A Robotic Evolution

Steve Coates welcomes Dr. Joseph Wagner, Chief of Urology and Director of Robotic Surgery at Hartford Hospital. This month marks the 20th anniversary of FDA approval for robotic prostatectomy and Dr. Wagner was one of the first in the nation to perform this groundbreaking procedure. He’ll take us back to what that was like for him and for the patient – and he’ll also describe how this technology has changed over the past two decades.

Learn more about Robotic Surgery at Hartford HealthCare's Tallwood Urology & Kidney Institute

Transcript

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SPEAKER_05 0:02

Hartford Hospital in general has always been a forward-thinking institution. You know, go through the halls and you see what we were the first of doing in different arenas. It's impressive. So we are the first in Connecticut to get the robot, first in the state to be doing, you know, urologic robotic cases. I think the institution embraced it right off the bat.

SPEAKER_00 0:24

Welcome to more life. In this episode, Steve Coates welcomes Dr. Joseph Wagner. He's Chief of Urology and Director of Robotic Surgery at Hartford Hospital. This month marks the 20th anniversary of FDA approval for robotic prostatectomy. And Dr. Wagner was one of the first in the nation to perform this groundbreaking procedure. He'll take us back to what that was like for him and for the patient, and he'll also describe how this technology has changed over the past two decades. Here's Steve Coates.

SPEAKER_04 0:56

So a milestone anniversary this year for robotic prostatectomy and for robotic surgery in general. In May 2001, you performed one of the first urologic robotic surgeries in the country. Then you come to Hartford Hospital and we start a whole new journey in robotics here. Take us through that history.

SPEAKER_05 1:19

I think it was 1999 or 2000 that the robot came out and was approved for cardiothoracic surgery. So I happened to be at Beth Israel Medical Center in Manhattan at that time. One of our cardiac surgeons, they got the robot for, but I quickly saw the utility and what I thought it would be useful for in the urology arena. I heard about a guy in Germany named Johann Binder who was doing um procedure and Ichsprech and Bisschen Deutsch. So contacted him, saw what he was doing, and thought that it was sort of the way to go for prostatectomy. So what we did is I was taking the robot and then just doing inanimate training. And we were all set to go. Probably could have even been one of the first in the country to do it. But my boss back then said, let's pump the brakes a little bit. I hear it's going to be FDA approved pretty soon. Why don't we wait for FDA approval just in case this isn't the way to go? That we're not really going out on a limb here just to be first. So that's what we did. So I'm pretty sure it was May 23rd or so that the uh robot received FDA approval for pelvic surgery, and I did a case a few days later.

SPEAKER_04 2:31

So you've got the technology, and then how do you sell that to the patient who's going to become the first patient of this new technology?

SPEAKER_05 2:38

So you don't sell it. You know, I get the terminology, but that's the one thing you don't do. You tell them, like, here's what I do. I do these surgeries right now laparoscopically. Here are the pluses and minuses of laparoscopic versus open. If I use the robot, part of that laparoscopic procedure is a lot easier for me. I really think this is going to have an advantage. So the question is do you want to be a person that does this early? Would you rather do the conservative thing?

SPEAKER_04 3:06

And people make their choice. And obviously the first case was successful.

SPEAKER_05 3:10

Yeah, it was a big news splash, and I think it was the New York Daily News. You know, there's a picture of him hugging me the next morning. But he's 79 now. I literally just got an email from him two weeks ago, and he's cancer free. He did great.

SPEAKER_04 3:27

To me, the thing that's amazing about robotic technology is the fact that you have this amazing control while not necessarily right over the patient.

SPEAKER_05 3:36

When I was in New York, Mount Sinai took out a gallbladder in France from Mount Sinai, right? You can do that. Obviously, the further away you get, the more technical challenges there are. And the further away you get, the more ethical challenges there are.

SPEAKER_04 4:04

So you come to Hartford in the early 2000s and the robotic technology follows you.

SPEAKER_05 4:09

So I started in May 2001, and I think it was in the spring of 2002 or the summer of 2002. Dr. Shickman and I ran into each other at a meeting, and he said, Listen, I heard you're doing, you know, robot prostates. I'd love to come down and see. So he came down and watched me in New York, was blown away by the technology. And I'm from Connecticut, I'm from the area, and Dr. Shickman and I knew each other from medical school.

SPEAKER_04 4:35

Of course, Dr. Steve Shickman is the physician-in-chief of the Tallwood Urology and Kidney Institute, for those who aren't familiar.

SPEAKER_05 4:41

Yeah, thank you. So he called me a few weeks later. They didn't have robotic surgery here. They weren't even doing laparoscopic prostates at that point. So I came up, did a few laparoscopic prostates just to show sort of my surgical skills for lack of a better term. And they decided they wanted to move forward. And we did our first robotic cases in December 2003.

SPEAKER_04 5:02

Was there any pushback or resistance about going robotic?

SPEAKER_05 5:05

I really don't think so. If it was, it was behind doors that I wasn't in the room. But uh no, I really don't think so. I think that you know Hartford Hospital in general has always been a forward-thinking institution. Um when you you sort of you know go through the halls and you see what we were the first of doing in different arenas, it's impressive. You know, so we were the first in Connecticut to get the robot, first in the state to be doing you know, urologic robotic cases. I think the institution embraced it right off the bat.

SPEAKER_04 5:36

When it comes to robotic surgical procedures, it seems like urology is always on the leading edge. Why is that?

SPEAKER_05 5:44

Yeah, you know, that's a that's an interesting point. You know, part of it might be since the 1930s, 40s, we've always been a specialty that has had to use scopes, right? And we're working in tiny tubes and areas. So as scopes get smaller, more flexible, more facile, we figure out things more and more that we can do with them. And maybe minimally invasive surgery is just sort of an extension of that mindset.

SPEAKER_04 6:14

And I think when people think of robotic surgery, they may have this vision of Star Wars, but really these procedures are guided by physicians through this technology, correct?

SPEAKER_05 6:25

The best example I think I can give is when you go to uh you go to Chuck E. Cheese and you and you go to that machine where you have the two claws and you're operating the two sticks and looking and and controlling things. But that's the best analogy. I'm looking at what I'm doing, and I'm operating foot pedals and levers and graspers to tell the robot what to do. So it's really not much different than someone in construction working a backhoe or anything else. It's just more sophisticated and finer and working in a tighter space.

SPEAKER_04 6:58

When you started this, training was kind of learn as you go, I guess, but is this routine now for surgeons to be trained in everything robotic?

SPEAKER_05 7:08

When I started doing it, there was personal training, meaning we figured out how to do it on our own, and there were different pockets across the country doing things kind of differently. But we'd get together at meetings, people would talk, you'd look at other people's videos at meetings and say, Oh, that's a better way to do it than I am. They would look at yours and say, That's a better way to do it than I'm doing it. And gradually things just sort of morphed toward a common way of doing these. That there are nuances now, but they're not huge nuances between uh different surgeons, you know, doing these. We just sort of figured it out. And then you just have to stick to your ethics, right? And your ethics are you got to do what's safe for the patient, number one, and number two, you want to give them a good outcome, right? So for prostate cancer, I want to cure them of their cancer, I want to make sure they have good urine control, and I want to try to maintain their potency, their sexual function. That's the trifecta, that's what I'm trying to accomplish in a safe manner. And if the robot helps me do that more effectively, great, I should do it. And if it doesn't, I shouldn't. If I have a tricky case, I'll call in one of my partners and say, hey, listen, what do you think about over here? What would you do? Um, you know, we're very transparent and open that way, asking for help.

SPEAKER_04 8:29

Are you still doing open surgery in some cases?

SPEAKER_05 8:32

From a time that I went in thinking I was going to do a robotic prostatectomy on a patient, I've only not completed it three times. That's it.

SPEAKER_04 8:41

And when you made the decision to go more robotic, I'm guessing that decision was based on positive outcomes you were getting in patients.

SPEAKER_05 8:50

Again, right place, right time. You know, when I came here in 2004, Vin Ladone, who was one of our urologic oncologic surgeons, and he had done thousands of open prostatectomies. So for the first year that I get here, he continues open. I continue with the robot, but it became quickly apparent that the robot patients were going home earlier, losing less blood, and having less complications, and a little bit better outcomes as far as getting all the cancer out. But he and I took the opportunity in 2014 to look at our results 10 years later to find out were these men still cured of their cancer? How potent were they sexually? How good is their urine control? And what we showed was, again, a little bit of a nod toward the robot being better than open.

SPEAKER_04 9:42

It's hard to imagine that we could get even more advanced, but what is on the horizon for robotic technology in the next 20 years or so?

SPEAKER_05 9:50

So just like your TVs, right? We sort of went from standard to high def to 4K. So the visualizations and gotten better and better. Now we have fluorescence. I flip a switch on the robot and it's almost fluoresces. It's a different light. So it lights up different structures that I inject, and I can inject their blood to see vascularity. It gives me a different kind of look. So I think there's going to be more things that we can inject and have different types of fluorescence to determine what tissue's cancerous, what isn't, things of that nature. Now we have vessel sealers and tissue sealers and all these things to control bleeding while minimizing tissue damage. The instruments continue to get a little bit smaller. You're just tweaking things. What's going to be the big next revolution? I don't know, because if I did, I'd probably be doing that right now, not chatting. I hope I recognize it when it comes. I'd like to think that I did do a good job recognizing this. So you make your your guesses.

SPEAKER_04 10:53

Hey, Doctor, thanks for your time and congratulations on this important milestone, a personal milestone, and also one for Hartford Healthcare. Thanks.

SPEAKER_05 11:01

I appreciate the time.

SPEAKER_00 11:03

Thank you. Steve Coates and Dr. Wagner. Check the links in this episode's notes to learn more about Hartford Healthcare's Tallwood Urology and Kidney Institute and robotic surgery. For Hartford Healthcare, I'm Enron DePierre. Thanks for listening to More Life.

SPEAKER_03 11:18

I'm ready for my clothes up. All the faces start to light up. You know I love this feeling. I got more life than I like. If you feel it, then you know it. We can go anywhere we want to go.