I'm Doctor Keith Kowalczyk, I'm a urologic surgeon
at MedStar Georgetown University Hospital.
I mainly focus in robotic surgery and urologic oncology,
specializing in prostrate cancer and kidney cancer.
I'm a general urologist so I'll see all sorts of urologic diseases,
but I primarily focus on urologic oncology
which is kidney tumors, bladder tumors,
prostate cancer and things of that nature.
I operate on these tumors if need be,
or if there are other minimally invasive approaches
I also take a minimally invasive approach to most of these tumors.
Urology is, in my opinion, better than any other surgical specialty
because we are able to follow our patients for a long period of time,
not just by operating on them but treating them medically
and following them for follow-up and whatnot.
And I also enjoy the technology that urology provides.
We've really been on the cutting edge. At first laparoscopic surgery
and now robotic surgery, we were the pioneers in these fields.
I really enjoyed being part of bringing robotic surgery to the forefront
for some of these diseases.
I love my job because I always wanted to be a surgeon
but I also wanted to treat cancer my whole life,
and a big part of urology is oncology.
Probably 60%-70% of what we do is oncology.
And I like being able to see patients, and see them in a real time of need.
To be having a diagnosis of cancer is a very hard thing to take,
and I like to walk them through that process
as well as be able to treat them and hopefully give them good outcomes
and follow them up for long periods of time.
Robotic surgery is essentially an evolution of laparoscopic surgery.
It's keyhole surgery in which a camera is used
through small incisions to look through the abdominal cavity
or the organ of interest.
Other small keyhole incisions are then made to insert instruments
that we use to perform the operation.
Under traditional laparoscopic surgery
we as the surgeons control the instruments with our own bare hands.
With robotic surgery there's a robotic console
that comes over and actually handles the instruments
while the surgeon is at a separate console
and controls those instruments completely.
Now, the benefits of this is that the robotic instruments
are much more precise than traditional laparoscopic instruments
and also the interface of the robot eliminates any surgeon tremors
so it makes it a much more precise surgery.
Additionally the camera used for robotic surgery
is much stronger than traditional laparoscopic surgery.
It has a three-dimensional view
so I'm able to see any of the organs of interest much, much better,
and it also has magnification of the surgical field,
up to 10 to 12 times magnification
depending on the series of robot that you have.
So all of this adds up to a much more precise,
much more clean surgery in my opinion.
I'm often asked by my patients whether I'm performing the surgery
or the robot is performing the surgery,
and it's an important point to make
that the robot is simply an extension of my hands
to perform a better surgery for them.
When I perform robotic surgery
I'm in complete control of the robot.
The robot mimics my hands and I'm simply using the robot
as another surgical tool to provide them a better surgery.
It's also important for patients to realize
that it isn't just the robot that makes a better surgery
but it's the experience and the training of a surgeon
that makes a better surgery.
Patients with elevated PSA, or Prostrate-Specific Antigen
who are worried that they have prostate cancer,
anyone with a renal mass,
patients with blood in their urine
or who have a worry about bladder cancer.
I would see all of those types of patients,
evaluate them and figure out what kind of treatment is best for them.
The most common robotic surgery that urologists perform
is a radical prostatectomy,
however we've also applied it to kidney surgeries as well
such as a partial nephrectomy which is removal of a kidney tumor,
a pyeloplasty which is a repair of an obstructed or blocked kidney.
We've also these surgeries to radical cystectomy
which is a removal of the entire bladder for bladder cancer,
as well as other complex, urologic reconstructive procedures.
Anyone that's a candidate for surgery in general,
which means that they are generally healthy,
have a greater than 10 year life expectancy
is a candidate for robotic surgery.
In fact I think more patients are candidates for robotic surgery
than open surgery,
for example men with higher BMIs or heavier men.
Traditionally that was a very difficult procedure to do
if you did it open because you just didn't have the visualization.
With the robot we're able to visualize the prostate much easier
in these heavier men, and in fact have been able to offer surgery
to men with higher body mass index.
I'm often asked if patients with inguinal hernia repair
or umbilical hernia repairs are able to undergo the procedure
and the answer is yes, they can still undergo the procedure as well.
You get the overall benefits of traditional laparoscopic surgery
which includes lower blood loss, less pain, smaller incision,
shorter hospital stay, earlier convalescence
or earlier return to work, but the added benefits
are just because of the more precision that the robot allows us.
The 3-D magnification plus the 10 to 12 times magnification
allows us to see the neurovascular bundle around the prostate,
which is the nerves that supply erections much, much better
and theoretically lead to better nerve sparing.
Additionally we're able to see the urethral sphincter
that controls continence much better
and that can possibly lead to lower rates of incontinence.
Actually in a study that we've performed recently
we've noted that there is lower perioperative complications,
lower mortality as well as lower long term complications
in men undergoing robotic surgery versus open surgery.
So there are multiple benefits
to performing the robotic surgery over the open surgery.
Generally any prostate cancer treatment
you worry about long term erectile dysfunction
and urinary dysfunction,
and that includes radiation treatments or surgical treatments.
So robotic prostatectomy can lead to erectile dysfunction,
however in younger men who have good baseline erectile function
are able to undergo a bilateral nerve sparing procedure.
They can have very good outcomes
and potentially regain acceptable erections
within one to two years after surgery,
although some men may require pharmaceuticals
or some men may require medications to help them out.
As far as urinary incontinence,
total urinary incontinence is very, very rare after the procedure
but it can happen in less than 1% of patients.
Using the robot we've actually noted
an earlier return to urinary incontinence
than those undergoing the open procedure.
This normally improves within a year after surgery,
especially with Kegel exercises and pelvic floor rehabilitation.
Kidney surgeries can be very complex,
especially if you're doing a partial nephrectomy or a pyeloplasty,
a partial nephrectomy being removal of just a tumor
and a pyeloplasty being reconstructing a blocked kidney.
After we do these procedures
it involves a lot of reconstruction of the kidney
or suturing of the kidney,
so that makes these very difficult procedures to perform laparoscopically
and often they were performed open.
The robot allows much more dexterity,
it allows me to suture the defect from the tumor much quicker,
much easier and also allows me to reconstruct a blocked kidney
for a pyeloplasty much faster and much easier.
When we detect a renal mass,
the main treatment is surgical excision.
Kidney tumors don't respond to traditional chemotherapy
or radiotherapy, so the primary treatment
if the patient is a surgical candidate is surgical excision
either by removing the entire kidney or just the tumor itself.
If a patient is older and has more co-morbidities
and has a small renal mass, say less than three centimeters,
they may also be treated with surveillance,
just by monitoring the tumor over time
with CT scans or MRIs or even ablative technologies
which involves freezing or burning the tumor under radiologic guidance,
however the gold standard of treatment
is removal of the tumor either by removing the whole kidney
or removing just the tumor itself.
Since the introduction of the robot
it's made it much easier for us to perform this surgery,
so more and more urologists are able to offer patients
what I call nephron-sparing surgery or partial nephrectomy
where just the tumor is removed,
the remaining normal kidney is left behind
and that patient is much better off with having much better renal function
and still having two kidneys intact
rather than taking the entire kidney out
which was unfortunately more commonplace before the robot.
The Firefly Fluorescent Imaging technology
was introduced to robotic surgery in 2011
and we're fortunate enough to have that technology
here at MedStar Georgetown University Hospital.
When I use the Firefly Imaging,
I mainly use it for partial nephrectomies
or removal of a kidney tumor while sparing the rest of the kidney.
When I was the Firefly, a tracer is injected into the IV
and then I'm able to toggle to a special view on the robotic console
which gives me a fluorescent image.
The blood supply to the kidney then lights up
in somewhat of a black light effect
and I'm able to see the complete blood supply to the kidney.
This is important because 25% of patients
will have anomalous or extrarenal arteries
that we just don't see before surgery.
If those aren't controlled then that can lead to more blood loss
so the Firefly lets me see
where all of the blood supply to the kidney is
and lets me control that
and potentially lead to lower blood loss.
It also allows me to identify any arteries
that may be going directly to the tumor.
This is good because then I'm able to just cut off that blood supply
to that single artery
while leaving the blood supply to the rest of the kidney
which is better off for the patient
and leads to better renal functional outcomes
because then I can just remove the tumor itself
and spare the blood supply to the rest of the kidney.
In addition the Firefly allows me to differentiate
or tell the difference between normal kidney tissue
as well as tumor tissue.
So potentially that can lead to a lower positive margin
or a lower risk of leaving any tumor behind
because I can really see the outline of the tumor
much better with the fluorescent imaging.
I think the main benefit for Firefly will be for complex tumors
that are in the middle of the kidney,
large tumors that have their own blood supply.
These are very, very difficult procedures to perform laparoscopically,
robotically, even open,
and many times these tumors would have to be removed
by radical nephrectomy, removing the whole kidney.
Recent reports have questioned the utility of PSA.
I believe that the data that we have right now is inconclusive
or incomplete at best. In fact, more recent studies
have shown that PSA with longer term follow-up
actually does have a benefit in men as far as mortality goes.
The bottom line is we can all agree that PSA isn't the best screening test
or isn't the greatest test that we have
but it's the only test that we have. Yes, we need better markers
but this is the only test that we have to screen for prostate cancer.
Since PSA was introduced in the early 1990s,
mortality has been greatly reduced from prostate cancer
as well as metastasis which is painful for patients.
That's been greatly reduced since the introduction of PSA.
Additionally there needs to be a distinction
between over-diagnosis with PSAs and over-treatment.
Just because one patient is diagnosed with low grade prostate cancer
does not necessarily mean
that they need to have an aggressive treatment.
So I still recommend that all patients be screened.
Those who are at high risk, who are African American
or have a family history start to be screened at age 40
while everyone else gets screened at age 50.
I've even started doing some baseline PSAs on patients in their 40s
to risk stratify them, because there is some data
that any patient in their 40s that has an elevated PSA over 1
is at increased risk for prostate cancer in the future.
So I still definitely recommend PSA screening.
PSA is not a black and white test
and you really have to look at the trend,
you have to look at the patient history.
It's not something where it's: "oh, it's over four. You need a biopsy."
You really have to look at the trend of the test.
So looking at it as a black and white test then yes,
it's not a good marker because it's not a specific marker
but again, it's the only thing that we have,
and using it in an intelligent way and making intelligent decisions
by having an informed discussion with your patient
on whether we should get a biopsy,
or even an informed discussion with your patient
on what kind of treatment you need,
that's more responsible than say: "let's not screen at all."
I think number one is that we take a multidisciplinary approach
to all of these problems, kidney cancer, prostate cancer
and bladder cancer. We have a very good relationship
with our medical oncologist as well as our radiation oncologist
and therefore patients will get a fair assessment.
As far as robotic surgery of highly trained surgeons
that perform robotic surgery,
we've done a multiple of these procedures over time,
we're very comfortable with performing robotic surgery,
and studies have shown that going to higher volume centers
and going to more experienced surgeons leads to better outcomes.