BackTable Urology
Ep. 189 Legends of Urology: Origins of Robotic Surgery with Dr Mani Menon
Tue, 17 Sep 2024
Did you know that robotic prostatectomy has its roots in both the immigrant experience and the renowned manufacturing legacy of Detroit? In this episode of BackTable Urology, Dr. Mani Menon, a pioneer in robotic surgery, joins Dr. Aditya Bagrodia to discuss the development of robotic prostatectomy technology. --- CHECK OUT OUR SPONSORS Siemens Healthineers Theranostics https://www.siemens-healthineers.com/en-us/clinical-specialities/theranostics Photocure https://www.photocure.com/ --- SYNPOSIS Dr. Menon reflects on how robotic prostatectomy techniques have evolved over his career. He shares his journey from India to the United States, highlighting his trailblazing work at the Vattikuti Urology Institute at Henry Ford Hospital. He also talks about the challenges of working with robotic technology, recent advancements in the field, and what the future may hold for robotic surgery. --- TIMESTAMPS 00:00 - Introduction 03:05 - Dr. Menon’s Early Life 06:51 - Experiences of an International Medical Graduate 19:51 - The Move to Henry Ford 36:44 - Transitioning to Robotic Surgery 41:36 - Patient Outcomes and Reflections 47:50 - Technological Advancements in Surgery 55:52 - Looking Ahead --- RESOURCES Photocure https://www.photocure.com/ Siemens Healthineers https://www.siemens-healthineers.com/en-us/urology-equipment
We know that TURBT procedure is critical in the care of patients with non-muscle invasive bladder cancer. With data that shows that CIS was missed by TURBT in more than 45% of radical cystectomy cases and 86% of residual tumors have been found at the original resection site, it's clear that enhanced visualization could be a significant benefit during TURBT's.
Further, with only 23% of patients coming back for re-resection, it's all the more important to do a complete TURBT right from the start.
This week on the Backtable Podcast.
These were all people who worked in the automotive industry. Detroit had the highest concentration of industrial robots in the world. What they felt is they had seen the power of the robot in welding and soldering and screwing in areas where the hand couldn't get into.
What they felt is that they came here because they trusted me and I had told them that I was very well trained in open surgery and they said, well, if you think this robot is going to help you, we've seen how it helps us. What do we have to lose?
Hello, everyone, and welcome to Backtable, your source for all things urology. You can find all previous episodes on Apple, Spotify, YouTube, and on backtable.com. Now, a quick word from our sponsor. From concept to completion, there's a lot to consider when building a theranostics or PSMA PET-CT imaging program.
It's nearly impossible to be an expert in every aspect of this care pathway, but the success of your program depends on it. Get the support you need from an experienced team. Open your web browser and search Siemens Healthineers Theranostics. You'll see the complete Theranostics care pathway and how they can help you customize it to meet the needs of your prostate cancer patients.
Visit their website or stop by Siemens Healthineers booth at the local and national American Urological Association and Large Urology Group Practice Association meetings.
You deliver the care, they'll deliver the rest.
Now, back to the show. This is Aditya Begrodia as your host this week, and I'm very excited to introduce our guest today, Dr. Mani Menon from the Department of Urology at Mount Sinai Health Systems, where he serves as a professor and director of education and director of precision prostatectomy. Dr. Menon, welcome to the show. How are you doing today? Good to see you.
Thank you for inviting me, having me here. It's an absolute honor. I had to really curtail the introduction because that could nearly certainly take the whole hour-long episode here.
but without being hyperbolic here, Dr. Madden's absolute legend in our field, largely known as the father of robotic surgery, a gold cystoscope winner, recipient of an Indian presidential citation in the Smithsonian Institute as a part of a recognition of American immigrants. And I also learned the first Indian surgical trainee at Johns Hopkins University. Is this actually all true, Dr. Menon?
I don't know the part of the first surgical training at Johns Hopkins. It's like 99% true. They may have had somebody who filled in when there was an unexpected vacancy. I don't think so. I think that's also true.
But the rest of it is. Well, again, it's an honor. And I think it's worthwhile to start at the beginning. I would love to hear it. Why medicine? How urology transitioning from India to America? Can you tell us a little bit about that process? Well, it...
In a nutshell, I was and continue to be a wimp surrounded by strong women who told me what to do. I grew up with my mother. My father had died when I was very young. And she idolized her uncle, who was a prominent physician who had died. And she wanted me to become a physician. So I became his physician. Came to the United States.
I was a general surgical resident at my medical school, JIPA, in Pondicherry. And there was a change in administration, and I fell out of favor with the new chairman of the Department of Surgery. So once again, being a wimp, I decided that I would flee India and come to the U.S. I came to the U.S.
to become a neurosurgeon, and then I rapidly realized that urine was more appealing to me than CSF and became a urologist.
Okay, so the first spot that you landed was Philadelphia. Is that right?
Yes, yes, yes.
So just for a minute, let's maybe think back to the time. This is pre-email, smartphones, maybe a letter here or there, international flights, leap of faith. I'm heading to Philadelphia with a few bucks in my pocket. Just walk us through a little bit of How old were you? What stage of your life? What were you thinking? And what does this actually look like in a somewhat granular fashion?
I was 24. There was no match there. So you applied and you went wherever you got it. And I was accepted in the middle of the year, in January of 1973, to the Episcopal Hospital in Philadelphia. I was delighted to get into the Episcopal Hospital. It was a major teaching affiliate of Temple University.
It had a reputation for training excellent surgeons, but much more, it was a community hospital that had a neurosurgical residency embedded within its facilities. a GME, when I thought this would be my best chance of getting into a neurosurgical residency. So that's how I ended up at Episcopal. It was a cultural shock to me. Episcopal was in the middle of Philadelphia's worst neighborhood.
I didn't have a car, and in order to go home, I had to take the subway, I think it was called the L, and then take a bus. It would take me two hours to get home, and then at four o'clock in the morning, I had to get back to be there for rounds at six. I think I was chased a couple of times and yelled at, but I never actually got the privilege of being mugged.
I had, when I first landed, they gave us intern squatters, which were right across the hospital. And I was not used to locking my doors, and so I left the door open. And next to my room was the chief resident. And I think my first week when I was back, I found that somebody had broken into the apartment, broken into the chief resident's quarters and stolen his TV and everything else that he had.
No computers back then. And they didn't have to break into my apartment because it was open. They came in and they found that I was sleeping on the floor. I had nothing, so they left me $5 and walked away.
So it was not too much to take at that point. Yes. How about specifically... Put us in the shoes of being an international medical graduate in the early 70s. Do you recall, were Indians favorably considered as hardworking, integrated? Culturally, did you fit in? Were there lingering racist undertones?
I don't know that there were racist undertones. I think it cut both ways. At Episcopal, it had traditionally been a hospital run by foreign medical graduates. I think 80% of the internal medicine residents were FMGs, as we were called. Not so much the surgery department, but the chief resident was from Mexico.
And the hospital had just started to turn, the GME program had just started to turn, and most of the surgical candidates had become American medical graduates. And when they became American medical graduates, we took two residents a year, they didn't want to take call every other day. So I think a plan was hatched, let's get another person to fill in the spot. Since he or she is coming in January,
He would not be eligible to go through the program in July, and this will kind of help the call schedule. So I felt that I was looked at a little bit more critically than somebody who had gone to medical school in the U.S., which I was willing to accept because, you know, after all, there was an unknown quantity there. When I went to Hopkins, it was interesting.
I started at Hopkins as a PGY-3 because I had done my general surgery at Episcopal and in India. As a PGY-3, I was a first-year urology resident. And I'd go to the emergency room, very busy emergency room at Hopkins, and the security guard would check my ID because, again, as you alluded to, Hopkins had never had an international medical graduate in any of the surgical programs.
I mean, I didn't look at it like he was just doing his job. It was a he. They were always he's, the security guards. But then the other thing happened too. I felt that all the residents around me and all the other specialties felt that if I was good enough to get accepted at Hopkins, I must be pretty special.
And so I was completely accepted, maybe even treated more charitably than if I had been just a Harvard medical student. They had plenty of those, but they never had a gypna student there.
Well, yeah, I think that's a... open perspective, certainly. I can imagine some of those experiences could lead to some persistent anger, irritation, discontentment, but it sounds like you were able to see the silver linings, maybe get a little bit of a benefit of the doubt, particularly at Hopkins, where it seems like your academic career really started accelerating under the mentorship of
Dr. Walsh, Dr. Catalona, and some of the absolute thought leaders in her field. And tell us a little bit about that. Being there in that environment, did it mold you? Was it consistent with the way that you operated?
How would you reflect on that? Oh, it changed me completely. When I came from India, I was simply told, listen to what your professors say, and you were considered a good resident if you were simply able to parrot what they said. Whereas Walsh and I started at the same time. I mean, I started as the lowest of the low, a one-year fellow in urology. I wasn't accepted into the full program.
And Walsh started as the department chairman at that point. But, you know, I was the first person he hired, secretary, bottle washer, resident. Because I was, by definition, the weakest possible resident that they could have hired, they matched me with the strongest possible senior resident.
And the first years and the third years in urology, the PGY-3s and PGY-5s, took tandem rotations or took parallel rotations. And the person who was the PGY-5 resident was Bill Catalona. And Bill and I became very, very good friends. And Bill took it upon himself that I wouldn't fail. He made it his point to cover for me, to support me, and make sure that I succeeded.
I don't know why he did that, because I don't think he particularly liked me, but I think it was just a challenge of taking this person and making sure he didn't flop. That appeal to Bill.
All right. So in general supported, you'd mentioned earlier that you'd fallen into some disfavor with the chairman of surgery at your home institution. And I was curious, was this disruptive behavior? dynamic energy always kind of a part and parcel of your MO? Or was this something that was cultivated and developed? Those were just the cards that were dealt to me.
You know, I was the golden boy of the previous chairman of surgery. These two people didn't get along well. So they were always fighting and maneuvering. And so the previous chairman got transferred. And the new chairman said, well, you know, you were this person's favorite son. Let's see how you do with me. It wasn't something that I could do anything about.
So transformative experience at Hopkins. And I have to imagine you were offered to stay there for as long as you wanted, but you went out to seek your own fortune, so to speak. Is that right?
Yes. I came to the U.S. because my wife wanted me to come to the U.S., and she was a resident in nuclear medicine at Hopkins and wanted to get a radiology residency. It was not accepted at Hopkins. She was accepted at the places that I looked at.
And initially it sounds like your interest was both in nephrolithiasis, kidney stones, as well as cancer in the early days. Is that correct, Dr. Menon?
It was mainly in kidney stones, you know, very, very little in cancer. There was no PSA testing. So, you know, Pat Walsh had done 12 radical prostatectomies in the year that I was the chief resident. Most of them were spectacular, but some of them, there was a lot of blood loss with that. And it was kind of unpredictable, at least to me. I think 40% of all that we did at Hopkins was kidney stones.
And 25% of the major open surgery was kidney stones, much more than cancer. So it seemed like that's what I wanted to do.
Okay. Okay. And then across your path, particularly maybe in St. Louis, you cross-pollinated with some of the other notable greats in laparoscopic surgery. Did that happen? Kavusi, Klayman, did you all overlap?
Clayman and I were contemporaries. Clayman finished his residency at the University of Minnesota and went to UT Southwestern to do a fellowship, I think Charlie Park. I did not do a fellowship. I went straight to run the Stone Clinic at Wash U. So when I left Wash U and moved to UMass, I helped recruit Clayman to take my job.
If I had known that he was going to be so much better than me, I may not have been that anxious to recruit him. A sense of altruism, perhaps. So I introduced him to Bill Catalona, who had just become the chairman, and to Sam Wells, who was the chairman of the Department of Surgery, and helped smooth his transition. Lou was an intern, so I was part of the interviewing team for him.
There were 13 people who interviewed him, and 12 of them thought that he walked on water, and the 13th did not. And I was the 13th, so Lou has never let me forget that. But clearly, it had no impact whatsoever in his getting a residency, and we've been You know, good friends. I've admired him and Ralph Klayman for the tremendous work that they have done.
So amazing pedigree, awesome self-starter story coming from India, starting at a community program, winding up at Hopkins, you know, certainly at the time, unequivocally, probably the greatest. Urology program in the country, in the world, moving on to places like WashU, incubators of a lot of development.
I think at that time, it kind of seems like there is a critical energy mass accumulating for something special, something big. This is my sense, just learning a little bit about you. Is it accurate?
And can you talk a little bit about getting to Detroit and going from really important work in nephrolithiasis continually funded by the NIH to changing the way that urologic surgery and urologic cancer surgery is performed?
I was interested in kidney stones, and I had the privilege of working with Albert Leninger, the renowned biochemist who wrote the textbook of biochemistry. So I spent a year in his lab. Hopkins at that point had gotten a spore project on calcium transport, but they didn't have anybody in the department who was interested in stones, so they told me, you become the stone person.
I thought that since we were talking about stones, we should talk not just about calcium transport, we should talk about oxalate transport. On an equimolar concentration, oxalate is 10 times more potent than calcium in causing precipitation. And Dr. Langeau was happy to let me do that because it was a new area for him.
So as the result, within three months of moving to WashU, I had an NIH grant and a BA grant, which it turns out was pretty remarkable. I mean, WashU had lots of great researchers, but to get two grants, particularly as a surgeon, within three months of starting, it caused people to open their eyes. So once again, I think there were some political issues.
The department chair, Bill Fair, moved to Memorial Sloan Kettering, and the new department chair, the transition was a little awkward. Dr. Wells, Sam Wells, he promoted me to associate professor with tenure, and I became the youngest clinical tenured professor at Wash U. Again, I didn't lobby for it.
I didn't know what it meant, but it clearly meant a lot in the narrow world of academic medicine and how we are. So that and the two NIH grants propelled me to the University of Massachusetts, where I became a chair when I was 34, two years out of my residency. Three years, two to three years.
So things were working well, you've got experience in grant writing, funding, basic translational clinical research, now getting some administrative experience at your new position at UMass. And how long were you at UMass? I was a chair there for 14 years. All right. So that was a good early, mid-career experience. And what prompted the next change?
Same thing. A new Department of Surgery chairman. And actually, the department had wanted me to become the chair. We were a division, like UC San Diego was for many years. I did not want to become the chair because I thought it would take me away from clinical work and research. And But the new chair saw me as a threat.
And my lack of political skills, not having a filter between my brain and mouth, did not stand me in great stead. So I decided that I would move from there rather than, you know, fight these battles constantly.
And the next stop was, of course, Henry Ford.
At Henry Ford.
So obviously, or it seems obvious to me that that's really where all the pieces of the puzzle really started coming together in a major way to have such a dramatic impact. And maybe just walk us through that. I mean, surely it wasn't just you woke up one day and you said, I want to revolutionize the way prostatectomy is done. Here's how I'm gonna do it.
Or there's this new robot that you heard about, or there's this amazing foundation. Tell us a little bit about the Vatikuti Institute, of course. How did that develop organically, intentionally, serendipitously? Walk us through that, please.
So Raj Vatikuti was a young man who had done very well for himself in the software industry. He had come from India, much like Sundar Pichai and Satya Nadella had come. I mean, he had They were his contemporaries. The audience, Sundar Pichai is the CEO of Alphabet and Satya Nadella is the CEO of Microsoft. So we're not talking lightweights here by any means.
And Mr. Vatikuti felt that he wanted to give something to his community, which was Detroit. He had no idea of medicine, what medicine was, and so he hired a bunch of consultants saying, I want to make an impact. Where should I make the impact? And they said, well, what disease do you want to impact? He said, what disease should I do? Is there a disease called cancer? I said, yes, yes.
I think I want to make a difference in cancer. And then he said, well, you know, there are many kinds of cancer. Which kind of cancer do you want to make an impact? Then he said, what are the commonest cancers where I can make a difference? And they said breast and prostate. Then he called around to see who were the people who were doing breast and prostate cancer work.
And, you know, here again, maybe this is affirmative action. When there was somebody from his home area who was working on cancer, he kind of felt a bonding and a friendship. And we just got along well. And that's how we decided to fund it. It may have helped because, and this is again the lack of filter in my mind, when he said, how should I set this up?
And I said, well, there are three major institutions in Detroit, four, but one you decided you don't want to fund because somebody else had funded it. And so the three institutions are the University of Michigan, William Beaumont Hospital, and Henry Ford. And maybe you should fund all three and make them work together. So he said, well, how much money should I give?
And I said, well, why don't you give $30 million to the University of Michigan? They can spend $20 million to do breast and $10 million for prostate. Give us $20 million, and we'll focus it on the prostate. And then give $10 million to Beaumont, who can focus it on breast. So roughly, you will have equivalent prostate and breast growth. And he liked that.
I almost got fired because it was not my business to advocate for Beaumont, the University of Michigan. But this guy felt, you know, this is a person I can trust. He's trying to do the best he can for me and my foundation, not trying to do the best for him. And so he decided to fund us. And here is his business foresight.
He decided the conditions that he placed were that only I would have sign-off authority. He did not want a committee, the cancer center, research department. I should have sole signatory authority. It was all current use funds. He did not want an endowment. He wanted me to spend it down because he felt that that would have the greatest impact.
Now, I had to put together a proposal, but the key note of that proposal was to develop minimally invasive surgery. And the reason that I wanted to develop minimally invasive surgery was to try to decrease the blood loss that I saw from the occasional radical prostatectomy. But more than that, Detroit, for many, many years, was the most depressed city in the country.
We had a 30% complete unemployment and a 50% underemployment rate. 40% of the patients I saw were African-Americans. We had... an HMO that was capitated, and we had computerized medical systems long before any other place, any other hospital in the country had it. And so when I searched the medical data, I searched it, Ashutosh Tiwari, who was my fellow, searched it for me.
What we found was that the survival rates were lower in the African Americans than in the Caucasians. But when we adjusted it for the type of treatment they had, A confounder that we could not exclude was that African Americans overwhelmingly chose to have radiation therapy as opposed to radical prostatectomy. And when I talked to them, it was two things.
One is they were worried about the Tuskegee experiment that they would be experimented on. But a lot of them, these were assembly line workers, they were brought up with the concept that if you cut someone open and expose the cancer to air, the cancer would spread. And no matter how much I tried talking with them, I could not break that.
I thought maybe they didn't trust me because I was in black. And so I recruited people from that background, from that community to go and talk with them. But they still were afraid of being cut open.
Given this health care system with equal access to health care and complete follow-up, because this was a capitated HMO and you didn't have to pay to get the thing, African-Americans, stage for stage, still did worse than non-African-Americans. We had a large Arab-American population and a large Caucasian population, and the overall survival and the cancer-specific survival were better than that.
And I got the idea that if we developed a minimally invasive surgery, maybe I could walk to them and say, listen, I'm not exposing your cancer to air. You know, I'm putting in a camera and taking the thing out and putting it in a bag. There's no exposure of cancer to the air. Why would you consider that? And that turned out to be correct. That's fascinating.
Yeah, you got to meet people where they're at at the end of the day, right? And we live 30 minutes from the border. There are cultural things undoubtedly that impact us. So you show up in Detroit and you've got somebody that you can relate to and put together a sound business proposal, a plan. You've got an idea.
There was no business proposal. These guys were too smart. I did come up with the business proposal to do robotic surgery, but I had to preface it by saying nobody had done it. There were 19 robots, 18 robots in the world. This would have been the 19th robot. All 18 robots were in cardiac surgery departments. No cardiac surgeon had gotten it to work.
Prostate cancer was the furthest from the company's viewpoint. They had no idea that this would work, but I wanted to try it. And he said, sure. And I said, well, don't you want a business plan? So he said, you just told me that nobody's done this before. You don't know whether it will work. The company doesn't think it's going to work. What kind of a business plan are you going to give me?
They're all going to be fake numbers. So I trust you. Take it. Do what you want with it. Come back to me in a year. And if I'm not happy with what you did, I will fund you again.
Yep. That's a reasonable pilot program, so to speak. Yeah. Yeah. Well, and let's talk a little bit about Intuitive. You know, once upon a time, I think academics and industry were seen as difficult to coexist. But I would say now and certainly it would seem the relationship that you all had with Intuitive was extremely beneficial to all parties, starting with the patients.
Tell us a little bit about that, if you could.
Well, I had a very good relationship with Lonnie Smith, who was the CEO of Intuitive, with Gary Goodhart, who succeeded him as the CEO, and with Dave Rosa, who succeeded him. Those are the only three people that I had a good relationship with. So when I had the funding approved by Mr. Vaticutti and by Henry Ford, I flew over to Sunnyvale with Ash Tiwari.
I said, I'd like to think about doing this. And Lonnie said, well, are your cardiac surgeons on board? And I said, no, they don't even know that I'm coming and talking with you. Well, how about your laparoscopic general surgeons? And I said, well, I haven't talked to them either. So, well, certainly you've done a lot of laparoscopy. Actually, no.
Lani said, listen, there are eight people in this company. We desperately need to sell robots. But I'm not sure that I'm doing you a favor by having you buy the robot because I don't think you know what you're doing. And I said, well, no, I don't think I know what you're doing, but I'm not sure that you know what you're doing either because you built this for cardiac surgery.
You tried it for with 18 cardiac surgeons. And where has that taken you? So he said, OK, well, you know, if you decide to do this, I've warned you, we will support. So that was a good help. I realized that I loved working with the robot, but I didn't like working with their marketing division and I didn't like working with their sales people. And so I have never given a talk for Intuitive.
I have never proctored a case for Intuitive. It was a separation of church and state. I would do the cases to the best of my ability. I would collect the data as accurately as I could and then let the data tell me whether what I was doing right and what I was not.
Well, that's important. I think maintaining that balance, especially when you're on the ground floor, so to speak. And all right. So, so they took a chance on, you took a chance on them. You've got your robot, you've got the support of the Institute and time to do something. And walk us a little bit through that. I mean, did you do some lab prostates and see how that went?
Did you have people come in and do some lab prostates? Did you travel? Did you do pig labs? I mean, or was it like, let's just find a patient, see how it goes? How did that whole process work to one day I'm going to try to do a robotic prostatectomy?
Well, you know, as I said, I was a wimp, so I had to do my groundwork to make sure that the patients didn't suffer. I didn't want the patients to suffer because I hated complications, but I also felt this was not a way that I could repay somebody for their philanthropy. I had to make sure that I succeeded so that he succeeded. And actually, at the time we got the funding, there was no robot.
It was not FDA approved. So the goal was to develop a laparoscopic radical prostatectomy program. And I had done some laparoscopy when I was at UMass, but I rapidly realized that I was not a laparoscopic surgeon. I didn't want to do that. So I had one of the junior people do it. And all they did was laparoscopic lymph node dissection.
Laparoscopic radical prostate surgery was a whole different thing. I called up the best laparoscopic surgeon I knew. A person had just written a paper about doing laparoscopic radical prostate surgery. And that was Lou Cavusi at Hopkins. And I said, Lou, what do you think about laparoscopic prostate? And he said, it's a terrible idea. He said, I've tried doing it.
And, you know, I'm a very good laparoscopic surgeon. I'm pretty good. But this operation brought me to my knees. So I said, OK, let me call Alan Parton, who you know, was in the next office and was an open surgeon, and maybe he would see the value of laparoscopy. And Lou was not a prostate cancer surgeon. Ditto from Alan Barton, saying, this is a terrible idea. You should never do that.
It's a really bad operation. So I decided I was going to do it. I mean, these two people said, no, I was going to do laparoscopic prostatectomy. I thought I would call Ralph Klayman. I'm cashing in all my IOUs here. So I called Ralph and said, Ralph, what do you think about laparoscopic prostatectomy? And he said, you know, buddy, this is a terrible idea. I mean, I've heard you.
You've had some good ideas and some bad ideas, but this is the worst idea that I've heard from you. But knowing you, you've already talked to Luca Vusi and he's told you it's a terrible idea and you've decided that you want to do it anyway. So let me stack the deck a little bit in your favor. Go talk to Bertanghino in Paris. He is the only person who can do it.
And if you can collaborate with Bertanghino, you might have a job. And I said, well, I called you thinking maybe you would come and do it. He said, I'm not going to do it. He said, And I said, why not? I mean, you're the father of laparoscopic surgery. He said, buddy, you can take a golf club and put it in any golfer's hands, and there'll only be one Tiger Woods.
And that Tiger Woods is Bertrand Guillot. So I got on a plane and went to meet Bertrand. And the short thing of this is I arranged for them to come down one week a month to do laparoscopic prosthetics, straight laparoscopy. And we would batch our cases. They would do them five days in a row, nine cases a week. And then we wouldn't do any for another three weeks. And they would teach me.
And it wasn't pretty. I really did not like doing laparoscopic surgery. But it also wasn't that pretty. when they did it, not to me. It was magnificent when they did it in Paris. It was not as good as I had seen Walsh do the open radical prostatectomies here. And the big difference was the BMI in body weight. The French patients had a BMI of 21, 22.
You put the laparoscope in and the prostate was begging to be taken out. whereas the Detroit patients had a BMI of 35. It was a struggle, just going through seven inches of fat on the anterior abdominal wall. And this became very apparent to me when Bertrand and Guy Valencian came.
Bertrand was an Olympic-level fencer, incredible athlete, and he stayed with me during this whole year when he was doing it. We would do two cases and he would just come home and collapse. Whereas I would see him in Paris and he would do three or four cases and would bicycle 15 miles to his home.
And Brassand essentially said, if I were an American surgeon, I would not have developed laparoscopic prostate. I mean, we are so lucky to have the people that we have. And then Barsan left for Memorial Sloan Kettering. And I had two choices, close the program or come up with something else. And the robot was there. I had seen it in Montsouris.
Guy Valencien had a mobile robot or a rotating robot for a week. And Valencien had asked me to sit down and do a little bit of the dissection. And I loved it. I thought while I was very sure I couldn't do a laparoscopy, I was pretty sure that I could do robotics. So I got the robot and we would run two rooms in parallel.
I would start the robotic case in one room, and in the next room, Bhatand would do a laparoscopic case with Jim Peabody and the residents. So it would be Tiwari and I doing the robotic case, and Bhatand and Jim and someone else doing the laparoscopic case. I could operate for about 20 minutes, and then the tension was too high.
You could see the band around my forehead from pushing my head into the console visor. Within about 40 minutes, Bhattacharya would have finished the laparoscopic case, and then he would come. We would remove the ports. He would put the laparoscopic port, same ports. So he would just change instruments and complete the laparoscopic prosthetic. This went on for about three cases.
On the fourth case, I finished my case before he had done his 1,000 laparoscopic prostate. That was just a fluke. I mean, I think this patient had good anatomy, and Bhartan's patient did not have good anatomy. We didn't know what it was on the outside. They both looked the same, but on the inside, they were very different.
So like your governor from California said, I felt that there must be a pony in there somewhere. If I could, at four cases, be quicker than Bhartan was at 1,000 cases, Maybe I could learn from that. That's what happened. I mean, the fifth and sixth case, I was no longer as quick. But by the 18th case, I was reproducibly quicker than the laparoscopic surgeons.
The blood loss was the same, and the outcomes, as we could see it, were the same. The margin rates and the biochemical recurrences were the same. So once again, because we had to do our cases when the French surgeons were there, we batched them. So we would do five robotic cases in a week while they do five laparoscopic cases. And at the end of it, we would collect the data and see how things did.
We videotaped every case and we would go over the case at the end of the day, even though we would dog-tired and tried to figure out what bad moves I had made and what good moves I had made. And everything was fair game. I mean, the nurses, the anesthetists, they were all part of this team. I insisted on the same anesthetists and the same nurses. And the residents were the same. It was all Tiwari.
And we would, you know, try to find out what, how we could improve. But then when we went to the OR, I didn't want 10 people giving me 10 different approaches of doing this. Why don't you cut here? Why don't you cut there? And all that. The time for that discussion was over. I was going to do it my way, unless they saw something really that I was doing that was really terrible.
Now, if I had been in my shoes, I would have said, Menon, you're terrible. You don't know what you're doing. But Tuwari did have a filter between his brain and his mouth. You know, I would ask him, am I doing the right thing? And if he didn't, if he would do things a little differently, he would say, interesting, Dr. Menon, interesting.
And so that was my cord to take a step back and see what am I missing here? I could cope with that. But then he had... a hidden message for me which i couldn't cope with and that is when i really screwed up he would say wow you know at that point i really had to back off and uh and pause
Well, that's amazing. I mean, it shares so much humility that, first off, I can learn something from other people and a commitment, both at your end and at the end of your French guests that would ostensibly leave their status quo one week a month for up to a year. And then being open to receiving some input from a fellow, no matter how naturally talented and gifted they may be.
And it sounds like it worked, you know, that maybe four or five cases in, it's like the first time you get out to play golf and you hit a decent shot, you're like, I think I'd like to keep coming back because that felt really good. Yep.
Yep.
So those were the early days, and I love you kind of walking through that in some degree of granularity. Did you ever think about quitting? Did it ever seem like, you know what, this is brutal, this is a beat, this is not going anywhere?
Yes, case one, I almost quit. It was an enormously expensive proposition to do this. We paid them close to six figures a week to come over here because I didn't want them to feel, God, why am I doing this? I wanted to make sure that it was there. And now I work for a big institution much like UC San Diego, and the analogy would be
You know, if Manoj wanted to recruit somebody from Australia to do nerve grafting and said, I want to pay him four times what I'm paying myself. I mean, institutions simply won't buy that. Our institution did because of the, this was grant funded, didn't cost them a penny. And the donors wishes that, you know, I should be given latitude to develop the program the best way that I did.
So the first robotic case was a very strong, muscular African-American. who had a Gleason 4 plus 4 cancer. Probably not the case that I should have picked, but just the way the informed consent was done, he happened to be the first person who agreed. And I felt ethically the person who agreed first should have this done.
And the surgeon who was doing it started doing the prostatectomy, went posteriorly, developed the planes, and was about to transect the urethra, but he couldn't figure out where the prostate ended and where the urethra started. And that's just because this person was so muscular and the robot magnification was different from the laparoscopic magnification.
And the anatomy in an African-American pelvis is different from a Mediterranean pelvis. So I think we spent about an hour arguing about where to cut the urethra. I couldn't tell him where to cut it. I mean, he was the surgeon. I mean, I was learning from him. But We ended up opening him up. And I ended up having to do an open radical prostatectomy.
And it's really difficult to do an open radical prostatectomy in a person with unfavorable anatomy who has had four hours of laparoscopic surgery. But the only thing that I learned from it is that I knew the anatomy in my patients better than the French surgeons did. Because I was used to seeing this anatomy and they weren't.
So where I wanted to transect the urethra laparoscopically was where I ended up transecting the urethra open. And, you know, we did the case and I went home and I got a call saying, The patient isn't moving his leg. He's paralyzed. So I said, call the neurosurgeon and I'm coming in. And as I was driving in, I said, if this person doesn't move, I'm going to cancel the program.
You know, we were legally bound to honor their contract for a year. This was their first case. So I would somehow have to justify this with our administration and the donor, because I'd spent a lot of money into this. We had agreed to buy the robot, which was, you know, a million dollars, $999,000. But I couldn't conscientiously have a patient become paralyzed because I was trying something new.
By the time I went there, the patient was moving. When I was told that it was either stretch on the sciatic nerve or the femoral nerve, I forget which, maybe from the retractors on the femoral nerve or the sciatic nerve from the reverse Dellenberg position with the hips flexed, and that he would be okay. And he was okay. He had a Gleason 9 cancer with seminal vesicle invasion.
He was incontinent and impotent. Not the best way to start the program. But I saw him 14 years later. He has an undetectable PSA. He is incontinent and he's potent and he's a fan of the procedure that he go figure.
Oh, that's a, yeah, I mean, that would get you thinking once or twice when you get in there and try something new, particularly, especially perhaps if there were skeptics. And I'm curious, were there skeptics?
I'm not sure, you know, one of my closest friends, Paul Schellhammer, Well, it was in the OR because he wanted to see robotics. So he was there for this case, and Paul's an absolute gentleman. It kind of shocked him as to how primitive we were. But I think what he told me is, I like the way that you converted him to open.
So Paul became a friend, and he got a robot for Eastern Virginia Medical School much before UCSD got one or UCSF or UT Southwestern.
Early adopter.
Yes.
So it sounds like maybe around case 1820, you were starting to kind of understand and appreciate that you touched upon something potentially disruptive. And on the one hand, the rest is history. On the other hand, it's been nearly a quarter of a century since then. And maybe I'll ask you to reflect a little bit on the changes.
I mean, clearly the market share of robotic prostatectomy is an obvious one, but the changes kind of in terms of the operation and how it's been refined, is that meaningful? Is it incremental? And perhaps ask the same question about the technology. and how it's advanced. Is that meaningful? Is it incremental? First, let me talk about the technology.
The lenses that we dealt with were called POC, and they were fuzzy, and I couldn't see through them, and I would constantly complain to Intuitive, you need to get me better lenses. You can't send me out to do these cases with these lenses. And they said, oh, no, these are the best lenses known to mankind. Well, now they call them the POC lenses, piece of crap for POC.
But they did get better lenses. The next set of lenses were the Shoei system, which was very good. And then they got the Olympus. And then they got the SI system, or the S system, which was high definition, and the SI. So, I mean, it's very, very different technology. But Maybe it's like a car that you drive today and you compare it to a car that you were driving in the year 2000.
I mean, both the cars would get you where you wanted to go, but there's no question that any car that you buy today is much better than the car that you could get 20 years ago.
That's a perfect analogy. We were just in Tucson for the Arizona Electric Society and I rented a car. It was a Corolla, a 2024 Corolla compared to my 2008 CR-V. I felt like I was in a luxury car that was incredible with all types of bells and whistles and safety features. So the technology's advanced and as somebody who's been in urology for, gosh, almost 15 years, I certainly see it advance.
And sometimes I say this is a big change and sometimes it seems a bit more incremental. Maybe just to put something kind of concrete out there, The new DaVinci platform, is it exciting to you? And the, I would say, renewed interest in other robotic platforms, is it exciting to you?
The answer is yes, but there was something that I had meant to touch upon. I'm going to put you on the spot now. No good deed ever goes unpunished, and you've been incredibly gracious. So let's say you were me. You were starting in Michigan, or let's just say you were starting in Michigan. trained with Pat Walsh, and you thought you were a pretty good open surgeon.
In fact, you were the first open surgeon outside of Hopkins who had done a nerve-sparing radical prostatectomy, even before Peter Scardino or Bill Catalona had done it, just because you happened to train with Dr. Walsh when that did, being in the right place at the right time. And you have a patient that you want to explain to him about robotic radical prostatectomy.
You've done a thousand open radical prostatectomies. You're a good open surgeon. You've done 18 robotic cases, and you're kind of feeling that you're getting ready to, this is something. How do you counsel a patient as to whether he should do open cases or robotic cases? I mean, how exactly would you approach the patient?
It's a timeless question, even for anybody just starting out their career and they're asked that inevitable question of how many of these have you done? Yes. I mean, first off, I think you got to be honest, starting out with training. Here's where the kind of numbers come from. In this particular instance, I would tell them that my experience with
open surgery, and an effort to improve patient outcomes. We're exploring things that are novel, disruptive. But with that, there come some unknowns, some risks, explicitly risks specific to laparoscopy, to not having your hands in there, being able to feel to do something a I would try to quantify that. I think my general style is to prepare for the worst and hope for the best.
And I think that's precisely what I do for the patient. And then ultimately say, kind of got our workhorse, which I'm familiar with, and we've got something new that I'm exploring and can look you in the eyes and say, I think I can help you and likely not hurt you through this novel approach. What appeals to you? And we go with that.
That's exactly what I did, more or less exactly what I did. And then we measured everything. So I looked at the first 100 patients I had counseled, and 70 of the 100 chose robotic surgery and 30 chose open radical prostatectomy, which surprised me. I would have thought it would be the other way around, or maybe 10% would choose robotics. And then I tried to find out why they did that.
And this was the reason I wanted to mention this. I wanted to give a shout out to these hundreds of the early patients who were incredibly brave. These were all people who worked in the automotive industry on the assembly line. And at that time, and even now, I think, Detroit had the highest concentration of industrial robots in the world.
They were all used at Ford and GM and what was then called Chrysler and AMC. So what they felt is they had seen the power of the robot in welding and soldering and screwing, no pun intended, in areas where the hand couldn't get into.
What they felt is that they came here because they trusted me and I had told them that I was very well trained in open surgery and they said, well, if you think this robot is going to help you, we've seen how it helps us. What do we have to lose? If you're not able to do it, you will just do the open operation.
I don't see that happening at Sinai, where Tuareg is dealing with Wall Street bankers and high-powered attorneys and New York Yankees players and things like that, and everybody wants a fifth opinion and a sixth opinion before they do that. I don't know that I would see it at UC San Diego. But it certainly happened in Detroit.
And I want to reach out to these people who worked under very difficult circumstances, under very trying economic conditions, but they had faith. They had faith in their physician doing what they thought was right. And I guess some of them, they liked the idea that I wasn't exposing the cancer to it.
I mean, I love that. And it really does come back to the patients. And I think a lot of us practice in different environments with different demographics. And again, I think meeting people where they're at. And sometimes when you have the ability or lack of ability to do a lot of shopping around, you have a specialist type of relationship and that's tremendous.
And I would say, you know, the rest is history. It seems like you became the destination to learn about, to refine robotic surgery. I mean, you know, literally, honest to God, this morning from eight to nine, I gave a lecture to the radiation oncology residents and staff, GU staff. And we talked about advances in surgery and the last 20 minutes was a narrated robotic prostatectomy that I'd done.
And we just kind of walked through it and to show that, to teach that, to talk about the intrafascial planes, the extrafascial planes, the hood sparing, show them that anatomy, when to stay close and far from the urethra. was so cool. So I think for education, for outcomes, for refinement of a surgery, it's been just absolutely massive, not just in urology, of course, but across the way.
And with that, when you reflect at this stage of your career on what you've been able to do Maybe I just ask you as we come up on an hour to talk a little bit about, you know, the best parts of your legacy. I think it's the people I've trained.
It's a mode of life. I did not train them to do the greatest number of cases or write the greatest number of papers. I tried to tell them to take care of their patients and be kind and decent and generous with their time. and I've learned from the people. I mean, my boss is somebody whom I had trained, and I mean, I've told you about all the bosses that I've had problems with.
This boss I don't have a problem with, and it isn't that I changed. It's that he's just a good human being.
So there's no periodic wows these days. Those are maybe he sticks to that's interesting.
No, no. I don't go to the OR, so I guess there's less chance of a wow and an interesting there. The thing that I am frustrated about were two of the last things that I did in robotics which haven't caught on. You know, we first did prostatectomies and it took four or five years, but as you said, that's now become standard of care.
Well, then I was told that you can do prostates, but there's no point in you doing kidneys, and it should either be done open or laparoscopic. Well, now laparoscopy is true, but most of the difficult cases that you do with a robot, most people won't be able to do laparoscopically in fear of any cable thrombus and so on and so forth.
I may have done the first robotic inferior vena cava thrombus in the world, level three thrombus, or level two, two and a half thrombus, together with Rani Abaza. And that's now accepted in places other than Memorial Sloan Kettering. And then we took the robot and went to Mansoorah so that we could learn how to do robotic cystectomies. I did a cystectomy a day, 15 days in a row,
where the Egyptian surgeons were doing an open cystectomy 15 days in a row, and then we compared data. We did that, and that's been successful. I mean, Peter Wickland, who is here, has done over 600 radical cystectomies in New York, at Sinai, in addition to the thousands he's done in Europe. But there were two things that I tried which have worked technically but have not caught on.
One was robotic kidney transplants. It has caught on, but the main reason it hasn't caught on in the U.S. is that the transplant surgeons are not as skilled in robotics as the urologic surgeons are, and the transplant surgeons do the transplants. In India, kidney transplants are done by urologists and it's taken off. And in Europe, in many places, it has taken off.
But I had hoped that would be my swan song contributions to urology. We also... I came to the conclusion that most, if not all, people with intermediate-risk prostate cancer should not have a radical prostatectomy because the side effects of ED are about 50% across the country. If you can identify an area where there is no cancer, you can preserve it.
In particular, the nerves that maintain penile erection, the nerves that make nitric oxide, half the nerves are where Walsh's neurovascular bundle is. or Menon's veil, or Tuareg's hood are, but half of them are between the prostate and the seminal vesicle and around the seminal vesicle. And if you do nitric oxide staining, that's where the nerves are.
And very simply, the more nerves you preserve, the better the outcome is. And if you can figure out a way to preserve those nerves that are around the seminal vesicles, and these are microscopic nerves, you really need to stain them to see them. There's no landmark to them other than you know they're there. The potency rates are about 90%.
So this is something, a modification of radical prostatectomy that my patients called Menon's precision prostatectomy. And I've not been able to get traction on that. We've written about it. We've published it. I have eight-year data on it. And the data is robust. But for some reason, I came across it as I was in the latter part of my career.
Had I thought about this five years before I did, this would be the standard of care, much like nipple-sparing mastectomy for breast cancer has replaced radical mastectomy.
Maybe a couple of additional contributions, but I can tell you as a urologist, as a open and robotic surgeon, as an Indian American urologist, the impact that you've had on our field directly, indirectly as a part of your legacy, the Mennonites, if you will, that are out there spreading the gospel is tremendous. So this has been an absolute honor for me to spend an hour with you and hear about the
genesis of this massively, massively important tool in our toolkit. And let's see what the future holds.
Well, thank you, Adil, for taking the time. And thank you for speaking with Dr. Bhandari, who is the one who made the connection. Always a pleasure talking with you. Say hello to Manoj and everybody there at UCSD.
Absolutely.
And Chris Kane, Chris Kane, of course.
Well, let's see what the future holds. So thank you. Thank you, Dr. Bhandari. Bye. Bye.
Thank you so much for listening. If you haven't already, make sure to follow, rate the podcast five stars, and share with a friend.
If you have any questions or comments, you can direct message us at underscore Backtable Euro on Instagram, X, or LinkedIn.
Backtable is hosted by Aditya Bagrodia and Jose Silva.
Our audio team is led by Kieran Gannon, with support from Aaron Bowles, Josh McWhirter, and Josh Spencer.
Design and digital marketing led by Brian Schmitz.
Social media and PR by Chi Ding. Administrative support provided by Judy De La Cruz.
Thanks again for listening and see you next week.