ROBOT ASSISTED RADICAL PROSTATECTOMY SHAWNEE MISSION MEDICAL CENTER SHAWNEE MISSION, KANSAS November 2, 2006

Transcription

1 ROBOT ASSISTED RADICAL PROSTATECTOMY SHAWNEE MISSION MEDICAL CENTER SHAWNEE MISSION, KANSAS November 2, :00:14 ANNOUNCER: Over the next hour, urologists will perform a robotic radical prostatectomy live from the operating room at Shawnee Mission Medical Center in Shawnee Mission, Kansas. With the assistance of the da Vinci surgical system, surgeons will remove the prostate gland through minimally invasive keyhole-size incisions. 00:00:31 DAVID F. EMMOTT, MD: We're able to do a more precise job of preserving sphincter musculature and the tissues around the prostate that are important for bladder function, bladder control. Overall, patients can resume their usual lifestyle and activities much more rapidly after this prostatectomy. 00:00:52 ANNOUNCER: With the guidance of 3-D cameras positioned inside the body, surgeons carefully maneuver the robot's instrument arms to the prostate. They then remove the prostate, treating the cancer while preserving surrounding structures of the bladder and reproductive system. Patients experience less bleeding, shorter hospital stays, and reduced scarring than with traditional open surgery. 00:01:13 DAVID F. EMMOTT, MD: Basically, they're able to resume their lifestyle more rapidly. It's a real winner for patients who want to get back into the mainstream of living. 00:01:22 ANNOUNCER: During the program, viewers may questions to the surgeons. To send your question now, just click the MDirectAccess button on your webcast screen. And now your host. 00:01:36 SUSAN D. SWEAT, MD: Welcome, ladies and gentlemen. We are coming to you live from Shawnee Mission Medical Center in Shawnee Mission, Kansas. Today we will be performing a radical prostatectomy with the assistance of the da Vinci Robot. I'm Dr. Susan Sweat. I'm joined in the O.R. today by Dr. David Emmott and Dr. Scott Montgomery, who will be performing the surgery. I have just a few housekeeping notes, though, before we get started. First, we will be answering viewer questions later in the webcast. To send us your question, just click the MDirectAccess button on your webcast screen. We welcome your questions, and we hope to answer all of them. Also, continuing medical education credits will be available to medical professionals. If you are interested in obtaining CME credit, click the CME button that will be visible at the end of the program. Finally, later on we'll be speaking with a former patient to get his perspective. Now it's time to go to the O.R. and join Dr. David Emmott and Dr. Scott Montgomery. Dr. Emmott, can you tell us where you are in the procedure? 00:02:39

2 DAVID F. EMMOTT, MD: Good evening, Susan. Thank you for that introduction. I wanted to first of all thank all of our guests for joining us here in operating room one at Shawnee Mission Medical Center, and I want to reinforce the concept that this is a team approach. This has taken a number of people in order to make this a successful program. I want to first of all introduce my partner, Dr. Scott Montgomery. This is Jennifer Minzi, she's our operating room technician. And Cindy Cummins is a scrub nurse also. Our anesthetist is Terry Johnson. She's hiding over there on the other side of our patient. And this is our robot. We have already begun our surgery so that we can show you the most interesting parts of this procedure. The patients are obviously been positioned, and then we have -- we have gained access into the abdomen, placed ports into the abdomen, and then the robot has been brought in and what we call "docked," which means that the arms of the robot, which is this octopus-like machine here have been attached to these arms. Through those ports, we will place instruments that will go into the abdominal cavity. Those instruments provide us the opportunity to do dissection, cautery, cutting, suturing, all kinds of things that are necessary for surgery. We have already created a space above the bladder by detaching the bladder from the anterior abdominal wall, and we have already isolated the sides of the prostate gland. And at this point, we're about halfway through the demarcation between the bladder and the prostate. So we're going to go ahead and get started. We've got plenty of work to do. We really appreciate your interest in our program. We hope you find it educational. Please feel free to call in questions. We'll try to answer those as well as possible. 00:04:38 SUSAN D. SWEAT, MD: Thanks, Dr. Emmott. Do you want to give us just a short rundown on the patient age, PSA? 00:04:45 DAVID F. EMMOTT, MD: Oh, yes. This is a 67-year-old gentleman who was found to have an elevated PSA. He underwent evaluation with a biopsy of the prostate, which detected carcinoma in his prostate gland. His staging studies for metastatic disease were negative. He considered many options for treatment, and after we had discussed robotic prostatectomy, he elected to have this procedure. He is quite healthy, and we anticipate that we're going to do a great operation for this man. 00:05:28 SUSAN D. SWEAT, MD: Great. Let's then switch to Dr. Montgomery. Do you want to tell us a little bit more about the port placement? 00:05:35 SCOTT A. MONTGOMERY, MD: Yeah. Let me give you a quick kind of rundown orientation here. I think pan away. At this point, I always thought the patient looked a little bit like Doc Ock in Spider-Man 2 with all these arms coming out here, so probably give you some orientation what's going on. This is actually his head down here, his chest would be here, and then the feet and the legs would be coming up this way. We purposely place the patient at an angle; we use gravity to our advantage to give us more access in the pelvis, get the abdominal cavity away. Then we -- as Dr. Emmott mentioned, we use CO2 gas to kind of inflate the belly to give us more space. You can see, it's -- the robot's moving now. David's already got started. This is the right end of the robot here, the yellow arm. I don't know if you can see the color, per se. Everything's kind of covered and -- in sterile plastic here. This is the middle arm, which is the camera arm itself, and the optics on this are fantastic. Dr. Emmott's going to be able to see much better than I can or you can on a webcast at the console. It's actually three-dimensional there. these are the two different left arms here, which you can switch back and forth between the two. And then finally, these two ports here are going to be for the assistant ports. It's very important through the operation to keep the field clean to get good exposure, and

3 that's going to be my job to hopefully make David look good through this whole process, so... 00:06:58 SUSAN D. SWEAT, MD: Very good. Very good. Thanks, Dr. Montgomery. Can we join Dr. Emmott now at the procedure and let him describe exactly where he is in the case? 00:07:07 DAVID F. EMMOTT, MD: Right. To get the audience oriented, this is where the urinary bladder is underneath this. 00:07:15 SUSAN D. SWEAT, MD: Actually, David, what we're seeing right now is you at the console. 00:07:17 DAVID F. EMMOTT, MD: Oh, okay. 00:07:18 SUSAN D. SWEAT, MD: And then we'll go -- maybe we can switch then to -- and now we're back to the O.R. You can show us what's inside now. 00:07:26 DAVID F. EMMOTT, MD: You can see this, where we have been coming down through this tissue. This is the prostate up here. And this is the urethra going through the prostate. This had a catheter in it just a minute ago which we have retracted into the prostate. This is the inside of the bladder right here, and you can see the smooth lining of the bladder; that's the bladder mucosa. Here's the catheter. Okay, so now that's -- our objective here is to detach this and then we will mobilize the prostate and then work from this end in that direction to remove the prostate gland. So we're going through the bladder neck -- what's called the bladder neck, which is the posterior -- this is the posterior bladder neck, and we're using some cautery to do this. We'll be identifying some important tissue and structures in this region momentarily. 00:08:26 SUSAN D. SWEAT, MD: I think it's important to notice how -- what good visualization you have and the -- the really limited bleeding that you have right now. 00:08:38 DAVID F. EMMOTT, MD: We hope to keep it that way. The better we can see, the better job we can do. And -- but that's really an advantage with this approach. We really rarely lose very much blood on these cases. And again, not to jinx ourselves, but you know, we've done over 250 of these cases and have actually given one transfusion. So we see that as a real advantage for our patients. 00:09:13 SUSAN D. SWEAT, MD: Exactly. I think we could go ahead and take maybe our first question. We have an question, and the question was: how long have you been performing this procedure? 00:09:24 DAVID F. EMMOTT, MD: We started in December of 2003, so we're coming up on our third year anniversary. And as I mentioned, during that time, we've now performed around -- a little over 250 cases. It was very anxiety-provoking to get started because we were the first ones in the area. There was really nobody in the Kansas City area who had taken on this type of project at that time, but we realized the benefits this would have for our patients, and we took a methodical approach to learning as much as we could about it. Fortunately, through the kind generosity of Dick and Barbara Scholl, who donated the robot to the hospital, it's made all this possible. 00:10:25

4 SUSAN D. SWEAT, MD: Right. Let's go to a second question. The question was: are your patients required to store some of their own blood before surgery? And Dr. Montgomery, maybe you could comment on that for us. 00:10:37 SCOTT A. MONTGOMERY, MD: No, actually, we don't store blood beforehand. We've found that's actually kind of counterproductive. It's a fairly rare event that someone would need a transfusion, and by donating blood beforehand, they're just going to start with a lower hemoglobin to start the operation, so we -- we have not routinely done that. 00:10:56 SUSAN D. SWEAT, MD: Dr. Montgomery, can you also compare the da Vinci method with the open method? 00:11:00 SCOTT A. MONTGOMERY, MD: Yes. The biggest advantage with the da Vinci is the time of recovery for the patient. The -- I think anyone who's having an open operation gets excellent cancer control with the da Vinci or the open operation, but the speed of recovery with the da Vinci is considerably faster. You know, a couple comparisons: the average time in the hospital is at least two days shorter with the da Vinci. The routine now is about one day in the hospital versus three to perhaps four with the open operation. Catheter time's just one week versus two to three weeks with the open operation. And then return to the normal lifestyle, we've had patients playing tennis as early as, you know, two weeks out afterwards and just getting back to work much quicker. I would say one's a little different, and some people are more aggressive in getting back to work than others, but it's definitely an advantage with the da Vinci. 00:12:01 SUSAN D. SWEAT, MD: I agree. I agree. I just want to remind our audience that what you're seeing is through the laparoscopic camera, you're able to view Dr. Emmott working. He's already separated the majority of the prostate and bladder, and he's working towards the seminal vesicles and the bilateral vas deferens. Dr. Emmott, do you want to comment on anything currently? 00:12:28 DAVID F. EMMOTT, MD: Well, right now, as you see, we're pushing this prostate tissue in a upward direction. And Scott, that looks like that might be that peritoneum back there. I think we're going to go right through here. Let's see if we can reestablish our proper plane. But we are -- we're going behind the prostate here. Scott, I think that's peritoneum back there. We may -- we may need to come right back through here just a little bit, so... 00:13:08 SUSAN D. SWEAT, MD: Well, while you're working, why don't we go to some PowerPoint slides so we can talk a little bit about prostate cancer. I'd like to show our fantastic team that we have working on 3 South. Without these wonderful nurses and all the assistants and everything that we -- all the people that we have on 3 South, our program would not be as successful as it is, and we really want to thank them and really give them lots of credit because they really help take wonderful care of our patients. 00:13:48 SCOTT A. MONTGOMERY, MD: Looks like you're right on target there. 00:13:51 SUSAN D. SWEAT, MD: We'll talk a little bit about prostate cancer. Many people ask, you know, what is the prostate, what is it used for? It's really a gland that adds nutrients for the fluids for sperm. And the fluid is added to the sperm during ejaculation. And the urethra is what you urinate through, and that runs through the

5 middle of the prostate. Prostate cancer is when you have abnormal cells that grow out of control. It can spread locally and invade local tissues and also spread beyond that prostate. It usually starts as a small gland, and in general, prostate cancer is slow-growing. But it can spread to the lymph nodes and it can also spread to the bony skeleton and other areas of the body. Prostate cancer's the leading type of cancer in men. It's the second-leading cause of death in American males, and there will be over 40,000 deaths each year in the United States. Your best prognosis is for early detection, and there have been recent studies that have shown there is some lower mortality rates when you have early detection and treatment. Early detection also affords patients many options for treatment. Usually we ask that patients get a PSA, which is a blood test called Prostate Specific Antigen starting at age 50. If they have a family history of prostate cancer, they should start at age 40. A digital rectal exam, or where we feel the prostate through the rectum, is also important at the time they have the PSA. Any abnormality in the PSA or digital rectal exam will require a biopsy of the prostate. This is usually in the office. It's ultrasound-guided. It's very short and very well tolerated in the office. When we do the biopsy, the pathologist is able to look at the tissue, and they look at the glandular structure of the prostate. Prostate cancer is scored on a scale from 2 to 10, with 10 being the highest and 2 being the lowest. The most common is a Gleason 6. One number is added to the second number, and it's just describing the architecture of the glands and how unlike normal they look. Staging of prostate cancer is performed with PSA, digital rectal exam, transrectal ultrasound, Gleason score. Oftentimes patients get a bone scan, specifically if they have a high Gleason score or if they have a high PSA. CT and MRI can be used really at the discretion of the physician. And then once you have the biopsy and the prostate out, it goes to a more formal staging system, which is called the TNM staging system, and that's Tumor, Nodes, and Metastasies. Briefly, we'll just go through the stages of the disease, and then we're going to check back with Dr. Emmott and see where he is in the procedure. Stage one is usually a disease that -- the disease cannot be felt. It's either found at a procedure called TURP or it's found because the PSA was elevated, and that prompted the biopsy. Stage two is when you can actually feel an abnormality on the prostate exam, either on one side or both sides. Stage three is when we have felt that the cancer has spread beyond the prostate, either into the seminal vesicles, which are just outside the prostate, or just outside the capsule, which is a thin layer of tissue around the prostate. Stage four cancer is when it has locally invaded the other organs, such as the bladder or possibly even the rectum or the pelvic sidewall. Now I think we should go ahead and join Dr. Emmott again and see how far they've progressed in the procedure. 00:17:59 DAVID F. EMMOTT, MD: Well, we've -- actually, we've entered a space here that's behind the prostate, and we're going to see some important structures here called the ampullae of the vasa, which are where the vas deferens, which are the spermcarrying ducts enter into the prostatic urethra. The -- these are important landmarks for us. We -- we know that they're in the -- we're in the right plane when we see these structures. I'm going to come back here just a little bit, Scott, just to kind of get a little more length on that. And this is -- this was just a little bit tricky back here. We may have actually been trying a little too hard, but this actually looks like what's called the seminal vesicle, which is another structure that attaches to the prostate, and we'll be dissecting that out too. Through this layer, this is muscle tissue right here, but this will probably be what we call an ampulla right here. And we'll try to isolate this. This is a rounded structure that will -- has a fairly muscular consistency. And we'll be isolating this and then dissecting it backwards away from the prostate gland.

6 00:19:41 SUSAN D. SWEAT, MD: Okay, well, Dr. Emmott, while you're working, we're going to field a few more questions. One of the questions was: is the cancer visible at this time? 00:19:57 DAVID F. EMMOTT, MD: No. 00:19:58 SUSAN D. SWEAT, MD: Right. And I think it's important for those that are watching this that we -- in this gentleman specifically, we are not visualizing the prostate cancer. The cancer typically is inside the prostate, and we are not able to see that pushing out unless it's at more of an advanced stage or advanced, you know -- advanced stage. 00:20:19 DAVID F. EMMOTT, MD: Correct. 00:20:21 SUSAN D. SWEAT, MD: Dr. Montgomery, maybe you can comment on the next question. 00:20:24 SCOTT A. MONTGOMERY, MD: Okay. 00:20:25 SUSAN D. SWEAT, MD: It says: are we going to do a nerve-sparing procedure, and how do you do that? 00:20:30 SCOTT A. MONTGOMERY, MD: Yes, on this gentleman, we are. He has actually very favorable numbers. A very low-risk disease. And that's really our decision, when and when not to do a nerve-sparing. If someone has aggressive cancer that we're concerned may be outside the prostate, we don't want to be leaving cancer behind in an attempt to spare the nerves. So this gentleman actually is a great candidate for it. How you spare the nerves is you peel away -- it's called the lateral pelvic fascia, which if I can point here, is going to be right over here -- peel that away from the prostate, and that'll come a little later. They're very fine nerves that run along this fascia just outside the prostate, and you have to be very careful during that dissection to use very little cautery and very little tension, otherwise you can damage those nerves. 00:21:20 SUSAN D. SWEAT, MD: Right, thank you. One of our other questions was: can you compare this procedure to the green-light laser procedure? The green-light laser procedure -- I'll go ahead and field this question while you guys are working -- is a procedure for benign prostatic hyperplasia, or problems from benign growth of the prostate. The da Vinci prostatectomy is for a cancer of the prostate, and so they're actually two separate procedures for two separate indications. Now we'll go back, and what you're viewing is Dr. Emmott continuing to work with the bilateral ampulla of the vasa and the seminal vesicles. 00:22:03 DAVID F. EMMOTT, MD: Yeah, this is -- sometimes it's a little hard to differentiate these, but I believe this is the ampulla on the left side. Notice we took a piece of the ampulla off the right side, which we'll -- we retrieved, and we'll use that as a pledget later when we restore the continuity between the bladder and the urethra, called it an anastomosis. And I'm just cutting through this with cautery now. So we're just going to take our time here and make sure we identify everything. And I can use this other instrument that is coming in from above and see the grasper start to come to life in just a second. Here we go. And I'll use that -- that's called the fourth arm. It's actually my second left hand. I have two instruments on the left side of the patient,

7 and one of them is called the fourth arm, which is the second da Vinci instrument that we use to give us extra graspers or other instruments to help us out with the operation. 00:23:25 SUSAN D. SWEAT, MD: Right now on the camera, we have Dr. Emmott moving the -- and controlling the da Vinci instruments from the console. And Dr. Emmott, can you comment on how your -- your job is different from Dr. Montgomery's job? 00:23:46 DAVID F. EMMOTT, MD: Well, I'm sitting here across the room. He's at the bedside, so he's -- he's actively trying to expose tissue for me so that I can further along the operation, and my job is to control these instruments, let him know if -- if I need him to retract something or show me a little better anatomy. 00:24:20 SUSAN D. SWEAT, MD: Right. So we have one physician at the console using the special devices that allow you to control the instruments, and then Dr. Montgomery's actually with the patient and assisting -- assisting you. 00:24:34 DAVID F. EMMOTT, MD: That's correct. 00:24:36 SUSAN D. SWEAT, MD: Right. 00:24:38 DAVID F. EMMOTT, MD: Now, this is a seminal vesicle on this side of the patient, on his left side, and we're going to probably have to isolate this just a little bit better, Scott, and then may come across some of this in the course of this. I think this will be okay to come across this at this point. Wasn't our initial intent, but we will come across this. 00:25:08 SUSAN D. SWEAT, MD: Well, while you're working, I think we'll go back and do a few more slides. 00:25:13 DAVID F. EMMOTT, MD: Okay, go ahead. 00:25:14 SUSAN D. SWEAT, MD: Great. Prostate cancer, you know, is -- is diagnosed by the biopsy after having your PSA, digital rectal exam, and then our treatment options really are dependant on the stage of disease, the patient's age and health, and really the patient's personal preference. For patients that have early-stage cancer, there are several options. One of them being watchful waiting, external beam therapy, brachytherapy, which is where we put small, little radioactive seeds in the prostate, cryosurgery, which is where we are using needles to freeze the prostate, and then there's surgery. And that's considered radical prostatectomy. There's open surgery, there's conventional laparoscopic surgery, and then there's what we're doing today, which is the da Vinci prostatectomy, or robotic-assisted laparoscopic prostatectomy. The goals of prostatectomy first and foremost are to remove the cancer and to do a very good cancer operation. There are very good cure rates for localized disease. One of the second goals of surgery is to preserve urinary function. Thirdly, also to preserve erectile function. We would like to be able to analyze the prostate after surgery to assess the -- the risk of recurrent cancer, and that's where you get your pathologic stage, and you also use that to -- it's plugged into your TNM system, which is the Tumor, Node, and Metastasies, and stage helps you predict who would have recurrence and who -- what their chances are. Many patients are candidates for nerve-sparing prostatectomy. The nerves hug the sides of the prostate and run very, very closely along the prostate, and so what we would like to do is to gently push and tease those nerves away from the prostate in order to preserve erectile function.

8 The da Vinci makes this -- permits us to do this in a very -- very nice way because of the enhanced magnification and then also the ability to have the endo-wrist movement of our instruments that allows us to see those neurovascular bundles and push them away quite gently. What you're seeing right now in the camera is Dr. Montgomery utilizing some clips through his assistant ports. Those are used for small vessels to control bleeding and to obtain hemostasis. Dr. Montgomery, do you have anything to add about what you're doing? 00:28:20 SCOTT A. MONTGOMERY, MD: Now, I just -- when you were talking earlier about the two functions, one of the things that kind of impressed me when I first saw the da Vinci is how coordinated and how smooth David's movements are at the console because of the robotic aspect of it versus -- I can see the sucker here in the middle or the clip, he'll -- may see some tremor or some shaking or so forth, and that's just the nature of a laparoscopic instrument over -- over a da Vinci or robotic instrument. One of the features of the robot, it takes the tremor or any -- any -- any subtle movements out while you're operating. 00:28:57 SUSAN D. SWEAT, MD: Yeah. Yes. And we will go ahead and talk a little bit about the da Vinci system while you and Dr. Emmott continue to work. The da Vinci surgical system is a computer-enhanced surgical system. It is a master/slave system with the surgeon in control. The surgeon operates at the console, and that's Dr. Emmott, and then you have an assistant surgeon that's next to the patient, and that's Dr. Montgomery in this case. The surgeon is immersed in a three-dimensional image of the surgical field, so Dr. Emmott is able to place his head and forehead in the device, and then what he sees is what you are actually seeing on the TV -- we're looking at Dr. Emmett right now, and then we will switch to the -- what he actually sees while he's looking in the console. 00:29:49 DAVID F. EMMOTT, MD: I'm trying to get a hold of that, Scott, with this fourth arm. I've really -- I haven't made this look quite as -- 00:30:01 SUSAN D. SWEAT, MD: One of the things that allows us to be able to use the da Vinci system is the endo-wrist instruments that really move like our human wrist -- like our human wrist, excuse me, so we have increased dexterity and maneuverability and precision. And that's more difficult with traditional laparoscopic instruments because they're straight and they don't bend and move like the endowrist instruments or like our own human wrist. 00:30:35 DAVID F. EMMOTT, MD: That's an ampulla, Scott. SCOTT A. MONTGOMERY, MD: Yes. 00:30:37 SUSAN D. SWEAT, MD: Again, what Dr. Emmott is doing is his hands are placed in the special devices, and he is moving the -- he's directing the instruments that have been placed inside through the da Vinci ports, inside the human body. And at the very beginning of the case, all of these ports were placed in very small keyhole incisions, and we have a wide variety of instruments that are available, whether that be a scissor or a grasper, cautery devices, and needle drivers. We have a few more questions. It says -- and maybe, Dr. Montgomery, I'd like you to maybe address this. It says: when the nerves are retained, does the overall size of the prostate, will that affect the nerve recovery? 00:31:41 SCOTT A. MONTGOMERY, MD: Does the size of the prostate -- 00:31:43

9 SUSAN D. SWEAT, MD: Does the size of the prostate affect nerve recovery? And what I think they're meaning is return of erections. 00:31:50 SCOTT A. MONTGOMERY, MD: Oh. In -- in a kind of a roundabout way, it does. A very large prostate consumes a lot of space in the pelvis and just makes the surgery in general a little more difficult. And a smaller prostate is somewhat difficult to discern the margins, so ideally you want a prostate kind of average size, 30, 40 c-- 30, 40 cc's. At the same time, I don't think we've seen a -- a significant difference in potency rates or nerve recovery in patients with a larger or smaller prostate. It may make our operation a little more difficult at the time, but I don't know in the long run it makes a big difference. 00:32:20 SUSAN D. SWEAT, MD: I agree with that. Another question, it says: what percentage of da Vinci procedures result in positive margins? 00:32:40 SCOTT A. MONTGOMERY, MD: I'll take that one. We've actually looked at and compared positive margins here at Shawnee Mission with an open versus the da Vinci and found no difference between the two. I always tell my patients that this is the same operation, just with different tools and a different approach, so either the prostate -- the cancer is confined to the prostate or it's not when we start the operation. And if we do this with an open or a da Vinci, there shouldn't be any difference. And that's exactly what we've found. The overall positive margin rate with the open I think was 27% and with the da Vinci was 26%, so virtually identical between the two. 00:33:20 SUSAN D. SWEAT, MD: Another question from one of our viewers: what specific criteria would argue for a traditional open prostatectomy? 00:33:31 SCOTT A. MONTGOMERY, MD: Well, at this point, Dave and I are probably more comfortable doing it with the da Vinci than we are open. Probably the only criteria is if someone was exceedingly obese. The problem you get into is there's very little room in the pelvis, and it just makes the surgery very difficult. Of course, an obese patient, I'm not sure an open operation's any easier though, Susan, so for us if you're a candidate for the open, for the most part, you're a candidate for the da Vinci. 00:34:02 DAVID F. EMMOTT, MD: I would agree, but we also -- we do have -- if somebody's had a lot of previous pelvic surgery, it does limit the da Vinci as a technique to use for that patient, so we sometimes will -- although, having said that, we've -- we've been able to do the robotic prostatectomy on quite a few patients who've had previous surgeries. 00:34:35 SCOTT A. MONTGOMERY, MD: That's a good point, David. I -- I have had one patient here recently that had active Crohn's disease, where it's an inflammatory disease of the bowel. In that individual, there's a big advantage in doing this as an open procedure because you're actually not getting into the abdominal space with the open procedure where you do with the da Vinci. 00:34:56 DAVID F. EMMOTT, MD: This might need a clip here, Scott. SCOTT A. MONTGOMERY, MD: Okay. 00:34:59

10 SUSAN D. SWEAT, MD: I'd just like to remind our viewers now to make sure you send in your questions, to click the MDirectAccess button on your screen. We welcome all your questions. 00:35:20 DAVID F. EMMOTT, MD: We use -- we use some different lenses on our da Vinci system. We use a lens that is, you know, straight lens, and then some that have an angle on the tip. We're currently using a lens that angles down. Okay, let's clip that. We're going to be using less cautery now and more clips as we go through some of this tissue. And see, that was a blood vessel that -- 00:35:54 SCOTT A. MONTGOMERY, MD: David, do you want to switch to zero degree? 00:35:57 DAVID F. EMMOTT, MD: I really don't know if I've got this vesicle all the way up here, Scott. I want to -- I need to look there, and then I think we'll be ready. 00:36:08 SUSAN D. SWEAT, MD: So, Dr. Emmott, you're still working with the seminal vesicles and starting to make the plane underneath the prostate. Right there, that's the bladder, yes. 00:36:18 DAVID F. EMMOTT, MD: I think we kind of dug into the bladder a little bit, but now I think we're going to switch to what's called a zero-degree lens. And it's real important that we change our console because the computer needs to know which lens you're using. And if we have the computer on a setting that's not compatible with the lens, it compromises our visualization, so we're going to switch to a zerodegree lens. Jennifer is switching the lens. It's important that she keep the lens that's not being used warm so that when it's placed in the abdominal cavity, it doesn't fog, which obviously will compromise our ability to see. So at this point we're going to go to a zero-degree lens, and you may notice as we put the scope in, the zero-degree has -- we're coming in at a little different angle. It also tends to provide a little better light. And -- 00:37:30 SUSAN D. SWEAT, MD: Dr. Emmott, can you just go ahead and orient us? We had an question, somebody was asking about where the prostate was, so can you just orient us real quick? 00:37:37 DAVID F. EMMOTT, MD: This is prostate up here. And we're -- now we're getting behind the prostate back here and these are -- this is the lateral right and then left sides of the prostate. But this is the top of the prostate left and right. 00:37:57 SUSAN D. SWEAT, MD: Great. Great. 00:37:58 DAVID F. EMMOTT, MD: And so we're coming underneath the prostate now. 00:38:00 SUSAN D. SWEAT, MD: And the plane that we're making is between the prostate and the rectum. 00:38:02 DAVID F. EMMOTT, MD: Correct. SUSAN D. SWEAT, MD: Correct. 00:38:04 DAVID F. EMMOTT, MD: And you know, like -- unlike other surgery, with this surgery and where we commonly are operating, when we see fat, we kind of like that because that means we're -- we're in a plane between organs or structures, and fatty tissue tends to represent safety, and so we're developing a space now beneath

11 the prostate, and it's going to go -- we can go all the way from here, all the way out to the end of the prostate. You can see we're breaking through into fresh territory here. 00:38:45 SUSAN D. SWEAT, MD: That's a really nice plane there, and it's not muscle and it's not prostate tissue, it's just the tissue that lie in between. And sometimes that's fat and sometimes it's just connective tissue. 00:38:56 DAVID F. EMMOTT, MD: Correct. This little guy right here wants to bleed a little bit, so we'll take care of that. And -- 00:39:11 SUSAN D. SWEAT, MD: One of the questions from our viewers was: do you get any tactile feedback from the robotic instruments? 00:39:19 DAVID F. EMMOTT, MD: That's a good question because initially, there was a real concern about that because people thought that the lack of being able to physically touch these structures with your fingers was a -- a disadvantage with the robot, but in actuality -- and the answer is no, we don't get tactile feedback, but you develop a real sense as you use these tools regarding the -- the tissue response to your manipulation that gives you a really good idea as to, you know, what kind of tissue you're working in and if it's in a -- if you're in the right plane and it's really interesting because you do develop this sensation that's what we call visual tactile. And we're going to come through some of this tissue; these are the blood vessels that go to the prostate, so initially you don't have tactile feedback, but you develop a new kind of sense. And without being -- I mean, the name of the machine is -- the company that makes the machine is called Intuitive, and -- and that's -- it becomes an intuitive thing, you know, the -- the sensation of what you're seeing and what you're doing with the tissue. 00:41:00 SUSAN D. SWEAT, MD: And Dr. Montgomery, you were just getting ready to place some clips. Can you tell us where you're placing those and on what structures? 00:41:09 SCOTT A. MONTGOMERY, MD: Yeah, this is the lateral pedicle here. This is -- the blood supply comes up -- in our bottom left -- up to the prostate. So what David is doing is kind of thinning out this tissue, and I can come in with this clip applier here, which I'll show you, which, when I fire it, fires these other clips across here to just occlude the tissue. And the metal has memory to it and holds it and keeps any ongoing bleeding from happening. And here comes one right here. 00:41:35 SUSAN D. SWEAT, MD: And here he's placing a clip right now, yep. 00:41:37 SCOTT A. MONTGOMERY, MD: And there it is. And that one backed up a little bit. That was a bad example. Hopefully I'll do better next time. 00:41:45 DAVID F. EMMOTT, MD: Nobody's perfect, and neither are those clips, but we're trying. I think this is sort of -- this is a better direction here, Scott. We'll slide through here as we push this prostate down a little bit. Yeah, that looks like that's probably a -- some pedicle structures here. This is blood supply going to the prostate, so this needs to be controlled. And we try to use very limited cautery in this region. I think that's a -- a pedicle here. 00:42:50 SCOTT A. MONTGOMERY, MD: What we're looking at here is -- this is the lateral pedicle over here, the blood supply coming in. The bladder will be down -- if you look

12 at my clip applier here, the bladder will be down here, the prostate up above. So we're starting to work on the left side, and we're going to be developing that neurovascular bundle here in just a second, the nerve-sparing part of it to help preserve his erections after surgery. 00:43:13 DAVID F. EMMOTT, MD: Down on the back side. That's going to go with the prostate, it looks like. See where that's coming from. Well, we'll have to find that and put a clip on it, Scott. I'm going to try to get under that ledge there and -- perfect. I got that vessel that we were struggling with a little bit. 00:43:56 SUSAN D. SWEAT, MD: Well, Dr. Emmott, Dr. Montgomery, while you're working away, we're going to introduce one of our former patients, Mr. Danny Buda. Mr. Buda underwent a robotic prostatectomy. We're going to talk to him about that. Why don't you go ahead and tell us how it came about that you saw Dr. Montgomery and how it came to be that you actually were chosen for the da Vinci prostatectomy. Or that's what you chose. 00:44:25 DANNY BUDA: Well, yeah, two years ago, when I was diag-- two and a half years ago, I was diagnosed with prostate cancer. As a patient, they give you too many options to take care of it. So after a matter of elimination, weighing out the advantages of the da Vinci versus the traditional, there was no question in my wife and I's opinion that the da Vinci would be the best suited method for me. At the time, I was 56 years old and healthy and never been in a hospital before. 00:45:00 SUSAN D. SWEAT, MD: And how was your experience? How long were you in the hospital? 00:45:03 DANNY BUDA: Overnight. Discharged the next morning. Next day after that I was out walking. Not very far, but I was walking. And I believe I was playing golf in about five weeks, so based on some of the friends of mine who have had the traditional surgery, I was light years ahead of -- less pain and less discomfort than -- back to normal activities with my life. 00:45:35 SUSAN D. SWEAT, MD: Right, and that's one of the real advantages to the da Vinci prostatectomy. How long was your catheter in? 00:45:41 DANNY BUDA: A week. I believe a week, and that was an experience, too. 00:45:52 SUSAN D. SWEAT, MD: Oh... How much pain did you have afterwards? 00:45:58 DANNY BUDA: Minimal. I was very surprised. They give you -- as needed -- pain medication, and I don't believe I took any of the pain medication because I followed the instructions of what the doctors told me to do and just sort of take it slow and easy, and I was very surprised having never been in the hospital before to have a procedure, so I was very pleasantly surprised. 00:46:23 SUSAN D. SWEAT, MD: Well, good. And what is your advice to other patients that tell you that, you know, they have prostate cancer? What do you -- what are you telling them? Your friends? 00:46:34 DANNY BUDA: Well, a lot of people call now because they know I've experienced it, and you can't really freak yourself out worrying about it because there are professionals like yourself, Dr. Emmott, Dr. Montgomery that will take care of

13 everything. This is such a new and extremely efficient way of treating something that, in the past, was very frightening to men. You worry about continence issue, you worry about the erectile dysfunction issue, you worry about how much pain you're going to have, will you have to wear a diaper, and none of that was true. I mean, it was -- everything was very -- explained very well, and Shawnee Mission here does an excellent job taking care of it. And I believe when I talked to Dr. Montgomery and Dr. Emmott, they were at patient number eight, so it was truly a leap of faith. 00:47:37 SUSAN D. SWEAT, MD: And now they've done over 250 and continue to grow. Yeah, very good. Very good. 00:47:41 DANNY BUDA: Absolutely. 00:47:44 SUSAN D. SWEAT, MD: We're going to head back now to Dr. Emmott and Dr. Montgomery and see where they are in their procedure. 00:47:48 DAVID F. EMMOTT, MD: Well, we're defining the corner -- what we call the corner of this prostate over here, and Scott's going to put a clip on some other vessels in this region, and we're going to hopefully kind of round the bend on this thing. This is -- hello. Those kind of vessels can be a real pain because they get your camera all dirty, but as we get around this corner of the prostate, you'll see we're just kind of gently teasing this tissue away and going to kind of round the bend on the prostate here. And that's going to need a clip on there, too, Scott. If you can get it. 00:48:55 SUSAN D. SWEAT, MD: Well, while working, let's take a few more questions from our viewers. The first question here is: what is the general duration of post-surgery incontinence? Dr. Montgomery, you want to field that? 00:49:06 SCOTT A. MONTGOMERY, MD: Say that again, Susan, I didn't hear you. 00:49:08 SUSAN D. SWEAT, MD: Oh, I'm sorry. What is the general duration of post-surgery incontinence? 00:49:11 SCOTT A. MONTGOMERY, MD: The general duration. Tough question. It's -- it's -- first of all, it's very variable. And I don't think you can have any one answer for any one patient. I tell patients when the catheter first comes out, they are going to leak for a while, everyone does. And it takes a while to get that control back. Hold on a second here, Susan, I've got to help out here for a second if I can. 00:49:33 SUSAN D. SWEAT, MD: All right. Well, I can talk a little bit, too. I -- when you talk to patients about incontinence after surgery, everybody's a little bit different. It depends on their body habitus, it depends on -- on their age. Certainly, younger gentlemen typically get their full continence back a little quicker than older gentlemen, say over 65 or 70. So I prepare everybody that most people do leak initially when the catheter comes out, and then it's gradually gained over the next several months. And some of the studies have shown, you know, by six months, over 90% of patients are completely dry. And so that's the typical -- typical post-op recovery would be that some people are very dry quite quickly and some people, it takes a little bit longer. So everybody's a little bit different. Here back to Dr. Montgomery working -- or, excuse me, Dr. Emmott working at the console. 00:50:39 DAVID F. EMMOTT, MD: Well, that was a bit of fun, wasn't it?

14 00:50:41 SCOTT A. MONTGOMERY, MD: A little excitement there. 00:50:42 DAVID F. EMMOTT, MD: I don't know if we've got it all yet, but we're going to head - - try to delineate this a little bit better, and I thought we had a little bit of work left to do here, and let's see if we can -- 00:50:58 SUSAN D. SWEAT, MD: I do want to go ahead and show a slide here of the difference between a patient that has an open surgical incision versus our robotic assisted prostatectomies. The open surgical incision is typically an incision that goes from the bellybutton or the umbilicus all the way down to the pubic bone. The incisions from the da Vinci are in a -- a half-circle shape starting at the umbilicus, going around as you can see in the picture. They're usually, you know, about a centimeter long, except for the one that is near the umbilicus or bellybutton, and that's usually where the prostate is removed. once the prostate is removed completely, once all the nerves have been pushed away and the blood vessels have been secured, we put it in a endocatch bag, which is a device that allows us to kind of keep it contained, and we don't distort the anatomy, we won't change the surgical margins, et cetera, and that way we're able to remove the prostate in one whole section and -- and do that so that it's -- it's intact. And that way we can send it to pathology. Pathology then typically then would paint the outside of the prostate. And when they do that, they will make certain sections at particular places in the prostate and look for positive margins. They look at the apex, they look at the base, they look around the sides. And then when they give us the report on the final pathology, it's in the Gleason score system, so they'll say it's a Gleason three-plus-three, which is a total of six, or a Gleason three-plus-four, which is a total of seven, whatever, you know, numerical value they come up from looking at the larger specimen, not just the -- what we have from the prostate's biopsies itself. And they'll also give us a report on the margin status: is it positive, is it negative? And as Dr. Montgomery stated, you know, the margin status has been just as good with the da Vinci as it has been with the open system. So that's -- I just wanted to let you know what the differences were with respect to the incisions and let you know a little bit how we remove that prostate. Typically, they lymph nodes are also removed, and we usually do that after we have removed the entire prostate. And then we finish it with the anastomosis. And the anastomosis is where you will attach the bladder back to the urethra. When Mr. Buda said that he had to wear a catheter for a week, that's to allow that -- that tissue between the urethra and the bladder neck to go ahead and -- and heal. Traditionally, with the open prostatectomy, most people have left their catheters in for two weeks and sometimes three weeks, and that's just depending on usually surgeon preference. 00:54:12 DAVID F. EMMOTT, MD: We're about to get this prostate mobilized. I'm sorry we didn't get further along this evening, but I think everybody gets a flavor of the type of surgery this is, and thanks to Danny Buda, we can -- you know, we've got personal testimonial of how this was an advantage for him. And we think this is a -- a real advantage for our patients. This is -- as you can see, it sometimes appears a little bit awkward, but believe me, we're making progress and we're -- we're doing, I think, some of the most exciting work in urology right now. Okay, I think we'll put a Hemolock on here, Scott. 00:55:00 SCOTT A. MONTGOMERY, MD: Okay. 00:55:03

15 DAVID F. EMMOTT, MD: We're going to put a big clip on here. And on this side, we'll be able to turn this corner a little bit better. 00:55:09 SUSAN D. SWEAT, MD: So right now, Dr. Emmott and Dr. Montgomery are isolating the blood vessels that go to the prostate. That's a Hemolock that's being placed currently. That is to control -- control and basically clamp off the blood vessel, and then he will divide that above there. And sometimes the Hemolocks are a little testy and don't want to go on just as perfect as you'd like them to, so you have to get a -- get a new one. And that one went on just perfect. And Dr. Emmott is now dividing the tissue above the clips. And the clips will stay with the patient, and they do not cause any harm or any problems. Dr. Emmott will continue to divide the prostatic vessels and the pedicle to the prostate, and he will then move on to the nervesparing portion. Again, there's a thin veil of tissue that runs up the side of the prostate, and that can be excised and divided, and then the nerves can be gently pushed away towards the rectum and the pelvic sidewall away from -- away from the prostate. And he's getting started on that now. Go ahead and describe that. 00:56:34 DAVID F. EMMOTT, MD: Now this the nerve-sparing component of the procedure, and we're going to try to use minimal -- minimal clips and certainly no cautery in this area, but we're going to peel this tissue off the side of the prostate. The nerves that are commonly referred to, the neurovascular bundle, are found in this tissue right along in here. And you can see, it's obviously very close to the prostate, so this, I think it's a huge advantage with this magnification system because we can take this tissue right off the side of the prostate. 00:57:17 SUSAN D. SWEAT, MD: That's one thing that you forget when you're sitting there watching this, the great magnification that you have. And it's something that you get used to seeing all the time, but you certainly don't have this kind of magnification with the open prostatectomies. 00:57:30 DAVID F. EMMOTT, MD: Correct. Yeah, it's pretty hard to see any of this anatomy without this kind of telescopic magnification. And these tissues, we're just sliding right off the side of the prostate. And -- 00:57:49 SUSAN D. SWEAT, MD: And again, the neurovascular tissue is -- the nerves and the arteries that go to the penis for erection are -- are, you know, involved in this tissue. 00:57:59 DAVID F. EMMOTT, MD: They're all in here. SUSAN D. SWEAT, MD: Exactly. 00:58:01 DAVID F. EMMOTT, MD: So this is all being -- 00:58:02 SCOTT A. MONTGOMERY, MD: Looks great, David. Nice job. DAVID F. EMMOTT, MD: -- protected and preserved. And then we're already out to the urethra here, so this is the end of the prostate here, so that gives you a pretty good idea of what the nerve-sparing component of the procedure is. And back here, we're again developing more space beneath the prostate. And you can see, with just kind of this open scissor technique, we can sort of push that tissue away, creating this plane around the prostate and preserving the tissue next to it. 00:58:40 SUSAN D. SWEAT, MD: So that nerve-sparing -- that was on the right side of the prostate. 00:58:45

16 DAVID F. EMMOTT, MD: That is correct. And we haven't finished on the left side, so we're -- 00:58:48 SUSAN D. SWEAT, MD: Right, we'll get started on the left side. 00:58:49 DAVID F. EMMOTT, MD: We're going to probably get -- we've had a -- well, we've got a little bogged down over here, but we're -- we're getting ready to break through here. I think we're going to put a clip right across there, Scott, and then we're going to be ready to roll. 00:59:04 SCOTT A. MONTGOMERY, MD: Right there, Dave? 00:59:06 DAVID F. EMMOTT, MD: Right across this. See that vessel right there, that's a big vessel. Perfect. And we're going to come right through here. 00:59:14 SUSAN D. SWEAT, MD: So now you're working on the -- the vascular pedicle to the prostate on the left side, and then after Dr. Emmott and Dr. Montgomery secure that, they will again proceed on with the nerve-sparing portion on the left side of the prostate, pushing that veil and nerves and arteries away from the prostate. And once the nerve-sparing portion of the radical prostatectomy has been performed, that's when the urethra is identified and carefully -- urethral length is preserved. And then it is divided. And again, that's when the prostate would go in that endocatch bag that I spoke of earlier so that we can remove it in its entirety. The prostate will be removed. The lymph nodes are then taken and sent to pathology as well. The bladder will be reattached back to the urethra over a catheter, and that's really -- that kind of -- that will conclude the -- you know, the majority of this procedure. We do place a drain and we'll need to remove our ports and close our incisions, but once the prostate is removed and the anastomosis is completed, the major tough portion of this procedure is -- is all completed. 01:00:49 DAVID F. EMMOTT, MD: I think that's a good spot, Scott. Go ahead and put a clip on that. I'd like to be able to get this prostate completely mobilized before we go off the air, but we may not have time, so we definitely want to -- we've shown you a pretty good dissection on the right side. And this might need a clip right here, Scott. 01:01:11 SCOTT A. MONTGOMERY, MD: Yeah, I think so. 01:01:14 DAVID F. EMMOTT, MD: We got a few clips down here. We're not -- 01:01:17 SUSAN D. SWEAT, MD: One of the tests that we do to make sure that our anastomosis is water-tight is, once Dr. Emmott has sutured the bladder neck back to the urethra, a new Foley catheter is placed. The blan-- the balloon of the Foley catheter's inflated, and then we place water or normal saline into the bladder and make sure that our anastomosis is water-tight before we tie our sutures and move on. So that's an -- an excellent way for us to make sure that that anastomosis is working very well. He's work-- Dr. Emmott's working on the left side nerve-sparing procedure, and it looks like the nerves are coming off quite nicely again, Dr. Emmott. 01:02:16 DAVID F. EMMOTT, MD: Yeah, I think we're -- we're just about to the point where we would be transecting the urethra to completely remove this prostate, but you can see this prostate's completely mobilized, we have a little bit of tissue right here, and then we're going to come through here and remove the rest of this prostate, so I think our time's up. Thank you again for joining us. We hope that you've found this