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.


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.

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.

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

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