Do Not Learn a Technique: Learn the Biology Underlying the Disease

• 22 Mar 2021 10:27:43 AM
• |General Urology

Dear All,

Yesterday there was a good programme conducted by USI on Operative Urology performed by Master Craftsman using Lap Technology.

During discussion with other experts, much consideration was placed on Robot Assisted Procedures and its advantages over Lap Assisted Procedures. Though they openly did not criticize open procedures, one could make out from their discussion that they believed that open surgical procedures have little role in present day Urological Procedures especially when dealing with Urological Malignancies.

When a child gets a new toy to play with, we often see that they discard the Older Toy even if it is in good repair. This not only extends to children but also all of us. When there is a new Toy available to help surgical procedures, we go gaga over the new introduction and begin hailing that as God’s sent from Manna. This applies not only for Surgical Options but also Medical Options.

As regards Surgical Options are concerned, No study can clearly state the utility of a procedure over another due to several complexities involved with the procedure. The experience of the surgeon performing the procedure reins paramount. A statement made a while ago by a leading Urologist stated that ‘it is not the technique employed that is paramount but it is the Surgeon performing the procedure’.

Yesterday we saw an excellent lap assisted Partial Nephrectomy. But in the discussion that followed, most discussed on the merit of Lap Assisted with Robot assisted PN. There was a brief discussion on Sinus Fat involvement and this was not well addressed to my mind. Removing a tumour by PN when the sinus fat could be involved is suicidal to say the least. There are centres, even in India, who shy away from performing PN when Sinus fat involvement could be present or suspected and resort to RN in such cases and this is done with utmost interest of the patient in mind. The reasons given for proceeding with PN do not hold water in the opinion of many.

Today, RARP is considered as the procedure of choice for P Ca. With all the advances in technology associated with RARP, still many patients progress to advanced diseases and many salvage therapies needs to be implemented. The earlier results that we heard about RARP, performed for Low Volume, Low Grade Disease is no longer acceptable as it has been found that many of these patients would have survived with better quality of life if they had placed on AS. Today most RP are being practiced on more High Risk patients and various combinations of High risk are being considered for RP including Oligometastatic Disease. Salvage Surgeries as recommended, no doubt, leads to progression of disease in many. Recent articles suggest that RP’s in present scenarios do not prevent progress of disease in many and appropriate subsequent treatments are necessary even if performed Robot Assisted.

If as mentioned, the newer modifications of RP resulted in better outcome as regards UI and ED, why then has a speciality called ‘Penile Rehabilitation’ emerged and their incidences of UI and ED after RP (whichever technique) is much higher than what Urologists mention after RARP.

The same is being discussed regarding Cystectomy and the recent studies have found no difference whether RC is performed by Open or with Robotic Assistance.

I am providing the link of Cochrane Review published by Bhavan Prasad Rai, Nikhil Vasdev, Prokar dasgupta et al published in BJUI (2020).

https://bjui-journals.onlinelibrary.wiley.com/doi/epdf/10.1111/bju.14870 (PDF available)

The main aspect that we need considering when offering a mode of treatment, be it surgical or Medical is not the technique adopted in Surgery or the Medicine prescribed, but it is the understanding of the Biology of the Underlying Disease. We should not follow a ‘One size fits all’ policy or have a view of ‘my way or highway’. It should be realized that ‘The disease will remain, but technical details will either evolve or become obsolete’. True advances will come from a better understanding of the biology of the disease, which will lead to enhanced strategies to prevent, detect, and treat it.

I am confident that in future we will dispense with our fad of technology but will revert to better understanding of the disease and provide optimal treatments depending on the need and not entire base it on technology

I am sure this brief write up will ignite our thoughts and make us realize that treatments offered should not be technology based alone but it should be based on several other factors including understanding of the Biology of the Condition.

With warm regards,

Venu

Comments(2)

• 

  Ravindra Sabnis

  22 Mar 2021 02:31:10 PM

  This write has potential to ignite several minds. 

  Several points are made in write up 

  1) Technique of surgery. - Robot Vs lap Vs open. No doubt open is declining & for reasons well known to all. Open surgery was the main stay in past but things have changed. In some areas open surgery is out, in some in transition & in some still it is best. 

  Stone surgery - open surgery is out. In partial - open surgery has limited role if at all. Robot Vs lap is debate which will go on. But robot has benefits that it comfortable to surgeon & it has brought 20 years experience surgeon & 2 years experienced surgeon to same level. 

  2) More important point you have brought is sinus fat. I have seen many workshops & many people boasting how complex mass they did with partial. If sinus is involved, stage is T3A- which is total contraindication to partial. Question is how accurate is imaging study to diagnose that - answer is no. Hence in cases, where tumour is reaching sinus, big, I feel it is better to do radical (when other kidney is normal). I think already many conferences debate is already going on - are we stretching the limits of partial too much just because of robot & expeties. Biology of cancer does not change just because you have robot. We have done many times, radical when we were about to do partial & most of them report is T3A. SO in this regard I totally agree with you that sinus fat is serious matter & saying that sinus invasion is only small area, I have removed everything, margin -ve is violating principles of cancer surgery 

• 

  Dr. Roy Chally

  22 Mar 2021 06:29:57 PM

  Venu has raised many issues

  1 New diagnostic and therapeutic tools

        Aggressive marketing is a fact

        The benefits usually overstated

        Limitations rarely highlighted 

        Company sponsored literature truthful?

        We have to look at cost benefit ratio

  2. Lap and Robot has many advantages. But the end result is the same as in open 

  surgery. Here the experience and expertise of the surgeon is of paramount importance.

  The claim that with Robert one can get better results than open surgery is not proven. In fact even today in very difficult renal sinus tumours in solitary kidney open surger is still the preferred option. 

  3. Understanding the biology of tumour is of paramount importance. Many new imaging and diagnosed tools are available now to stage the disease better. We must be aware of the limitations of these studies particularly in one’s centre. Surveillance protocols and minimally invasive total ablation of the disease are the products of these studies. In the near future medical treatment for small volume cancer may be a reality.

  4.  Today we do not have a technology to diagnose renal sinus fat invasion. In small renal tumours in renal sinus, the capsule of the tumour can be delineated well in MRI. When we can see an intact capsule in the area of renal sinus we can presume that the sinus fat is not invaded. In large tumours extending to renal sinus this doubt will be there, and nephrectomy is a better option. 

  5. That Impotence and incontinence are better after robotic surgery is only a myth. Here the surgeons expertise is more important.