Beijing United Family Hospital successfully applies robotic surgery in new indication

Thursday, November 1, 2018 News on IT in Healthcare
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BEIJING, Nov. 1, 2018 /PRNewswire/ -- On September 27, Beijing

United Family Hospital (BJU) was visited by for an interview with Prof. Zhu Gang, chief urologist and head of the department of surgery, following his completion
of a difficult and high-risk surgical operation two weeks ago. " Cancer treatment is a comprehensive approach, while the success of a surgical operation is a demonstration of doctors' teamwork and a hospital's overall strength," he said calmly, yet with an air of confidence reflected by the smile on his face as he spoke.

However, the operation was not as "calm" as Prof. Zhu was during the interview. This was the world's first case of a robot-assisted retroperitoneal lymph node dissection (RPLND) following testicular cancer chemotherapy + inferior vena cava tumor thrombectomy (IVCTT) + vena cava reconstruction. Although other hospitals in Beijing have performed similar operations, those were for kidney cancer. The one performed by BJU involved testicular cancer that had metastasized to the retroperitoneal lymph nodes and a tumor thrombus that had formed after the tumor had invaded the inferior vena cava.

Patient with testicular cancer was found to have a long tumor thrombus

In May 2018, BJU's urology department received an American patient with testicular cancer.

Six months prior, he had undergone a right radical orchiectomy at another hospital due to testicular tumor. His pathological examination revealed a mixed germ cell tumor, including seminoma and embryonic carcinoma components. In May this year, the patient's enhanced CT scan showed retroperitoneal and inferior vena cava lymphadenopathy and right hydronephrosis. In this case, he turned to BJU for further treatment.

After the first consultation, Prof. Zhu and Prof. Francisco José Martínez Portillo from Spain immediately organized a multidisciplinary team (The mission of a multidisciplinary team or MDT, which is made up of a group of senior experts in multiple disciplines, is to formulate a personalized diagnosis and treatment plan for a patient by way of group discussions. In the MDT model, a team of experts from the diagnostic, surgery, and oncology departments and related disciplines conduct a comprehensive evaluation for the patient prior to treatment, to jointly formulate a scientific, rational and treatment plan that is fully compliant with all medical standards) within the hospital. The PET-CT suggested that the patient had lung and liver metastases, and lymph node fusion resulting from the retroperitoneal metastasis, which had become attached to the inferior vena cava. After more than an hour of discussion, the MDT reached a consensus that the patient should first be given a chemotherapy regimen and then be evaluated for further treatment. 

After two chemotherapy regimens, the CT confirmed the disappearance of lung and liver metastases in the patient and significant shrinkage of the retroperitoneal lymph node, however a 13cm-long tumor embolus in the inferior vena cava had been clearly identified. The inferior vena cava is the largest vein in the human body and collects the venous blood from the lower part of the body, carrying the blood to the heart.

In patients with testicular cancer, a tumor thrombus is normally removed by an incision of the inferior vena cava. Risks associated with such operations include massive hemorrhage, pulmonary embolism caused by tumor thrombus dislodgement, and the need to reconstruct the vena cava, Prof. Zhu said. Moreover, as, in the case, the thrombus was lying across the bilateral renal veins, it may be necessary to remove the right kidney, a risky procedure with a mortality rate between 5% and 10%. Such procedures have long been considered extremely risky in surgery and are known as "no-go zones."

Soon after, BJU's urology team reconvened the MDT. They advised the patient to undergo further chemotherapy regimens while preparing for surgery. The patient and his family accepted the advice from Prof. Zhu's team. The examination results after four chemotherapy courses were mixed. The good news was that PET-CT indicated the disappearance of the lung and liver metastases, and no hypermetabolic lesions were found in the abdomen; however, the bad news was that although MRI showed the tumor embolus had been reduced in length, it still existed. 3D image reconstruction showed that the inferior vena cava tumor thrombus was 9.8cm long and had invaded the first hepatic portal.

The MDT meets five times to fully prepare for each aspect of the surgical procedure

Prof. Zhu met with the urological team several times to talk about and decide on the final surgical plan, while, in separate discussions, he invited physicians from each department that had some involvement in the process, including anesthesiology, oncology, pathology, ultrasound, the intensive care unit, and the operating room nurses, for preoperative cross-departmental discussions and preoperative preparation. Due to the complexity and high risk of the operation, experts from the various departments undertook a comprehensive evaluation of the patient's condition. The urological team dug deep into the available literature, from both domestic and foreign sources, to understand the latest research progress. Although they could not find any similar surgical cases that could serve as a reference, they looked at relevant disease guidelines and theoretically determined the indications for the operation. They agreed that with the right theoretical and technical preparation, it would be feasible to deploy the da Vinci surgical robot to perform the surgery at BJU. The research that they undertook convinced the team that this would be the world's first case of such an operative procedure.

"An effective MDT depends on the hospital's overall leadership, the expertise of the doctors and teamwork,"  Prof. Zhu said.

After the MDT convened five times in just a little more than one month, the urological team finally decided on the da Vinci surgical robot as the medium to perform the surgical operation consisting of a regimen of testicular cancer followed by an RPLND + IVCTT + a vena cava reconstruction. There were as many as twenty major steps that had to be completed before the surgery could commence.

In addition to the urological team, other departments were fully prepared before the surgery and put themselves on standby status in case of an emergency arising during the procedure. Chief anesthesiologists Liu Wei, Yang Lu and Liu Xingshuai used esophageal ultrasound to detect the presence and monitor the status of the tumor thrombus during the surgery, which, once it has been severed, could lead to a potentially fatal pulmonary embolism. Tian Jiangke, director of the department of ultrasonography, assisted in intraoperative localization of the tumor thrombus using ultrasonography. The laboratory department was also involved, preparing intraoperative blood, to ensure the safety of the patient during the surgery.

Balancing risk and reward to save a patient's life

The operation was performed on September 12, 2018 as scheduled. Dr. Zhang Kai and Dr. Li Hongbo served as assistants, while Prof. Martinez prepared for open surgery in case it became necessary. The patient was found to have a very severe adhesion between lymph nodes and perivascular tissues during the operation. The operation entailed, from end to end, a thorough dissection of the retroperitoneal lymph nodes; a complete separation of the inferior vena cava; placing an inferior vena cava vascular plug at both ends of the tumor thrombus; the localization of the tumor thrombus using a robotic ultrasonic probe; creating an approximately 10cm-long incision along the inferior vena cava wall; severing the tumor thrombus; as well as suturing and completing the inferior vena cava reconstruction.

Most notably, they innovatively used a robotic ultrasonic probe to locate the tumor thrombus. When operating the robot, Prof. Zhu could observe the patient's inferior vena cava and internal tumor thrombus within the same field of view by inserting a ureteroscope into the vena cava lumen called vena cavoscopy. Dr. Yang monitored the tumor embolus and gas embolism using esophageal ultrasound, while Dr. Liu closely monitored the vital signs of the patient to ensure the effectiveness of the anesthesia. The operation took more than 9 hours. After severing the tumor thrombus, Prof. Zhu completed the inferior vena cava reconstruction, with no need to sacrifice the patient's right kidney.

A once-in-a-lifetime operation

During the meetings of the MDT, some colleagues admitted to their fears as the operation was complex and risky. Prof. Zhu allayed their fears and sought to encourage them. "Such an operation is challenge but a growth opportunity for the whole team," he said. "It may be a once-in-a-lifetime operation for me while representing a milestone at BJU. Previously, most people thought of services first when mentioning our hospital. On the heels of years of research and development, our hospital has made great progress in both the academic and technological fields. This operation is a good example."

When answering the question as to whether there were challenges in undertaking and completing such a "first-of-its-kind" surgical operation, Prof. Zhu explained that before the surgical operation was successfully completed, he tried not to think about the honor associated with "the most..." and "the first-of-its-kind in the world". Instead, he focused on considering how to successfully complete the operation with his team, which is a mark of growth for a surgeon such as himself. As a surgeon, the most important thing is to ensure the safe completion of the surgical operation.

Technical support: da Vinci robot-assisted Surgical System + 3D image reconstruction

This is the first time in medical history that 3D image reconstruction technology, which presents the 3D image through computer graphic processing and analysis combined with virtual reality (VR) based on early CT or MRI images, was used to identify the location of tumor thrombus. After reconstruction, images can be split or combined on demand. The existing 3D image construction technology restored the real 3D physical structure, providing a visual representation, and accurately determined the location and size of the lesion and relationship with the adjacent organs. Images, which could be rotated on demand, displayed organs, blood vessels and lesions in a visual presentation, in addition to surgical simulation and lesion measurement.

Prof. Zhu further added that BJU is one of the first hospitals in the country to apply the preoperative 3D image reconstruction and the da Vinci robot-assisted Surgical System in treating a genitourinary cancer, significantly reducing the complexity of the surgical operation. The combination of preoperative 3D image reconstruction and da Vinci robot-assisted Surgical System improves the physician's ability to accurately locate any part of the anatomy, increasing the level of precision needed for the surgery, while reducing the likelihood of operation-related complications and the time needed to complete the procedure, as well as enhancing safety. Prof. Zhu said, "In such cases, the mortality rate is between 5% and 10% for open surgeries, a percentage that most surgeons find unacceptable, while the percentage falls to between 1% and 2.4% in robot-assisted surgeries."

Following the operation, the patient was quickly transferred from the intensive care unit (ICU) to the general ward. He was discharged 7 days later. The patient's children made a card, saying thank you for helping our father.

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SOURCE Beijing United Family Hospital

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