Minimally invasive oncologic surgery: The best is yet to come

Inderbir S. Gill, MD, MChThe use of minimally invasive surgery in urology has evolved and expanded since its inception. Inderbir S. Gill, MD, MCh, who is widely considered the international leader in minimally invasive urologic oncologic surgery, says the best is yet to come. In this interview, Dr. Gill discusses what he calls the three most significant advances in minimally invasive oncologic surgery, how the current model for education can be improved, and the next frontier in minimally invasive surgery. Dr. Gill is chairman and professor of the Catherine and Joseph Aresty Department of Urology at the University of Southern California (USC), founding executive director of the USC Institute of Urology, and associate dean of clinical innovation at the Keck School of Medicine of USC. He served as a consultant for Mimic Technologies, which has developed a surgical simulator in conjunction with USC.Dr. Gill was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, The Uehling Professor and founding chairman of the department of urology at the University of Wisconsin, Madison. 

What would you say are the three greatest advances in minimally invasive surgery in the last quarter century? 

The biggest advance has been the substantially increased application of minimally invasive urologic/oncologic surgery. In 2015, we are now able to bring a confident, even an increasingly dominant presence in this arena. This has taken a quarter of a century to come to fruition.

Second are the advances in robotic technology that have further improved our ability to do minimally invasive surgery. I personally used to be a laparoscopic aficionado. Now, for a host of very good reasons, I have become a convert to robotic surgery.

Third is the increasing push toward obtaining level one evidence-randomized, controlled trials. Gone are the days of do one, see one, teach one. Now, appropriately, far more robust and dependable level one data are required.

NEXT: How can the current model for education in minimally invasive surgery be improved?

What is the current model for education in minimally invasive surgery, and how can it be improved?

The current model involves taking the resident, fellow, or mid-career surgeon through the operation at a center of excellence, where they observe, do, and learn. This is sub-optimal. So, how can it be improved? We believe there are two ways to improve robotic training: robotic “time-out” in the operating room and procedure-specific simulation.

At USC, we have instituted a policy of robotic “time-out.” After the surgical “time-out,” we now do a robotic “time-out,” wherein the resident, the fellow, and/or the faculty go over a pre-printed program, which specifically lists the pre-identified steps of that particular operation that the specific resident will do based on his/her PGY rotation level. At the end of the case, the resident will rate the fellow and the attending as to the robotic learning he/she obtained from that case. Also, the fellow will rate the resident’s performance, and the attending will rate the resident’s and the fellow’s performance and provide objective critique. This feedback loop is electronic and automated, using the iPhone.

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Since instituting this “time-out” policy at USC a few months ago, we have already collected objective data from over 150 robotic surgeries. We feel this strategy will enhance and objectivize robotic training.

The second arena for improvement is simulation, which has been a great buzzword for a long time but without a whole lot to show for it. Now we are on the cusp of procedure-specific simulation wherein the specific simulation is for that intended patient-specific surgery. We have developed what I believe is the first procedure-specific simulator for robotic partial nephrectomy.

NEXT: What are the major obstacles in minimally invasive surgery in 2015?

What are the major obstacles in minimally invasive surgery in 2015?

The major issues are twofold. The main issue, which is not even as much an obstacle as actually being, at least to me, a stimulant or even an inspiration, is the resistance from some open surgical colleagues. I say this is a stimulant because it is very important to hold any new development to the highest scrutiny and rational critique, to hold minimally invasive surgeons’ feet to the fire, so that at all times, due diligence is brought to bear, without any convenient shortcuts.

However, at centers of excellence, we are now there, and appropriate recognition from our esteemed open colleagues, on the shoulders of whom literally all this has been built, would be reasonable. It is important to realize that our open surgical colleagues have helped elevate the field significantly by spurring minimally invasive surgeons to provide higher quality data.

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The second obstacle is cost. Lowering the financial costs is something that will take a while, but with increasing efficiency, I am confident the costs will come down.

Can you discuss a technique in minimally invasive surgery that failed and what we can learn from it?

The one that comes to mind is minimally invasive decortication of polycystic kidney cystic disease. At one point, there was a feeling that if you decorticated multiple renal cysts, it would possibly improve renal pain and function. That certainly did not pan out.

The fact that laparoscopic prostatectomy did not continue to be a viable option is more a reflection of the steep learning curve of laparoscopic surgery and the ongoing advancements that robotics has brought to bear, rather than a failure of that technique.

NEXT: "My personal opinion is that live surgeries advance the field enormously."

What is your opinion of live surgical demonstrations?

My personal opinion is that live surgeries advance the field enormously. Of course, there are some very important prerequisites that have to be satisfied for this to work. First, you have to choose surgeons who are very, very good-at the top of their game-to demonstrate live surgery. Second, the appropriate set of circumstances should be available in the operating room and identical to the surgeon’s home turf and home team. Third, detailed informed consent with the patient is necessary, of course. Fourth, the overall atmosphere must be one in which the surgeon is not feeling pressure to do anything he would not do in his normal setting. Finally, there must be full disclosure.

I think that all these prerequisites are easily satisfied. Once this is done, I feel live surgery really stimulates the attendee and becomes a very powerful and unique teaching tool. Live surgery has been an important platform that has helped teach surgeons and increase the penetrance of minimally invasive expertise in the field. I recognize that there are those who feel live surgery may be a step too far. However, given the prerequisites I mentioned, which are readily satisfiable, live surgery represents a viable teaching tool. Certainly, pre-recorded surgical videos and simulators, when they get advanced enough, facilitate teaching as well.

What is the next frontier in minimally invasive surgery?

I think the next frontier is truly substantial minimally invasive surgical presence within the chest, abdomen, and pelvis. And it is already beginning to happen. For example, to be able to perform the entire robotic bladder cancer surgery completely intra-corporeally (radical cystectomy, high-extended lymphadenectomy, and urinary diversion) within 4-6 hours while completely satisfying all surgical/oncologic principles is a substantial advance. So, we are now routinely doing robotic orthotopic neobladders and Indiana pouches completely intra-corporeally.

Also, RPLNDs are now being done robotically, as is major oncologic extirpative surgery in the deep pelvis. We are even doing robotic level III inferior vena cava tumor thrombectomy for kidney cancer. This involves dissecting the liver off the vena cava, controlling the vena cava, extracting the thrombus, and reconstructing the vena cava, all robotically, all intra-corporeally. We are now in the midst of completing the initial retrospective comparison of open and robotic IVC thrombectomy surgery.

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I look forward to helping deliver truly substantial robotic surgical presence-reliable, reproducible, and routine-inside the abdomen for cancer and non-cancer applications. Doing so will represent a true advance.

In addition, technology is advancing, such that all intra-operative information during surgery will not be merely visual, but will be substantially augmented by overlaid preoperative imaging and novel intra-operative imaging. Molecular-based imaging will light up and differentiate the cancers that need to be removed from the adjacent normal anatomic structures that should be preserved. Intra-operative surgical finesse will improve down to the millimeter level, whereby we are able to effect cure yet preserve function. These and many other exciting things are on the way.

NEXT: "My clinical practice is exclusively robotic surgery, specifically robotic oncologic surgery."

Let’s talk about your practice and your career. Please provide an overview of your clinical practice.

My clinical practice is exclusively robotic surgery, specifically robotic oncologic surgery. I do outpatient clinic 1 day per week and I am in the operating room the other 4 days per week. My surgical cases encompass the entire range of advanced oncologic robotic surgery, including kidney, bladder, and prostate cancer.

How and why did you switch from laparoscopic urology to robotic surgery?

A fundamental personal philosophy of mine is that when I start getting comfortable, I start getting uncomfortable. I was getting very comfortable with laparoscopy, and I felt that we had reached the limit up to which we could push straight laparoscopy. The potential of robotics to further finesse surgical excellence is what fundamentally attracted me to it.

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This certainly was pushed along by patient demand. Honestly, every day in the clinic I found myself being asked to discuss the pros and cons of laparoscopic versus robotic prostatectomy, without any available robust data in this regard. We candidly gave the patients their options and offered both technologies, and things naturally gravitated toward robotic surgery. I think my team’s huge prior experience in advanced laparoscopy helped us take robotics to a whole new level, once we really got down to it.

NEXT: Dr. Gill's most fulfulling accomplishment

What has been your most fulfilling accomplishment?

My most fulfilling accomplishment is my sense of the growing acceptance from our open oncologic colleagues toward our diligence in trying to faithfully replicate every single open surgical nuance in all our robotic endeavors. We have achieved this by actively soliciting in-depth critiques and comments in the live surgery setting, as well as in our discussions and debates in various academic forums worldwide. We have always been open to learning not just the big picture, but also the small nuanced minutiae, until that acceptance is secured. That has been most satisfying.

The other accomplishment has been the enormous privilege to train and learn alongside more than 80 postgraduate urology fellows from the U.S. and internationally, and an even larger number of urology residents. This opportunity to engage in scientific brainstorming and discovery continues to be an amazing journey, which is now starting to pick up even more steam lately.

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