgery in 18 medical centers worldwide. He authored 520 peer reviewed scientific publication, 46 book chapters and hundreds of scientific abstracts and surgical movies. Dr Kaouk received 32 honors and awards including Cleveland clinic innovator award twice, Teacher of the Year award, and several best surgical movies.
Presently, Dr Kaouk holds membership with the American Urological Association, the Endourological Society, Society of Urologic Oncology, Society of Robotic Surgery, and the Lebanese Order of Physicians. He is a fellow of the American college of Surgeons. Recently, Dr Kaouk received an Honorary Fellowship of The Royal College of Surgeons (Glasgow).

Dr Jean Joseph currently serves as Professor of Urology and Oncology at the University of Rochester Medical Center. Dr Joseph completed his college education at Boston University. He later attended the University of Rochester School of Medicine, where he completed his residency in 1998. He received fellowship training at the University College London in reconstructive urologic surgery. Dr. Joseph completed a master class in laparoscopic prostatectomy at the Institute Mutualiste Montsouris (Paris, France). Dr Joseph completed a Masters in Business Administration in 2004 at the Rochester Institute of Technology.
In 2001, Dr Joseph was one of a handful of surgeons in the United States offering laparoscopic radical prostatectomy. Dr Joseph has also been a pioneer of robotic prostatectomy. He has performed over 4000 robotic procedures. He has been involved in a number of live surgical demonstrations at robotic symposia nationally and internationally. He has served as a proctor, traveling to many local, national sites, teaching other urologic surgeons robotic techniques.
Dr Joseph has served in a number of leadership positions. He has served on the Board of the Endourology Society, as President of the society of urologic robotic surgery. He has served on the development and bylaws committees of the Northeastern section of the American Urological Association (AUA). He is a graduate of the AUA leadership program, currently serving on the AUA content review committee.
Dr Joseph has edited 4 books, and authored numerous book chapters, and scientific publications. He has served as course director for a number of courses at the American Urological Association, and World Congress of Endourology annual meetings.

Mutahar Ahmed - Director of the Center for Bladder Cancer at Hackensack University Medical Center, Hackensack, NJ Assistant professor Hackensack meridian seton hall university school of medicine And Rutgers New Jersey Medical school.
Performing Robotic surgery since 2003
Performed Over 4000 robotic cases
Early pioneer of transition to using DaVinci robot in all aspects of urologic cancer and reconstructive surgery including intracorporeal cystectomy
Latest - performed over 150 Single Port robotic cases, all types that is being done with MP including Radical cystectomy with intracorporeal neobladder
Recipient of numerous awards and recognitions
Most proud of: Bi yearly live laparoscopic surgical workshops for Bangladeshi Urological Society to advance minimal invasive surgery since 2015 in collaboration with AUA

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello, on behalf of the Endourological Society and the chair of the office of education, Mr. Adrian Joyce, I am delighted to welcome you to the Society of Urologic Robotic Surgeons' first webinar in a comprehensive program in robotic surgery, which will occur every two weeks during the rest of 2020. You will receive CME credits after every webinar, and all webinars will be available online on the Endourological Society website, as well as the SURS website. It is my pleasure to introduce Dr. Jihad Kaouk, the president of the Society of Urologic Robotic Surgeons, who has worked tirelessly to create a program with several renowned international robotic surgeons. Dr. Jihad Kaouk.

Dr. Jihad Kaouk:

Thank you Dr. Sundaram, and many thanks to the Endourology Society and to the Society of Urologic Robotic Surgeons (SURS) for organizing this bimonthly event. We are excited to present to you many topics on innovations and tips and tricks of various robotic procedures in urology.

Dr. Jihad Kaouk:

Today the focus is going to be on single port surgery, and we have an exciting program of recorded surgeries. The first one is by Dr. Vipul Patel, who is very well known leader of robotic prostatectomy worldwide. Dr. Patel is the head of the Robotic Surgery Program in Orlando, and we will be listening to him detailing his procedure for 20 minutes followed by Dr. Simone Crivellaro who is the head of Robotic Surgery Program in Indiana in Chicago University. He will be presenting also a single port radical prostatectomy. The time left about 20 minutes would be a discussion between the panelists for the attendees.

Dr. Jihad Kaouk:

Please feel free to put your questions on the chat box and we will be able to answer them while the surgeries are presented and later on in the live moderation. With that, I just wanted to say that this is a CME event, and you can claim your CME by going into the links shown below on the Endourology Society. Again, thank you all for attending today and thank you for having the Endourology society and SURS as a society that serves every robotic surgeon in urology. With that, I would like to welcome Dr. Patel and ask him to start with his surgery presentation.

Dr. Vipul Patel:

All right. I was asked to talk a little bit about single port prostatectomy. I'm just going to share my experience with you. Probably just started the program maybe eight, nine months ago and probably were doing about 80 cases at this point. The robot many of you will be seeing, have seen, and some fundamental differences that we'll talk about, but I'll tell you more about our approach to the program itself. The first thought was "Is the SP fundamentally different from the robot that we are using at this time?" There are differences. You do work in a smaller space. You do have different pedals. You do work further away from the patient because the instruments have to stretch out because they have an elbow and a shoulder. They're non-wristed. You don't have a true robotic wrist. The capability of the instruments to have torque, traction, dissection is different.

Dr. Vipul Patel:

All of these things really are important. I think most people probably watching this are starting their programs and pretty early on, so I think this is really geared for them to understand what are the fundamental differences and how do you approach it? One of the most interesting things as you can see here on this picture is it's kind of a spaghetti of instruments in there. You have to understand now, you have a flexible camera and this camera angle has to change for each part of the procedure. I think those things are somewhat important to remember. These are the questions we asked and probably if you're starting a program you should ask. We could probably do these more in the panel discussion, but it's important for the team about training, the learning curve, benefits, potential dangers.

Dr. Vipul Patel:

These are all the questions that really should go through your head when you're starting a program. These are the most common questions I get. People say, "Look, you've done thousands of these multi-port, why mess with the single port?" And you know what? I think it's more of a philosophical reason. Every new technology deserves a chance. SP robot 1.0 may be the first version, but maybe 3.0 will become the standard of care. I think we won't know until we try it. Experienced surgeons should be the ones who evaluate the new technology. I think the hope is to lower the learning curve for others and then look at the potential long-term benefits. I think these were the reasons why we decided that we would try single port surgery.

Dr. Vipul Patel:

The initial goals are very important to assess for your team, and they're going to be different for each person. How to do it safely, margin rates, cancer control rates were very important to us. We obviously didn't want to increase complications, morbidity. We wanted to have good outcomes. Part of that was oncologic, but also we felt that operative times staying relatively low were important because the more the operative time, the potential for increased morbidity. Now, these were our concerns. There was some publications out there showing higher positive margin rates and long operative times. It was probably difficult for us to tell a patient instead of expecting a 90 minute prostatectomy, now it's going to be three hours. We made some modifications in how we started the program to kind of satisfy these concerns. I think first was the appropriate expectations. We knew we were going to try a new technology. We knew it would be more challenging, and we let the patient and the team kind of know what we were doing.

Dr. Vipul Patel:

What's success? It depends on what your bar is. It was the same when we went from open prostatectomy to robotic. How good you're doing on the new technology depends on how you were doing on the old technique. So, everyone's bar for success is different. Our goal is we wanted to do the procedure as similar to multi-port outcomes and technique with the SP. We didn't want to fundamentally change the whole procedure. Partly, it was patient selection. We basically picked patients we thought that we could give good outcomes to, similar outcomes between single and multi-port. They're usually healthy men, no large volume disease, smaller prostates, inpatients and sometimes we actually excluded the optimal candidate. If we had a 46 year old guy and his main concern was potency, he wasn't the one we were going to start with because we didn't know.

Dr. Vipul Patel:

Sometimes we excluded the optimal candidates because they just didn't want to do it. Single port plus one, I thought the best way for us to keep margins low and operative outcomes and time low was to actually add in the system port, so I could still clip the way I do clips and I could still retract and I could still suction. I think that did help us. We've published a lot of this recently in different journals about how we approached our initial learning curve. There were also a lot of decisions if you look at the literature, intraperitoneal extra, gelport, no gelport, system port or not. All of these questions we can discuss in our discussion. Outcomes, costs, it's going to be more expensive usually to start a new technology and the question about whether we could send these patients home or not.

Background voice:

Look at that.

Dr. Vipul Patel:

Surgical challenges I think were significant in the beginning. I always say the SP took a procedure that I could almost do in my sleep with a multi-port and now made me think about every step. That's not bad. It means that you're just doing it a different way, but we wanted to maintain the same surgical principles and I'll show you the technique of what we're doing. But we did have to modify because the instruments are different. You don't have a wrist. You don't have the same strength. The camera's flexible and has all the different angles. We wanted to do the technique the same way, but we knew that we still had to modify it to the robot.

Dr. Vipul Patel:

In terms of ports, basically you can see this is how we do our multi-port on the left, single port on the right. If you're extraperitoneal, you probably go below the belly button. But here when we went transperitoneal, we had to be at least 20 centimeters away because the instruments have to actually go in open and they have to triangulate inside. If you're too close, you actually have trouble because you can't move the instruments because they can't bend, so that's very, very important. Here's our videos as we start, you can see that this is the docking of our robot coming in here.

Dr. Vipul Patel:

It's pretty simple to dock. We have an accessory port, and then we have the regular robot just starting to dock. We did put the patients in some Trendelenburg to get the bowels out of the way since we were transperitoneal. Here we can see the beginning of the procedure. You can see that we're trans. We've got the instruments in there. The reason I put the XI on the left and the SP on the right is that's kind of my philosophy. I compare the procedure to how I would do it, multi-port and single port. The goal was to try and replicate it and do it as similar to how I was doing it before, but obviously to modify to the different types of technology. I think you can do that. I think it depends upon the patients you pick and where you are on the learning curve.

Dr. Vipul Patel:

Here's the bladder neck dissection. As you can see, a very similar look. Different angles based upon the instruments, but you enter the bladder the same way. What we found is that if you select the appropriate patient, we could actually do a good job and we could actually do it quite similar, whether we did a single port or a multi-port. What was different was the way we retracted, the way we suctioned. The exposure was different. You could only see certain angles with the SP. I think that we actually had a better view in many ways, with the XI. There were certain parts that were different. The seminal vesicles dissection, the angles were different, whether we were doing single port, multi-port.

Dr. Vipul Patel:

The biggest thing I found that was different was the traction. With the single port, it was very hard to get the same sort of traction. The instruments aren't built to deliver the same grip and the same torque. Exposure was sometimes challenging. I think that's something you have to know. I think the bigger prostates will be more difficult for you, and the exposure will be compromised sometimes. What's interesting is to see the side view. You can see here the side view. It's important to know that it does look like kind of a spaghetti of instruments. I think knowing that ahead of time is super important. The angles of the camera, you almost have to kind of memorize when you need to change the angles, when you need to rotate the cameras. This is what we put in our paper. We modified the actual technique depending on what part of the procedure. It wasn't just this static lens anymore. You could actually modify how you articulate the scope.

Dr. Vipul Patel:

This is the part that I think I had the hardest time with, which is the nerve-sparing. You can see on the left side is the XI. I used the 30 degree up camera. You just get a better view. Even though the SP is articulated, sometimes it was very difficult to get into that right spot. The other challenge that we saw with the SP versus the XI is the dissection. You can see with the XI, we can get into this space. We can use the instruments to sweep away the tissue. With the SP, you just don't have the strength of the instruments to be able to switch away the tissue as much. So, the nerve-sparing would be a little bit more difficult to get into the same planes. It would just take some time.

Dr. Vipul Patel:

The key was patients. What we found was that with selecting the right patients, we can actually do a very similar operation. I tried not to reinvent the wheel. I tried not to change too many things just to accommodate the single port technology. The goal was to still do a good operation. I thought for me that was selecting the right patients and also making sure that we had some assistance in there to help us during the learning curve. I think that was very, very important for us.

Dr. Vipul Patel:

The next part of the procedure after the nerve-sparings, obviously the apical dissection, the anastomosis. I have to say that overall, when I started the SP program, I wasn't really sure how we would feel, but I think the technology is better than I expected. It functions very well, especially in suturing. Even though there's no true wrists, I think during doing suturing and doing the anastomosis and so forth, it's actually quite good. The anatomy of the patient obviously makes a difference. It's going to do that on everyone. I think the suturing capabilities were better than I expected. The harder part was really the torque provided by the instruments. The actual ability to grasp instruments and to hold them and provide traction, that's what makes the part of the procedure a little bit harder.

Dr. Vipul Patel:

Here's the posterior reconstruction. You can see one versus the other. I think this is a good way to evaluate it. Put your two procedures side by side, whether you're doing single port or multi-port. See if you can do it the same way. I don't think you should completely modify your technique just to do single port. I think you should actually try to have as good outcomes with a new technology as you can, knowing that it's going to take a little longer. You may struggle a little bit more, but I wasn't really keen on changing the entire procedure just to accommodate the single port technology. You can see here, it seems the suturing works quite well from one to the other. It depends upon, obviously, the patient, but the capability of the single port robot is there. You can see on the right side even without a true wrist, you can actually get in there, and you can actually do the same things. It does take a little while. You do have to spend a little time in the lab. You do have to do some training to get this to work well.

Dr. Vipul Patel:

We've had a few publications on this. First, we published on our first 50 cases. In that one, it was really about "Could we maintain our margin rates low or comparable to what we were doing with multi-port?" We were able to do that. Operative time, I thought that was very important to correlate with morbidity. I didn't want to spend three or four hours doing a procedure that I could do in 90 minutes or less because I think it would have been hard to convince the patients to do that. So having the extra port definitely made the learning curve easier for us. You can see the pain scores after surgery were quite low. They did have the advantage of a single port. Our most recent data and publication is going to be a comparison between multi-port and single port. You can see in red there, the single port seemed to have a little bit less blood loss, but the operative time was higher. You're probably going to see about... In our hands, 20 minutes increased operative time compared to what we were seeing with the multi-port. It will take longer, but it shouldn't be two or three times as long.

Dr. Vipul Patel:

But what's interesting is the pain scores. There was a difference initially in the first six hours, but after that the difference seem to go away. What we found is the multi-port and the single ports, if you put them on the same protocol for management of pain and ambulation, they actually do very similar. We actually started to treat our multi-ports like single ports, and it was hard to tell the difference in many ways. We didn't see a big difference. Margins stayed reasonable, and they stayed appropriate. We were happy with our oncologic results as well. Overall, I can say that we probably are 80 cases or so in, and there's a learning curve. It is manageable. I think it's important to set expectations. It's very similar to be going from open prostatectomy to robotic prostatectomy. Can you get the same or better outcomes? That was important. We wanted to pick patients that we thought we could still give good outcomes. Sometimes even the optimal candidates we would pass over them because initially I thought the learning curve for the nerve-sparing was much harder, so we didn't select them.

Dr. Vipul Patel:

Low BMI, smaller prostates is very helpful. The assistant port I think was invaluable for us during the learning curve. It kept the operative times down and kept the margins reasonable. I think patient first. We know how to do a procedure with a multi-port robot. I think when we go to single port, we should try to do a good job as well. We were very important in sticking to our technique. We didn't change everything just to incorporate the SP. That was important for us. Other thoughts, I haven't yet seen anybody do a single port better than they do a Multi-port, and that's not saying anything against the single port. It just tells us that we've done thousands of one way, and we're just starting the other.

Dr. Vipul Patel:

There is a learning curve, and eventually it will catch up. We still have a lot of work to do to say that we can do both as well. Trans versus extra, I think it depends on who you are and what you're doing. We didn't see any difference in multi-port between the two procedures, and probably during single port, it's going to be similar. We just haven't studied it. Operative time, if your operative time is really high with single port, is it any better than a quick multi-port in terms of mobility? We don't know. Sending patients home the same day. Is there an advantage? What we're seeing is that if we treat the multi-port and the single ports the same, they actually do the same post-op. I think [inaudible 00:21:15] has said the same thing. His multi-ports are going home the same day sometimes as well.

Dr. Vipul Patel:

But I think whether you send them home the same day or not is more a matter of how you counsel the patient and how you prepare them for the type of surgery mentally. You tell them they're going to go home the same day, they're more likely to do it, whether they're single or multi. Then it's important to be careful. If you're sending them home same day, you have to make sure you code it correctly. Otherwise, it can be financially quite difficult for the hospital if you code it incorrectly. They sometimes don't get paid or get paid poorly. I think that's important to have that discussion with your team. I think single port is here to stay. I think this is version 1.0, and version 2.0 or 3.0 may become the standard of care. I think it will replace multi-port one day when the technology is right.

Dr. Vipul Patel:

I think other specialties will really do well with it, especially the ones I've listed here that are doing smaller procedures. We do need to improve the instrument strength, the dexterity. It needs to have more traction, more torque. The ability to dissect needs to be better, but that will come with future versions. Overall, I think I'm very optimistic about the technology. We're still learning. I'm definitely not an expert on single port surgery. I just shared with you my experience. Many of you have said you want to see the full video. You can just go to the YouTube website, and you can see a full case because I think that's really important when you start to watch full cases. Then the World Symposium, you can watch the master class. Thank you very much guys.

Dr. Jihad Kaouk:

Thank you so much, Dr. Patel. That was really amazing with a lot of pearls mentioned here. The take home message I get from your approach is that you are a super robotic surgeon with the multi-port. You wanted to keep your technique as you move to SP and try to use that experience transferred to the SP to do the same good surgery on the robot. That's one way to approach incorporating SP and the other approach... That sets me very well to introduce the second surgeon. That would be Dr. Simone Crivellaro, who will be presenting the extra peritoneal approach, where he moved from his intraabdominal to extraperitoneal to apply the SP hoping to minimize the procedure further. Let's move to Dr. Simone. But before that, I want to acknowledge again, the educational grant by Intuitive that made this webinar possible. Thank you to Intuitive for supporting educational activities like this one. Dr. Crivellaro?

Dr. Simone Crivellaro, M.D.:

Thank you Jihad. Thank you Vip. That was an awesome presentation. Let me tell you that it's always a pleasure to watch you operate. It doesn't matter if it's multi-port or single port, really. What I take from Vip's presentation is that overall, his outcomes... In his hands, they are least non-inferior with single port and with the multi-port. To me, that is good validation considering where he's coming from off this platform. You just heard one possible approach to this new platform from Dr. Patel. What you'll be hearing from me is slightly different. I was able to secure a unit of SP very early in the game in December '18. Since then, I essentially moved all my robotic practice from multi-port to single port. We've actually done over 200 cases now.

Dr. Simone Crivellaro, M.D.:

Along this journey, I was able to learn a lot of things about this new platform. One of the most important things that I have learned is that single port can guarantee better performance when you work in small anatomic spaces. I strongly believe this is one of the major value that we're adding, introducing a single port in our practice. Now when it comes to prostate surgery, smaller anatomic spaces, to me, it means to try to look beyond the standard intraperitoneal approach and start exploring different accesses, like the extraperitoneal one, the Retzius-sparing access, the transvesical one, or the transperitonealone. Now as urologists, some of these accesses are like back into the future because we are familiar with the extraperitoneal and the transperitonealbecause doing open surgery, that's what we were doing. The same experience has been trying to be translated with multi-port, but it never got popular.

Dr. Simone Crivellaro, M.D.:

In my opinion, it's because it's doable, but it's a little bit more difficult due to the nature of the multi-port technology. Now, moving toward these accesses, it becomes a little bit easier with this platform. It's more approachable. Moving away from the peritoneal and into the extraperitoneal space, we know that we're gaining some unquestionable benefit. We know that from our previous experience. Like we don't need [inaudible 00:26:52], like the bowel function return is going to be faster. We're working in a contained space, which essentially means we can control better whatever can happen after the procedure. We being able... We published that in a joint publication with the Dr. Kaouk and Cleveland Clinic to show that the extraperitoneal approach was providing less pain, earlier discharge when compared to the intraperitoneal SP. There are a good number of benefits that we can actually gain.

Dr. Simone Crivellaro, M.D.:

Now... And that's why I strongly believe that's a good way to use all the potential of the platform. If you want to go this route, you need to think about your setup though. The setup of the procedure, I think, is key when you're not going intraperitoneal. That's my setup for extraperitoneal single port prostatectomy. We usually make a three centimeter horizontal skin incision just below the umbilicus, then we do a two centimeter horizontal incision of the anterior rectus fascia. We split the muscle and at that point, we can perform a digital dissection of the retropubic space. You can or cannot use the balloon space maker. At this point, we are ready to introduce the Alexis retractor. Then it goes all the way inside the retropubic space.

Dr. Simone Crivellaro, M.D.:

At the same time, we'll also introduce this trocar here, which I call the sidecar. It's the five millimeter trocar which goes through the same skin incision and through a different fascia incision, which allow you essentially to have an extra access through the same incision. Then we can put our gel cap, and through the gel cap, we going to have the robotic trocar and a five millimeter ARC trocar. At this point we're ready to dock. Once the robot is docked, we can deliver an eight millimeter flexible camera and 36 millimeter robotic instrument through the two centimeter incision in the fascia. Notice that the trocar is completely outside of the abdomen. That's what we call the floating dock. That's key because the floating dock allows you to move the famous 10 centimeters that you need from the tip of the trocar to the target. You can move those centimeters back, which allow you to work on more superficial organs and which allow you to work in shallower spaces. That's what we call the floating dock, which is essential in order to perform extraperitoneal prostatectomy.

Dr. Simone Crivellaro, M.D.:

On top of all of that, I still have the five millimeter sidecar trocar to deliver flexible suction, rigid suction or whatever you need during the procedure. This is the setup. The procedure essentially starts with me introducing just the flexible camera inside the cavity because I want to make sure everything is okay and everything looks ready. Then the assistant will introduce the instrument. In this phase, it's crucial the use of the relocation pedal. The relocation pedal will allow me to essentially navigate the entire platform, the instrument and the camera inside a small incision and inside the extraperitoneal space. Once I'm in there, I can deploy the instrument as you have just seen it. You essentially start articulating your instrument in a very small space, but from now on it's business as usual, meaning you won't have a lot of clashing outside or inside of the patient simply because the instrument and the camera they're coming through the same incision. Whoever's tried to do multi-port extraperitoneal prostatectomy knows that sometimes it can be a little bit of a struggle with the lateral arms, all that part is gone with the single port.

Dr. Simone Crivellaro, M.D.:

Now I'm essentially cleaning up the fat on top of the prostate. The flexible suction is now introduced through the sidecar trocar. In this case, it's an NG tube. That's what I was using the very beginning of my experience, a 14 inch tube. You can use some commercially available, flexible suction like the ROSI. I'm actually now using a 15 blade drain. It's very nice to have a flexible suction because you can actually control the suction yourself. It's another step toward what I call a solo procedure, trying to minimize the assistance from outside and trying to be as much independent as possible. As you can see, you can grab the flexible suction in this case with the Cadiere, which is at six o'clock. You can put, at the same time, traction and suction using the instrument.

Dr. Simone Crivellaro, M.D.:

Now, I'm approaching the pelvic fascia on the right side. I agree with Vip that the major steps of the procedure, they shouldn't really change. In this case, of course I changed the approach, but the steps of the actual prostatectomy, they even changed a lot for me. What has really changed is the way that I am moving the instrument. The three instruments, they are collaborating to each other all the time, much more than before. Normally with the multi-port, as you have seen in the nice comparative video of Vip, you will use one instrument for traction and then the other two instruments then will perform the dissection. With the single port it's very different because you change traction all the time, and you can't forget about the traction instrument. You have to keep moving with the three of them in order to perform and be efficient during your procedure.

Dr. Simone Crivellaro, M.D.:

Now I'm putting the DVC stitch. I always do that. It's a habit that I have. You can or cannot do it, but it's just to show you how much the suturing... I think it's pretty much easy. The only difference with multi-port is that you don't have a wrist, as Vip mentioned. You have an elbow and you have a shoulder and so you have to plan your stich a little bit more than you would do with the multi-port, but I think the adjustment is very minimum. Now I'm approaching the anterior bladder neck, the Cadiere is still at six o'clock. I'm going to pause for a second because I want to do have your attention around this little fella here.

Dr. Simone Crivellaro, M.D.:

This is called the navigator and is another major feature of the single port that you want to check every time during your procedure. It gives you the relative position of instrument and camera in real time. When it comes to the instrument, it's important because if you have any clashing, any problem, any resistance in your movement of your instrument, you can check the navigator. You'll figure it out, what's happening and fix it. When it comes to the camera, it is even more important. Right now you can see the camera is green. That's what we call the Cobra mode. The Cobra mode is the ideal position of the camera, the position of the flexible camera that gives you more control over your instrument. That's the place in which you want to start every surgical step. Once you start with the Cobra mode, then you can modify. The camera is not green anymore, as you can see here, but it's very important to start with the Cobra mode.

Dr. Simone Crivellaro, M.D.:

Now, what just happened? I have switched the Bipolar with the Cadiere. The Cadiere used to be a six o'clock and is now at nine o'clock. Why? Because I need upward traction. I need to grab the catheter with the Cadiere to pull up, and I can still use the Bipolar to push down and to maneuver the flexible suction. This exchange of instruments around the clock of the platform happens very often, at least in my case. That's simply because you can manage your traction differently if you do that, you can put your Cadiere in different positions around the clock and have different kinds of traction. I can finally try to titrate my technique and the platform I'm using to the anatomy that I'm dealing with and not the other way around. This is something that I really appreciate about this platform. I can play a lot with more variables, and that helps me modify a little bit the traction and the technique in order to make it work for that specific patient.

Dr. Simone Crivellaro, M.D.:

Now, I'm working my way toward the seminal vesicle. I'm going to clean the camera in a second just to show you cleaning the camera isn't that really any more difficult than with the multi-port. Right now I'm going to drop, in a second, the catheter with the Cadiere and I'm going to grab the vas. This is something you can do with the multi-port as well and we've showed that very well, but to a certain point. Because the smaller the space, the more clashing you're going to have between the Prograsp and the other instrument which are bigger, and they don't come from the same incision. With the single port, you can really push that. You can really work in a very small space, as you can see here. And you keep having three fully functional instruments in terms of traction, in terms of dissection, or whatever you need to do.

Dr. Simone Crivellaro, M.D.:

That's one of the reasons why I say that this platform gives a very good performance in small shallow spaces. From now on, I'm just playing. See now the traction instrument is the Bipolar, and I'm using the other instrument to dissect. That's what I'm saying. This is what I mean when I say that you keep switching the traction instrument with the dissection instrument.

Dr. Simone Crivellaro, M.D.:

The next clip is about the nerve-sparing. That's the way I've been doing nerve-sparing even before. I don't like to leave clips behind. I do my nerve-sparing completely [inaudible 00:37:45]. Once I develop the posterior plane, I put a stitch at the base of the pedicle and then I cut cold to dissect my bundle. Now, commenting on what we just said I always put the camera at six o'clock when I do my pedicles because it's said, and it's true, if you have the camera at 12 o'clock sometimes it's hard to have a good view. In that case, you're probably going to have a better view with the 30 up with the multi-port, but if you have the camera at six o'clock like in this case and if you check the navigator, you understand what I mean right here. See the camera is at six o'clock. The Cadiere is at 12 o'clock providing a good traction, then I can keep going with the dissection with the Bipolar and the scissor.

Dr. Simone Crivellaro, M.D.:

Camera at six o'clock is something that I always do for pedicles and for posterior plane of the prostate in general because it really gives me a better view of that plane. Another good trick, you need to adjust your traction with the Cadiere much more often than you would do normally with the multi-port because again, you can't swing that much with this instrument. You have to get closer and closer with your traction instrument to the dissection plane. But as you can see, it's enough traction to get the job done. We normally put a lot of traction with the Prograsp with the multi-port, at least I was doing, which is good for the surgeon because it allows you to perform your dissection faster. But I don't know how much good it is for the nerve because of course, more traction means more damage.

Dr. Simone Crivellaro, M.D.:

Now for the urethra, I actually relocate back the camera at 12 o'clock. I'm going to stop again the video to check the navigator, and my camera now is at 12 o'clock and again, in Cobra mode. That gives me a very good view of the ureter stump, and having a flexible camera in this phase also helps because you can really go close and check to see what's happening now. You can check the lateral part of the urethra very well and keep going on with your dissection. Once again, using the flexible suction by yourself, I think it's a plus. It really helps me being autonomous. This is the procedure reconstruction. I'm using a V-Loc 3.0 with an SH needle. The Cadiere, the third instrument, is not in active use now because it's holding. If you check the navigator again, you see that's the Cadiere right there. It's off screen and it's holding the prostate in the corner of the extraperitoneal space in order for the prostate don't drop and being in my way during the anastomosis. I just... The Rocco stitch that I do is my version of it. There are a lot of versions of it, but I didn't have to change that because I was using multi-port.

Dr. Simone Crivellaro, M.D.:

One thing about the extraperitoneal approach and posterior reconstruction, I noticed that it's a little bit harder to pull the bladder neck down, to push the bladder neck down. That's because we didn't dissect the bladder that much. So it's a little bit less mobile, but with a little bit of patience, you can do as a good job as you would do with the multi-port. Once I'm done with this, I'm going to start the anastomosis. Kind of my own suture here, and the assistant will give me the anastomosis. In this case, the stitch is going through the robotic trocar, which is something you can do. 'Cause remember, I don't have an assistant trocar. The only thing I have is the sidecar, which has some use, but it's a five. So an SH needle will be struggling going through that. So for needles, we use the actual robotic trocar, and the need for the anastomosis is pretty much the same.

Dr. Simone Crivellaro, M.D.:

Just a comment about the way the single port works for suturing. Again, not having a wrist doesn't allow you to do a couple of things that you would normally do with the multi-port. Like an example, it's really hard to throw a stitch right at you at six o'clock that I was normally doing during the anastomosis. You have to go a little bit more lateral than six o'clock, and you have to position your arm in a good position to throw whatever you want to. In other words, it's a little bit less forgiving than the multi-port. But again the adjustment, to me it wasn't that difficult. I did train in the lab a good three or four sessions, a couple of hour sessions each before the first case. That really helped, and it's something that I really recommend doing before you start the first case.

Dr. Simone Crivellaro, M.D.:

But I don't believe the suturing is really a problem, both for prostate and for kidneys. I'm going to forward this a little bit because this part really is not worthy of any particular comment. As you can see, there is no suction from the assistant. I'm managing my own traction with the flexible, and most of the time I connect the Foley catheter with the suction. That really helps to keep the anastomosis clean and makes things faster. Because when it comes to the operative time, I would agree with Vip that it's longer. It's a little bit longer. Especially at the beginning, but the more you do these cases, the more you get autonomous and independent and the more you become faster. You are essentially decreasing variables. It's just you, so you can manage things the way you want. You can manage your traction the way you want, the suction the way you want and I feel that really impacts on your operative time at the end of the day.

Dr. Jihad Kaouk:

One more minute, please.

Dr. Simone Crivellaro, M.D.:

Sure. I was just about to say that this brings me to my conclusion, which is very simple. So simple it doesn't need a slide. I really believe that these SP platforms... Every new technology has a role, and this new platform has a big role when it comes to working in small spaces. I really think we should go that way in order to make an effort to minimize the invasiveness of what we do and to gain clinical benefits for our patient. Thank you very much.

Dr. Jihad Kaouk:

Thank you so much, Dr. Crivellaro. That was also amazing. It is nice to see that you can do all the moves you want to do through the extraperitoneal space. We have 15 minutes left, and this 15 minutes we would like to have some discussion with our esteemed panelists. We have assembled a panel of experts in SP also. We have Dr. Jean Joseph from University of Rochester, a leader in extraperitoneal robotic prostatectomy and doing single port prostatectomies. Dr. Mutahar Ahmed is from University of Hackensack, and they have done everything with the SP: cystectomies, fistulas, prostatectomies, you name it. Dr. Jeffrey next from the University of Alabama who just this morning did a single port cystectomy just before he joined us, a very experienced single port surgeon. So I welcome you all, and I would like to start with Dr. Jean Joseph. Would you like to have comments to the surgeons about their approach and maybe in reference to the extraperitoneal approach? Dr. Joseph?

Dr. Jean Joseph, M.D.:

Yes. Thanks Jihad. Great demonstration by Dr. Patel and Dr. Crivellaro. Wonderful to see, and the chatbox was very active here. As far as extraperitoneal’s approach is concerned, I'm excited to see this becoming mainstream after pushing for it for nearly two decades. The question in terms of the balloon dilator, as far as Simone. Do you see value in it? Because I have personally seen value in terms of helping with the dissection quite early on exposing the umbilical fascia for you to ultimately get you right to the target organ, which has been to me of value of the extra bit of space. Dropping down the bladder with a balloon dilator you get down pretty quickly to the target organ and it saves you a lot of time as opposed to the finger. Do you have any thoughts on that?

Dr. Simone Crivellaro, M.D.:

Yeah I... First of all I know you've been putting a lot of effort in the extraperitoneal space and I believe for good reasons. So maybe the time has come. But in regard to the balloon, I really believe it's important to use it especially when you start doing this. It really helps you because it develops the space very nicely, and when you get inside with the camera, you already have all your anatomic landmark available. So it makes orientation much, much easier. I think when you are a little bit more experienced with that, you can still do a good job with your finger, and then especially with the single port, start with a very small space. I mean, smaller than a tennis ball, and then dissect your way down to the pelvic floor That way you're also avoiding an extra cost.

Dr. Chandru Sundaram:

So I agree with Simone, I don't use the balloon dilator. I just use a finger and feel the bone, the pubic bone and the arch. And that's basically your landmark and the area of... target area is so small is needed initially. You just use the instrument to bring it down. I mean, it saves some money, but I'm pretty sure initially I think using balloon is a good idea.

Dr. Jihad Kaouk:

I totally agree with both of you. And I must say, once the space is developed, surgery is very similar to what you do intra or extraperitoneal. Really mastering this initial step is important. We were able to do kidney transplants extraperitoneal using the single port. So the space is excellent. I would like to go to Dr. Nix here and ask him about the question about lymph node dissection for the SP prostatectomy. Your thoughts?

Dr. Jeffrey Nix, M.D.:

Can you hear me okay?

Dr. Jihad Kaouk:

Yes we do.

Dr. Jeffrey Nix, M.D.:

Yeah, I think right now... And I'd be interesting in what you guys do. Right now, if I'm going to do an extraperitoneal approach, I don't do lymph nodes. If I'm going to do lymph nodes, then I do an intraperitoneal approach to the prostate. I think the node dissection is just as good. It's a little bit more awkward on the left side. You have to play with the angle of the robot a little bit and just remember what Simone says, all these arms are one unit. So if you rotate over, you can get a really nice feel for it. I think you can manipulate the vessels really nicely. I feel like what Vip said is precisely the key. I think you have to be able to do the same thing you would do multi-port or you're not providing adequate care to your patients.

Dr. Jeffrey Nix, M.D.:

I definitely think you can get a really good node dissection. You can go all the way up to the common. I mean, again, the other thing that one of the discussion... which was brought up in the discussion is you can put your port anywhere with a single port. You can put it paramedian, you can put it subxiphoid. There's really no limitations. Someone with a large midline mesh, do your prostatectomy with the paramedian approach. It really is of no... It doesn't matter. I think that gives you a lot more... We did a retroperitoneal node dissection for a local recurrence for someone who had an oophorectomy two years ago, a paraaortic local occurrence. And it was a beautiful single port approach, extraperitoneally. So I think you can get anywhere you need to go for nodes.

Dr. Jihad Kaouk:

Thank you Dr. Nix. I totally agree with you. For the comment of the nodes and the extraperitoneal approach, I think the key is the floating dock of the robot. If the robot is retracted to the skin level or above, you can turn the robot to the side and can go above the common iliac if you need. You only lose depth so the field becomes shallow as you go to the side. The solution is to back up that robot out of the skin level when you go in, and you can do as good as intraperitoneal dissection. I would say it's as effective, if not more than the multi-arm robot because with the multi-armed robot, you cannot retract more lateral the lateral ports while here all your ports come from the midline.

Dr. Jeffrey Nix, M.D.:

That's a good challenge to me. So I'm going to have to do that now. Extra peritoneal for all the prostates.

Dr. Jihad Kaouk:

Once you put that dissection at the balloon and the dissection, then it becomes business as usual. Remember you drop the bladder from the very beginning plus that when you dock the robot, you only have one incision and docking takes us about seven minutes to do. Then at the end, you close one incision. That's the extraction site, not five or six incisions. So ultimately I feel this procedure can be even faster once we master it to the level that we do with the multi-port now, but that's yet to be proven.

Dr. Jean Joseph, M.D.:

I would also comment in terms of the amount of insufflation that you need, I don't know how much Vip has experience with that in terms of extraperitoneal. We're very experienced with it. We can drop the pressure down quite low. There are others who are on this call who published on doing no more than six millimeters of mercury of pressure. So extraperitoneally, you truly maintain the pressure quite low with the advantages attached to it.

Dr. Jihad Kaouk:

Absolutely. So with the air I said we don't go above 12 because we think that above 12 millimeter at sea, the subcutaneous emphysema risk becomes more. We like to keep the patient flat, so no Trendelenburg position. That allows us with the extraperitoneal approach to have that bubble only in the extraperitoneal, push the peritoneum up and the bowel. So it makes space for you, and you don't need gravity to get the bowel out of the way.

Dr. Jean Joseph, M.D.:

Can I ask a quick question, as far as the use of the camera angulation? I don't know any of you on the panel as to how much you use the camera angulations because we were stuck to the way we were used to with the SI or the XI. Any comments? I know that Simone made some remarks to it as to wait for the camera and how much you... The Cobra move, what have you... Please comment on that. That would be helpful because to me that's technology that's not being fully taken advantage of.

Dr. Muhatar Ahmed, M.D.:

Yeah. So yeah. I mean, you're right. I mean, it requires some learning, but I... For prostate, I use zero degree most of the time, but when you are working on the nerve, when you're working at the apex, or when you are looking to find a seminal vesicle and dissecting, that's where the angle comes in handy. I think you could make an acute angle, you could make an obtuse angle. This is, I think, where it comes in a little bit of an advantage with the SP. However, most of the time, I think you could get away with zero, but you have that option to change these angles. One thing they are doing though, I think they have already made the transition is that you could once you've made the angle and you want to move back, you cannot just move back.

Dr. Muhatar Ahmed, M.D.:

You gotta hit the camera button or relocator button to make the camera become straight again. Then you can move back the camera. So that's a real problem, but they have, I think, made an adjustment that you could just press a button and it will automatically fall back to zero degrees and then you can move in and out easily. But that technology is not out yet, or the software is ready for it because that's what sometimes happens. That once you make the angle, it's very hard to move back unless you press that button to make it zero again. And it takes a little time.

Dr. Jeffrey Nix, M.D.:

I think... Yeah, I would add to that and say with the floating dock, it kind of dummy proofs you being too close to the target organ cause that's the biggest problem is you have to get that camera out really far to Cobra it. That takes some getting used to for like, if you're converting from multi-port to single port. That was the thing I probably messed up the most at first was being too close to the target organ. So I think if you're not going to be too far away with the single port, I guess is the thing I would say cause you can always advance that instrument like you would a single port. But to sort of give you some error proof, I think this is one of the big benefits of the gel point and the floating dock is you can be above the fascia. It's not a big deal. It doesn't matter. So don't be afraid to use that. Cost is worth it I think in your first 20 or so cases cause it just prevents you from running into that hurdle. I don't know what the other presenters think.

Dr. Muhatar Ahmed, M.D.:

The kidney case, I think extraperitoneal kidney, a lot of times you don't have enough space, and you need that to go back to zero, to pull back. In prostate, I don't think you need that much. You could work in any angle you want pretty much.

Dr. Jean Joseph, M.D.:

That's the cons of the retroperitoneal.

Dr. Jihad Kaouk:

If you don't mind, I just want to say that on another topic that is if we want to really find a difference, a recognizable difference in the invasiveness between MP and SP, I think we should not just replicate the same good work that you do with the MP. For example, when we do the pyeloplasty, nowadays, we do it from a Pfannenstiel incision. So a Pfannenstiel small incision, we can dock a gel port and go with the single port robot all the way up. That's not doable with the multi-port, but think about the advantages of a Pfannenstiel incision, especially in pediatrics. And we're seeing that difference. So all our pyeloplasties are outpatient cases, and the incision is a bikini line incision that is really hidden down there.

Dr. Jihad Kaouk:

So these are the kind of advantages that I feel I can get used of this new purpose-built robot for the single port to go to areas where otherwise I could not do with the multi-port.

Dr. Jean Joseph, M.D.:

Can I ask Vip a question?

Dr. Jihad Kaouk:

Of course, I totally, yeah. I'm sorry go ahead.

Dr. Jean Joseph, M.D.:

I remember you asked me to an extraperitoneal prostatectomy for your conference over 10 years ago. At that time, there wasn't much support for extraperitoneal. Do you see with the easy access a change towards more SP extraperitoneally?

Dr. Muhatar Ahmed, M.D.:

I think that's the that's the key point is that the SP robot allows you to do surgery without going into the abdomen, being it for prostate, being it for kidney. I mean, Vip knows that a long time ago we were doing intra, then we went extra. Then we gave up extra and went back to intra. But now with this SP, it's really letting us go back to that extraperitoneal space.

Dr. Simone Crivellaro, M.D.:

Look, I want to know what Vip thinks about the extraperitoneal. I'm very curious. I want to know it.

Dr. Vipul Patel:

I think we need to see the data. I think you... Ultimately one is going to be better. We had that discussion when we did multi-port. We didn't see a difference. It's going to be people's preference. I don't think you're going to see any major differences in the data. It's going to be hard to prove one's better than the other. I think people should use what they're comfortable with. Obviously both work. If you have good patient outcomes, it doesn't matter. I mean, if you get three hours faster for someone's bowels to move, or you get them home 20 minutes earlier, it doesn't make a difference. But if you are doing something you're not comfortable with, and you have a major complication that's going to be a problem.

Dr. Vipul Patel:

So I think you'll see, there'll probably be more extraperitoneal done with SP, but it's going to be hard to show the difference in a randomized trial, truly head to head. I think you should pick what you're comfortable with and go that way.

Dr. Simone Crivellaro, M.D.:

Now we did one and there wasn't much of a difference. I just want to say that with the extraperitoneal, you don't get into the issue of lysis of adhesions. Similarly, you don't create adhesions for the future or future surgery.

Dr. Muhatar Ahmed, M.D.:

Correct.

Dr. Jihad Kaouk:

Guys, we ran out of time. So I hate to stop such a great discussion going on here. I would like to take a moment to thank everyone on this panel. Dr. Patel and Dr. Crivellaro, amazing surgery presentations. Thank you for the panelists. Thank you for all of you who attended this session and gave us an hour of their time. I hope this was worth it. I would like to say, please join in two weeks from now, same time to have the second session. That would be on July 24th at noon. And there will be Dr. Ash Tewari And Dr. Richard Gaston presenting robotic radical prostatectomy in a couple of different ways with moderators, Dr. Bernard Rocco and Dr. Declan Murphy. Tune in. See you then. Thank you, everyone. Have a wonderful weekend.