Urologic and Robotic Surgery at MUSC Health Lancaster Division with Aravind Viswanathan, M.D.

Residents of the Lancaster and Chester counties don’t need to travel far from home to receive state-of-the-art surgical care. Aravind Viswanathan, M.D., a urologist and director for robotic surgery at MUSC Health Lancaster Division, discusses the range of urologic oncology and other surgical options offered, including the da Vinci robotic surgical system, a technology that offers shorter hospital stays and faster recovery for patients.

“I think the most common question that people ask [about] robotics is if it's automated versus human-driven. And it's completely human-driven. The fact is, the robot is just like an extension of my hand, so I'm still 100 percent in control. What I'm able to do with my hand outside gets translated inside the body, just without having to make a big incision for my hand.”
- Aravind Viswanathan, M.D.

Topics Covered in this Show:

• One of the reasons Viswanathan decided to become a urologic oncologist, versus another specialty, is because of the stigma associated with urologic conditions that may cause some patients to be hesitant to seek care. He wants to make sure all patients are able to receive the very best of care, no matter the type of condition they face.
• A major advancement in the treatment of urologic and other cancers is robotic surgery. It is an extension of laparoscopic surgery, with benefits such as enhanced precision and faster patient recovery time when compared to open surgery.
• Extensive training was acquired by Viswanathan for his specialization in urologic oncology and robotic surgery. Today, he uses robotic surgery to treat cancers such as prostate, bladder, and kidney cancer and is the director of Robotic Surgery at MUSC Health Lancaster.
• Under Viswanathan’s leadership, patients in the Lancaster area have access to robotic surgery, with no need to travel long distances like in the past to have access to this type of care.
• He says it is important for patients to know that robotic surgery is fully human-driven by the surgeon, and all the surgeons are trained and continue to stay up-to-date on the latest advances in robotic surgery.
• Some patients may assume the quality of care or access to technology in smaller hospitals is different than that in larger hospitals, but Viswanathan says that isn’t the case. At the MUSC Health Lancaster Division, people can feel safe getting the latest in surgical care close to home.

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Patients living in the Lancaster and Chester counties don't have to go far to experience the very latest technological advances in surgical care. Dr. Aravind Viswanathan joins me today to talk about the growing range of surgical options offered within the MUSC Health Lancaster Division using the da Vinci robotic surgical system. Dr. Viswanathan is a urologist and director of Robotic Surgery at MUSC Health Lancaster Division. Welcome.

[00:00:46] Aravind Viswanathan, M.D.: Thank you very much for having me.

[00:00:47] Erin Spain, MS: Tell me why did you decide to specialize in oncology, specifically urology, why you decided to go into this particular field?

[00:00:56] Aravind Viswanathan, M.D.: I think there's a lot of stigma associated with cancers when it comes to anything remotely associated with genitalia, right? There's a big stigma associated with it. So I liked kind of having become a part of that patient's family when you start talking about these intimate issues. Unfortunately, prostate cancer is very prevalent. About one in six men in their lifetime get prostate cancer. Bladder cancer, kidney cancer, those are less prevalent. I also take care of patients with penile cancer, testicular cancer. These surgeries that we do, especially robotic surgery, endoscopic surgery, open surgeries. you just have a wide array of surgical options that you can offer these patients.

[00:01:32] Erin Spain, MS: Robotic surgery is still a new idea to many patients, and it can sound a little futuristic. Explain what robotic surgery is at MUSC Health Lancaster Division.

[00:01:32] Aravind Viswanathan, M.D.: Robotics, essentially in a nutshell, is an extension of laparoscopic surgery. Laparoscopic surgery people talk about as keyhole surgery, small incisions, you go with the camera. It's certainly much better in many cases if you're able to do a laparoscopic as opposed to open in terms of patient recovery. However, laparoscopic surgery does have some limitations. You're essentially using these chopsticks kind of instruments. They're kind of these straight instruments that you don't have a lot of maneuverability. You can't really rotate your wrists. So if you need to do like complex suturing and things like that, especially in the deep pelvis, which is where I do most of my work, it's very challenging to do that.

So robotics essentially just makes it much easier for the surgeon to operate in these very tight spaces without having to make a big incision. Same advantages as laparoscopic surgery in terms for patient recovery is faster. Most patients are, after for example, like a prostate cancer surgery, they go home the next day. The pain and recovery associated with the surgery is also significantly better compared to open surgery. And that's from a patient perspective, and again, from a surgeon perspective, you're just able to do a lot more things that you otherwise wouldn't be able to, and you get great visualizations, almost like putting a microscope inside the body and you're able to kind of see everything in fine detail.

[00:03:01] Erin Spain, MS: I think it's also important for patients to know that you have spent many hours mastering the use of this tool in a variety of complex surgical procedures. Tell me about the training that goes into this.

[00:03:12] Aravind Viswanathan, M.D.: I'm a urologic oncologist. So, I, you know, after undergraduate, you do four years of medical school. And after that, you do residency, where you kind of train in the specialty that you're interested in. Urologic residency, mine was five years and then after that you can go straight into practice or if you want to kind of sub-specialize in something, get more trainings focused on something, you can do something called a fellowship. So I did a urological oncology fellowship for one year at MUSC Charleston, which I finished a little over a year ago, and after that I started at MUSC Lancaster as an attending physician.

[00:03:44] Erin Spain, MS: You mentioned that you are fellowship-trained here at MUSC Health in Urologic Oncology. You work on cancer tumors. Tell me about the benefits of robotic surgery specifically for the cancer tumors.

[00:03:56] Aravind Viswanathan, M.D.: Robotic surgery is now being utilized in many different specialties, like ENT uses them, cardiothoracic uses them, general surgery does, gynecology does, so there are multiple specialties that use the actual equipment, but I think it was initially started off purely for urology because in the pelvic area, especially where the prostate is, it's a very, very tight space. And even with robotic surgery, it's sometimes challenging, let alone trying to do these things open. You're just staring into like an abyss when you're doing these surgeries.

So I think it has a lot of advantages. Specifically, you know, prostate cancer, no doubt, has radically changed how we perform surgeries, I would say. I would estimate more than 95 percent of prostate cancer surgeries that are performed in this country are done this way.

Certainly, the fact that we're able to offer it to the patients of Lancaster, that's a game changer. Because before I came here, we were not doing them and these patients were having to go to Charlotte or even Charleston to kind of get these surgeries. And unfortunately, we have a lot of prostate cancer where we're at right now. Prostate cancer does tend to affect African American men disproportionately more. And unfortunately, when socioeconomic factors also play a key role, that is if you're not getting timely cancer screening examinations, you're catching these cancers at later stages.

Other malignancies that I treat like bladder cancer and kidney cancer, kidney cancer specifically; we do these things called partial nephrectomy. So if someone has a tumor in one of their kidneys and it depends on multiple factors where the tumor is located, how big the tumor is, patient characteristics, all that kind of plays a role. But whenever possible, we try to do partial nephrectomies, and the idea is that you're taking out just the cancer and removing good kidney behind, so that way you're decreasing the chance of patient ending up in chronic kidney disease or end stage where disease requiring dialysis. Someone who had two kidneys, if you take out one kidney, I think the chance of them going on dialysis is low, but chance of them ending up in chronic kidney disease is high. But the stakes are much higher if you're working in someone who only has one kidney. Those complex surgeries when you have to do partial nephrectomy, again, you can do the old school way of doing open surgery, but that involves a big incision where you're cutting through a big surface area of muscle. And these patients, if you're gonna end up with that surgery, they usually stay in the hospital two or three days, significant pain and discomfort. Again, that's also a game changer in terms of robotic surgery where you're making these small incisions, just like a laparoscopic surgery, just taking out just the tumor and leaving most of the kidney behind.

[00:06:30] Erin Spain, MS: It was a priority to bring the robotic surgery platform to the Lancaster division. And it's been more than a year now since the robot was first used. Tell me about how it's being used, how often it's being used, and what this means for your patients.

[00:06:46] Aravind Viswanathan, M.D.: I think it certainly positively, no doubt impacts the patients in a good way! I can't tell you the number of patients who, you know, even the idea of going to Charlotte, which is 40 minutes away, is going to be a big financial challenge for them, let alone going to Charleston, for example. So, the fact that we're able to offer right here is a big gamechanger. And I can tell you, our volumes have gone up. I'm booking out prostate cancer surgeries about two months from now. I'm doing one to two a week.

[00:07:12] Erin Spain, MS: We also have good transplant surgeons that I work with for complex cases. There are a lot of things about the hospital that has changed in the past couple of years. We're doing a lot of kidney transplants. Our ICU staff have completely revamped. So there are a lot of things about the infrastructure of the hospital, not just the robot itself, but the things that come with it, you know. Complexity of patients have increased, postoperative care ability to manage those things. I think we're becoming more and more of a higher level center. I would love for you to explain to listeners what it's like on a surgery day in the operating room and how you and the entire team interact with the robot.

[00:07:49] Aravind Viswanathan, M.D.: Operating days, they're good. The fun and challenging thing about surgery is that no single surgery is the same. Every patient's anatomy is different, their tumor biology is different. It's still definitely a humbling process every day. There are cases that goes completely smoothly, and there are cases that are challenging. But yeah, I think we have a good team to provide good care for patients.

[00:08:11] Erin Spain, MS: Are there some procedures that you wouldn't use the robotic tool for that you're still using regular laparoscopic surgery or open surgery?

[00:08:20] Aravind Viswanathan, M.D.: I personally use a robot more than the laparoscopic, but there are circumstances where we do open surgeries, and patients may not be candidates for robotic surgery. So, instances for that is mostly not so much for prostate cancer. Prostate cancer, it's kind of hard-pressed for me to imagine an instance where I would need to do open rather than robotic. 99.9 percent it's robotic surgery. But we certainly have very large kidney tumors, and then bladder cancer patients that those are big surgeries. Those take about six hours or so. And if I'm concerned about amount of time the patient needs to be under anesthesia, open surgery is a little bit faster, at least in my hand, compared to the robot.

So, for bladder cancer of someone, I want to get them off anesthesia as quickly as possible. I would do open surgery. And then for large kidney tumors, where you can actually get an IVC thrombus where the cancer actually starts to grow into the big vessels, which kidney cancer tends to do that about 25 percent of the time. So, in those instances, it's much safer to do open surgery. Because you can get into significant bleeding, you're worried about controlling vasculature, making sure that cancer is completely eradicated. So there's still multiple scenarios where open surgery still has a role. So I think we're kind of equipped for both. If someone is able to be done robotically, I'll absolutely do it robotically, just from a recovery standpoint. But there are instances that are just based on patient and tumor characteristics, that you have to make that judgment call.

[00:09:48] Erin Spain, MS: What sort of questions do patients have for you when you explain that this is going to be a robotic procedure?

[00:09:53] Aravind Viswanathan, M.D.: I think the most common question that people ask when robotics is if it's automated versus human-driven, and it's completely human driven. The fact is the robot is just like an extension of my hand, so I'm still 100% in control. It's just that what I'm able to do with my hand outside gets translated inside the body just without having to make a big incision for my hand to get there.

[00:10:15] Erin Spain, MS: Are people curious when they know that this is the type of procedure they're going to have? Do they want to see the instrumentation?

[00:10:21] Aravind Viswanathan, M.D.: I do show them pictures and I think they're always very fascinated when I show them the pictures. We are having an event where showcasing the robot. It's open to the public, community type of event. So anybody who's interested in coming to take a look at it, learn more about it in a hands-on fashion, we certainly have that event upcoming.

[00:10:40] Erin Spain, MS: This is the Da Vinci surgical system. That is the robot system that is used at MUSC Health. Share with me the ongoing education and training that you and your team will undergo to make sure that you're using everything with the da Vinci robot system to its fullest potential.

[00:10:45] Aravind Viswanathan, M.D.:  We are very careful in terms of when we're changing out instruments. We have a safety system in place which depends on me, which depends on my bedside assistant. We are in close communication to make sure everything goes safely. And I think in terms of the long-term goal, we're always trying to push our envelope, so to speak—more complex cases. We're attempting patients who have had other major surgeries. For example, we did a case a couple of weeks ago. Especially now that we're doing a lot of kidney transplants, we did a patient who had a prior kidney transplant that we did a prostatectomy on. So there are things that are probably pretty rare, even in major academic institutions kind of doing those things. Patient had to have an autotransplant. So pretty nuanced scenario. But they essentially had to have their own kidney removed and had to have it put in a different location within their own body.

[00:11:45] Erin Spain, MS: What do you want patients and families considering robotic surgery at MUSC Health Lancaster Division, what would you like them to know?

[00:11:53] Aravind Viswanathan, M.D.: I would want someone to know that our hospital is heading in a very good direction. We have hired a lot of physicians. Most of whom did their training at MUSC Charleston, not just myself, but the general surgeons here, transplant surgeons here, they were all my colleagues when I was doing fellowship down at Charleston. So we're essentially an extension of MUSC Charleston, just triage north. And the reason I say all this is that I think historically, just hearing from patient stories, they would prefer to go to Charlotte for bigger hospital because I think they think bigger city, better care. But the fact is that we're trying to change that notion. We're trying to provide the same good care that someone at Charlotte or Charleston would get.

There's nothing inferior about what we're doing. That's what we strive for. I think you know, urology is probably not a specialty that anyone thinks of, like they need to go see a urologist. But if there are things like, prostate cancer screening, blood in the urine, any of those things, I would say just don't sit tight on it just because you kind of have any stigma or just don't know much about it. We're here as medical doctors because there are diseases that affect these organs. So if you have any concerns, seek care. At least talk to your primary care about these issues and they can make the referral. But I'm always of the mindset that there's strength in knowledge more than kind of being in ignorance. So get information.

[00:13:16] Erin Spain, MS: What do you do to optimize your health and live well?

[00:13:20] Aravind Viswanathan, M.D.: I think you need time for self-reflection. Most days things go well, but there are days when your patients do have complications despite our best intentions. You just try to have a positive outlook. It's kind of a meditation, but you just kind of have to have like an inner dialogue. It doesn't necessarily have to be peace and quiet of not thinking about anything. It could also be the opposite. You can actually actively think about something and kind of say, what can I do better? Is this the way I'm feeling about this? Is this truly helpful or is this kind of just working against myself? So you can have that inner dialogue, but I think you need to set aside some time to have that inner dialogue.

[00:13:54] Erin Spain, MS: Well, thank you so much for your time today and all of these insights. This is a really great opportunity for your patients in the Lancaster area. Thank you for coming on the show.

[00:14:04] Aravind Viswanathan, M.D.: Thank you very much for having me.

[00:14:05] Erin Spain, MS: For more information on this podcast, check out advance.MUSChealth.org.