Dr. Eun shares how the surgical robot can greatly expand the treatment options available to urologists and their patients. He also reviews some of the novel ways in which he and his colleagues have used the surgical robot both as a team and in collaboration with colleagues from other specialty areas.
thank you everybody actually I'm really happy just to see blake up here does blake trained the friendship with me a few years back and so let's get to see old friends. Well I'm honored, thank you very much for the mid atlantic for inviting me to speak to you guys on this topic. Um Okay so here is my disclosures, do some meeting activities for intuitive teaching. Um uh johnson, johnson consultant mel c is a company we came up with and I'm a owner shareholder. So um I had the great pleasure of Training at Henry Ford in the early 2000's when robotics was just getting started and it wasn't really well accepted. And we used to always say before we went up to present at the a way with anything to do with prostate, wear a cup, wear a helmet and wear a flak jacket because you're gonna get assaulted. Um and things have really changed since then. I recently went to dr manning's retirement in Detroit and um celebrating his retirement and um uh you know we actually brought the slide up showing what the robotic rooms used to look like when we used to operate with the Da Vinci standard with the S system. And you can see this vintage um you know over under double three D. Projector that used to operate in. And then in 2000 and six they built this Fantastic, you know this this technology really didn't exist. three d. screens that 110". It was almost like military grade equipment that was set up behind the walls. Um and so I really was able to have the opportunity to train at a place that was really thinking outside of the box and really pushing the envelopes and you know, I used this slide a couple weeks ago when I was in Detroit. You know, the things that I learned from there, I think greatly affects the way that I am and what I've done. Um, and so far in my tennis years of my career. Um, and uh, one of the biggest struggles that I have with my chief resident. You know, if you see, I see Zach back there, uh, learn with your eyes before you do. Um, you know, the surgical planes. I feel like is like one of the most difficult things to teach our, our residents as they have to learn how to expose um, the tissues before you can see and before you can then go there. Um, you know, master of one, not mediocre at all. It was, you know, regarding lap open and robotic men and would say pick one and just get really good at that. And I really took that to heart and I feel like that really helped me my career out and what I'm able to do. Um, you know, one of the things I'm always struggling with is resisting casting judgment. You know, you get good at what you do and then you have opinions and I always try to quiet that voice inside me that wants to criticize when I see something done differently, Something done very differently. Um And uh and I feel that um that keeps you open minded and allows you to help evolve and to accept things that are concepts that may be new Um doing things the old way, why do it the same way? Maybe you can find a better way with the way that you do it? Um simple prostatectomy is one of those things that's really changed in my life. You know, we used to drop the bladder and copy the open surgeons doing a retro pubic prostatectomy um for like a 300 grand plan. Um We stopped dropping the bladder one day and just want to transmit sickly and started doing simple prospecting is that way. And then we started running a 360 degree anastomosis and putting your thallium €2 thallium, not just opposed to your strip but putting it all the way around. We realized transfusion rate became really low 3%. And we started uh not doing C. B. I. And sending them home the next day as a regular. We just did one on yesterday before I came up on a 310 grand gland. The guy's already home, right? And so things like that um you know uh you know following the old ways that things were done doesn't always need to be. And so I found that to be a very interesting concept that I learned when I was there challenging dogma if it doesn't make sense. Also similar uh in a similar vein, volume focus and intensive, high quality teaching produce a consistent product. It's very interesting to me, you know, we were there at the time of very high volume, we were doing 7-800 prostates a year and um seeing the residents that all came out of that, we all have different, you know, God given abilities, but to see that every single person that came out of that program during those years could do easily do a sub one hour prostatectomy on a regular basis was like something that really stayed with me um that that that amount of volume and high intensity coaching with heavier new trainees, you know, on the hot seat Really produce a consistent product and I always took that with me and I try to as much as I can these days without the same amount of volume, try to replicate that um in in my practice and in my training. So I left Detroit in 2008 and you know, two different quotes that really kind of are very fundamental to me um from my old boss to my new boss, right? And the attitudes were a little bit different, but I think they're both very important, right? Um you know, Danny one day, this will just be called urology is that at this point we're calling this urology, but at some point a lot of this is going to get better, it's gonna get applied to a lot wider applications and we're not gonna say it's robotic, this robotic, it's just gonna be back to urology and that's become so true in my life. And then allen telling me be careful what we do, what we do and we claim and he's telling me to just be cautious, right? Um you know that you have to take this in a stepwise approach. Don't be so excited in the beginning. It really kind of reeled me in and also gave me kind of um you know, goals that I wanted to accomplish in my career. And I see these are two different sides of the spectrum, both very wise and correct. Um and I really took those both to heart, You know, 10, 11 years later. This is, you know, the list of the things that I can do robotically is very diverse, potentially the widest indication that anybody has done some of it's on the even not even in the field of urology. I'll show you some videos on some of the spine access that we did in the early days. But you know, I look at the robot in many ways like a swiss army knife and we essentially um approach. Almost all open operative urology now robotically in the way that I I see things and I'm a little careful to say that this is not for everybody. I'm not saying this is the right thing for everybody, but in a in a developed surgeon that has very advanced skill sets, you can almost attach attack most surgical indication, not all robotically. So one of the things that I did when I moved To temple in 2012 was to build an operating suite where I could try to do and mimic what we did at Henry Ford Hospital. There's a lot of intensive, high volume, um, good, high quality teaching. So we built this master control room where we typically will put four of the consoles in there and so that I literally bounced back and forth between two seats. I have two operating room environments. We try to stagger our cases So that as one case is finishing the other ones already starting and with that from one vantage point I can see what's going on in two rooms. We can really, you know, do a lot of volumes of 4-5 cases in a day and also not Run back and forth between two rooms, terrified that somebody's gonna get hurt and I can't help you know, that situation and fix it. And so with this set up, I feel like I can do much more quality teaching. I'm not ripping through a case to be able to jump into the next room to get to the other one and I can let residents and fellows run further, uh, you know, without reeling them back in. And so this is currently the system that we have here. So, you know, pushing the boundaries. You must have a foundation of excellent training. I think that's definitely true. I must be honest with yourself and with your patient, you know, people always ask me how did I get to this point where I'm able to do so much. And I think that along the way, you know, I always told my my trainees what I do today is not what the way I started off. I got to this point very slowly incrementally. And along the way, you've got to tell your patients, you know, look, I've never done this before and I still sometimes say that or I've not done many of these, you know, uh, and we can get the right surgeon in here, we can open, we can do uh, you know, the other way. But um, you know, I'd like to try to try to try to do it with a closed abdomen if possible. And most patients have been able to be kind enough to go along with this. Um, and you have an obligation then to then publish and present, you know, just looking at my pattern of practice, you know, less than 10, maybe less than 5% was benign reconstructive urology back in 2000 and eight and 10 years later we looked at it, it's about 40% you know, yesterday before I left here, I did a simple prostatectomy, I did a buccal graft rhinoplasty and I did arrest a sparing radical prostatectomy, sent the guy home the same day, you know, it's um two out of three cases being uh um a non oncological cases typical on some days. And so it really brings into the, into um you know, the thought, the thought I had was, you know, tertiary care centers and the role of tertiary care centers. Is that the way that I used to see my practice in the way that I see it now in the beginning I struggled with trying to get volume and I felt like in some ways I was competing with the private practices and I always realized that that was not a good thing to do. You know, it's much better to partner with these referral groups and take on the case is that they don't want to do necessarily and they will, they are happy to refer those cases to you. So I see that that that really kind of the role of the tertiary centers if you're, if you're at an academic center and you're just doing what the private practice guys are doing, you know, um you're you're in some sense is competing with them and you can't really make a great case to say, hey send those patients to me because they may be doing just as good of a job as you are, but if you are kind of able to take on the very difficult, you know, high complexity cases then you really do have a role and then you can really partner up with the referral guys and many people here in this room has sent me cases so thank you. But I see my role as a partner with the regional urologists and so so just so let's have a little bit of fun. 10 minutes left. We're gonna go through some of the kind of fun cases. Some of the interesting cases that I kind of pulled pictures and some video on. So this was a guy that saw me um maybe about nine months ago he was in urinary retention. We actually worked him up for a simple prostatectomy And ended up on biopsy that he had cancer. So we um took his prostate out, this was a bloody case. Um we really struggled with the size of prostate. Ultimately we thought it was 400 g, it was 500 g. Here we used the the second generation vessel sealer robotically to help us because of the big blood vessels associated with this. Uh so you know in in the in the area of oncology. I think we do a lot of the very advanced, very difficult to do cases and a lot of the robotic surgeons that are out there doing these cases will send the very difficult ones too. There's a 69 year old gentleman. He had a little bit of renal insufficiency. Pre operatively had bilateral eight centimeter masses. Had seen a bunch of consultations around town. I looked at this and said I think I can parcel both of these. Um and so we did them stage six weeks apart and you can see here from the video if the video will run That. Um I mean these are very empathetic, very complicated tumors. He was being told that he was most likely going to be on dialysis. Um they were centrally occurring both about eight cm or so. You could see both the specimens. Um the guy still owes me a beer because 18 months later his creatinine is less than two and were able to save both kidneys and do bilateral complex partial hysterectomies on him. So this is a also another kind of fun and interesting case wasn't fun at the time when I was doing it. It was a cable from back to me uh a friend to me on a very large tumor. Um uh What what we discovered intra operatively, you know, we had vascular on standby for this. What we discovered in collaborative ways we were doing this was that this tumor was just completely eating into the posterior view of a wall. And so I told my vascular surgeon, I think we're opening, we're probably gonna need to put a graft in here. He told me that why don't you go ahead and keep going, I'll give you the graft and well so it in and I'll kind of treat you like my resident. Um Really interesting in this case as I'm cutting up towards the upper portion of the I. V. C. Um There's actually a communicative filter there that you'll see in a second. As I come across here you can see this whole posterior wall um involved with us. So we actually cut out a large segment. One of the biggest criticisms when I first started doing these back in around 2009 was what happens if the tumor grows into the Vena Cava Wall. And um um I think that you know as I've you know, come across this experience. My my answer now would be at work of the vascular surgeons to put in the graft and if possible to do it robotically you can see here that uh we were able to successfully so on this craft were able to unplanned, get Dobler's on on the vena cava. Showed that there was a good pattern C. And still be able to complete the case as is. Um So moving on. So here this is a little bit so this is moving away from urology that they're neurosurgeons. When I was at pennsylvania hospital asked me if I'd be help willing to help them with putting in um uh all four L. Five L. Five S. One cage. And so when we first started with L. Five S. One. Um I never really knew what I was getting into when I started doing this. But we would co doc a robot with a C. Arm and then completely mobile. So if there's a L. Five S. One, you could do it below the vessels where it split. But L. Four L. Five was a very difficult dissection here were completed this section of the cava and the aorta free off of the spawn. You can see the anterior spinal ligament here would put slings in right. And um You know the the lower ones below the cable verification would be about a 20 minute section. But this one will take about two hours to do completely mobilized and put clips in, put little slings across them and have my bedside assistant, you know they're attached to extracorporeal sutures and my assistant would be able to pull them on either side and kind of split the great vessels and they would put drilling harbor. And here I'm showing that we we have L. Four L. Five and then L. Five S. One both exposed. Um The neurosurgeons don't know how Look at a screen and do minimally invasive surgery. So I would literally hold their hands and screw with them so that they wouldn't endure the patient with the but you know we did this as a proof of concept. But you know what one thing I have to say is that we did this um we published 16 cases of doing this but what I learned my lesson. And the reason why I'm showing you this is that you know this was not an operation that's really duplicated. You know you can't, this was so difficult and it was so risky that um and what I realized early in my career was that developing things that are too technically difficult that's not really reproducible is not helpful to anybody right? That you can say that you did it, you can be proud that you did it but you're not really furthering the field along. And so I've started to focus things not on things that are so crazy and um and hard to do but trying to develop things that are doable to try to advance the field together. So here is another fun case. This is um I'm showing you this because there was a left sided um tumor thrombosis that came up to the short of paddocks but not up to the paddocks. And this is morbidly obese Jehovah's witness B. M. I. 55. And the interesting thing about these cases that you have to actually start on the right side, do all the vessel work first and then flip them to the other side to do that affected me. And so um you know for the residents that are out there the S. M. A. S. Is crossing. So if you start on the left side you will never be able to get across it. And so unfortunately if you're gonna do this minimally invasively you have to flip and uh be safe always on both sides. Um So again there's a fun case. Uh I probably share more patients with vascular surgeon than anybody else out there. We do a lot of cases together. So this is a case where um you know there was perforated prongs of ibc filter and um and uh it was obstructing the ureter. So we had to do some type of urethral reconstructive case. You could see it was very short segment that was affected of the ureter but it was pulling it in towards the cave. Um And so here um you know, just kind of showing you a few seconds of this. Um We were able to do the dissection strip the prongs free um and then um take this out and then do the original pair. So we were able to see that where the prong hit the ureter and then we did a short hike, a chemical, it's repair. Um and then we're able to do a urinal plastic there and the patients now doing great. Um I think I have a full fractured vena cava filter coming up next month. I'll be a little bit more fun, harry to do another interesting case. A 27 year old guy with a 23 centimeter cystic mass completely filling his pelvis. It was thought to be maybe originating from the summer vesicles a giant cyst um patients unfortunately gotten to the point where he was bilaterally obstructed with hydra necrosis, elevated creatinine three attempts at ex lap to try to get this thing out. The patient just came to me desperate, right? They said that you know he was offered a total pelvic exoneration and that um he wanted to try to get another opinion. I told him look you probably need a public generation. I'll try to do this robotically and I think this highlights one of the really interesting things about the robots and the ability to crawl into a crevice of space and have enough room to work. And so you know maybe on another day I wouldn't have been able to do this, but this is my longest case I ever did about Close to 15 hours of just you know just bathroom breaks and getting something to drink and going back and operating but were eventually able to lift this whole thing out of him, not do any kind of exoneration. He still has all of his organs, had a daughter um a few years later um has no recurrence uh and has created creatinine stabilized. You can see pre operatively that picture on the left side. I mean he looked like he was pregnant because it was so large in space occupying. So um one of the areas that I lecture on a lot. We actually have a course at the a way on this. If you guys are interested in this topic is the new role of the robot and upper tract reconstructive cases. Um, and so um, you know, a few things that I'd like to share, you know, these are some of the slides taken from that is that you know, I routinely now going on very hostile abdomens after X labs and gunshots And I'd say 98% of the time we're able to complete the case right? Um, even though there is no place to work, were able to free up enough room and slowly get ports in it. So, you know, in the right center, you know, and there's a few people like that out there that have this type of experience, you know, prior radiation re operated fields are not necessarily contraindications. We we do this actually very regularly at temple now um, you know, we use near infrared to look at perfusion to be able to try to identify your orders that are completely um, you know, scarred into the field. Uh we also tend to use buccal graft appendix for different ways. Um, there's a lot of new reinvention of old techniques that we're able to do to get a solution for the patient that has a badge little structure problem. And in in nine out of 10 times were able to avoid an illiterate or an auto transplant and fix the person and make them hardware free. Okay, so move a little quickly for the interest of time. So you know, my my motto is fixed. It don't manage it. And people with a lot of structure. We all have these type of patients in our practice. Um, you know, but you know, the new paradigm now should be, um, to get them harbor free, let them have a normal life without getting stent changes for the rest of your life. Um, you know, and this is probably we do on a weekly basis. Um, you know, this is a gentleman who had a, um, a complete your edible avulsion injury after start being struck by a mack truck. Um, and he had an emergency splenectomy. They put up permafrost to me and send them to me like a year later and he showed up with his attorneys, they're ready to sue everybody. I was going to do an affected me on him, but he really wanted this thing to be saved. Um, so I told him I'd give it a shot. This, this was very early on in my experience where I hadn't done a lot of buckle graphs here, you can see, we put intra Luminal I C G in to find these, your friends, um, using firefly technology to be able to see it. Look, you know, without that, I would have never been able to do this case. And that's one of the the illustrations I wanted to show, is that putting I CG into the order. You know, we've developed these techniques that we're not around before to be able to find things that were you know next to impossible to be able to find. And with that technology technology we're able to do cases that even a few years ago I would have told you that were impossible. So here we did a downward slope etc. To close the gap because there was a ton of fibrosis on the girders, bring it together, close the gap, do an augmented repair where you put a back wall together, put a ruler in measure the defect and then put a buccal graft in. And sure enough um you know after a very long and tedious case where so here I knew this case was going to actually end up not as an effect on me and as a urinal pair when we were able to put that back wall together, put a nice healthy post your plate together. Um And then so this buckle grafted and so for the interest of time I'll kind of move along. This is probably one of my worst catastrophes that I've seen. The 51 year old um B. M. I. 61 morbidly obese was getting history copy by R. G. Y. N. And she wanted a biopsy. Something that looked long. Well it ended up being a complete your order Save maybe three cm of disappeared. Even managed to pluck off the renal pelvis as well. So 18 centimeters of your door with a renal pelvis there was nothing to. So to intra operatively, I actually didn't believe it until I went and dissect out the hill. Um, there was no real pelvises. My initial plan, which was an illegal ureter. I wasn't sure where I was going to sew it into. We actually found an 11 centimeter appendix, probably the longest appendix I've ever seen. So we did a downward net for Pepsi to bring the kidney down. We did a soulless hitch to bring the bladder up. We did a lower pole, kill acosta me and put an appendix in between and it worked and she's now hardware free. She comes back and sees me every year. It's just remarkable. You know, you have to have all the options on the table. That's not the operation that I envision myself doing and yet we're able to put it together and she's now hardware free. So, um, you know, rise of robotic reconstructive surgery. There's a lot of things that you can do. There's a textbook that we're currently writing right now. It's going to be the first one that's coming up 10 years after training, You know, after hopefully I've grown a little bit wiser, 3000 plus cases. Um, um, you know, and during this time that I've, what the things I want to say to the trainees is that be neo in matrix, you know, where they are critically watched as much video as you possibly can to replace for the lost hours that you've lost for our limited hours. Try to scrub and assist as much as you can actively seek video editing projects get out there and present. Be interested. Um, take on projects. Ask your attendings bug the hell out of them until they give you something to work on. Be hands on. There's, especially with the through the A. U. A. And servers, there's a master classes that we're able to offer to residents jump on those. You know, go to those meetings, get your hands on, don't be shy. Ask the attendings. Don't, you know, people come up to me asked me all the time. Do don't watch go train where there is volume. Maybe it might be a fellowship that you might need to go to where boundaries are being tested and pushed. Fresh ideas are applied. So, um, if you guys are interested, we do have a course on upper track reconstruction at the A way. Um, I want to say thank you for those out there that refer to us. We really do appreciate it. And um, there's also a 21 to 22 fellowship spot that we're taking applications for. Thank you