Medically Speaking #5

Welcome to Self Regional's Medically Speaking Podcast. Today we have a special guest with us, Dr. Todd Hanson. Todd is one of our new urologists that just joined our practice about a year ago and is also a very skilled robotic surgeon. So in today's episode, we'll be learning a little bit about Todd and the surgeries that he does, and a little bit about robotic surgery in general. So with that, Todd, thanks for joining me today. And just maybe tell us a little bit about your background, where you're from, and how you ended up in Greenwood. Well, thanks for inviting me to be part of your podcast. Originally, I grew up in Arizona, and my wife is from New Mexico. And we met at undergrad. and coming out of residency we practiced in Wyoming for 17 years and then you recruited us away to to come up here to Greenwood and join Greenwood and we've had a fantastic experience and so I come with with four kids in tow and two that are in college so we've had a great experience for our family and they've been very welcomed here. Oh good to hear well we're certainly glad to have you here. That's for sure. I know our community is blessed to have you as well and the skill set that you bring. So let's just talk a little bit about robotic surgery in general. And maybe you can just give me the background a little bit on robotics and how it kind of evolved and kind of the type surgeries that we do today as compared to where it started. Sure. That's kind of an interesting story. The robotics was actually primarily developed, as I understand it, via NASA and the military, and they were looking at ways of kind of doing some remote surgery and things like that. And they developed the technology, which at the time wasn't working out real well for them. So they ultimately sold it to a company called Intuitive. And Intuitive picked up and kind of became the forefront in robotics. There's other robotic surgeries out there but uh for intra-abdominal surgery they really um are the only fda approved uh company that has a robot that's used for that and um so they they sold the technology to intuitive and were didn't really know quite where the home was and as they were going around seeing some different surgeons there was a urologist in texas and they were actually there to to market it to the cardiothoracic surgeons but the urologist was doing laparoscopic prostates and he said hey I think I could use this doing prostates and so it was an exceptional tool for doing that and so it really quickly took off primarily in urology and then as the technology evolved and people got better at it and learned how to apply it more than it really farmed into a lot of the other fields and so that's how it it kind of got started that was actually relatively recently it was early 2000s that that the first prostatectomy was performed by 2005 as I was coming out of residency it was really starting to become a little more of a popular thing where people were starting to train on it and i started um first doing robotics in 2007 so um in the spectrum of things it's still relatively new gotcha so what are some advantages of say robotic surgery versus the traditional either open or laparoscopy surgery yeah so it it allows you to do procedures laparoscopically that you just can't traditionally do laparoscopically and so obviously the advantage of doing something laparoscopically first and foremost is you have a lot smaller incisions which equates to typically a quicker recover and a lot less pain and then if you have to do an open procedure if you do a nephrectomy or remove a kidney you might end up with a large incision traditionally from from the middle of your sternum off over to the side versus if you're doing it laparoscopically you can use several small incisions. And so it's allowed us to transition many surgeries, which had to be done open because of the constraints of typical laparoscopy and to then do them laparoscopically. So the technology behind that is primarily that the instruments are wristed. When you do general laparoscopy, you're stuck with a straight instrument that goes into the body and you can open and close it but there's no wristed action and and with a robot you've got a wristed instrument that then makes things like suturing and dissecting much more natural and much more easy whereas before it was very very difficult it also improves things like your dexterity and and even your visualization becomes much much better because rather than looking at things that you know maybe as you're standing up in an open procedure is a really tough angle you can actually take your scope right down where you're working and see it up close and and get very good visualization of course all that ultimately equates to just better outcomes so in the short term you think well you get a lot less pain and discomfort potentially but lots of times even more importantly you just get better surgery because for example if you're doing a prostatectomy and you're trying to sew the urethra back up to the bladder your your visualization your better your ability to do a nice watertight anastomosis is just really enhanced or if you're you know trying to spare critical structures like the nerves you can just you see and do a lot better because your your handling of the tissue is a lot finer and it's like you're working at it almost under a microscope rather than from a far distance with your with your big paws in there pushing things around for sure you're a big guy like me with big hands and uh definitely can get in there a lot tighter with the with the robot than you can with big hands that's for sure well no that's good information and then um also just thinking about the future of robotics what what are you uh what do you see kind of going forward like the next five or ten years and for future developments for robotic surgery? Yeah, that's a great question. So I think the real answer is none of us really know for sure where all it's going to lead. But there's some paths that are becoming rather evident. Number one, they're changing the nature of a lot of the robots. For example, currently, you can use a robot that is kind of like doing a colonoscopy, except at the end of the scope, you would have two instruments that come out, so like a needle driver and some scissors. And rather than having an open colon surgery to remove a polyp that's too big to treat with colonoscopy, either the colorectal surgeon or the gastroenterologist can actually make a full thickness cut in the bowel, remove the polyp and then have the ability to sew it back up from inside the lumen and that's not real popular as of yet but but that would definitely be a that's something that's been done and is being done they also have robots in a similar fashion that can do the same thing in the lungs where you it actually you're mirroring the technology so you're taking pre-operative imaging and you're mirroring it onto the robot and you actually know where to go. You have a roadmap as to where to go to go find the lesion. So rather than just having all of these, you know, different bronchi with different branches and not knowing which one's going where and just having to go down this one and this one and this one, you mirror the technology such that the robot says turn left and turn right. And it's kind of like you have a GPS for the lung lesion. So you take your CT your preoperative imaging and you mirror it into the robot and it then begins to tell you which turn to take where to find the lesion and then it has instruments that come out just like from the colonoscopy and allows you to do the biopsy via the that so those would be two another area that it's expanding rapidly is now that is actually remote surgery the one of the big hang ups with remote surgery has been that the actual time delay that it takes for the information to transmit. So if I'm moving an instrument and I'm many miles away, there's a bit of a time delay between how it moves and how I see it move. And they actually know the exact time. I don't remember what it is, but you have to get your times lower than that or it becomes a very unnatural surgery. And now with the 5G internet and some of the technologies coming down with the internet, they're actually breaking that barrier such that remote surgery is becoming. They have done it, but it's somewhat difficult and complicated. But they're actually getting to the point where they're breaking the barriers, where remote surgery is going to become a very real thing, where your surgeon that primarily does the surgery may be in a completely different state and even completely different country and still be able to to do the surgery with an assistant who's probably a surgeon but maybe just doesn't do that exact surgery yeah that's really interesting i can remember when i was in medical school even that was like i think kind of the dream right so like say someone in the u.s military was in some type of a condition in another country in another part of the world and a surgeon in the united states would operate them on on them remotely but it sounds like the speed of which the communication happened was a barrier that may be getting solved. That's real interesting. Yeah, and my understanding is it's the Internet speed. And I guess from what I have been told at meetings and things like that by people who understand this much better and experts they bring into the field, that that's quickly starting to become a real reality. The other technology that's really coming up is, again, the ability to kind of mirror, to use multiple technologies, like to have a 3D recreation of maybe a kidney in the tumor and to have that mirrored onto the screen that you're using to operate such that the programming, they have artificial intelligence such that it's, you know, you can see where the tumor is um based on the pre-operative imaging and that's getting portrayed to your screen while you're operating so that it makes a bit of a roadmap for the surgeons and that that's actually coming you know that that's not too far away they're they're kind of there's a lot of formats developing along that line and i would be shocked but what some of the newer versions of the robots that are coming out don't have some of these other technologies but you know much like a lot of technologies you don't exactly know where it's headed until it hits you because it develops so rapidly but there's um robotic surgery both in um intra-abdominal surgery and elsewhere is just really taking off because we've just found that you know, we, we can find ways to use machines to be more precise in, in what we do. Gotcha. Well, let's switch gears just a little bit. I just want to talk about urology just for a few minutes. Um, and so like, uh, just in Greenwood and your time here, what are some of the common conditions that you see in our population? Um, and, um, and like I So what are the treatments for those common conditions? Yeah, so I think it's very similar to other populations. I mean, what are common urological conditions? Kidney stones is probably one of the most common. Enlarged prostates that need to be treated. Incontinence, you know, female incontinence. Female prolapse, where you're having difficulty with your bladder and uterus kind of falling down and falling out. Boy, you know, cancers, bladder cancer, prostate cancer, kidney cancer, kind of up and down the spectrum. You know, I think just there's a lot of general urology here and a lot to be done. And I don't know that it's so unique here as it is anywhere else. Although if you look at a map of what they call the stone belt, we're right in the center of that. And so kidney stones are probably one of the more popular issues that the higher incidence here than a lot of areas in the in the country. But short of that, there's just there's just plenty of urology to go around. Yep. Oh yeah. So like, um, you know, common things like the kidney stones don't necessarily require a robot. They're treated differently, but some conditions do require robotic surgery. What, like, what are the conditions that do require robotic surgery, for example, in urology? That's a great question. So, um, we use it with almost all the cancers, you know, um, so prostate cancer, uh, prostatectomies, that's probably one of the cornerstones to, the procedures that we do. Cancer in the ureters that drain urine from the kidney down to the bladder, we would use it there to maybe remove part of a ureter and then reimplant the rest of the ureter up into the bladder. Bladder cancer, that's probably one of the biggest procedures we do with it, where we will remove an entire bladder with the robot and then reconstruct it using a piece of bowel to divert it and do lymph node dissections all at one shot. Kidney cancers. So many, most of the kidney cancers are now caught thanks to our lovely ER doctors and all the CT scanning. You know, they find them much smaller now. And so I'd say the majority of the kidney cancers that come in, we can actually treat just by removing the part of the kidney that has the cancer in it without having to remove the entire kidney and that would be a very common procedure that we do robotically and as well as removing the entire kidney and then you know there's several benign issues as well maybe scarring in the ureter where we have to to kind of bypass the scarring or even a simple prostatectomy where we're not removing the prostate for cancer but we're removing it for, for enlargement, um, you know, issues like that, that come up that we also use it for. Um, those would probably be the primary, um, procedures that we do with it. Yeah. So prostate enlargement, I think that's something pretty much every man's going to have to deal with at some point, right? Many of them will. Yes. Fortunately, most of them can be managed with medication. And then there's some that progress to surgery, such as maybe doing a laser or something actually via the urethra. But there's a small portion that progress to needing a bigger surgery to actually treat it. But most of them, gratefully, we can treat with even more minor things. Yeah. Yeah, absolutely. So another thing that you and I have spoken about before that is, um, maybe either unrecognized or maybe just not being treated in a large extent here in our community is like urinary incontinence in women. Um, let's talk about urinary incontinence in women for just a second. And like some of the treatments that are available for that. Yeah. Thanks for reminding me about that. Um, so, so there's two different issues that kind of go along. Um, one is prolapse, um, where, you know, basically you have a hernia of the vagina right things are starting to fall down and fall out and um the robot actually provides a great avenue for that because probably the best procedure for for a lot of those patients is to suspend the the vagina back up um using a piece of mesh and securing it to the sacrum and and we can do that laparoscopically using a robot rather than doing an open procedure like when i first learned to do it um and so that you know female reconstruction um is actually a large portion of what we do with the robot and then kind of along those same lines um although a separate problem is the leakage of urine and lots of times women will will develop a stress incontinence because um and have prolapse and so both need to be fixed but not everyone who has stress incontinence necessarily has to have prolapse procedure and not everyone who has a prolapse procedure needs to have stress incontinence surgery either but to to fix a stress incontinence where you leak when you giggle or or run or cough we we use a small piece of mesh underneath the urethra called a mid urethral sling and that's probably the most common procedure to treat that and all of those are we can do very well here and are very skilled at and then you get into the other types of incontinence um again if we're just on the female side then you're talking about you know urgency and frequency which primarily would be treated with medication and and and and also you can have an overflowing continence you know and that would need to be addressed in other ways And part of the beauty is we've also, South Regional Hospital has invested in the equipment that allows us to now sort that out in clinic with a fairly easy study that allows us to do the right studies and get the right answers so that we're treating the right problem in the correct way. I don't want to try and continue to treat a stress incontinence with medications and vice versa. I don't ever want to take someone who has an urge incontinence and do surgery because that's not going to do them any good either. And so we've made some big investments in bringing in the right equipment to allow us to make the right diagnosis and then also perform the right treatments. and so that almost spans the the gamut of female reconstruction um there there are some other small things but that's probably the the overwhelming majority of patients would would be able to get treated and fixed and and dealt with um here in in really the most um the most up-to-date manner that that's out there you know it's not like we're having to use old techniques or um really the most up-to-date therapy that exists yeah and that's one thing todd that i know our community really appreciates you being here and some of the advanced procedures that you bring it's a it's a big deal it's uh i hear it weekly where someone's just really glad to be able to offer those services and i've said it before i'm sure you've heard me say it too um one of our big goals here is to be able to provide as high level of service here in greenwood itself regional as you can get anywhere as you can get in Atlanta or Charlotte or Casper, Wyoming, or anywhere else for that matter. And, um, we appreciate, uh, the services that you're bringing to allow us to be able to do that in the field of urology, uh, and with your partners. So we definitely appreciate that. Um, I thought we might touch on just for a second, um, just because I know a lot of men out there have questions about prostate cancer, just specifically like when should someone start getting screened for prostate cancer. What are signs of prostate cancer? Just some, maybe just talk about that for a little bit. Yeah, that's a great question. Regrettably, by the time you get signs, it's kind of the cat's out of the bag, as is the case with many cancers. You don't really want to wait until you have signs. So screening recommendations, if you have a strong family history, it's probably wise to start checking a PSA, which is still considered kind of the best screening methods. So a PSA, I should back up a little bit. A PSA is just a blood test, prostate specific antigen. It's a protein made by the prostate that's unique to just prostate tissue. And when that's elevated, sometimes, not always, but sometimes that can be because you have prostate cancer. And so generally, if you've got a strong family history, it would be wise to start screening when you're 40. If you do not have a strong family history, then our typical recommendations would be from the age of 50 to 70. And sometimes we cheat a little bit and in the real healthy males, we'll go up to 75 or so to screen for it. Interestingly, and what's sometimes difficult for a lot of both providers and, excuse me, both providers and patients to understand is actually sometimes you start getting older and you're still screening and you're actually doing yourself more harm than good. And that's a whole nother complex story. But that's why we limit it. That's why we cut it off is you can actually get to a point where you're causing more difficulties than benefit. So I remember you asking about screening. I think there were some other things in your question. You're going to have to remind me. So screening from 40 to or from 50 to 70 for those that are not of high risk for those that are of high risk age 40 to 70 would be your recommendations and the screening would consist of a blood test being a psa sure so if someone's psa comes back elevated what's what's the next step yeah i mean so um you know like much things you have to kind of interpret the elevation right so someone who has a chronically elevated PSA and it's just over the baseline and you're a little older, you may choose to watch that and have a discussion about that. Obviously, the younger you are, the more excited we're going to be or the larger the change. And so if there's a significant change, we would typically recommend proceeding with a prostate biopsy where we do an ultrasound in clinic and then actually numb it up and then obtain tissue to look at. At the same time, the other thing that is frequently done is an MRI of the prostate that can help us. And you can have a debate as to whether to do that first, or I think most of the world is settling on the fact that we should do a biopsy. And then if it becomes more of a question after a negative biopsy, you would then consider doing an MRI of the prostate to look at there. There are other markers. There's actually lots of other markers out there that can sometimes give some added information, but primarily PSA is still the best thing to do. And then biopsy and or an MRI. Gotcha. And then I guess if you make the firm diagnosis with tissue biopsy and or imaging studies than perhaps prostatectomy or there's other treatment options as well for prostate cancer? Yeah, absolutely. So the latter, there's lots of treatment options. The first thing to understand is actually we've come to realize in the medical community and urology specifically that there's a lot of prostate cancers we just don't need to treat at all, that they are low grade and that we can safely follow them. And if they begin to meet criteria for needing treated we can treat then and actually not have any worse of an outcome and that's now been shown in many studies there was a great study just came out of europe in the european journal that looked at several thousand men and again confirmed this exact same strategy that we've started practicing more and more and more so not every prostate cancer even needs treated and then you kind of get into well let's say they do they do meet criteria for needing treatment And then your two main therapies would either be surgical removal via prostatectomy or radiation. There are other treatments out there, but those are the two main treatments that are kind of the most time-proven and shown to be the most effective. Todd, tell us how you keep up with the latest advances in urology and your specialty. Yeah, that's a very interesting question. I'd always heard physicians talk about how you've really got to stay up to date in your profession. And if I was really honest training, I always wondered if I would be one of those surgeons and physicians that was able to stay up to date. And you would kind of hear about the importance of that. And yet, as I look back, I realize that that's actually been the biggest key to me having a lot of success in my career is my willingness to kind of stay up to date. You walk a fine line, honestly. You don't want to embrace every technology. There's lots of technologies that come by that don't end up being as good as what are initially promised. And you don't want to just embrace technology to embrace technology. On the other hand, you don't want to miss out on kind of improving your skills and making sure that you're up to date. So what are things that I do personally to try and stay up to date? I mean, obviously, we go to a lot of national meetings. That helps tremendously. You have to invest the time in that and the time to learn at national meetings. Some of it is done via, you know, reading journal articles and and and things like that. And and at other times, it's just having a need and saying, how am I going to do it? And and and figuring it out and reading and and kind of continuing to push yourself. And so, um, you know, that's my career has, has gone in directions that I never would have anticipated. And the technology that I've, I've embraced along the way has, has been immense, but it, it comes with, with some commitment and work as a, as a surgeon and physician. I mean, you've probably heard me say this, but when I started doing robots at first, I mean, I would record every single one of my cases. So one of the beautiful things about robotics, actually, is it's very easy for everybody to see what's going on. You can record your cases. You can send them around. I can sit down and watch the very best surgeons and how they do it, and then I can learn that. And so the learning curve has really changed dramatically. It used to be, you know, you'd watch another surgeon do a case, and you were lucky if you could see half of what they could see, and there was no real great way to record it or to share it, whereas here you can actually record cases, you can have other people look at it, you can look at it yourself. it's really revolutionized how we learn to do a lot of surgeries. You can go to courses where, you know, they, you have the experts just teach you how to do these things. And then you can take, you know, I would take every single case I did and just sit down and watch it like two or three times and go through every step I took. And, you know, what went well here? What went bad here? You know, how could I improve that? How could I make that a little slicker next time? And that takes a lot of effort. And I always hope that as physicians come along and they're doing this, they take the time to kind of put that type of work in, because I know for certain it makes a huge difference in your skills. You do get to a point where I don't know that you have to do that every time or that, but even now, you know, these images are available such that you can go back and if you have a case that maybe doesn't go quite the way you were anticipating, you can go back and look and review and say, okay, what did I do well here? Or you can have other surgeons look at it as well and say, you know, maybe you should have tried this, maybe this works. And then most importantly, you know, you learn to do it and then you go and watch. I still periodically pull out other people's videos or go to conferences and watch them and say, gosh, what are they doing a little bit differently? you know what what have they found that works better because to to be to not think that there's not other people out there that that don't you know learn other tricks along the way you're crazy you know the reason this has developed so quickly and become so good is because people have been very good about sharing and and and and demonstrating their various advancements as they make them and so that's allowed the entire urological community to really move ahead um because they you know you you're not the only one coming up with new tricks you know um the communication and the ability to integrate is is just immense and and not only can you can they describe them to that you verbally they can also um you know you can actually watch how they do it which is just a real game changer. And even one of my favorite lectures that I'd frequently go to was a urologist out of Washington University in St. Louis. And he actually has a whole lecture he gives. I've watched him give it two or three times. I forget the name of it, but he shows you all the things he's done wrong. And that's also really helpful, honestly. And he says, you know, you might get the idea to want to do this, let me show you what happens when you do. And so, you know, he goes back and he takes videos of complications and says, look at, you know, look at where I made a mistake and, and look at what caused these complications and what this led to. And, um, it just great information, you know, because we, we learn not only from other people's success, but you, you have the opportunity to learn from their, from their mistakes and that they're so open and willing to, to share that and to be upfront about it, I think is really a game changer that that exists and that people do that. Yeah, that's awesome. I mean, what a no better way to learn, right? You know, to me, that's kind of the difference between a good surgeon and an excellent surgeon, right? It's taking that time and to put in that work to really hone those skills and to watch and learn from others mistakes and and also their successes so i commend you for that that's awesome um is there anything else today todd you might want to share with our listeners again folks from out around the community maybe watching or hearing this yeah i don't know i i think primarily i just um incredibly grateful to the self regional hospital the investments they've made the sacrifices they've made, I think that there's a very strong desire from the very top up to try and make sure that we're providing a very high quality service to the community. I felt that as a physician, and I think the patients benefit from that on a routine basis. And I think the only thing is that I would say is I actually think, I think most patients would actually be surprised at the level what care they're getting. It probably gets taken for granted because you don't really recognize what level you're really getting. You just think, well, this is just the way they do it and this is the way it is and everybody's doing this. But I actually think most patients would be incredibly surprised at the high level of care and the high level of the equipment and the training and the staff that we have i it probably gets taken for granted not intentionally but it probably gets taken for granted a little bit and i just think self has made a tremendous commitment to to make sure that they provide the an outstanding care and and quality and not just not just care but making sure that it's care that makes a difference you know that it's not just boy we want to become a robotic program but we want to become a robotic program that's really making a difference in people's lives and and i think that that commitment just goes a long ways and so i'm very grateful to have found an environment where that's the case and and i'm grateful to self for for being so supportive well thank you todd i really appreciate that and um Um, and I mean it heartfelt, love you, man. And thanks for being here. And, um, you know, what you, what you bring to the community is, uh, it's a big deal and, and, uh, uh, definitely appreciate it. And, and your lovely family too. Glad to have you all here. All right. Well, um, I think we'll wrap it up and, uh, that's the end of today's, uh, medically speaking podcast. We appreciate you all joining us today, uh, for this great conversation with Dr. Todd Hanson, and we look forward to seeing you next time. ♪ ♪