Surgeon: Jens Rassweiler and Ahmed Ghazi

Moderators: Duke Herrell, Evangelos Liatsikos and Aly Abdel-Karim


Prof. Jens Rassweiler

Prof. Jens Rassweiler started his Urological Education 1982 at Katharinenhospital Stuttgart (Head: Prof. F. Eisenberger). From 1988 to 1994 he was Vice-chair of the Department of Urology Medical School Mannheim (Head: Prof. P. Alken). He was involved in the clinical introduction of extracorporeal shock wave lithotripsy including three generations of lithotripters. 1992 he was the first German Urologist to perform a laparoscopic nephrectomy.

1994 he became chairman of the Department of Urology and Pediatric Urology at the SLK Kliniken Heilbronn, University of Heidelberg. From 2008 to 2016 he was chairman of the EAU Section of Uro-technology (ESUT). 2007 he was president of the Society of Intra-renal Surgery. 2009 he organized the World Congress of Endourology in München together with Prof. C. Chaussy. Since 2010 he is president of the German Lithotripsy Society. since 2016 he is chairman of the Section Office of European Association of Urology. 2015 he became member of the Association of Academic European Urologists (AAEU) 2017 member of the Association of Genito-Urological Surgeons (AAGUS). 2019 he was president of the Endourology Society. 2020 he was president of the German Society of Urology.

1999 he received the Publication Award of EAU and 2013 the Hans Marberger Award of EAU for the best publication in endourology in Europe. 2014 he received the Ritter von Frisch-Award of DGU, 2015 the Ralph Clayman Mentor Award of the Endourology Society, and 2016 the Gustav Simon Medal of the SWDGU.

He is Doctor honoris causa (Dr. h.c.) of the Universities Timisoara (2009), Cluj-Napoca (2013) and Bucharest (2017). 2018 he became Fellow of Royal College of Surgeons in Glasgow (FRCS).

Ahmed Ghazi

Dr. Ghazi, received his medical degree and completed his Urology residency (2000-2005) at Cairo University. He completed a series of international minimal invasive, endourology Urology fellowships in Paris, Austria (2008-2010) and Rochester, New York (2010-2012).

He was appointed at the University of Rochester (2012). In addition to his clinical duties he perused research grants in education, simulation and surgical training. He completed a Masters in Health Professions Education program at the Warner School of Education (2020) form the University of Rochester.

Dr. Ghazi with a team of biomedical engineers founded the Simulation Innovation research laboratory that utilized 3D-printing and hydrogel technologies to build personalized replicas of bodily organs. This innovative technology, through medical simulation has improved trainee’s education , performance and patient outcomes. He was awarded several grants including a Clinical and Translational Science Award, and several NIH grants to evaluate the use of personalized patient models in improving surgical performance and patient outcomes. Dr. Ghazi believes in a reciprocal relationship between research, teaching & surgery, where each informs & strengthens the others. He strives to produce academically rigorous research that is theoretically sound but translates directly into a safer surgical environment with reduced surgical errors and improved patient outcomes.

Dr. Duke Herrell

Dr. Duke Herrell is Professor of Urologic Surgery, Mechanical, and Biomedical Engineering at Vanderbilt University (VU). Herrell is the Director of Robotic Surgery and the Vanderbilt Endourology Society Fellowship. He has extensive clinical experience in minimally invasive and robotic surgery.  Dr. Herrell served on the AUA National Practice Guidelines committee and is current Secretary of the SESAUA. He has published over 150 peer-reviewed articles. Dr. Herrell works with the Vanderbilt University School of Engineering and is a founder of the Vanderbilt Institute in Surgery and Engineering (VISE), a funded trans-institutional center focused on combining engineers with surgeons to solve clinical problems.  Dr. Herrell is a funded researcher including PI on two current NIH funded RO1s. He has served as a co-investigator on RO1, R21, SBIR, and NRI (National Robotics Initiative) grants. Dr. Herrell helped found two current medical device startups commercializing VU intellectual property. He has served as a featured speaker on topics such as next generation robotics and the future of imaging in surgery.  His main areas of research include development of new robotic platforms, advanced surgical devices and procedures, and the role and utilization of intraoperative image guidance. 

Dr. Evangelos N. Liatsikos MD, PhD

Dr Evangelos Liatsikos is the new elected Chairman of the European School of Urology (ESU). He is a Professor of Urology and the Director of Urology Department at the University Hospital of Patras in Greece. He is a Guest Professor at the University of Leipzig in Germany and Adjunct Professor at the Medical University of Vienna, Austria. He was Chairman of the European Section of Uro-Technology (ESUT) from 2016 to 2020. He is distinguished in literature for his research in Laparoscopy and Endourology, with his work accounting for more than 290 international publications. Dr. Liatsikos has also been invited as a speaker and live surgeon in a series of the most prestigious urological congresses worldwide. For his scientific contribution, Professor Liatsikos was nominated for the “Arthur Smith Endourology Lectureship” award in 2009 by the World Association of Endourology. He received the award of “Academic Endourology Fellowship Program Director” on November 2016 during the World Congress of Urology.

Aly M. Abdel-Karim, MD

Professor of Urology, Alexandria University, Egypt

Member-Elect of the Board of Directors of Egyptian Urological Association (EUA)

Director of Training Program of EUA

Dr. Aly Abdel-Karim has more than 70 international publications with main interest is laparoscopic urology.

Dr. Abdel-Karim is considered as one of pioneers of Single port laparoscopic surgery as he is the first to start doing LESS in Egypt and Middle East and he has many collaborative publications about LESS with the most imminent centers from US and Europe. Dr. Abdel-Karim has conducted more 35 teaching course of Laparoscopic Urology and has been invited as a guest speaker and live surgeon in a series of many prestigious urological meetings worldwide.

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello and welcome. I'm Chandru Sundaram welcoming you on behalf of the Endourological Society and the Society of Urologic Robotic Surgeons to our fabulous webinar today on Innovative New Technologies and Techniques in Robotic Surgery. This will also include innovations in training as well as simulation. We have had extremely successful bi-weekly seminars in robotics over the last several months, and I am delighted you were able to join us. This will be the last robotics seminars for 2020; we look forward to monthly robotic seminars from SURS and the Endo Society in 2021; same time, Fridays at noon Eastern time, and we look forward to you joining us.

Dr. Chandru Sundaram:

Today we have exceptional speakers; Dr. Jens Rassweiler and Ahmed Ghazi. We have moderators; Duke Herrell, Dr. Evangelos Liatsikos, and Dr. Aly Abdel-Karim. I am certainly delighted to introduce you to them and I will now talk about their accomplishments. Dr. Rassweiler needs no introduction, he is truly an institution in robotic surgery and a pioneer. He is the Chairman and Professor of Urology at Heilbronn and the past president of the Endourological Society. He has multiple other accolades and awards that I will not go into. Dr. Ahmed Ghazi is an Assistant Professor in the University of Rochester and the Director of Simulation, and also a Co-Director of the Robotics Fellowship.

Dr. Chandru Sundaram:

We have a terrific moderators; Dr. Duke Herrell, Professor of Urology and Biomedical Engineering at the Vanderbilt University in Nashville, Tennessee; Dr. Dr. Evangelos Liatsikos is the Chairman of the European School of Urology, as well as a Professor and Chair at the university of Patras in Greece. Professor Dr. Aly Abdel-Karim is a Professor of Urology in Egypt in the University of Alexandria. I am delighted to welcome them. Dr. Jihad Kaouk, who's the past president of SURS, will not be initially with us because he has another engagement, but he has done a phenomenal job in putting these webinars together. These webinars will provide you with CME credits and there will be mechanisms for you to obtain CME credits for the time you spent viewing these webinars. And there are some disclosures for all the speakers that are listed here.

Dr. Chandru Sundaram:

For today's webinar we will have presentations by Dr. Rassweiler for about 18 minutes followed by presentation by Dr. Ghazi for another 18 minutes. During this time, please use the chat function and all your questions and queries and comments will be answered by our esteemed moderators who will also use the chat function. Following these two presentations, we will have live discussions by the moderators and the speakers. We wish to thank Intuitive Surgery for supporting our webinars; these webinars are available at the Endourological Society website as well as the Society of Urologic Robotic Surgery website. Please check out those websites, there're lots of information and content on this webinar as well the past webinars.

Dr. Chandru Sundaram:

This is our last webinar, like I said to you, but there're lots of offerings from the Endo Society and SURS in 2021. We encourage you to join the Endo Society; it's very easy to become members and there are lots of benefits that you can check out at our website. And we also look forward to meeting you in-person in Hamburg at the WCET 2021 in September. Hopefully, by then we will be past the pandemic. Thank you all for joining us and we look forward to two fantastic presentations from our speakers. Professor Rassweiler, please.

Dr. Jens Rassweiler:

Yes. Dear friends, ladies and gentlemen, dear Chandru. For me it's really a pleasure to be part of this webinar and, particularly, in the collaboration with SURS and the Endourology Society which I had the privilege to be the president last year. So what I want to do is to talk about Innovative Robotic Techniques and Technologies and mainly in advances in robotics.

Dr. Jens Rassweiler:

So, we heard Intuitive is sponsoring this event; there is, of course, a new robot and this is not without da Vinci because we had the SI dual-console. This concept has been taken over to the next generation, the X and XI, mainly the XI that we personally use in our OR. And what has happened here is this is, really, creating a new step further. Two things I think is important; what you saw on the right side is the 30-degree up-and-down. So we don't have, like we may have now with ENDOEYE from Olympus, a real 30-degree 3D system but we have now made it much easier to lift up/down and this could be nice in a sacropexy, as here, or in a cystectomy case or even if you have a Santorini's plexus, dorsal vein complex is that is a little bit difficult to reach.

Dr. Jens Rassweiler:

And, on the other hand, I think this is also very important you have the table movement using the Trumpf Medical table, which is combined with a system with the da Vinci XI, so you do not need to unlock the trocars when you want to change the positioning of the patient. The next thing what also has happened and my coworker, Dr. Teber, has done this; this is now robot meets robot, this is intra-operative planning and 3D fusion in a da Vinci system. So you combine two 3D systems; the Dyna CT creates almost real-time 3D system. And initially now if you want to overlay a 2D image of a CT, even if it's in a 3D format, you do not the same. But here, on the console, you see in your system directly the 3D and I think this is really very important.

Dr. Jens Rassweiler:

And if you look now to this image, even in 2D like you have it now, it's marvelous and imagine you are sitting at the console and you see the whole thing in 3D so you have the 3D overlay of a virtual reality that is based on a CT or something. So, this is, you can really say a classy real time image that you get and this, of course, helps you much more because you do not need to do a certain segmentation, you have it directly. Of course, robot meets robot it's a lot expensive solution, but it shows you where we may go in the future.

Dr. Jens Rassweiler:

And next, you see here what are the new robots that are on the market. And this is the second one that we have is the Senhance system. So, it uses an open console with eye tracking and it has an arrangement of three separated carts. Senhance used to be a European project, so far a company from Milan, but TransEnterix has bought the whole thing; and they have a CE mark, they sold about 40 devices now. And, I must say, I used the device and with the eye tracking I had some problems, and you see it here. We did this at the Center and now you see it here, live, a radical prostatectomy which has been performed with the Senhance system.

Dr. Jens Rassweiler:

So you see it here directly where it works; this is the situation inside the operating room. This is not a da Vinci. And what is, I think, more important is if you look now at the situation inside, mainly during the dissection, and what you see here, the instruments have mostly only four degrees of freedom. So, it looks more or less like a laparoscopic procedure, it is not go looking like a robotic procedure; you see here the straight instruments going to the vas deferens, and this is exactly what it is. So, if you are an laparoscopic experienced surgeons, it may really help you. And this is Dr. Kullis who has done this case. But of course, if you are trained with a robotic device, which maybe in the States mostly is the case, you may have probably some problems, but you will see this device because it has e-market, spreading out a bit more in the future in Europe.

Dr. Jens Rassweiler:

Now, the next thing comes from Korea, and this is the Revo I system. Initially, this system is created or developed at the Yonsei University in Seoul and in collaboration with Samsung. Initially it looked like an open console but now, in the last version, the device looks more and more similar to a very well-known device that we know, namely the Intuitive system. And Dr. Rha, who is a member of our society, a well-known member, he used this; he has already published a paper in the British Journal about doing a Retzius-sparing prostatectomy with this device. He did it here on the right side in Seoul. What is the fact is now you have three devices in Korea; the device has not a CE mark, that it has not an FDA mark and so two clinical trials are going on even on different places, but not outside Korea.

Dr. Jens Rassweiler:

The next device is the Avatera this comes from Germany. So now in Germany we have something, it's maybe a semi-closed console, it's the principle of a closes console with an ocular. Here in the back you see Professor Stolzenburg, who is involved in this, sitting at the console; it's a little bit like with microsurgery device so they are using this ocular system. They have another open monitor there, so that's why we can call it semi-live, so if you have additional figures coming from an intraoperative ultrasound, so it will not displayed at the console like we have seen it before from da Vinci, so it will be outside. The clutch is done by the fingers, there is no pedal. They are using single-use instruments, and what I can show you is a cadaver radical prostatectomy at the Institute of Anatomy; here you see Professor Stolzenburg, you may know him, you see that device which is seven degrees of freedom, eight-millimeter instruments. And here you see, it's the scissors that are working and maybe we go to the next where you see doing him an anastomosis.

Dr. Jens Rassweiler:

And I think very important if we want to compare the next devices is not what they fancy things they can do, is really how the end effectors are working and he is of course a very experienced surgeon. Here it looks quite nice but you see the angle of the instruments of the end effector is a little wider than we know this from the da Vinci. But nevertheless, you see he is now doing a very nice end-to-end anastomosis using the Quill stitch, so it looks quite nice. This has been recently shown at the ERUS 2020 meeting.

Dr. Jens Rassweiler:

The next device comes again from Europe... it's no more Europe; from UK, I must say, it's outside of the EU since now. It's an open console with polarized glasses, five-millimeter instruments, it has only bipolar coagulation. But nevertheless, it has a very, very nice sophisticated handpiece. It's not a laparoscopic instrument like you have seen it with Senhance. So I think my coworker, Dr. Gozen, has worked with this and it looks very nice. And here you see Prokar Dasgupta, the editor of the British Journal, doing a case; again, here a cadaver radical prostatectomy and you see the device and, again, you may have a look at the angle of the different instruments here.

Dr. Jens Rassweiler:

So, this is just the exposure of the Retzius space which is quite easy to see and probably it's more interesting to have a look here to do the anastomosis. And, again, the same thing that you have seen with Professor Stolzenburg is how does it work to do this anastomosis? And maybe I put it a little bit in front. And you see if you have a narrow pelvis, again, I also can observe that the angle of the instruments, is a little larger than we know this from the da Vinci device. But of course, also, Professor Dasgupta, he's an excellent surgeon so he's of course, able to master this and the first trials they are now ongoing procedures. They have a CE for this with studies or first cases in human being and that's what we will see in the future and the same, of course, with the Avatera.

Dr. Jens Rassweiler:

Now, this is what we have for robotics. So I think there are a lot of interesting things; I have not shown you the Hugo system of Medtronic because they are not yet so far. They wanted, initially, to start in India with their cases but it takes a little longer. This is something what we also have in the future and, of course, also, we have the collaboration with J&J. So, this is another system that at Google they will come out, but there are not real things that are now ready to go. What is already in use for endourology is the Avicenna Roboflex, you may know that I'm using this every day.

Dr. Jens Rassweiler:

So, this is the console with a two handles for rotation and to do a deflection of the instruments. And here you see this again, and you can really use it very fine and particularly if you have multiple stones this is a very nice device, not for one big stone but if you have a complicated nephrolithiasis with multiple or larger stones, I think this is really a very, very good device to use. Here you see that you can also use it in combination and one really advantage is that you separate the surgeon who is at the console from the assistant who is at the bedside so you can nicely collaborate. And it's a little bit like with the da Vinci device bringing in a Hem-o-lok or something. So here it's you bring in, for example here this is engage and then you pull it out and then go in again.

Dr. Jens Rassweiler:

Of course, there are other systems now on the market; the Monarch system from Auris, this has been also now acquainted by J&J, and bought by J&J. I think also they are really a big player or will become a big player in the market of robots in laparoscopy and endourology. It is the Hansen tube technology that has been used primarily for the first case a device that was made for angiography, and this I has done the first case but it didn't went well. But now the Monarch system, as you see here, has already approval and FDA approval for the biopsy and for bronchoscopy. And the interesting thing is what you see here, these like for the next generation playing toys. This is the controller here; so it's no more sitting there, so you have just a little bit of a play box that you can use a pad to do this. And then here you see Desai showing his first experimental cases at the last WCE meeting in Abu Dhabi.

Dr. Jens Rassweiler:

We had already autonomous robots for endourology and the first one was the Probot. And it's interesting, it was based on transurethral ultrasound, which was very fancy at the time, Wickham worked on this. They were using the Vapotrode; some of the older guys may use this, this is a kind of vaporization of the prostate. But the trials finally were stopped particularly with the morcellator due to complications. So, they did the first 16 cases and that's it. And then a long time, nothing has developed until the principle of aquablation came up here with a device. Here you see the controller and you see, probably, here in this video showing how it works out.

Dr. Jens Rassweiler:

So, you're using this time the TRUS image together with the endoscopy because, of course, you do an endoscopy, you determine exactly the position of the sphincter, and then at a certain time you will then start with a morcellation. And, I think, the tissue ablation is based on a hydrodissection technique. Anyhow, there are a lot of trials on the way. Hemostasis might be one of the problems but this is the first device who is a really autonomous robot that it works.

Dr. Jens Rassweiler:

And, finally, we are coming to the last development and we have caused Dr. Herrell here with us, who is involved in this development, this is based on the robot-assisted transurethral surgery. They are using hollow tube technology; also in Korea, there are a similar system is used for neurosurgery, and this allows fine movement. And this has been now made into this Virtuoso device that is, of course, more or less existing experimentally. You see here the experiment and on this side, maybe I can show you how it works inside. And this would be now a new way of en bloc resection; so, you would do not the en bloc resection just with your scope and single-handed. So you are double-handed here and you can do a very nice job. Maybe, also, you can suture, you can treat a fistula; I guess there is a lot of things you may do in the future, and just sitting on this Virtuoso system. So, we will see what is the next step and Dr. Herrell may inform you maybe even a bit better than I could do this.

Dr. Jens Rassweiler:

So, in summary, robotic technology will be used increasingly in urology; you have seen some examples. We will see how the market will develop; we have seen the earliest thing. For example, the next systems are using 20 lives for the system now already since this month. da Vinci has increased his lives to 13, so it's already a reaction. We have the integration of virtual reality and navigation technology, like the Dyna CT that realizes quasi real-time navigation. And then, of course, we have some new robots for endourology as I mentioned and show to you. Thank you very much.

Dr. Chandru Sundaram:

Thank you very much, Professor Rassweiler. That was certainly a look into the future, and it was fascinating. So here's our first poll question, "What would be your first expectation from a new robotic? Platform; design; ergonomics; cheaper price; size; and have haptic feedback. Please answer those questions, and we'll move on to the next presentation. Looking forward to hearing Professor Ahmed Ghazi from University of Rochester. Ahmed?

Dr. Ahmed Ghazi:

Dr. Chandru, Dr. Kaouk and distinguished moderators, thank you very much for giving me the opportunity to present in this masterclass series. Today I'm going to be talking about Advances in Simulation Technologies for Robotic Surgery. Part of this work is funded by NIH RO3 grant as well as a multi-year research grant from the Intuitive Surgical Foundation. These are my disclosures, none of which are relevant to this talk.

Dr. Ahmed Ghazi:

When we talk about the goal goals for simulation training for any field of surgery, including that of robotics, we're really talking about three main pillars. A basic skills simulation is where we acquire the skills or teach the trainees to acquire skills that are needed for the core competencies and needed to actually utilize this technology. And if we go to procedural skills simulation, here is where we take one and often more of these basic tasks into the context of an actual surgical procedure; to open the endopelvic fascia in a radical prostatectomy, you need to do retraction, you need to use the EndoWrist, you need to use cutting, sometimes cautery. But you also need to be aware of the anatomical cues, as well as the technical elements that are involved in the procedure.

Dr. Ahmed Ghazi:

Finally, going to crisis management simulation, and this is something that we've been lacking compared to other high-stakes industries, is the ability of the surgical team, not only the surgeon, at this point, to identify and manage and correct unexpected events during the surgery, like major bleeding. And this is something, truly, with these advances in different types of robots, we need to focus on, specially that we are a distance from our patients during robotic surgery. With the advances in 3D image segmentation, as well as 3D printing, there is a new emerging type of simulation known as patient-specific simulation. And this is where we create replicas of patients' organs, either virtually or physically that, when practiced on, can directly translate into improved surgical outcomes.

Dr. Ahmed Ghazi:

When we talk about basic, I will be talking about every single one of these categories within the context of virtual reality, augmented reality, and 3D printing technologies. So, when we talk about virtual reality in robotics, all of us aware of the simulation platforms that are used. The most common is the da Vinci Skills Simulator because this is a backpack that is actually placed on the console and, therefore, utilizes the same master controls. The other two are standalone simulators developed by dV-Trainer or Mimics and 3D Systems, and they have their own version of the master controls which are slightly different.

Dr. Ahmed Ghazi:

Regardless, all these actually house a variety or a library of basic skills that focus on the major context of robotic surgery which is; camera navigation, using the actual clutch and EndoWrist manipulation, using cautery and different types of energy devices, also being able to suture and the use of a fourth arm. FRS, on the other hand, is a proficiency-based multi-specialty basic skills curriculum, and this was developed by a consortium of over 50 experts and funded by the Department of Defense. In addition to the basic skills and mainly of them are advances in suturing, it also incorporates more than one basic skill like retracting and precise cutting. Also, pattern cutting and the ability to actually disconnect this structure off soft tissue and, also, they are very task-oriented; so, the skeletonization and the dissection of a vessel, also securing both ends by cautery and then precisely cutting in the middle.

Dr. Ahmed Ghazi:

10 modules have also now been introduced on the SIM NOW platform for the single-port surgery, the most prominent of are the normal and the reverse camera pose that teaches you how to use the COBRA component of the actual endoscopic COBRA or the endoscope in the single-port. Also, there is the workerbot that allows you to actually simultaneously use your arms to move people off an escalator, and this prevents you or teaches you to prevent collisions which are very common in single-port. And, finally, the ring obstacle course that teaches you to move the actual full quart into different quadrants of the simulation, because you have to move it differently than compared to multiport surgery.

Dr. Ahmed Ghazi:

Mimics has taken team training to another level; it has developed a virtual reality laparoscopic trainer that can be connected to its actual simulator and, here, the assistant and the surgeon can interact and teach each other by passing instruments. Also, there is a very good retraction feature because that's what the assistant can do sometimes. But, more importantly, is the clip function; as we all know as robotic surgeons, that is something that involves a long learning curve, and you actually have to induce the correct amount of pressure to close that clip. It has great ergonomic function but my only thing is that the assistant ports are in one line, contrary to real surgery, they are usually staggered.

Dr. Ahmed Ghazi:

Looking at procedural skills training, virtual reality has gone a long way. And this is the 3D Systems radical prostatectomy module; you can actually do a bladder neck dissection, also do a neurovascular bundle this section, and a vesicle urethral anastomosis. And they come in guided modules where they actually teach you step-by-step how to do the procedure or do the various steps but, also, they come in evaluation modules. And the evaluations in any form of virtual or augmented reality is usually in the form of motion-based metrics that are path length, an economy of motion, or errors where there is extensive tension that is produced on the tissue or missed targets.

Dr. Ahmed Ghazi:

Mimics took this a step further and developed an overlay augmented reality platform for robotic prostatectomy known as the Maestro. It starts with a storyboard with the actual surgeon, knowing all the steps of the procedures as well as the different instruments that are required, then it goes into the OR and does a high-definition, 3D, stereoscopic recording of the procedure, and then develops an interactive element. What I really like about this is, from the very beginning when they're sitting at the console and following the surgeon, they can actually get quizzed on the anatomical cues for example, "Where is the levator ani muscle? Where is the actual prostate? Where's the neurovascular bundle?" It then commences into following the various steps of the procedures, having them replicate the movements, but also asks them questions like, "Where do you think the clip would be placed?" They also have a series of anatomical and procedural elements or questions that come in and it's very nifty that you can actually able to do a simulation at the end.

Dr. Ahmed Ghazi:

But one of the things that worries me about these procedural platforms is they are limited to a single technique and a single pair of instruments; so if you do a retrograde rather than an antegrade nerve sparing, you're limited to what is available, usually, by the developer surgeon. Also, if you use a different type of suturing or suturing needle, like an RB-1 versus a UR-6, you are confined to what is available here. They still need to work on some of these visual haptics as you can see here; these are some of the glitches that I recorded using our simulator that we have at the University of Rochester. I have to say, this is a huge leap in virtual reality but they still have some issues with the tissue responsiveness, the bleeding is also somewhat impractical and, to tell you truth, a procedural model that actually embodies the anatomy, the pathology, as well as the mechanical properties of human tissue is lacking.

Dr. Ahmed Ghazi:

And we thought that we might have an answer in 3D printing. But when we think about 3D printing, we actually think about hard, usually plastic, unrealistic models that are more of a visual aid rather than a hands-on simulation. So here at the University of Rochester, my lab underwent significant polymer research and we were able to combine 3D printing with polymer casting or molding and developed what I like to call physical reality. And this is the bladder takedown in our prostatectomy module. Here we build anatomy and pathology; so you can do the anterior approach, or the posterior approach depending on what you want to do. You can also see that we can use cautery, because this is a hydrogel that propagates electricity, but also you can notice that charring effect on the bladder neck; these are all purposeful things that we deliberately placed inside the model to create realism.

Dr. Ahmed Ghazi:

The bladder is built in multiple layers and therefore it can be watertight so when you open it, there is a gush of fluid. Here, because it's a tight bladder neck, you won't see the ureteric orifices. Subtle things like the bladder neck got opened up very nicely here, so very easily they can see the seminal vesicles. You can notice the different tissue densities; dense connective tissue and also less dense connective tissue. This is truly because PVA, the hydrogel that we use, you mold it into different formulations and give different densities. Because we use a casting technique, we are able to place a pedicle that, when you cut through it, it's going to bleed.

Dr. Ahmed Ghazi:

And, also, something that I'm really proud of is the ability to put sensors into things like the neurovascular bundle. All of us know that this is something that we need to measure, but something that is almost impossible to measure in patients. The vesicourethral anastomosis is watertight if you're able to incorporate the mucosa into every one of these and, here, you can see that the trainee is actually pushing down with the fourth arm to create a tension-free anastomosis. These are things that you cannot learn in virtual reality or augmented reality. And this is how they're made; we start off with an MRI, there's a sophisticated process of molding each component of the prostate, here is where we add the pedicle and the sensors within neurovascular bundle. The bladder is made in multiple layers; all this is combined, placed in a 3D-printed pelvis, and then covered with different densities of connective tissue. All this is non-biohazardous hydrogel and that's why you can use it in the operating room. So, you need an actual robot to be able to train on this, but you should have a robot if you're training your trainees to do this. But the beauty is here you don't need to decontaminate your instruments or the robot, unlike the cadaver or the animal models; this is a non-biohazardous material we use here.

Dr. Ahmed Ghazi:

We wanted to incorporate metrics into these models because a simulation is only as good as the metrics that it is able to evaluate performance with. And we wanted to create two things; objective metrics and metrics that were very clinically relevant. Positive margins; who can defy that a positive margin as a metric that you can give back to the trainee as feedback. And here we infused the prostate with fluorescent dye that only becomes chemically activated after the prostate is removed to see any positive margins on the resection base, and we found a difference in our experts and novices between the actual minor and also macroscopic margins. So, you see the margin of the right base? If I tell my resident or my trainee, "There's a positive margin at the right base," and they look at the video, they understand that they were in the wrong plane of deception and how they can correct it.

Dr. Ahmed Ghazi:

The integrity of vesicourethral anastomosis is also a very important thing, as we all know and, therefore, we just fill the anastomosis of the bladder with 180 CCs of fluid after the simulation is done. We were also able to find a difference between experts and novices but more importantly, we had experts rate the video of the anastomosis of these people using the validated Ray score and we found a very high correlation between the ray score and the metric that we used.

Dr. Ahmed Ghazi:

We come back to the sensors. I have to say that we try as experts and we try as robotic surgeons to create somewhat of a tension-less anastomosis but we still induce some pressure on the neurovascular bundle during the retraction and during dissection, but you can see the signal is very minor. But you look at the trainee, on the other hand, not only are they are in the wrong plane, and they're maintaining significant higher level of retraction therefore putting more tension on the bundle, but also when they are actually dissecting in the neurovascular bundle, they're doing it in the wrong plane and very forcefully.

Dr. Ahmed Ghazi:

This is the summary of the printout that they get at the end of the simulation, and I really don't need to highlight who is the novice and who is the expert here. We found very good difference between experts and novices in all the metrics that we were looking at but, again, we found a very high correlation between the metrics that we used in the sensors and the gear score. But, more importantly, the metric that was highlighted the most was forced sensitivity, so we're actually measuring the tension or excessive tension that is being delivered in these neurovascular bundles.

Dr. Ahmed Ghazi:

Errors are a huge thing that we really don't know how to measure in the simulation world but if you create an anatomical model and let the resident do their thing, they will usually run into a complication. So, here's a hilar dissection where they're trying to skeletonize the artery. The beauty here during this partial nephrectomy simulation is they got control of the actual bleeder. And I said, "Look, let's continue this. This is an opportunity where you can practice putting in the rescue stitch," and they were able to do that and continue doing the partial nephrectomy simulation. So, this is a lesson they would never be able to learn in the operating room. We have a consortium of multiple institutions, internationally and nationally, where we're collecting the data especially from the prostatectomy model and using artificial intelligence applications to enable us to give feedback back to the trainees.

Dr. Ahmed Ghazi:

We used the same technology to develop patient-specific modules for complex cancer surgeries. This is one of my patients with a six-centimeter posterior hilar tumor, and this is something that would often go to a radical nephrectomy but this patient had some renal dysfunction and wanted to preserve the kidney, so we took the CT scan, segmented it out, created the CAD, and then started to create molds from this. And these molds are way more sophisticated than what we used in the prostatectomy model just because we are creating an accurate replica of the patient so there's no going wrong here. We started with the hollow vessels, added PVA that is similar to the peri-hilar fat, then added a different formula for the medulla, then added a final formula for the cortex where the tumor was incorporated and we end up with a realistic hydrogel organ of the patient that when you cut through it, it will leak urine if you violate the public calyceal system but also bleed to the small channels. This is an example of the kidney coming out of the mold showing the actual tumor and also the hollow vessels.

Dr. Ahmed Ghazi:

In order to reach these characteristics, we had to do sophisticated mechanical testing and this is the basis of my RO3 grant. We looked at rigidity, we looked at compression, we looked at the elastography. But, because our models bleed, we wanted to make sure that the running hemostatic layer that all of us put in actually led to a decrease in blood flow but, more importantly, we wanted to make sure we didn't make the kidney too soft that the sliding-clip renorrhaphy clips actually tear through the kidney model and, therefore, we're giving the surgeons the wrong type of information. This is the publication that we actually published and found a great formulation where we were able to compare our PVA to categoric and porcine kidneys, and found a very good correlation.

Dr. Ahmed Ghazi:

In order to ensure anatomical accuracy, like I said before, we CT-scanned our models because our models are very radio sensitive. We made a CAD out of them, similar to what we did in the patient, and then overlaid the CAD of the patient and the CAD of the model and ended up with what we call a comparative study using the parts comparison tool. Here you can see we get a visual differentiation of not only where we're off but how far we are off. And I'm proud to say that 90% of the model, even in the tertiary benches of the arteries, were within three millimeters. In order to create a realistic simulation experience, we put this in a body cast, surrounded it with all the relevant organs almost made half of the patient's body, took it get down to the operating room in the hospital at University of Rochester, hooked it up to blood bags, and then was able to do the simulation on the actual robot that we're using.

Dr. Ahmed Ghazi:

Here is a simulation on the left and the live surgery on the right, and I really like to show this because this is after ischemia, and after flipping the kidney and dissecting it and addressing the actual cutting out of the tumor. If you look at the base of the resection in both of these videos, you'll see these strands that were there; we did not purposely put those in. Those are there because we recreated the mechanical properties off real tissue and, therefore, this simulation responds to cautery, to cutting, to suturing the same exact way as a real-life surgery would.

Dr. Ahmed Ghazi:

This is something that we realized was a great thing. So, one of the practicing surgeons was like, "Can I look at the simulation?" I was like, "Why do you want to look at the simulation? This is not something we usually do in patients." And they were able to actually debrief themselves by looking at the tumor and figuring out, "Did I get too close to the tumor? Did I get close to a critical vessel or the pelvic LCL system was breached and unnoticed? Did I take too much normal tissue out?" And we have done this now regularly; this debrief is considered part of the simulation, now we have to examine the specimen and write a report, and it truly added a lot of benefit to the surgeon.

Dr. Ahmed Ghazi:

Moving over to the virtual reality world, Iris is a 3D rendering software. Now this is not the only one out there; this is the most popularized one because Intuitive Surgical is the one that delivers it. And it is an iOS device, so you download it in the app store, and then you send their patients DICOM images through a secure link and then they're able to send you back this 3D reconstruction. You can even connect it to Tilepro and have intraoperative navigation. So, this is an example of a patient complex hilar endophytic tumor that I did; I was able to localize where the tumor was even before I did the ultrasound using the CAD.

Dr. Ahmed Ghazi:

And then after that, after I induced ischemia time, I was able to do a very good hilar dissection. But also, using the transparency function, I make the tumor totally disappear, and therefore I'm able to see the vessels I'm going to encounter. So, if you realize, there's a artery in the vein on the left there that I was able to avoid by looking at the CAD while I was doing the dissection. But, more importantly, I was able to find these small feeding vessels that you see I'm cauterizing there by just rotating the CAD a little bit more. This patient came out with negative margins; I was able to see the section very well without a lot of bleeding since I control the feeding vessels, ischemia time was less than 20 minutes and blood loss was less than 150.

Dr. Ahmed Ghazi:

Other groups in France have also done this, but they use an augmented reality platform. So, using an ultrasound, they identify the kidney and the tumor and then, using a manual registration process on the screen, they are able to fix the tumor and the feeding vessels to the kidney no matter how you move the kidney around. So, after this registration process was completed, no matter how you manipulate the kidney, the tumor and the feeding vessels remained constant. Their publication showed that they were able to do off-clamp partial nephrectomy because they knew where the vessels were at all time, clipping them before they actually started to bleed. Again, Duke Herrell, their lab is as a hub of innovation, and they actually have this touch-based registration system where the robotic arm is used to register the kidney consistently, and I'm proud to say that they actually used our models for this publication so that was a great collaboration between both of us, and I'm waiting to see this technology come out.

Dr. Ahmed Ghazi:

Crisis management training. So, I want to spend the last 30 seconds on this. There are no virtual augmented reality or any cyber platform that I found for crisis training management that was realistic. So, in order for us to do this, we needed get an operative team in our lab, we needed to design a curriculum, we needed to design a checklist because, again, the surgeon is far away from the patient and therefore we have to know the role of every single person in there; the circulator, the first assist. We also needed to develop an actual model, enabling it to cause massive bleeding.

Dr. Ahmed Ghazi:

So this is an example of the model that we built, and this is a retroperitoneal tumor that the surgeon first has to cut out, and then find the feeding vessel, and then use a stapler or clip or whatever instrument they actually used in order to secure this. And this is the checklist that we were able not only to teach them but you evaluate them. So, this is one of the simulations that we went through. She's dissected the tumor down the base, put a stapler through it, and before she fired the stapler, major bleeding started. So, at this point, we actually throw a [inaudible 00:42:31] into that arm so she can't use it anymore, forcing them to go into trying to convert to an open approach. So, first, she does the great thing when she controls the bleeding first using the fourth arm. Then she calls for instruments; she calls for extra help. And she has an actual lap pad come in so that she can do compressing; realize that beeping is getting louder and faster, that's the vitals of the patient, so we're pushing them along to actually convert to an open procedure.

Dr. Ahmed Ghazi:

She did a great thing; where she didn't feel comfortable removing the robot and releasing the bleeding, so she's made a small incision, put a gel coat in there, and was able to secure the bleeder, but then spent a good 15 minutes trying to figure out how to use the wrench in order to release that stapler. And, therefore, we created online modules for them to be able to learn this, and then had them do the simulation one more time and, finally, we found out that their conversion time decreased from 10 minutes to three minutes, and also the blood loss went from 2,000 to 1,000. So we were able to achieve some level of competency. And thank you very much for this opportunity.

Dr. Chandru Sundaram:

Thank you very much, Professor Ghazi. That was a phenomenal presentation regarding the future of simulation. I have two quick questions for you; one is, what is the cost of it and, what is your training curriculum in your institution that incorporates all of this? And, after I read this poll question, "Do you think robotic surgery will also have a major impact in endourology?" "Yes. It starts with RIRs and continues with aquablation of the prostate until robot-assisted resection of bladder tumor." "No. I don't think this will happen mainly because of it's too expensive." Or, "I do not know at this time." So you can answer that, then we'll hear from Dr Ghazi, and we'll get all the panelists involved.

Dr. Ahmed Ghazi:

Thank you very much for the question. And, yes I do get a question of the cost every time I give these. So, we are a research lab, so we can't really tabulate the cost. But I can tell you this that it is cheaper than getting a cadaver, the anesthesiologist for the animal labs and, also, the costs that go into the biodegradability of this. The range for production in our lab using personnel and using the materials that we use is approximately 800 to $900 per organ, depending on the sophistication that you want it, because we can also do partial task trainers. But that prostatectomy is around that range. And, again, it gives you the ability to use this anywhere, even in your operating room.

Dr. Ahmed Ghazi:

The curriculum that we've built; again, I have a master's in education, so I built the curriculum from the ground up. We start with the virtual reality platforms, we actually go into the procedural simulation that I showed you, just to get them through the steps of the procedure themselves, then they go through partial task trainers like we have a tumor that you just cut out, we have the anastomosis on its own, we have the neurovascular bundle dissection on its own. Finally, when that is achieved, they then go into full simulation. They do about five of these, on average, and they're proficiency-based so they have to reach expert levels. And once they finish this, they then start their robotic surgery training in the operating room.

Dr. Ahmed Ghazi:

So, you can just imagine these residents hit the ground running. One of the most important things is actually something where we get these residents to do these complex cases that we've made in the lab. We have these hydrogel models that have very complex partial nephrectomies that they would not dream of touching in the OR; they are able to do it in the simulated world and figure out how they are able to plan with this. So, it becomes a very exciting curriculum where they not only stop at proficiency but they go towards excellence.

Dr. Chandru Sundaram:

Thank you. Professor Rassweiler, a question for you, "In five years, where do you see robotics as far as the number of systems, number of manufacturers in play; right now it's da Vinci, either the XI or the single-port. Where do you see it in five years? What do you see the picture of robotics?

Dr. Jens Rassweiler:

So, I think within the next year this will be the decisive year. We will see, probably, the next three on the market. That's namely Avatera, and the [Vesue 00:46:40] system, and probably maybe also the Hugo RAS from Medtronic. And there are so strong companies so I think they will continue, and so probably in five years the patent issue is no more a big deal, so I would expect five companies at least on this market, and maybe two companies on endourology. Maybe this can be joint venture, and I think we'll have to ask Duke about the near future of the Virtuoso system. I think this is a very promising system, so this could also be then in five years on the market.

Dr. Chandru Sundaram:

Let's ask Duke himself. You have done a lot of work, very innovative work. I know you collaborate with engineers and robotic scientists in your institution. Tell us a little bit more about your work and where you see the future of robotics.

Duke Herrell:

Yeah. No. Thank you so much. And just fantastic talks, I mean I have the privilege of working around and knowing Jens for many years and truly an amazing leader. And then Ahmed and I have become good friends and colleagues over the last couple of years as I've seen his work emerge and I just have to say truly just amazing work. I mean, I want to go train in surgery in the next five or 10 years again because it's going to be so much better than what we went through.

Duke Herrell:

From a Virtuoso surgical standpoint, I can tell you that right now the company is progressing, we're nearing our third prototype. We have some early clinical advisory boards, we're shooting hopefully for approaching the FDA for approval for human studies. And, again, this is a very complex process that I didn't really understand and not sure I completely do at this point but hopefully in 2022 we'll be garnering approval from the FDA is our goal.

Duke Herrell:

And some of our early targets, as Jens mentioned, we certainly think there's a lot of room to make BPH and enucleation a more translatable procedure. A lot of RCTs, a lot of gold-standard work there but not translated out to the community and the world like it should be. Very much reminds all of us, I'm sure Chandru and I and all of us remember the early days of lap versus robotics and it's the same thing; you give a great craftsmen a great tool and they can do wonderful things, and so that's our hope. TURBT needs improvement; there's a lot of other rigid endoscopists in the world, such as gynecology, and so hopefully we can help all those out. But I certainly appreciate the opportunity to mention it. Thank you.

Dr. Chandru Sundaram:

Fascinating, Duke. Professor Liatsikos, you're an experienced robotic surgeon in Europe, you're also the chair of the European School of Urology. My question to you is, today, what would you say the most advanced technology or instruments within the da Vinci system is? For instance, I use the Vessel Sealer Extend with a new generator and I found that really, really useful; much faster sealing and much less thermal spread. So, like that, what other instruments would a robotic surgeon today have planned to get using the da Vinci system in your opinion?

Dr. Evangelos Liatsikos:

First of all, all these extra tools have to do also the costs, because in many markets a lot of people cannot afford to use the sealers and all the other additional options of the robotic system; some people actually use the three arms of the form because they can't afford to expand their expenses on this. But what I would love to see, and we see it in a certain sense but not up to the level I would like to see it, is I would love to do a partial nephrectomy and have, on top of my kidney that I'm operating, an artificial intelligence, accurate depiction of exactly the tumor on the vessels. That, when I move my camera, this moves on a very accurate point. So I see that this exists in a way right now, but I would love to avoid using ultrasound, for example. If we get to the point that we do not need the intra-renal ultrasounds to localize the tumors, I think this will be the major advancement in my opinion.

Dr. Chandru Sundaram:

Yeah. Very appropriate comment. Regarding cost you brought up a very good question, and I'll have that question for Professor Abdel-Karim. You're in Egypt, cost is important, so how do you manage cost and yet stay on the cutting edge in robotics in a country like Egypt from the surgery standpoint and the training standpoint?

Dr. Aly Abdel-Karim:

I think this is a very important point in developing countries like in Egypt. Of course, as a laparoscopist I would be happy to have a robot that would make my life much easier. However, as you know that the cost is not only related to the robot itself but also to the running and expenses of the equipment. So, so far in Egypt, we have only one robot, unfortunately, I'm not happy to say this. We are planning to have another robot here in Alexandria, hopefully we'll have this very soon.

Dr. Aly Abdel-Karim:

Still, we have financial problems so, hopefully, with the new robot that Dr. Rassweiler have shown to us that will reduce the cost, so by this we can have this new robot. So, in the future, I'm sure, if we have the robot, I think that will allow more urologist to practice doing the laparoscopic surgery because as you know that with the lap convention laparoscopy is still hard, especially for the advanced procedure like radical prostatectomy and partial nephrectomy. So, hopefully, with the improvement of the economics and reducing the price and the cost for the robot, we can get more robots here in Egypt, and many other countries.

Dr. Chandru Sundaram:

Thank you very much. Professor Rassweiler, you had a question, a comment, go ahead.

Dr. Jens Rassweiler:

Yes. I have a comment or give some details. It's very interesting because if we think about 150 or 100,000 Euros, at least, for maintenance of for the da Vinci device, the new devices, the maintenance is only 30,000 so they are really thinking about this. I think the initial cost for buying the device it's also lower but it's still in a million range or something; this will be not so cheap, this is clear. But the maintenance and the cost per instruments and all this will be lower. So I think this could be a good argument and this could be even an argument to sell the devices in these countries.

Dr. Chandru Sundaram:

So, one question for the panel, anyone can take this. We have a poll here, "What retraining would be required for current robotic systems to be certified prior to utilizing a new emerging systems? You could answer one of these points here and we'll review those results. But I have a question to the panel regarding automated performance metrics, "Do you think a time will come where the robot will be able to assess your competence based on how you do on the robotic system based on the movement of the instruments, your hands, your eye tracking, and so forth? Anyone can answer this.

Duke Herrell:

Let's give that to Ahmed.

Dr. Ahmed Ghazi:

Thank you, Duke. So, we actually did a consensus conference a couple of weeks ago and we're preparing the manuscript actually answering that question. The problem with AI or artificial intelligence; it's great in taking a significant amount of data and correlating it with outcomes, but then you don't know which one of these things that you can change in order to improve outcomes. So, we say that your outcomes are good but your performance metrics are bad; it comes down to the outcomes at the end, so the patients are doing well. Well, the problem with these outcomes is they're not granular enough.

Dr. Ahmed Ghazi:

What AI is trying to do is AI is trying to look at your progression. So, these automated performance metrics are trying to tell you that as you progress through doing more and more cases, you actually tend to get better in certain things, but this is the component that you can actually improve in. So yes, there is a future for us all getting reports and being able to maintain our certification through this. However, our ability to take it down to a granular level by saying that moving the fourth arm a few times during your anastomoses led to improved patient outcomes, that's what is questionable here. So, the link between both of these is not enough and the reason that is we do not have enough data. So, if every one of us had that black box that certain institutions do have, and Andrew Hong is a leader in this field, and is able to collect all this data and have a group of machine-learning or computer science experts look at this data, they will reach a conclusion.

Dr. Ahmed Ghazi:

And I think we're lagging behind in the urology world because if you've heard of the Surgical Metrics Project done by the American College of Surgeons at their annual meeting in Chicago; they had 480 surgeons go through a simple identification of closing and opening in the colon and they find out that they collected metrics for EEG, for eye tracking, for their heart rates, for their movement, audio, and now they're using artificial intelligence to figure out what the decision-making process is. So, if we want to get into that world, we need a big amount of data because that's how AI works; it takes big data, and converts it into translatable meaningful data if we have it. But giving them a small sample is never enough. They're all old [crosstalk 00:56:42].

Dr. Chandru Sundaram:

We have 30 seconds. Any comments from our panel and our speakers? Yes, Dr. Rassweiler?

Dr. Jens Rassweiler:

I have a question to Ahmed for this excellent lecture. Alex Mottrie in Orsi is working on proficiency-based training. So as an approach, you have now the different modules, would be this the same approach or do you think you could integrate this? Maybe you can comment just on this?

Dr. Ahmed Ghazi:

Jens, thank you very much. And yes, we are looking at a proficiency-based progression. The idea is identifying what the experts; we don't have data on the tension during nerve-sparing anywhere except from our model. So, now we're having the group of experts do it and that is our benchmarks. We are then working on novices or trainees getting to that level and defining that learning curve. So yes, very good question. Thank you very much.

Dr. Chandru Sundaram:

10 seconds for Professor Herrell. Duke.

Duke Herrell:

I was just going to put in a plug that I want to say Jens's group, Porpiglia's group, and our group have all been working on image-guided giving Evangelos what he asked for. And, hopefully, between the three of us, we're solving some of those problems. So, thank you.

Dr. Chandru Sundaram:

We have all the leaders here. It's been a fantastic one hour. Thank you all very much. I couldn't have asked for a better webinar today. And to the audience, thanks for joining us. Happy holidays. Have a safe and wonderful new year. Look forward to seeing you in the COVID-free 2021. Bye-bye.