(UroToday.com) The first speaker, Dr. Inderbir Gill, delivered a thought-provoking presentation on the potential of bladder transplantation—a frontier in urology that has yet to be explored in human patients. Dr. Gill began by highlighting the success of transplantation as a treatment for failing major organ systems, such as kidneys, livers, and hearts, as well as non-critical organs like faces, hands, and even penises.
Yet, despite these advancements, bladder transplantation remains uncharted territory. The reasons for this are clear: the complex vascular anatomy of the deep pelvis and the procedural challenges associated with the bladder make this a daunting endeavor.
Dr. Gill argued that the current alternative—using the bowel for urinary diversion—is far from ideal. He outlined the significant drawbacks of this method, including high rates of readmission, complications, metabolic and nutritional issues, and recurrent infections. Patients often experience incontinence, incomplete emptying, and other dysfunctions, leading to a diminished quality of life. With artificial bladders proving unsuccessful over the years, the need for a viable alternative is pressing.
Since 2021, inspired by a pivotal publication from Dr. Granberg, Dr. Gill and his team have embarked on the ambitious journey toward bladder transplantation. They initiated their work with preclinical development across three vascularized models, ultimately securing approval from the United Network for Organ Sharing (UNOS) for a Vascularized Composite Bladder Allograft (VCBA) program.
The path has been anything but straightforward. The team initially used a pulsatile perfused cadaveric model to simulate clinical scenarios, but this approach fell short of expectations. Undeterred, they transitioned to research donors who were ineligible for clinical organ donation, which allowed them to more accurately replicate real surgical conditions. In this setting, they successfully developed and tested a robotic technique, achieving the critical milestone of sustained bladder perfusion. Building on this progress, Dr. Gill’s team then mastered an open surgical technique using brain-dead, heart-beating donors. To further hone their skills, they conducted an open bladder recovery on the back table (seen below), ensuring they were thoroughly prepared for any challenges that might arise and familiarizing themselves with different approaches to their goal.
With these significant strides, the team is now actively recruiting candidates for their first human bladder transplants. This journey highlights the relentless effort, time, and innovation required to push the boundaries of medical science.
Dr. Gill’s team’s progress, from refining surgical techniques to overcoming the challenges of perfusion, marks a significant step forward in the pursuit of bladder transplantation. Dr. Gill's presentation underscored the importance of preclinical work in shaping a platform for future, more daring endeavors. He emphasized that while the journey is fraught with challenges and raises many questions, it is precisely this tenacity and courage that drive innovation forward. His work is paving the way for what could be a revolutionary advancement in urology, offering hope to patients who currently have limited options.
Title: Laparoscopic Renal Denervation for Refractory Hypertension: Foundation and Preclinical Studies
Up next, Dr. Chang took the stage to discuss a groundbreaking advancement in the treatment of refractory hypertension to showcase a novel approach aimed at overcoming the limitations of current treatments. Dr. Chang opened his presentation by highlighting the critical role of the kidneys in blood pressure regulation. Overactivity of the renal sympathetic nervous system is a major contributor to both essential and resistant hypertension. Historically, surgical interventions were employed to manage hypertension, with Alfred W. Adson pioneering the first surgical sympathectomy in 1925. While bilateral thoracolumbar sympathectomy became a common practice, it was associated with a significant 5-year mortality rate and serious complications due to its invasive nature and non-selective approach.
In the 21st century, catheter-based intravascular renal denervation (RDN) devices emerged as a less invasive alternative. Despite advancements, only two devices were FDA-approved.
These devices had disappointing results and have faced significant challenges.
Dr. Chang outlined three fundamental limitations of catheter-based RDN: the risk of endothelial damage due to limited control over energy delivery, insufficient energy penetration (only reaching 2-3mm when 31% of nerves are beyond this depth), and anatomical variability that renders the approach unsuitable for a substantial portion of patients.
To address these issues, Dr. Chang's team developed a novel laparoscopic extravascular RDN approach.
Their preclinical studies, including tissue modeling and ex-vivo experiments, demonstrated that this new technique offers more effective denervation compared to traditional catheter-based methods. The team further validated their approach through in-vivo studies, which confirmed its ability to lower blood pressure. They also noted that while incomplete denervation led to rebound hypertension, near-complete denervation significantly reduced blood pressure.
The team’s collaboration with HyperQure™ led to the creation of a specialized device for this procedure.
They tested various temperature settings and found that a protocol of 50°C for 70 seconds yielded optimal results without causing gross or intimal injuries. Even under "worst-case scenario" conditions—such as using the device at 53°C in small, distal vessels—the procedure demonstrated a high safety profile.
Dr. Chang also explored the posterior retroperitoneal approach in a modified prone position for its convenience and direct access to the renal arteries, which was tested in cadaver studies.
This approach is now being evaluated in a human trial in Korea and is in the process of securing Institutional Review Board (IRB) approval with five major U.S. institutions.
In conclusion, Dr. Chang’s presentation illustrated the limitations of current catheter-based RDN techniques and highlighted the potential of the novel extravascular approach. His work underscores the importance of innovative problem-solving in advancing medical treatments. The rigorous testing and development process exemplifies how effective innovation can emerge from addressing fundamental issues and striving to improve patient outcomes. Dr. Chang’s efforts demonstrate that through creativity and persistence, groundbreaking solutions can indeed transform the landscape of medical care.
Title: The Current and Future Landscape of Telesurgery
In the final segment of the plenary session, Dr. Raju Thomas delivered a compelling talk on exploring the transformative potential of telesurgery, its current status, and the promising future that lies ahead. Dr. Thomas began by addressing the foundational question: what role does telesurgery play, and how safe is it? Reflecting on the historical significance of the Lindberg operation, where underwater transatlantic cables connected surgeons in New York with those in Strasbourg, France, Dr. Thomas noted that while this pioneering effort laid the groundwork, significant progress has been made in surgical robotics since then. However, there has been a noticeable lack of practical application until recent developments in telesurgery.
Drawing a parallel to the dramatic evolution of telecommunication since Alexander Graham Bell’s telephone invention in 1876, Dr. Thomas emphasized that network advancements should match the rapid progress in surgical technology.
The most recent notable achievement in telesurgery occurred in 2023 when a successful operation was performed in China. The procedure demonstrated a latency of less than 100 milliseconds, though the goal remains to reduce this to around 15 milliseconds. Dr. Thomas highlighted the complexity of setting up such sophisticated systems, underscoring the need for precise coordination between remote teams.
Throughout China, 11 telesurgeries have been conducted, with some cases involving impressive distances.
For instance, one surgery required the surgeon's assistant to be 1,500 kilometers away, highlighting the necessity for flawless synchronization between the teams. Another notable procedure, a triple-console radical prostatectomy, involved a staggering distance of 2,700 kilometers, further emphasizing the challenges and capabilities of modern telesurgery.
Dr. Thomas also introduced various types of robotic systems, including the MIRA Robot and the Space MIRA—a miniaturized in-vivo robotic assistant capable of performing operations on simulated tissue and even being operated from space.
Despite these advancements, Dr. Thomas acknowledged that significant uncharted territories remain, such as the compatibility of heterogeneous systems, cybersecurity, cultural implications, and physician licensing.
The progression to remote surgery demands extensive experience, as surgeons must be well-prepared before undertaking solo remote operations.
The FDA’s guidelines on evaluation challenges and knowledge gaps highlight the essential components for successful telesurgery: seamless integration of surgery, connectivity, and evaluation methods. Real-time data processing, local-remote team interactions, and network reliability are critical factors in achieving effective telesurgery. Dr. Thomas shared a "10 Commandments" figure, which outlines best practices for optimizing telesurgical procedures.
Dr. Thomas concluded by emphasizing that telesurgery is not just a feasible and safe reality but also holds immense humanitarian potential. It promises to enhance healthcare equity, expand access to surgical care, and provide new opportunities for education and training. The key to unlocking these benefits lies in proactive, collaborative efforts among specialists, robotic companies, doctors, patients, telecom companies, and other stakeholders. By staying vigilant and innovative, the telesurgery community can address current limitations and integrate this technology more effectively into practice.
The plenary session on "Pioneering Innovations in Progress" highlighted the forefront of medical advancements with transformative insights from three distinguished speakers. Dr. Gill’s work on bladder transplantation illustrated the potential for revolutionary change in urological care, emphasizing the need for rigorous preclinical research to overcome existing treatment limitations. Dr. Chang’s exploration of laparoscopic renal denervation showcased a novel approach to managing refractory hypertension, addressing critical challenges with innovative solutions that push the boundaries of current technology. Meanwhile, Dr. Thomas’s discussion on telesurgery underscored the evolving landscape of remote surgical care, demonstrating how advancements in connectivity and robotics can enhance healthcare equity and access. Collectively, these presentations underscore the essence of pioneering innovation: tackling entrenched problems with groundbreaking solutions, continuous research, and cross-disciplinary collaboration to drive the future of medicine.
Presented by:- Inderbir S. Gill, M.D., University of Southern California
- Chang Wook Jeong, M.D., PhD, Seoul National University, @drboss_urology on Twitter
- Raju Thomas, M.D., FACS, FRCS, MHA, @roboraju on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea
Moderated by: William W. Roberts, MD
Written by: Seyed Amiryaghoub M. Lavasani, B.A., University of California, Irvine, @amirlavasani_ on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea