Robotic surgery for urinary bladder cancer – a personal experience


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.

Ca bladder blog

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 –

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.

The Da Vinci surgical robot in action

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

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

 To connect with him on social media, please visit or follow him on twitter @DrGaganGautam

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