Robotic surgery – the frontline treatment option for urinary bladder cancer

Robotic surgery for urinary bladder cancer is now the leading option in cases where the disease requires the removal of the bladder and creation of a new reservoir or passage for urine from a part of the intestine. This technology now enables an early recovery of patients after surgery and a decrease in chances of complications – while retaining the same cancer control probability of conventional open surgery. In the following video, Dr. Gagan Gautam demonstrates the technique of removal of bladder and creation of an ileal conduit via robotic surgery.

 

So, how is robotic surgery better than conventional open or laparoscopic surgery? Express healthcare finds out from two leading robotic surgeons in India.

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Robotic surgery for urinary bladder cancer – a personal experience

DR. GAGAN GAUTAM – THE HUMANE BEHIND THE MACHINE

My father recently went through a radical cystoprostatectomy with extended pelvic lymph node dissection and urinary diversion at the MAX Hospital in Delhi. For those of us like me whose knowledge of such procedure was as robust as a commoner’s in the remote part of India understanding the French and Greek delicacies – it was time to hit Dr. Google and Dr. Wikipedia for that piece of instant knowledge. After going through 48 hours of instant crash course I couldn’t have been more depressed. Anyways it was time for me to pack my bags and take a long flight from Atlanta to New Delhi.
As I was touching down Delhi, little did I realize that the coming few weeks will not only change my outlook towards doctors in general but also hospitals.

Next morning, we met Dr. Gagan Gautam – The Little Master.

We got Dr. Gagan’s reference all the way from United States from another Master in the same field and a family friend, who felt that there’s no one better than him in this field in India. With that reference when we walked into his office in MAX Saket Hospital expecting to meet a self obsessed, boisterous handsome young man. Handsome he was, as my Dad told everyone, but he was anything else like what we assumed.

To describe Dr. Gagan would be like describing Pele, Lionel Messi, Sachin Tendulkar, Napoleon, Lata Mangeshkar and Mother Teresa all rolled into one. Calm Confidence, Care and Compassion comes close to describing someone who sure has deep mastery over what he does.
From the moment I met him first time for consultation and three weeks later, after multiple tests, when he performed that complicated surgery with utmost compétence, there wasn’t a moment where I had any doubts in his abilites.

Though, apprehensive we were.

Coming back to the procedure itself – it’s a complex 8 hours surgery, where the bladder and prostate are removed and with urinary diversion. Radical cystectomy entails removal of the bladder, adjacent organs, and regional lymph nodes. In males, radical cystectomy generally includes removal of the prostate as well as the urinary bladder. Urinary diversion entails removal of bladder and requires the urinary flow be redirected in several forms.

These surgery can be performed by open procedure or using Robotics. With my faith in Digital Technologies and its potential benefits to mankind, I personally had an inclination towards Robotics. This was supposed to be a very complex surgery with an average total time of 7-8 hours.

After an elaborate discussion with Dr. Gagan Gautam, we were more than convinced that Robots were the way. Now the question was on The Man Behind the Machine – Though as mentioned before I or the patient, My Dad, never had an iota of doubt in our mind about him. But rest of the family had to be satisfied. So we went on a CIA mission for a day, starting from experts at TMH, Mumbai to Senior Doctors in Bangalore and finally ending back in Delhi. And at every instance there was only one message that came back – Dr. Gagan is the Best Man that can be Behind the Machine for this kind of procedure. Finally in the evening my Uncle who’s been a famous Senior Orthopedic Surgeon himself in his days gathered the entire family and expressed his golden opinion. He asked everyone if we were aware of Napoleon’s Battle of Lutzen. He explained that in that war when Napoleon was losing the battle inspite of having the best generals on his side, he called his team to review the battle plan. All his best generals walked him through their own version – finally, a little frustrated, he told them – “Today as I stand in the battle ground, I don’t want my Best General to fight for me but I want my LUCKIEST General to fight for me.” He went on to explain the nuance of a successful surgery – “It’s when The DOCTOR’s Skills, PATIENT’s Perseverance and the ALMIGHTY comes in single line – Miracles Happen”. And we don’t have doubts over the first two, we will have to wait watch for the third one, so let’s go and get it done.

While we never had any doubts on Dr. Gagan’s ability as a Senior Robotics Surgeon, what struck all of us was his humane approach towards this whole thing. That started from the team he had, which included a few that we met and interacted almost on a daily basis – Dr. Puneet Ahluwalia, Mr. Majo and Mr. Abhishek his coordinator. We never met a more compassionate team of people in any profession leave alone in medical profession. We reached out to them over weekends, late nights, holidays and the response time was always less than thirty minutes from the moment they received it. They put to shame some of the IT folks and Client service organizations responsible for system maintenance and customer service in terms of response time and that too with utmost empathy. But then a Team is as good as the Captain and Captain is as good his Team. Dr. Puneet himself was always available and was a true reflection of Dr.Gagan. I am a Digital Practioner myself and I was so glad to see the new generation of Doctors adopting to Digital Technologies so easily for a seamless patient experience.

Some observations on the MAX Hospital in Saket, Delhi. In the past I have had very poor experience in Hospitals in India. We realized that most of the hospitals in India after being taken over by large Corporation have become a money making machines and have little care for patients. When we walked into Max, every place I saw one message – “MAX, Where Patients come first”. Being in the field of consulting, I thought it to be another Marketing Tag Line. And I am so glad that I was so wrong. Every hospital staff that we encountered was an epitome of Dr. Gagan and his team – very down to earth, approachable, caring and compasivo. Their whole attitude is to get the patient well and get them out of hospital healthy and hearty as soon as possible. If there’s ever a word called personal care in a Corporate Hospitals in India, we found it at Max. Also, my father found the pain management process at MAX outstanding.

After I started interacting with Dr. Gagan for a while, I got a little worried of my own job smile emoticon:-). Dr. Gagan could very well have been a successful Consultant, a CEO, a rising Entrepreneur in the Silicon Valley, a Preacher and later I realized he could as well have gotten us that missing Gold Medal at Rio in the long distance running. The kind of expertise that he brings to the table along with his serene calm personage, when he meets his patient is just exceptionnel. I can relate one incident to highlight the same – When we realized the seriousness of my dad’s disease and the complex and long nature of the procedure, we were hesitant to tell him so. But Dr. Gagan was pretty clear that he needs to share the same with my Dad. He had an hour long conversation with various audiences – my family including my Dad, my Dad alone and my family alone. He took a lot of time to explain the details of the disease, the sickness and the realization of the reality of the situation and the way he did oozed utmost confidence of a Master who was in total control. His calm comportement, the confidence that he executed was like watching Messi having the ball in the box while playing for Barca or when Sachin walking out to bat against the fierce Australian team. Also, the patience and time he gives to his patients and his family to go over the details is just exemplary. I am also in a Client Services Business and always try to avoid prying customers who want every details of execution and risks associated with it – Dr. Gagan taught me otherwise.

For me Dr. Gagan Gautam is almost a paradox as an expert Robotics Surgeon along with rest of his personal traits. How can a person who deals with Robots day in and day out as a profession, be so humane and compassionate towards his patients. But then we have never seen a more human character than Optimus Prime or a Superman.

My two young boys, my wife and my entire family have been following Dr. Gagan like a shadow on his social network and have become a big fan of him – My boys described him best in one word, well – one word on twitter – 

“SUPER ROBO DOC” – The Human Behind the Robots
Dr. Gagan Gautam – YOU ARE THE BEST.

Feedback by Bibhakar Pandey. He is Venture Leader and Digital Practioner, lives in Atlanta, Georgia with his wife Rashmi and two boys. His Father Bibhuti Pandey, who is a patient of Dr. Gagan Gautam is a Senior Lawyer practicing Law in Supreme Court and High Courts in Patna and Ranchi. He lives with his wife Sudha in Patna, Bihar. His Daughter Shweta works in a Multinational Medical Firm and lives with her husband Balaji in Bangalore, Karnataka.
For any query on the patient experience during the surgery or this article please contact Bibhakar Pandey on email – pbibhakar@gmail.com

Advanced kidney cancer now amenable to robotic surgery

Advanced kidney cancer has a potential to spread to other parts of the body like lungs, liver or bones; however in certain rare circumstances, the tumour grows within the veins of the kidney and blocks the main vein of the body (inferior vena cava) going towards the heart. This blocks the flow of blood to the heart and may lead to severe complications. A piece of the tumour can also get detached and get lodged in the heart or lungs causing sudden death. Fortunately, even in this advanced stage, removal of the kidney and the tumour thrombus (clot) from the vein can potentially cure the patient. This is usually done via conventional open surgery due to the complexity involved in blocking multiple sources of blood supply to the vein, opening the vein, removing the tumour from it and reconstructing it in a way that there is no leakage of blood from it. This involves a large cut (incision) on the body and results in significant blood loss, high complication rates and delayed recovery. Robotic surgery can now be offered in this rare condition to enable the patient to recover faster with less pain, discomfort and blood loss.

This procedure, technically known as robotic radical nephrectomy with IVC thrombectomy, was recently performed by Dr Gagan Gautam – Head of Urologic Oncology and Robotic Surgery at Max Institute of Cancer Care, Saket, New Delhi on Sanjay Doolabh, a 46 year old businessman from Zimbabwe, who was discharged 3 days after surgery and flew back to his country in a week.
“This represents a significant advance in Indian robotics as we can now offer potentially curative treatment to this rare group of advanced kidney cancer patients, with a minimally invasive robotic approach which may decrease chances of complications and hasten recovery”, Dr Gautam stated in reply to a question. “Till date, this operation is being performed in only a handful of institutions in the world and the worldwide experience is likely to be less than 50 cases.”
Dr. Gautam has been trained in robotic surgery at the University of Chicago and currently leads a team of urologic cancer surgeons who perform robotic surgery for prostate, kidney and urinary bladder cancer at Max Institute of Cancer Care, Max hospital, Saket, New Delhi.

Heading home – the patient’s side of the story..

Dr Gagan Gautam is the Head of Urologic Oncology and Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. He has played a key leadership role in establishing robotic surgery programs in India and has trained and proctored many surgeons in robotic surgery for kidney, prostate and urinary bladder cancer.

Robotic Surgery may prevent long term complications of hormone therapy for prostate cancer

Robotic surgery is now very well established as a leading treatment option for prostate cancer. In suitable patients, it is likely to provide the best long term quality and quantity of life. Even in men with relatively advanced disease (high risk/locally advanced) prostate cancer, robotic surgery offers a speedy recovery with excellent long term survival. However, a relatively under appreciated advantage of this technique is its ability to delay or avoid the need for hormone therapy in a large number of patients with prostate cancer.

Hormone therapy (androgen deprivation therapy in medical jargon) implies removing the male hormone, testosterone from the body by either removing its site of production (surgical removal of both testes, also called surgical castration) or suppressing it with regular injections (medical castration). Since, prostate cancer cells are dependent on testosterone for their growth and spread, this removal or suppression of testosterone in the body generally brings about a decrease in the amount of cancer and keeps the disease under control for a duration of time ranging from months to a few years.

However, hormone therapy takes a significant toll on the body by way of many short and long term complications. It causes fatigue, loss of muscle mass, loss of bone strength which may cause fractures, depression, loss of sexual function and a general slowdown of physical and mental functions. In the long term, it can lead to an increased susceptibility to develop diabetes, high cholesterol and weight gain. It has also been shown recently to increase the chances of having a heart attack or stroke in the future. In fact, the US Food and Drug Administration (FDA) and American Heart Association (AHA) have issued a warning advising a judicious use of hormone therapy in patients with prostate cancer and weighing the risks and benefits before starting this treatment in all patients.

Patients who undergo radiation therapy for prostate cancer also have to take hormone therapy ranging from 6 months to 3 years depending upon the stage and type (grade) of the disease. This is because radiation alone (without hormone therapy) has much inferior results as compared to surgery in most patients with prostate cancer. This addition of hormone therapy to radiation therapy, unfortunately, exposes patients to the combined onslaught of complications and problems associated with radiation as well as hormone therapy.

For suitable patients, choosing to undergo surgery may be the best way to avoid many of these complications, thereby leading to the best possible preservation of quality and quantity of life. While hormone therapy may need to be given even after surgery in certain situations, it has been shown that even in men with a relatively advanced disease (high risk/locally advanced prostate cancer), hormone therapy can be avoided or delayed in more than 50% of patients by choosing to undergo surgery for prostate cancer. Even if hormone therapy is required after surgery, it can be given in an on-off fashion (intermittent androgen deprivation therapy), thereby avoiding a continuous harmful exposure to the body for a long time.

So, while there will always be certain short term problems and risks associated with undergoing surgery, robotic surgery for prostate cancer may be the best treatment option for most patients with prostate cancer – especially in view of the recent realisation in the medical community that hormone therapy for prostate cancer may not be as innocuous as previously thought by many of us !

Dr Gagan Gautam is the head of urologic oncology and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is one of the leading specialists for prostate cancer treatment in India and is closely involved in the care, counselling and surgical treatment of patients with this disease.  

When a doctor becomes a patient – A story of a doctor who underwent robotic surgery for prostate cancer….

I am quite touched by this comprehensive feedback from a senior doctor who was diagnosed with prostate cancer and underwent robotic surgery in my care.

WHEN THE DOCTOR IS THE PATIENT:
PERSONAL ACCOUNT OF TREATMENT OF MY PROSTATE CANCER

I’m writing this piece with the hope that patients diagnosed with prostate cancer will benefit from my experience in accepting the dreadful diagnosis and in choosing the mode of treatment and the doctor (and hospital) to treat me.

My Story: I am 62 year old medical doctor (consultant paediatrician) residing at family house in Hyderabad (AP). Until recently we had been living and working abroad. It has been seven months (today 31st October, 2014) since I had Robotic/Robot-Assisted (da Vinci® ) Radical Prostatectomy (RRP) for Prostate cancer on 31st March 2014 by a team of doctors lead by Dr. Gagan Gautam.

Diagnosis: My story started with occasional dripping of drops of urine after voiding six months prior to my surgery. It was rather a nuisance than a ‘disease’. I mentioned this complaint to a colleague (urologist) in the hospital I was abroad. He advised me to do Prostate Specific Antigen (PSA) as a marker for prostate cancer due to my age rather than a finding of enlarged prostate. We came home for vacation and paediaric conference held in Indore in January this year. Before the conference I saw a urologist at a ‘five-star’ hospital in Hyderabad. He did not think it was necessary to do PSA as he was under the impression that the enlarged prostate was benign (not cancerous); he advised for clinical follow up to monitor the enlargement. However, I personally opted to do the PSA at that hospital on Monday 10th February 2014; it turned out very high (3x upper limit of normal). The following week I went back to the same urologist and showed him the result of the PSA and discussed the next course of action. He then ordered for trans-rectal ultrasound-guided (TRUS) biopsy of the prostate which I underwent in that hospital on Friday 14th February. After two careful reviews of the prostatic tissue in their laboratory the final report was issued out on 24th February as prostate adenocarcinoma (cancer) of intermediate grade.

Dilemma on My Choice of Mode of Treatment: The urologist explained the nature of the disease and the various options for treatment. In his opinion the best and most suitable treatment option for me was radical prostatectomy either by open surgery or by robotic-assisted procedure. Surprisingly what helped me to make up my mind did not come from high peer-reviewed medical journal (even as I am a doctor); it came from a Health & Fitness article (as I am now a patient rather than a doctor). The article that took me to the decision was an online one titled “Robotic Surgery for Prostate Cancer: An Automatic Choice?” by Lisa Farino for MSN Health & Fitness. The key words of the article caught my attention “It’s essential to consider a surgeon’s experience when deciding on treatment”. In this article Farino reviewed a number of issues on RRP including what was ‘robotic’ about prostate surgery, patients’ misconceptions about the procedure, what research said and did not say about open vs robotic prostate surgery and then concluded on the final note on surgeon’s experience. She then wrote, “The bottom line: The biggest factor determining the key outcomes of prostate surgery isn’t whether or not the surgeon uses a robot. With a highly experienced, talented surgeon, both open and robotic prostate surgeries can be performed well. The trick is identifying that highly experienced, talented surgeon who’ll give you the best chance of curing your cancer and preserving your quality of life afterwards.” She concluded by quoting Dr. Eric Klein, M.D., a urologist at the Cleveland Clinic, who said, “The robot is a tool; to have the best outcomes, you want to choose your surgeon, not your tool.”

So I set out to find and decide on the right surgeon.
I flew to Medanta – The Medicity, Gurgaon with my wife and met Dr. Gagan Gautam – Head of Robotic Surgery in his office on Saturday 28th February 2014.
He took history of my condition and examined me. He reviewed the investigations I had done in the Hyderabad hospital. He concurred with diagnosis done there. He took me through the options for treatment taking into consideration my age, my African origin, my good state of health (freedom from co-morbidity like diabetes, hypertension/heart disease) and the stage of the disease (confined to the prostate gland). He did so in great detail with humour and compassion. He agreed with my Hyderabad urologist on the mode of treatment for me. He then asked me to take time the make the decision on mode of my choice; operative treatment is normally done 6 weeks after the biopsy. He however advised that the prostate tissue be re-examined in Medanta to confirm the pathologic diagnosis given at Hyderabad and that I should do MRI of the prostate/pelvis at Hyderabad before my next appointment. I returned home Hyderabad that afternoon. I later obtained my prostate biopsy tissue blocks and slides and mailed them to Medanta hospital; the diagnosis was confirmed there.
After due consultation with my family and my other medical colleagues/friends, I opted for robot assisted radical prostatectomy by Dr. Gautam and his team. As I waited for the 6 week window, I read a lot on prostate cancer, its modes of treatment and in particular the RRP. It was a most trying moment in my life. Waiting for the date of the surgery was like eternity.

Pre-operative Assessment: Eventually the date was fixed on 31st March 2014. I flew with my wife to Gurgaon in the morning of Saturday 29th March. I was reviewed again by Dr. Gautam in his office. He reviewed the MRI examination I did in Hyderabad. It guided him on the tissue planes for the operative dissection. He re-examined me and then explained to me his plans for the operation. Later in the day, I underwent general clinical (heart, vascular & lung functions) and laboratory assessment (esp liver, kidney and blood clotting functions) as outpatient so as to ascertain my fitness to undergo the general anaesthesia, surgery and post-operative convalescence. I was seen by the anaesthetist and cardiologist. The assessment confirmed my state of good health. I was then admitted into the hospital in the morning of Sunday 30th March in readiness for the surgery on the following day.

Admission & Surgery: Early morning of Monday 31st March Dr. Gautam and team visited me and gave me assurance and confidence to face the surgery. That afternoon I was taken, in the company of my wife, to the operating theatre (OT) at around 2.30pm. The moment had come. In transit from the ward to the OT I lay supine watching the ceiling; the lamps therein moved pass me in parallax as I was wheeled on down the corridor. Finally we arrived at the OT and my wife was told to stay back; she bid me good bye. She was hoping, but not quite sure, that she would see me alive again soon. It was an emotional moment. I was taken into the theatre and she departed. I kept on praying. In the next moments the anaesthetists made final assessment of me. Eventually they put a mask on my face and asked me to breath in the gas. That was the last thing I remember as I slept. I woke up in what I came to know to be the recovery ward. The actual operation surgery took about 3 hours (2hrs and 40 minutes console time).

I made good and quick recovery and was discharged with urinary (Foley’s) catheter in place on the 3rd day after the operation (Thursday 3rd April). I was given appointment to return to the hospital for assessment and removal of the catheter on 8th April, eight days after the operation. I was given the necessary medicines to use and was instructed on the care of the catheter, the need to ambulate and do respiratory exercises. I stayed in a paying guest house across the road from the hospital. My stay in the house was uneventful and I made speedy recovery. The urine being drained into a bag has become grossly clear of blood by the 4th day. On the appointed date, I was re-admitted into the hospital’s urology day-care-ward. The urinary catheter was removed. I was instructed on how to do (Kegel) exercise to improve my external sphincter (pelvic floor, pubococcygeal) muscles in order to enhance voluntary control of urine voiding; I had already known how to do this even before the operation. Thereafter underwent simple ultrasound examination of the urinary bladder to determine residual urine volume after voluntary voiding of the bladder; it showed only 12mL which indicate good voiding. I was discharged later in the afternoon after about five hours of admission. Over the next several weeks I made good recovery. Within two weeks I was able to control my urination voluntarily such that I rarely wet my pants. I was able to hold urine well and void voluntarily at regular intervals of two hours.

Seven Months On After Surgery…: After the surgery I remained in my home in Hyderabad with the family until 30th May 2014 when we returned abroad.

Bladder Control: I virtually have full bladder control. I void on urge with good stream and without efforts. I make no conscious control of my liquid intake but I still avoid intake at bed time. I hardly wake up to void until my usual wake up time of 4am. Except when I sneeze or cough I hardly have any spill of urine; when I can anticipate these I can still keep check on it. I go out wearing my regular underpants without pad. Until my return home after the day’s business I do not go to the toilet to void more frequently than ordinary.
Even before surgery I used to void with reasonably good (jet) stream. However, I realize that it now takes me shorter time to completely empty my bladder (with ease). This implies that before the surgery my urine outflow must have been partially compromised even as ultrasound examination showed only small (acceptable) post-voiding residual urine. This was most likely due to the tortuous course of the urethra within the enlarged prostate.
Erectile Function: I am satisfied with the surprising return of the degree of this function within these seven months of the surgery especially in consideration of what I had read of the guarded prognosis on erectile dysfunction post operatively in the initial months.
Prostate Specific Antigen (PSA): the level of this antigen in the body is taken as a diagnostic marker for the risk of prostate cancer and, after prostatectomy, serial levels are used to monitor the prognosis. Before my operation, the first indicator to the diagnosis of cancer, my level was about 3½ times the expected highest normal level. It was usually expected that within six to eight weeks after prostatectomy the level should fall below 0.20ng/mL.
Below were the serial levels of my PSA:
• March 31th (pre-op): 16.85ng/mL
• May 12th (1½ months post op): 0.071ng/mL
• August 12th (4½months post-op): 0.02ng/mL
• October 13th (6½months post-op): ˂ 0.01ng/mL
These results are interpreted to imply successful removal of the prostate/cancer tissue.

Dr. Gagan Gautam: I am a fellow of, trainer/teacher and examiner in, two regional postgraduate medical colleges abroad, each with structured 4year training programmes. Most of my clinical/academic practice at home and abroad, since my medical graduation in 1978, has been in teaching and specialist tertiary hospitals. I have had the opportunity to head a largest state government-owned (1000-bed) hospital. I have also been appointed by both these colleges and national medical regulatory council to assess and accredit hospitals for postgraduate training across the country. I am therefore in good position to recognise a good hospital and to identify exceptionally talented doctors.
Dr. Gautam is a good doctor, an excellent clinician and a fine surgeon. He gave me good impression of himself from the very moment I first met him in his office on Saturday 28th February. In the course of his interviewing me, my wife and I sat across his desk. He took detailed history of my condition and made careful, thorough and relevant examination of me in a basic and professional manner. After the clinic examination he reviewed the laboratory investigation I had in Hyderabad. He then summarized his evaluation of, and opinion on, my case in a lucid and unassuming manner. He described the disease, its risks, modes of treatment and prognosis as was specifically relevant to me. He left open the choice of options of the treatment to me. In the course of the discussion, he made direct eye contact with us. I observed his good knowledge of the issues on the disease and his confidence in his competence to deal with its management. I also observed his calmness and composure. He moved his hands only when necessary and his fingers showed no tremors – features of a good surgeon. His humility as a doctor and respect for his patient and colleague (me) were obvious. We were satisfied with him and by the time we concluded the consultation we believed that we made the right choice of the surgeon I needed.
My second visit to his office was a day prior to my admission for the operation. He reviewed the MRI films and report done in my Hyderabad hospital. He re-examined me again and then made and explained his plan and extent of the surgery he will do for me. Even though the procedure for the operation is fairly standardized, the plan he prepared for me was customized to my condition. He was to remove all the prostate en-bloc including the regional lymph tissue while carefully sparing and preserving the nerves that regulate for bladder sphincter control and conserve erectile function. This tight-roped plan is aimed at removing (all or as much of as is possible and feasible) the cancer tissue leading to cure and ensuring good quality; the universal goals of the treatment are, first, to cure the patient (i.e., the prostate cancer is removed completely) and, secondly, to help the patient maintain urinary control (or continence, the absence of urinary leakage), and erectile function.
He performed my operation very well and successfully. My family and I appreciate the precision with which he did this. The serial level of my PSA over the past seven months is testimony to the success of the procedure. It is hoped that this marker will remain undetectable over time indicative of my cure. The overall quality of my life after the operation is beyond my expectation. I have been in close contact with him and he has remained consistent in his care and humility. I shall live the rest of my life appreciating how the operation he performed has turned around my life after the dreadful diagnosis. Medanta hospital is lucky to have him; he is a great asset.
I will not hesitate to recommend him to any patient on personal and professional grounds.

Sincerely,
Dr. B.A.U

Robotic surgery in India – Challenges and opportunities

There is little doubt that over the past decade, robotic technology has created a mini revolution in surgery. After taking the western world by storm, it is now headed our way, to India. The big question is … are we ready for it?

The scope of robotic surgery in the Indian healthcare scenario seems to be expanding rapidly. Only a few years ago the number of robotic systems in India could be counted off on the fingers of a single hand. However, the number is currently around 25 and is all set to explode in the years to come. It is estimated that over 2500 robotic procedures were performed in India in 2013. However, this is just a small fraction of the number of patients who can benefit from this technology. With rising levels of education and awareness, implementation of cancer screening programs, increasing economic strength, and the availability of modern technology, these numbers are likely to multiply many times over in the coming years.

This technology affords a number of advantages to the surgeon as well as the patient. It is now possible, with robotic technology, to see tissue details in magnified 3-D vision, that were never visualized earlier. Highly miniaturized and dexterous robotic instruments enable the surgeon to perform precise and accurate surgery resulting in excellent outcomes with decreased chances of complications.

However, an under appreciated caveat of this technology is the centralization of major surgical procedures in high volume centers. This is not necessarily a bad thing. Research studies have consistently shown that complex surgical procedures are best performed at tertiary institutions by experienced surgeons dedicated to that particular sub speciality. Not only does this result in optimal surgical outcomes, but also provides opportunities for dedicated follow-up, additional treatments and further research. Robotic technology permits more and more patients to be operated in fewer institutions by a dedicated group of surgeons specialized in the care of these patients. At the same time, robotics has greatly reduced the learning curve of complex surgical procedures, thereby enabling rapid dissemination and assimilation of highly advanced surgical skills by surgeons who are interested in performing robotic surgery.

Every challenge is an opportunity and vice versa. In India, there are certain unique challenges that have to be overcome before robotic surgery becomes widely acceptable. Even if we move beyond the oft cited constraints of cost and prioties in healthcare, availability of trained manpower remains a major issue. Currently, in India, there is a severe deficiency of adequate training facilities for robotic surgery. The establishment of fellowship programs and structured training for entire surgical teams is the need of the hour. Leading robotic programs in India need to take the lead in establishing these training centers. Proctors and preceptors from these Indian institutions need to play a role in helping other surgeons and establishments overcome their learning curve safely and efficiently.

Next generation surgery – The Da Vinci surgical robot in action.

Hopitals and insurance companies need to work together to work out issues regarding financial compensation for robotic surgery. We need to demonstrate definite improvement in patient outcomes, decreased hospitalization and a reduced readmission rate after robotic surgery to encourage insurance companies and government agencies to cover the additional cost of robotic surgery. This can only be achieved by maintaining a robust database for every major procedure done, using the robot.

There is little doubt that India is now ready for a rapid expansion and development of robotic surgery. In fact, due to the combination of a large case mix of complex medical conditions and his/her inherent ability to get comfortable with modern technology, in the times to come, the Indian surgeon may be in a unique position to provide international leadership in certain disciplines of robotic surgery.

[Dr. Gagan Gautam is the Head of Robotic Surgery and Uro Oncology at Max Institute of Cancer Care, New Delhi, India. Though his prime focus is the surgical care of patients with prostate, kidney and urinary bladder cancer, he is also involved in robotic surgery training and counselling and has been pioneering the safe and widespread adoption of robotic surgery in India. He has been invited to a number of national and international workshops and meetings where he has taken lectures and conducted live surgical demonstrations of robotic surgery]

View Dr. Gagan Gautam’s profile or visit his website

Contact Dr. Gagan Gautam or connect with him on twitter or facebook

Prostate cancer treatment in India – A personal experience..

Making a decision regarding the best treatment option for prostate cancer is a difficult task. Every individual with this disease is unique and the ideal treatment for one may not be so for another. However, it does help to learn about other people’s experiences so that one can get to know the expected outcomes of treatment by any particular technique or technology…

Here is a real life account of a gentleman who underwent robotic surgery for prostate cancer in my care. I am grateful to his daughter (who has penned this down) for sharing the intricacies of the decision making process…something that will strike a chord with so many gentlemen and their loved ones who happen to be in the same situation as this family was just a few months ago…

Posting real life experience of my father, a Prostate Cancer patient who under went RARP under the able hands of Dr. Gagan. [Posting from my Dad’s account]

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“Cancer” the word itself strikes fear. We hear it happening all around and somehow think we and our near and dear ones are impervious to it.

….and then it hits you or a family member out of nowhere. In our case my father who had just turned 60 few months back was diagnosed with Prostate Cancer in Jan 2014. No symptoms, no health issues just underwent routine health checkup and he was diagnosed with elevated PSA of 24. A rectal biopsy followed which confirmed the cancer with a Gleason Score of 3+4.

Our search for a doctor along with state of art medical facilities led us to Dr. Gagan Gautam at Medanta. At the time we were evaluating Surgery vs. Cyberknife (a focused radiation based approach where prostrate is not removed). We first fixed an appointment with Dr. Gautam and four of us literally spent close to 2 hours with him asking him questions and discussing the whole thing. The patience, grace and humbleness with which he attended to us and assuaged all our fears was really amazing. My Father (actually the whole family) was completely sold on the idea that he should be our doctor and that if surgery is to be done then he is the doctor who should do it.

We shelved our Cyberknife plans and decided to undergo simple and effective RARP surgery through Dr. Gagan. On the appointed day my Dad was taken in for surgery around 7 am and was wheeled back to his room by 3:30 pm. We spent a total of 3 nights in hospital and were home just around lunch time on day 4. My dad had his catheter removed in exactly a week’s time. His first month PSA was less than .02 which indicated the disease was controlled via the operation. 3 months down the road he does not use pads; his urine control is good, enjoys playing with his grandson and drives himself 25km one way to his work. I don’t think we could have asked for anything more. All thanks to Dr. Gagan Gautam.

PS: 
We decided on RARP because it was the latest treatment, less painful (only 5 holes ), has been in practice for close to a decade, recovery after surgery was fastest and chances of my dad having normal life like before were the best. Plus we did not want to keep the infected organ inside the body considering the age of my father, hence Cyberknife was a ruled out.

Cancer is a complicated disease and my father did have some lymph node spread as shown by the final biopsy which is done on the removed organ and tissue, thankfully the margins were clear. Also, the staging of cancer tends to change what started as 3+4 Gleason score for us was finally a 4 +4 after the final biopsy (cancer staging changed as well). In course of cancer treatment there will be good days, bad days and even more bad days, I think best we can do is to keep having faith and positivity. After God’s will, I attribute my Dad getting well to not only a highly skilled doctor, but also his own resolve and will to get better.

Good Luck!

To read the original post, please visit http://www.facebook.com/roboticsurgerydelhi/posts/635216833226179

Dr. Gagan Gautam is the head of robotic surgery and urologic oncology at Max Institute of Cancer Care, New Delhi, India. He is India’s leading expert in robotic surgery for prostate cancer and is closely involved in the counselling and management of patients with this disease. To know more about him, please click here or visit his website, http://www.roboticsurgerydelhi.com

To seek an appointment or to contact Dr. Gautam, please click here

To read his other blogs on prostate cancer treatment please click on the links below:

What is the best prostate cancer treatment in India?

Robotic surgery for prostate cancer in India – A video demonstration

Cost of prostate cancer treatment in India

Watchful waiting and active surveillance for prostate cancer

Recovery after robotic surgery for prostate cancer – What to expect?

 

 

Recovery after robotic surgery for prostate cancer – What to expect?

‘Is this a big operation?’ ‘How much time will it take for me to recover completely?’ ‘Will it be painful?’ ‘How many days will I have to stay in the hospital after the surgery?’ ‘Will I be able to climb stairs after I am discharged?’ ‘When can I drive? Go for a walk….?’

These are some very practical questions that I am asked almost everyday during my initial counselling sessions with gentlemen who have been diagnosed with prostate cancer and are considering robotic prostatectomy (robotic surgery for prostate cancer). Fortunately, the answers to these common questions are almost always better than what they expect to hear!

Robotic surgery has had such a positive impact on postoperative recovery that it is sometimes hard to believe that it still is ….and will always remain…. a major cancer operation.

When I talk to my patients about this, I just tell them the sequence of events that they are likely to go through before, during and after the surgery. I tell them that there is a 95% chance that they will be able to stick to this pathway. Roughly, a 5% chance does exist, for having some problems or complications during the recovery phase. However, the vast majority of these can be managed effectively, albeit, with extra medications or procedures and hospital stay.

What follows is a step by step description of what to expect after robotic surgery for prostate cancer:

Step 1: Admission

You will be admitted to the hospital the evening prior to the date of surgery. In some circumstances you may be asked to come in the same day early in the morning. Before admission, all the relevant investigations are reviewed and a clearance for surgery is taken from the anesthesiologists. This is called the pre-anesthesia check up or PAC. At this time, if necessary, further advice and clearance may be sought from other specialists like cardiology, endocrinology etc. This is to ensure that all potential risk factors are assessed and mitigated prior to the surgery. This is done with the sole intention of keeping you safe during and after surgery. The night before the surgery you will be provided a normal dinner and some medications to help you have a relaxing sleep before the day of the surgery. You will be asked not to eat or drink anything after midnight and will be requested to sign the consent form for the operation.

Step 2: The operation

You will be moved to the preoperative holding area about an hour prior to the time of surgery. Here you will receive antibiotics to decrease chances of infection and will be reviewed by anesthesiologists. You will then be moved to the main operating room and anesthesia will be administered. Robotic prostate cancer surgery, on an average, takes about 3-4 hours to complete.

Step 3: After the surgery (Postop day 0)

After surgery, your surgeon will meet your next of kin and provide them with information about your surgery and expected recovery. You will be able to meet your loved ones in the post operative recovery room after 1 or 2 hours when you have recovered from the effects of anesthesia. Thereafter, you will be moved to your room. You will be able to have a full liquid diet starting 4 hours after the completion of your operation, although some fluids will also be given intravenously for support. You will be encouraged to move all your limbs and do deep breathing exercises. You would be expected to be reasonably comfortable with the help of painkillers that would be administered to you. At this time you would have a urinary tube and a thin abdominal drain to remove fluids from the body.

Step 4: The day after surgery (Postop day 1)

On the day after the operation, you will be served a normal diet for breakfast and intravenous fluids will be discontinued. You will be encouraged to walk about outside your room for a total of 60 minutes during the day, in splits of about 10 minutes each. The abdominal drain will be removed and medications tapered down. Deep breathing exercises (incentive spirometry) and steam inhalation are very important components of your ‘home work’ on this day. This keeps your lungs healthy and prevents infection. You should be quite comfortable with the help of medications.

Step 5: The next day (Postop day 2)

This is the day you go home! You will be relatively pain free such that you can manage easily on oral medications, without the need for any injections. Your confidence in moving about and doing all your daily activities should be back. You can take regular meals, travel in a car, go for a walk and climb stairs. You can also take a shower on this day. You will be discharged with clear instructions on how to manage the urinary tube, which would be removed after 1 week. You will be prescribed some medications to ease your visit to the washroom and to keep you comfortable. Although you would likely have passed some wind by now, passage of stools may take another day or two in the course of a normal recovery.

Step 6: A week later 

You will be asked to come into the hospital and stay there for 3 – 4 hours in the daycare ward. Here your urinary tube (catheter) will be removed. You will be taught pelvic floor exercises (Kegel exercises) to promote early recovery of full urinary control. You will be advised on the proper use of continence pads, water intake etc. and sent home on the same day after you have comfortably passed urine a few times. If the pathology (biopsy) report from the surgery is available by that day, your doctor will discuss the findings with you. After this time, you should be well on your way to a full recovery. You can rejoin your work in about 2 -3 weeks. Most men are comfortable enough to start driving around the same time.

Step 7: A month later 

You will likely have fully recovered by now, except that you may be needing a couple of pads to control leakage. Even this is likely to rapidly improve in the coming few weeks. You should get your first PSA test 1 month after the day of your surgery. This will give you and your doctor an excellent idea about the control of the disease and the chances of requiring further treatment, if any. You will need to be in regular follow up with your doctor to ensure that you remain trouble free. Initially it will be once every 3 months. As the years go by, you are likely to require a visit to the clinic only once in a year.

I hope that you found this blog useful. I wish you a speedy recovery!

 

Dr. Gagan Gautam is the head of robotic surgery for prostate, kidney and urinary bladder cancer at Max Institute of Cancer Care, New Delhi, India. Besides being one of the leading specialists for prostate cancer in India, he is also an expert in nerve sparing robotic prostate cancer surgery, which has been shown to result in a faster recovery of urinary control and potency after prostate operation. To know more about him, please click here or visit his website http://www.roboticsurgerydelhi.com.

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here.

To contact Dr. Gautam or to seek an appointment, please click here.

To view his video on robotic prostate cancer surgery, please click here.

To read his blog on the cost of prostate cancer treatment in India, please click here.

To read his blog on robotic prostatectomy, please click here.

To read his blog on watchful waiting and active surveillance for prostate cancer, please click here. 

Kidney cancer treatment in India – Patient feedback

A diagnosis of kidney cancer does not mean that your are at the end of the road. There are innumerable stories of courage, innovation and determination that can inspire us. Fortunately, with modern technology and treatment techniques, there is hope for the vast majority of people who would not have been treated effectively till just a few years back.

One such story, is that of a surgical colleague of mine, a plastic surgeon in Iraq, who had came over with his father to me a few months ago. What follows is an extract from his post on http://www.facebook.com/roboticsurgerydelhi. You can read his post through a link at the end of this blog.

There is always light at the end of the tunnel….recovering well after surgery…..

“Everyone may face a hard time, and during that, you have to know who will be there with you to pass it.
My father Safaa Alhassany is 67 year old with past medical history of angina, hypertension, gout and DM. We discovered accidentally that he had a big tumour in the middle lobe of his left kidney and to make it complicated, the right one was shrinkage and with only 12% function!! Which meant a real ((disaster))!!
After a lot of consultations there in my country and here in India, there was no doubt that we are going to the dark side of our life..
There was no choice other than nephrectomy due to the size and site of the tumour.
Thanks Godness, following someone’s recommendation, I met Dr. Gagan Gautam and he was the only one offers a partial nephrectomy to save the kidney and get rid of the mass. Within a week time, he bravely took the plunge and operated on my dad and thankfully did it, saving about a half of the kidney after a super-major, long and difficult operation lasted more than 5 hours.After a month of this nightmare, I write my story just to say thank you to the one who saved our family Dr. Gagan Gautam and to let the others know that the hope is usually there but you have look for it carefully.
A big thank you to Dr. Gagan Gautam and his team.”

Dr. Hussein safaa

https://www.facebook.com/roboticsurgerydelhi/posts/632210403526822

Dr. Gagan Gautam is the Head of Urologic Oncology & Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. He is India’s leading expert in robotic surgery for prostate, kidney and urinary bladder cancer treatment. To know more about him, click here, or visit his website http://www.roboticsurgerydelhi.com.

To read Dr. Gautam’s blog on robotic surgery for kidney cancer, please click here.

Urinary bladder cancer treatment in India – choosing the right options

Imagine this. Everything is coming along fine in your life until you visit the washroom one day and suddenly discover that there is blood in urine. You feel no pain, no weakness, no fever. More likely than not, you ignore this – try to pass it off as a mild ‘infection’ and get on with your life. Until, after a few weeks, it happens again; And again. You visit your neighborhood physician who orders a few tests and an ultrasound exam. When the results come in you are shocked to discover that you have a mass in the urinary bladder, which is highly likely to be cancer.

Unfortunately, this is a common sequence of events for almost half a million people worldwide who are diagnosed to have urinary bladder cancer every year. The biggest impediment to effective and complete cure for bladder cancer is delay in diagnosis. The initial symptoms are all too often ignored by patients and doctors alike, while a curable cancer inexorably grows and spreads unnoticed to become life threatening. Bleeding in urine is a dangerous symptom and must not be ignored!

Smoking is the most common cause of urinary bladder cancer with about 50% of these tumors attributable to this single cause. Other causes – mostly unknown – account for the other half, and include exposure to certain chemicals and chronic infections of the bladder. Smoking is also a very important cause of recurrence of this disease in those who have already received treatment for urinary bladder cancer. Kicking the habit is essential to decrease the chances of bladder cancer coming back after initial treatment.

Urinary bladder cancer treatment in India is now quite standardized. Once a growth in the urinary bladder seen on ultrasound, the next step is to do a ‘cystoscopy’ which involves putting a thin telescope through the urinary passage into the urinary bladder under anesthesia. The tumor is visualized with a camera and is cut out and removed with specialized instruments. This procedure is called transurethral resection of bladder tumor (TURBT). This procedure not only removes the tumor but also provides vital information about the type (grade) and degree of spread (stage) of the cancer.

Depending upon the microscopic features of the tumor, bladder cancer can be either low grade (less aggressive) or high grade (more aggressive). This has important implications on further treatment. In terms of staging, it is vital to assess whether the bladder cancer is ‘superficial’, involving only the superficial (innermost) layers of the bladder or ‘muscle invasive’, which implies an infiltration of the cancer into the deep muscle layer of the urinary bladder.

For ‘superficial’ bladder cancer, the standard treatment involves regular follow up with repeated ‘cystoscopy’ examinations and the use of medications instilled directly into the bladder through the urinary passage at regular intervals. For ‘muscle invasive’ bladder tumors, the most effective treatment is to perform major surgery to remove the urinary bladder completely (radical cystectomy) and create a new bladder or tube using segments of intestine (urinary diversion, orthotopic neobladder or ileal conduit). While this has traditionally been performed via open surgery, urinary bladder cancer treatment in India is now getting revolutionized with the advent of robotic surgery.

Robotic surgery for bladder cancer offers a faster recovery, lesser blood loss, lesser pain and a possibility of a lower complication rate. Cancer control and cure rates are similar to open surgery.

In summary, smoking is the most common cause of urinary bladder cancer and blood in urine, its most common symptom. After initial removal via TURBT, subsequent treatment depends on the grade and stage of the disease. If required in a particular situation, robotic surgery for bladder cancer can improve outcomes and may be the next big revolution in urinary bladder cancer treatment in India.

This blog has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic surgery at Max Institute of Cancer Care, New Delhi, India. Dr. Gautam is a specialist doctor for prostate, kidney and urinary bladder cancer treatment in India and is the country’s leading expert in robotic surgery for these diseases. Max Institute of Cancer Care, a part of Max hospitals, Saket, New Delhi is a tertiary referral center regarded by many as the best hospital for bladder cancer treatment in India. It is equipped with state of the art facilities for radiation, chemotherapy and surgery for bladder cancer – including the Da Vinci Xi HD robotic surgical system. It is situated 20 minutes away from New Delhi’s international airport.

 To know more about, Dr. Gautam, please click here or visit his website www.roboticsurgerydelhi.com

 To connect with him on social media, please visit www.facebook.com/roboticsurgerydelhi or follow him on twitter @DrGaganGautam

 To seek an appointment or to get in touch with him, please click here