Robotic surgery is revolutionizing kidney cancer treatment in India

Hi tech robots performing complex operations on human beings through miniaturised instruments may sound like the stuff science fiction is made of …but it may be closer than you think. In fact, it is already here!

Robotic surgery has now entered the second decade since its inception around the turn of the century, and is now all set to revolutionise the way complex surgeries are performed. There are over 2000 surgical robots in the world today (>1500 in the US, ~ 20 in India) and they are increasingly being employed for the surgical treatment of cancers in India and abroad.

The most advanced robotic surgical system in the world today is the Da Vinci system developed by Intuitive Surgical (Sunnyvale, California, USA). It comprises of a console, patient side robotic machine and another cart, which houses the display monitor and lighting equipment. The surgeon sits at the console and through futuristic “master controls” initiates and controls the movements of robotic arms, which translate the movements of the surgeon to the robotic instruments inside the patient’s body. This system affords extremely precise and delicate movements made possible by the extreme miniaturization and flexibility of these special robotic instruments. Surgeon tremor is completely eliminated and the movements can be scaled (3:1) for greater finesse. Accompanying these advances in instrumentation, is the superb high definition magnified 3D vision of the operative field that the surgeon gets while sitting at the console of this robotic system. This enables the surgeon to see and appreciate minute structures inside the human body thereby making surgery potentially safer and more complete – aspects, which can be vital to a cancer patient.

Surgery for prostate cancer (robotic prostatectomy) is by far the most common cancer operation performed with robotic systems in the world today. Another condition in which the application of robotics is being considered a big step forward is – kidney cancer. Although relatively rare, kidney cancer is unique in being almost 100% curable if detected at an early stage when it is confined to the kidney and almost 100% fatal if it is detected at a stage when it has spread to other parts of the body. Kidney cancer treatment success rate is very high at early stage of the disease and very dismal at a late stage. Moreover, radiation and chemotherapy have been shown to be quite ineffective in this disease thereby leaving surgery as the only effective treatment option.

Surgery for kidney cancer broadly encompasses two separate types of operations – radical nephrectomy, in which the entire kidney is removed along with the tumor; and partial nephrectomy, which entails the selective removal of the cancerous portion of the kidney while sparing the rest of the kidney. Radical nephrectomy may be necessary in situations where the size of the tumor is large (typically more than 7 cm in greatest dimension) or when the location of the tumor makes it impossible to remove the tumor safely and completely without removing the entire kidney (as in the case of a tumor situated very close to the main blood vessels of the kidney). The removal of the entire kidney however, comes at a cost. The decrease in overall kidney function causes an adverse impact on the cardiovascular system and increases manifold, the chances of life-threatening complications later in life, such as heart attack and stroke. Moreover, in the long term, the chances of kidney failure and dependence on dialysis also increase significantly.

While radical nephrectomy may be inevitable in certain situations, most of the smaller and early stage tumors can be dealt with by the removal of the tumor itself while leaving the rest of the normal kidney behind (partial nephrectomy). In fact, it is universally acknowledged by all major cancer guidelines and medical associations that a partial nephrectomy achieves equal cancer cure for smaller tumors (<7 cm) as compared to a radical nephrectomy. At the same time, it enables the preservation of the maximum amount of normal kidney tissue and decreases the chances of heart attacks, strokes and dependence on dialysis. So overall, patients with small tumors in the kidney are likely to live longer, healthier lives if they choose to undergo partial nephrectomy rather than a complete removal of the kidney.

Though there are a number of ways of doing a partial nephrectomy (open, laparoscopic and robotic), robotic surgery has recently completely transformed the landscape in this type of kidney cancer treatment. In a number of major cancer centers in the western world, robotic surgery is now being used to perform over 90% of the total partial nephrectomy surgeries performed. Robotic surgery is also being increasingly used for kidney cancer treatment in India. The advantages of robotics in this operation are clear – excellent vision and dexterous fine instruments enable precise removal of the tumor and reconstruction of the remaining kidney with superior results and decreased complications. Since the operation is performed through small “keyhole” cuts without the need of a big open incision, the patient recovers faster, has less pain and is able to become fully active much earlier than conventional open kidney cancer surgery. Moreover, blood loss during the operation is significantly reduced and over 95% of patients do not require any blood transfusion thereby decreasing the transmission of blood borne infections.

The technology however doesn’t come cheap. The purchase and maintenance of the robot carries a cost, which invariably finds its way into the patients’ hospital bills. Using the robot inflates the cost of kidney cancer treatment in India by about 30% but some of this increased cost gets offset by the early discharge and less medications required after the operation. The chances of requiring readmission to the hospital also decreases, thereby decreasing the overall cost of kidney cancer treatment.

As the awareness regarding robotic surgery spreads in the country and as more and more robotic systems are installed in the top cancer hospitals in India, it is inevitable that an increasing number and types of procedures will be performed with the help of this technology. Already the robot is being used in a variety of different surgical specialties including gynecology, head and neck surgery and cardiac/thoracic surgery. This is only going to increase in the future. All this should translate into a significant improvement in the surgical care that is currently available at our medical institutions and enable surgeons to provide a relatively pain free, safe and effective solution for a gamut of diseases.

There is however, one important caveat that must be borne in mind prior to undergoing robotic surgery. Like any new technology, robotic surgery has a definite learning curve and requires specific training and experience in this modality. It may take up to 200 cases for a surgeon to become proficient in robotic surgery and become comfortable with this interface, which is completely different from open and conventional laparoscopic (“keyhole”) surgery. Although the technology is superlative, it is the man behind the machine that delivers the results.

This blog has been written by Dr. Gagan Gautam, head of urological cancer surgery and robotic surgery at Max Institute of Cancer Care, New Delhi, India. Dr. Gautam is the leading specialist for prostate, urinary bladder and kidney cancer treatment in India and is an expert in robotic surgery for these conditions. His institution is an 800 bed referral center recognised as one of the best hospitals for cancer treatment in India. It is equipped with state of art technological equipment including the Da Vinci Xi HD robotic system which is used by Dr. Gautam to advance the role of robotic surgery for the treatment of kidney cancer in India.

To know more about Dr. Gagan Gautam, please click here

To read a patient’s personal experience after kidney cancer surgery, please click here

If you would like to seek an appointment or would like to get in touch with him, please click here

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

To visit his website, please go to http://www.roboticsurgerydelhi.com  

Watchful waiting and Active surveillance for prostate cancer

Contrary to what a lot of people believe, prostate cancer treatment options do not start and end with surgery, radiation or hormone therapy. There are two other treatment options for prostate cancer that need to be discussed and evaluated in almost every newly diagnosed gentleman with this disease. And these are – Watchful waiting and Active surveillance.

Watchful waiting implies withholding active treatment for prostate cancer (surgery, radiation or hormone therapy) in men with advanced age or multiple medical problems till they develop significant symptoms from the disease. It is considered in men with early prostate cancer, who have a limited life expectancy of less than 5 to 10 years and have not yet developed significant symptoms from their disease. It is based on the premise that a significant proportion of men with prostate cancer have slow growing disease and hence will not be affected by it in their expected lifetime. It is very important to note that AGE should not be the sole criterion for applying watchful waiting in patients. I have come across many patients even in their late 70s who enjoy excellent health and have a life expectancy of at least 10 to 15 years and more. These are the patients who are very likely to benefit from active treatment for prostate cancer with surgery or radiation.

Active surveillance, on the other hand, is a treatment option for very early stage of prostate cancer which is expected to be localised within the prostate and has not spread beyond it. It can be applied to men with less aggressive types of this disease and can be recommended as an alternative to immediate treatment with radiation or surgery. For active surveillance to be considered, ALL of the following conditions should me met in the evaluation of the patient:

  • PSA should be less than 10 ng/ml
  • Gleason score in the biopsy should be 3+3 = 6; Men with Gleason 7 or above prostate cancer are not good candidates for active surveillance in most circumstances
  • In the biopsy report, not more than 2 cores should be positive for prostate cancer
  • There should not be an involvement of more than 50% of any core with prostate cancer
  • Clinical stage should be T2a or less (This is determined by your doctor on physical examination of the prostate)

If all the above criteria are met, a serious thought should be given to proceeding with active surveillance and withholding immediate treatment for prostate cancer. Active surveillance involves regular physical examination and PSA tests every 3 months, and a prostate biopsy repeated every year to ensure that the cancer is not becoming more aggressive. In case it is found that the cancer is increasing in volume or aggressiveness, immediate treatment is indicated. It has been found that by following this strategy, up to 70% of patients fulfilling the above criteria can safely avoid surgery, radiation or hormone therapy for prolonged periods of time with attendant benefits in terms of improved quality of life and decreased complications.

In summary, it is important to have a discussion with your doctor about all the treatment options for prostate cancer including active surveillance and watchful waiting. It is also a good idea to seek a second opinion from another source to increase your knowledge and reach an appropriate decision for individualizing treatment for prostate cancer depending on the person’s medical conditions, disease status and preferences.

This article has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. Besides being India’s leading robotic surgery expert  for prostate cancer, Dr. Gautam is also closely involved in the counselling and individualised care of men afflicted with this disease. His major focus is directed towards helping men in selecting and receiving the best treatment option for prostate cancer based on their personal medical conditions and preferences.

View Dr. Gautam’s profile here

If you are seeking an appointment, please click here

To read about robotic surgery for prostate cancer, please click here

To read about recovery after robotic surgery, please click here

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

To see a video of robotic surgery for prostate cancer, please click here

To read about the cost of prostate cancer treatment in India, please click here  

Cost of prostate cancer treatment in India

Being told by a doctor that you have been diagnosed with prostate cancer is probably one of the most traumatic experiences that anyone can have. The road ahead becomes uncertain and every step seems tricky and arduous. There is little doubt that prostate cancer extracts a psychological cost from the person it afflicts and also from his near and dear ones. This impact can be lessened by a compassionate and confident healthcare provider and perhaps more so, by caring and understanding family members.

The next step ideally involves an informative exchange of information amongst all stakeholders to ascertain a coherent plan of treatment. One of the major realities that one has to face in this situation is the cost of prostate cancer treatment, specially since this financial burden is often unexpected and unplanned for in a country like India, where the vast majority of population does not have medical insurance. What follows are a few important pieces of information about the expected cost of prostate cancer treatment in India, which fortunately, is still way below that seen in most parts of the world.

I shall be covering three established prostate cancer treatment options – Surgery, Radiation therapy and Hormone therapy. Other treatment options like HIFU, Cryotherapy and Cyberknife cannot be routinely recommended for the treatment of prostate cancer in India currently, since they are in an early phase of adoption with little information available about their long term outcomes and complications. Moreover, the discussion on how to choose the right treatment for prostate cancer is beyond the scope of this blog and will be addressed in another post.

Hormone therapy: Hormone therapy or Androgen Deprivation Therapy (ADT) as it is called in medical terminology implies the use of injections to suppress the level of Testosterone (male hormone) in the body to near – zero levels. This acts to decrease the growth and spread of prostate cancer for a duration of time ranging from a few months to a few years. While it is the mainstay of treatment for prostate cancer which has spread to other parts of the body (stage 4 or metastatic cancer), it is NOT recommended as the ONLY treatment for most cases of prostate cancer which is limited to the prostate region (localized prostate cancer) since it does not cure the disease but only controls it for some time. Invariably, with time the cancer starts becoming resistant to hormone therapy and starts spreading after that. The cost of hormone therapy ranges from 16,000 – 30,000 INR for an injection, which is to be given every 3 months. Some of the brands available in India are Zoladex®, Lucrin®, Eligard® and Pamorelin®.

Important points to discuss with your doctor:

  • A more expensive injection is not necessarily more effective. One should go for a cheaper, yet trusted brand to ensure that adequate effectiveness is achieved without excessive financial burden.
  • An injection imported from outside India is not necessarily more effective than an indigenous version.
  • You can often get these injections at up to 20% less than the MRP if you directly purchase it from the company representative. Your doctor should be able to provide you with the contact details.
  • Be careful about the storage requirements of the injection. Some of these require to be kept refrigerated during transportation and storage to maintain effectiveness.
  • A longer acting version (6 months) may be a cheaper option than two 3 monthly injections.
  • Removal of testes (surgical castration or bilateral orchidectomy) is a less expensive alternative to injections in the long run but is associated with an adverse psychological impact due to changes related to body image.

Radiation therapy: Radiation treatment is an alternative to surgery in patients who have prostate cancer that is localized to the area of the prostate and has not spread to other parts of the body. In most circumstances, radiation therapy needs to be combined with hormone therapy for 2 to 3 years in order for it to come close to the effectiveness and cure rates of surgery alone. Image Guided Radiation Therapy (IGRT) is currently the standard benchmark for the radiation treatment of prostate cancer in India. It is delivered over 6 to 8 weeks with 5 daily sessions in a week. The cost ranges from 2.0 – 2.5 lacs (200,000 to 250,000 INR) in most private institutions in the country with advanced radiation facilities. The addition of hormone therapy to this treatment increases the cost by about 65,000 to 1,20,000 INR per year bringing the total cost of treatment to about 4.0 to 6.0 lacs (400,000 – 600,000 INR), albeit spread over 2 to 3 years.

Brachytherapy, which is a form of radiation for early prostate cancer, involves the placement of radioactive ‘seeds’ in the prostate under the guidance of an ultrasound machine. These seeds need to be imported from abroad and the treatment can cost anywhere from 5.0 – 8.0 lacs (500,000 – 800,000 INR) depending on the number of seeds required and the prevailing currency exchange rate. It is one of the more expensive options for treatment, especially if it is combined with hormone therapy.

Surgery: The complete removal of the prostate, along with the adjoining structures (seminal vesicles, lymph nodes etc.) done with an intention to cure a patient of prostate cancer is called Radical prostatectomy. It can be performed in an open conventional manner or with laparoscopy or robotic surgery. Robotic surgery for prostate cancer is now available in the country and is currently considered by many to be the best treatment for prostate cancer in India. It has the advantages of a faster recovery, greater precision and lesser complications as compared to conventional surgery for prostate cancer. The cost of robotic prostate cancer surgery in India is usually in the range of 3.5 to 4.0 lacs (350,000 – 400,000). While this cost is about 30% more than that of conventional surgery, some of this gets offset by the earlier discharge from hospital, less medication use and decreased chances of additional treatment due to decreased complication rates with robotic surgery.

In summary, while the ideal treatment for prostate cancer in a particular patient differs from individual to individual based on their age, overall health status and stage of the disease, cost considerations do play a major role in the decision making process. All these implications should be discussed with your doctor in order to arrive at the most suitable decision.

This article has been written by Dr. Gagan Gautam, who is the head of urological cancer surgery and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is fellowship trained in robotic cancer surgery from the University of Chicago Medical Center, USA and is currently the leading robotic surgeon for prostate, kidney and bladder cancer in India. His institution, Max Hospitals, Saket, New Delhi is an 800 bedded tertiary hospital located just 20 min away from the International airport. It is an NABH accredited institution and is recognised as one of the best hospitals for prostate cancer treatment in India. It is equipped with state of the art diagnostic and therapeutic infrastructure including the Da Vinci Xi HD robotic surgical system, which is used by Dr. Gautam to perform robotic surgery on his patients who travel from all over India and other parts of the world.   

 To know more about his work, please visit www.roboticsurgerydelhi.com

To view Dr. Gautam’s profile, please click here

 If you would like to submit a query or seek an appointment with Dr. Gautam, please click here

 To know more about robotic surgery for prostate cancer, please click here

 To watch a video demonstration of robotic prostate cancer surgery, please click here

To read about the expected course of recovery after robotic surgery, please click here

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

To read about active surveillance and watchful waiting for prostate cancer, please click here

Robotic surgery for prostate cancer in India – A video demonstration

Dr Gagan Gautam, head of robotic surgery and urologic cancer surgery at Max Institute of Cancer Care, New Delhi, India, demonstrates the tips and tricks of robotic surgery for prostate cancer. A systematic and simplified approach decreases complications and enhances the recovery after robotic surgery for prostate cancer. By reducing the duration of surgery and stay in the hospital, it also serves to decrease the cost of prostate cancer treatment in India which offsets the cost of robotic surgery to a large extent.

Max Hospital, Saket is one of the best hospitals for prostate cancer treatment in India and provides specialist services for the treatment for all stages of prostate cancer. Robotic surgery for prostate cancer is a state of the art technique which improves recovery, decreases complications and provides excellent survival benefits to patients with stages 1 to 3 prostate cancer.

To know more about his work, please visit http://www.roboticsurgerydelhi.com

To view Dr. Gautam’s profile, please click here

If you would like to seek an appointment with Dr. Gautam, please click here

To know more about robotic prostate cancer surgery at Max Hospital, New Delhi, please click here

To read about the expected recovery after this surgery, please click here.

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

To read about the cost of prostate cancer treatment in India, please click here

To read about active surveillance and watchful waiting for prostate cancer, please click here

What is the best prostate cancer treatment in India?

Prostate cancer is the most common cancer affecting men all over the world and can cause a significant loss of quality and quantity of life in men affected by this disease. However, if detected at an early stage it can also be completely cured or controlled for a very long time with modern treatment methods available today. Max Institute of Cancer Care (a part of Max Hospitals, Saket) is an advanced tertiary care medical center in New Delhi, India with state of the art facilities for the diagnosis and treatment of prostate cancer.

The Disease

For a proper plan of treatment to be implemented, it is imperative to diagnose and stage the disease. The diagnosis is achieved by a prostate biopsy performed in response to either an abnormal PSA (prostate specific antigen) test and/or an abnormal physical examination of the prostate. Gleason score is a system devised by pathologists to quantify the aggressiveness of prostate cancer on the basis of how it looks under a microscope, after the biopsy specimen is made into a slide. As the Gleason score increases, prostate cancer becomes more aggressive.

Staging comes next. Staging involves an assessment of how far prostate cancer has spread from the prostate. If the disease is confined to the prostate itself, it is said to be localized. If it has gone outside the prostate but has not spread to the rest of the body, it is locally advanced and if it has spread to other parts of the body, it is said to be metastatic. An assessment of the spread of disease can be made by performing 2 tests – MRI of the prostate region and an MDP Bone scan.

The Operation

Robotic prostate cancer surgery (Robotic prostatectomy) is the most advanced treatment and in most circumstances, the best prostate cancer treatment in India (and in the world) today. For localized prostate cancer, it offers a very high cure rate with minimal long-term side effects. Even for locally advanced disease, it provides excellent long-term control/cure when used as the initial main step in a multi modality treatment approach with radiation and/or hormone therapy.

The main advantages of a robotic prostate cancer surgery are greater precision, faster recovery, lesser blood loss, less pain and better preservation of urinary control and sexual function as compared to conventional treatment. 95% of patients are able to leave the hospital within 24-48 hours after surgery and are fit for travel within 1 – 2 weeks.

The cost of prostate cancer treatment in India with robotic surgery is 3.5 to 4.0 lacs INR, approximately. For overseas patients, it works out to be approximately $8500 (US).  This includes cost of stay, all medicines, surgery charges, basic investigations and equipment used for the surgery. Additional investigations or treatment may incur extra charges but are usually not required.

The Surgeon

Dr. Gagan Gautam is the head of urologic cancer surgery and robotic surgery at Max Institute of Cancer Care, Saket, New Delhi. He is a US fellowship trained robotic urological cancer surgeon and his entire practice is exclusive to the surgical care of patients suffering from prostate, kidney and urinary bladder cancer. He has an extensive experience of working in top national and international hospitals including the University of Chicago Medical Center, Chicago, USA, considered as one of the most advanced centers for robotic cancer surgery in the world today.

Dr. Gautam is the leading robotic urological cancer surgeon in the country and has pioneered several advanced procedures for the treatment of prostate cancer in India . His endeavours are focussed towards providing his patients the most advanced and cost effective robotic surgery procedures available only at leading international institutions. 

The Hospital

Max Institute of Cancer Care at Saket, New Delhi is a part of an 800 bed state of the art tertiary care medical center situated just 20 minutes away from New Delhi’s Indira Gandhi International Airport. It is the hub of medical tourism in the region with many national and international patients undergoing complex surgical treatments here at any point of time. It is in the process of being accredited by Joint Commission International  (JCI) for its high standards of patient care and safety and is recognised as one of the best hospitals for cancer treatment in India. The hospital is equipped with the most advanced diagnostic and therapeutic equipment including the Da Vinci Xi HD robotic system which is used by Dr. Gautam to perform robotic prostate cancer surgery on his patients.

For our overseas patients, the medical center has a well staffed and efficient international patients’ division which caters exclusively to and facilitates the treatment of our guests from abroad. Facilities include currency exchange, exclusive pharmacy counters, interpreters for all major global languages, pick up and drop facilities from the airport, comfortable and economical guest house accommodation and visa paperwork.

Contact Details

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

To view Dr. Gautam’s profile, please click here.

To know more about his work, please visit his website www.roboticsurgerydelhi.com.

To read his blog on recovery after robotic surgery for prostate cancer, please click here.

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

To watch a video on robotic surgery, please click here.

To read about the cost of prostate cancer treatment in India, please click here.

To read about active surveillance and watchful waiting for prostate cancer, please click here.