Dr. Michael Nguyen's virtual education lecture explores how robotic assisted procedures are being applied across disciplines, with insights into multidisciplinary collaboration and evolving surgical practice.
Welcome to our monthly educational lecture series hosted by the physician relations team at Phoenix Children's. This lecture is CAME eligible and the code will be shared in the chat. Your liaison will send out a PDF of the slides and a recording of today's lecture. Today, Doctor Michael Wynn, pediatric urologist at Phoenix Children's, will be presenting a talk on small incisions, big results. Robotic surgery in the pediatric population at Phoenix Children's. If you have a question, please add it in the chat. Dr. Wen will have time at the end of the lecture to answer your questions. Dr. Wen, thank you so much for presenting today. I'm going to pass it on over to you so you can formally introduce yourself and begin your talk. Perfect. Thank you, Luisa. Good afternoon, everybody. Uh, thank you to the physician relations team for asking me to present today. Um, it's my pleasure to talk today about our new robotic surgery program, um, here at Phoenix Children's at the Arrowhead Campus. Um, in today's talk, I'd like to go through some of the history of robotic surgery and, you know, how we got here, what some of the advantages are over open and, uh, pure laparoscopic surgery and kind of what this means to your patients. Um, I'll also present some exciting new advances in the field of robotic surgery. You know, all this is done to improve the lives of our pediatric patients. Um, just a little bit about my, about myself. I grew up here in Mesa. I went to school down, um, at the UFA in Tucson, and then Dallas for residency and uh CHOP in Philadelphia for my fellowship. Uh, I've been practicing here in Phoenix, uh, since 2006, and I've always wanted to bring Um, robotic surgery, which I learned in Philadelphia back to our community here in Phoenix. There we go. I have no financial conflicts to disclose for this presentation. Uh, so before we talk about robotic surgery, I'd like to talk a little bit about the urology division here at Phoenix Children's. Uh, we have full, uh, I'm sorry, 5 full-time pediatric urologists on staff, um, with outstanding, um, APPs, um, including a nurse practitioner who runs our voiding disorder and Euresa Center. Um, as we know, these patients, um, can sometimes be challenging. So we have. Um, a dedicated nurse practitioner for that patient population. Um, we have locations, um, all around the state, including at, uh, Arrowhead in the Northwest Valley, obviously in Phoenix. Uh, we cover Scottsdale, Avondale, Gilbert, and even, uh, satellite locations like in Yuma and Flagstaff. Um, our offices, uh, include services such as, uh, in-office ultrasounds, uh, urodynamics, um, as well as percutaneous, uh, tibial and nerve stimulation or PTNS. Uh, which is an office-based neuromodulation treatment for patients who have overactive bladders. We, uh, participate in, uh, several multidisciplinary clinics, um, for the more complicated patients, including a, a stone clinic with our nephrologist, um, about bladder dysfunction clinic, uh, spina bifida clinic with numerous other providers, as well as a cloical anomalies clinic as well. Um, I've listed our office phone number, um, To be able to be reached out, uh, we can generally see patients either that same day or at the most within about a week's time, so we're able to get patients in pretty quickly. Um, so with that out of the way, um, I'd like to start this off with, uh, a short case presentation of someone who you may see in your office. Um, this is a 15 year old, uh, female who has been having intermittent left flank pain and vomiting for the past several years. Um, she has no significant past medical history, um, and has a normal exam, um, in the office. Um, here. Her labs and urinalysis have all been normal. Um, and she has had a renal bladder ultrasound as part of her workup. Um, so this is just a representative, uh, picture of her ultrasound. You see, um, what we consider grade 3 hydronephrosis of her left kidney, um, but no stones were seen or other, um, signs that would indicate, um, another cause for her flank pain. Um, she's then referred to us for further evaluation. Um, unfortunately, in the meantime, she was seen in the emergency room for more flank pain and this time underwent, um, a CT scan. Um, another representative slide of her CT scan showing the left hydronephrosis, um, and then on other cuts on the CT, you kind of start to see, um, this here. This is a, uh, lower pole crossing vessel that feeds the lower part of this kidney, and you can see it's kind of in the area where this, um, uh, pelvis meets the ureter coming down here. Um, And so what she has is a UPJ obstruction this time caused by a lower pole crossing the vessel. This is seen in about 11 to 25% of patients of the young patients who have a diagnosis of a UPJ obstruction, but the incidence increases as the patient gets older and it accounts for probably about half of the adolescent patients who are diagnosed with a UPJ obstruction. Um, you can see in this diagram here, this, um, blood vessel feeds the lower part of this kidney and it sits right over where this ureter is at. Um, so we discussed surgical options, uh, for this patient, including, uh, open surgery, laparoscopic approach, as well as, um, now a robotic-assisted laparoscopic pyeloplasty. Um, a pyeloplasty in this case, um, involves dividing this ureter, um, at the level of the crossing vessel, um, transposing the ureter, so now it sits on top of the vessel and then suturing the two ends back together again. Um, she ultimately underwent a very uneventful, uh, robotic-assisted laparoscopic pyeloplasty, um, and did very well and is now pain-free. Um, so you know what is robotics? Um, Broadly it can be defined as an automatically, I'm sorry, automatically operated machine that replaces some form of human effort. You know, your Roomba vacuum cleaner is an example of a machine that replaces people cleaning floors. The term robotic assisted surgery is then some sort of computer assisted device in the path between a surgeon and a patient that was developed to overcome. Some of the limitations of, of, um, minimally invasive surgery. Today, many of the robots involve using telemanipulators, which translates the surgeon's motions to control robotic arms inside the patients. Um, yeah, oh, sorry. See this here. So you know, the idea of robots have been around for many years, um, not surprisingly, beginning in science fiction movies, um, as early as this film in 1972 entitled Silent Running, um, this primitive looking robot was programmed to perform surgery on the character's main leg. Um, surgical robots were also used to transform Anakin Skywalker into Darth Vader in Star Wars. Um, so it's been in movies and science fiction movies. Uh, in real life though, um, this idea, um, began as early as the 1970s with NASA and the US Department, I'm sorry, the US Defense Advanced Research Project Agency or DARPA. Um, they're looking for ways for ways to perform, um, what's called telesurgery, and the basic idea was that a machine equipped with surgical instruments could be located on a space station somewhere controlled by surgeons on Earth. A similar plan was developed by DARPA researchers to develop a remote telesurgery unit that will allow surgical procedures to be performed on wounded soldiers in the battlefield. Here you can see doctors sitting away from the battlefield remotely working on a wounded soldier. That's kind of where the idea of robotic surgery came from. Um, The very first robot was what's called the Puma 200 back in the mid 1980s, and it was formerly used for industrial tasks, but then was used in stereotactic operations in which a CT was used to guide a robot to insert a needle into the brain for biopsies. This turned out to reduce the risk for hand tremors, which were oftentimes seen. Um, when a live person would do it during needle placement. In 1992, Robodoc was introduced in conjunction with IBM, and it was used to successfully prepare a cavity in the femur for hip replacements and orthopedic surgery. It carried out this task more precisely and more quickly than human surgeons could do. Um, next came ESOP in the 1990s. Um, I, I used this during my residency. This was developed in collaboration with Stanford University and some other government agencies, um, and it was FDA approved in 1994. Um, what ESOP was, was, um, it was a telemanipulator and a voice controlled software combined. To control, uh, a camera during laparoscopic surgery. So the surgeon would say commands like, um, ESOP move left or ESOP stop, um, and it would control the camera, kind of like a rudimentary Alexa or Siri system that we have now. Um, the major benefit was that it offered a stable view and eliminated some of the problems caused by, you know, tired or inexperienced, uh, person holding the camera. Um Next came the Zeus system, which combined actually the voice control of ESOP with robotic arms, um, allowing the surgeon to be at a console. Um, so this is kind of starting to look more like what we have now. Um, it was initially designed for cardiac surgery, uh, to take down the internal mammary artery, um, but other subspecialties began to recognize the feasibility. of this device for other approaches. Um, here at PCH we've had the Medtronic stealth AutoGuide robotic guidance system since, uh, 2020. Um, in fact, PCH was the very first hospital system in the US to use this Autoguide platform, and it was designed for positioning of instruments, um, during, uh, neurosurgical procedures. But most, you know, people today will recognize the surgical erotic system, um, as the da Vinci, uh, robotic system, which is probably one of the most widely used robotic systems in the world. Um, in this picture, you can see a surgeon working at a console, um, in the OR suite with a nurse and or assistant at the bedside helping with instruments. Um, you can see that this robot system, you know, has multiple arms, um, so it allows, um, what we can do kind of open and with laparoscopic surgery, um, but in a more comfortable setting, at least for the, the, the surgeons here. Um, it was designed by Intuitive Surgical, um, and first released back in the late 1990s. Um, it's, uh, I first used the first generation when I was a fellow back in 2004, and, uh, we now have the fourth iteration, which is also known as the XI system. Uh, with the previous generations, the robot had to be positioned in such a way that it can only operate in one area. The advantage of the excise system, um, is it allows for multi-quadrant surgery. So, um, you could be operating down in one area, move the robot, um, camera up to another part of the abdomen and start working there without having to undock the robot. Um, this made for much simpler, um, um, And, uh, surgery itself without having to undock. Um, it has a magnified 3D high-definition optics, um, and with the new XI system has much smaller instruments than what we were using with the very first generation of robots. Um, so this is kind of the working console, um, you know, just like the zoo system, uh, we work at this console, which then translates our movements, um, to the robotic arms inside the patients. The, uh, uh, foot pedals are used to clutch the arms to control the camera movement, as well as having, um, cautery as well. Um. Our current system at Arrowhead, um, is actually a dual console. So imagine two of these connected, um, which allows for an attending surgeon as well as fellows or residents to be working as well. Um, so it allows for teaching of residents in a safe way so that if they ever got into trouble, we would be able to quickly transfer control back to us, um, and then proceed. It also helps with teaching as well. Um, so the robot cart is then docked at the bedside. Again has 4 robotic arms with one of them used as our camera arm. This center boom then can rotate, um, which again allows for a multi, multi-quadrant access which I had mentioned before. Um, we currently use 8 millimeter trocars, um, with our camera ports, which is kind of a far cry from the original 12 millimeter ports that we would be using, um, with the original da Vinci robot. Uh, the, the company has tried to develop 5 millimeter robot, uh, instrument arms for pediatric patients, um, although this hasn't been quite as reliable. And so, um, we use 8 millimeters for all of our, um, incision sites. Um, this is a picture of actually the 3rd generation robot, the SI, um, and this is how it's connected to the patients. You can see the port sites in the admin. I believe this was a left poplasty, and so the patient's head is over on the left side of your screen. But uh yeah, that's what it looks like once the patient is fully docked with the robot. Um, so some of the advantages of using the robotic system over, um, traditional laparoscopic instruments are again, the improved 3D visualization as well as high definition. Um, we see things at 10 to 15 times magnification. Um, but I think the biggest advantage, um, at least for the surgeons, um, is that it mimics the motion of your wrists when you're trying to do surgery, kind of like what we would do in open surgery. You know, imagine with period laparoscopic surgery, you're trying to operate and so basically using two sticks, um, without any motion of your wrist there. Um, with the da Vinci robot, um, they use a technology called endo wrist technology, which allows for 7 degrees of motion, kind of like what your wrist would do. Um, it also mitigates, uh, tremors that surgeons may have. Um, and also as important, it allows for the surgeons to be able to sit down during the procedure, which improves, which improves ergonomics. Um, allows us to do longer complex case, uh, uh, cases with less, uh, surgeon fatigue. Again, this is the endo wrist technology there. So we control the arms with the picture on your right hand side here. And again, whatever your wrist can do is what this is what the instruments can do too. So it allows for the advantages of open surgery, you know, being able to do complex surgery with the advantage of having little incisions that you would find with pure laparoscopic surgery. Uh, if you indulge me for a couple of minutes. This is a video of kind of what things look like doing open surgery. Um, this was also a UPJ obstruction, but this one was due to, um, a little polyp inside that was causing the, um, blockage. So this is our view inside there. These again, the motions of the instruments. Um, so again, we get really nice high definition images. Um, here we're looking at, this is a left pyeloplasty. Um, you see the ureter down there. And we're dissecting out the renal pelvis with the ureter. We're replacing what's called a hitch stitch, which allows, um, this renal pelvis and ureter to be brought up closer to us. Um, here we divide the renal pelvis and you can kind of start to see that little polyp that was causing the obstruction. And just notice how the instruments move, kind of like what your hand would be doing if you were doing open surgery. So we now have Separated the ureter from the renal pelvis. And I'm measuring things. We're cutting into this ureter. Kind of what's called spatulation. And now we start suturing again. This is a key advantage of the robotic approach versus a pure laparoscopic approach. Um, makes suturing much more precise and easier to do. Here we've completed one side of the anastomosis. And now we cut out this, the, the defending segment again, that's the polyp that we see there. Now we place our stent down. The stent allows for this repair to heal without, um, leakage, stays in for about 6 weeks. We take it out, um, in a brief outpatient surgery after that. And kind of put things back together. All right, so that was kind of what things look like on the inside. Um, on the outside, again, this is what is important for the families. On the left, you see what kind of an open pyoplasty incision looks like, um, as the patient gets older. Um, and on the right side are, are robotic incisions. Um, so again, I think everyone would agree that cosmetically, doing this minimally invasive is the way to go. Um, this, uh, technique was devised back in 2011. This is called the HIIS technique. Um, and this is a way for us to, uh, improve cosmesis even more. Um, it stands for hidden incision endoscopic surgery. Um, and basically we place all of our robotic incisions, uh, down at the, at the bikini line and also at the umbilicus. Um, and so, You know, uh, when the patients are older, you'll hardly ever see these incisions there, even in this patient who had multiple ports put in. Um, however, there are some disadvantages, um, with using the robot, you know, it takes a, um, a little bit longer setup time, um, but with the XI and the new generation robots, it's not as big of a, of a factor. You know, once the troll cars are in, docking can occur in a couple of minutes. Um, you know, oftentimes, uh, all the time, we rely on tactile sensation in surgery. Um, and so you kind of lose a little bit of, of that during the robotic surgery. Um, although we can kind of rely more on visual cues with regards to handling of the tissue in this features to kind of make up for that. You know, the instruments are a little bit larger than traditional laparoscopic instruments, although 8 millimeters is still pretty small. Um, and lastly, there is the factor of cost associated with this technology. Um, so 2013, uh, people kind of looked at what the pediatric robotic experience was, you know, they pulled, um, 137 publications with over, um, 1800 patients, um, and they basically looked at GI surgery, GU surgery, and then thoracic cases. Um, and these are kind of a list at that time of some of the procedures that were done, um, with the robot. And you can see, you know, a lot of them are what we would do, open, um, In multiple different specialties, so it definitely even as early as 2013 gained a lot of traction. Um, in, in graph form, you can see early on, a little slow there, and then definitely by the, um, 2010s and even more so, this, um, technology has really taken off. Um, for our pediatric general surgery, uh, patients, um, you know, our, our general surgeons are now using the robot on our, um, on their patients. Um, one of the surgeries that, uh, we do or that they do is a cholecystectomy for gallbladder disease. And, um, in a recent review, actually, um, this past month, um, they looked at, um, 224 of their robotic, um, cholecystectomy patients. Um, and they showed similar outcomes to a pure laparoscopic approach, which is kind of the gold standard at that time, um, and found that it is very safe in the pediatric population. Again, you can see the graph here of how much robotic surgery has taken over for a common, uh, general surgery procedure. Um, are uh Our general surgeons have also started a bariatric program here at Phoenix Children's. I'm excited to hear about that. Um, but people are also doing robotic surgery for bariatric surgery too. And so I'm hoping in the future we can, uh, start utilizing this technology for that surgery. Uh, but this was done over in Loma Linda, this paper here, and, um, they were able to show that in their pediatric bariatric surgery population that they had a decreased length of stay compared to pure laparoscopic surgery. Um, they had a slightly increased operative time, uh, 90 minutes versus at least a little bit over an hour. Um, Again, this is one of those technologies that, uh, you know, it does take some, um, cases to get really good at. And so I would anticipate as these surgeons became more adept at using the robot that their operative times would decrease to the same, if not better than just pure laparoscopic surgery. Again, they noted no difference in their complication rates. Um, how about for urology? Um, again, in the adult world, um, this is a very commonly used, um, uh, technology, um, with regards to their surgeries, namely radical prostatectomies for prostate cancer. Um, I would say that most, uh, urology residents nowadays have never seen an open, uh, prostate surgery. Almost all of their surgeries are done with the robot. And in the adult world, again, they showed, uh, they showed shorter length of stays, uh, lower rates of blood transfusion, and lower complication risk as well. In the pediatric population, uh, we use the robot mainly for popplasties for EPJ obstructions. We will use it for ureteral reimplants for kids who have persistent reflux, as well as for what's called ureteral ureterostomies where there's a duplicated system and we need to kind of reconnect plumbing. Um We performed the first robotic surgery in a pediatric population back in, uh, 2006, um, and has since as a group, uh, performed over 400 robotic cases, um, in, in pediatric patients. Nationally, robotic p pyoplasties make up the largest number of cases in pediatric urology. Back in 2018, a group from Boston Children's looked at the national trends in utilizing robots for pyoplasties. Um, that is pictured in the green in this diagram here. So open and laparoscopic pyoplasties decrease annually by 10 to 12% respectively, while robotic surgeries actually grew 29% annually. Uh, the outcomes, upper bibiopsies have also been shown to be favorable. Uh, the Pittsburgh group, uh, reviewed six papers back in 2012 and showed a 97% success rate, which is the success rates that we find with open surgery. Um, so again, uh, uh, results are very comparable to open surgery, but you gain the advantage of having really little incisions with, um, uh, a shorter length of stay. Nowadays our patients go home probably by the next day for almost all of our pyeloplasty patients. Um, how about in infants? Um, so when I was a fellow back in 2006, we looked at 9 infants, um, and, um, we were successfully able to do, um, surgeries on, uh, patients less than a year of age. We did learn some things, um, some technical aspects about using the robot surgery, and nowadays, uh, we do many infant surgeries using the robots without any issues. So really, age hasn't been a, um, a factor, um, in, in being able to use the robot. Um, so, you know, there is an elephant in the room. Obviously, this technology is not, um, cheap, um, so it does come with, um, the cost of the robot. Um, so to be honest, this, uh, robot costs about 2 $2 million for capital hardware. Um, its annual maintenance is about $150,000 a year, and then there are costs associated with, um, uh, the instruments itself. The instruments are able to be used about 10 times more than they then have to be replaced, and so that's one of the criticisms of it. Um, one of the first papers to look at cost analysis, um, comparing, uh, pediatric urology, uh, robotic versus open data also came from Boston Children's. Um, they looked at 73 cases, performed from 2005 to 2009, um, and they chose the direct costs which are more reflective of actual resource allocation than insurance charges or payments. Um, these direct costs include anesthesia care, um, OR use, robot, uh, instruments, as well as, um, nursing and OR staff. A salaries. Uh, they found that on average, robotic-assisted laparoscopic surgery, uh, direct costs were about 12% lower than in the open, um, equivalent surgery. Uh, the difference was primarily because of, um, increased room and board charges for open surgeries. Again, those family, those patients tend to stay a little bit longer than, uh, the more minimally invasive surgery. Um, and so that, uh, represented about 42% of direct costs, um. Uh, because of the fixed costs of the robotic, uh, I'm sorry, the robot purchase price, its annual maintenance fees, the instrument costs, there can be other factors, uh, to help, um, make robotic surgery more cost effective. Um, you know, these include trying to minimize the length of stay comparing to open surgery, um, prudent instrument usage, um, having equivalent or better operating room times versus open surgery. Um, which also includes meaning selecting appropriate patients and procedures for using the robot, as well as having, uh, a consistent robotic team to help maximize efficient OR usage. Um, how about the cost between robot surgery and pure laparoscopic surgery? The, the Pittsburgh group found that robotic pyoplasties had significant shorter operative times compared to their laparoscopic groups, uh, which I would definitely agree with. This then translated to decreased total costs in the robot surgery group versus The laparoscopic group, which is why I think there are many advantages of using the robot versus trying to do this pure laparoscopically. Um, so some key observations regarding the cost of robotic surgery. Again, the, um, uh, there's fixed costs, um, which, uh, and variable costs, which tend to be higher in the robot surgeries, uh, but the robot surgery may be more cost-effective when you factor in length of stay, which, um, can be decreased. And then some future savings, uh, noted from that study would be shorter operative times, um, allowing more cases to be performed. Um, just like with any technology, companies are always finding ways to improve, um, on what's been done. Um, instruments can be made smaller, which equates to smaller incisions. Uh, we know the importance of tactile feedback in surgery, uh, which is unfortunately, um, diminished with robotic surgery. Uh, Companies are trying to enhance visualization during surgery, whether through using. You know, something like anatomic overlays of, of, uh, cross-sectional imaging, um, or through the use of what's called firefly or, or, uh, fluorescence imaging to help identify, uh, tumor margins and vasculature. Uh, these are all things that are being researched. Um, you know, we'll talk a little bit about AI, uh, which seems to be the new buzzword. Um, and lastly, um, you know, there's the idea of Of telesurgery, uh, which is why this was first introduced, um. You know, Charles Lindbergh made the first nonstop solo flight from New York to Paris in 1927 using the Zeus robotics system. What's called the Lindbergh operation was the first complete telesurgery carried out by French surgeons. They were sitting in New York and the patient was actually in France. Um, and this occurred back in 2001. Uh, this, I think, I believe was a cholecystectomy on a patient. It took them 45 minutes. Um, and so this may be something in the future as well. Um, nowadays, um, with the da Vinci system, um, they have a function where, um, you're able to almost phone a friend. So if you have a question in surgery or needed advice on something, um, You can actually get a hold of a surgeon who then can log on and see what you're seeing and help direct you, um, uh, with your surgeries, um, being able to see what you're seeing too. So again, these are advances to hopefully at some point, do, um, a remote telesurgery. Um, one exciting, um, research, stop this, sorry. Yeah, so one exciting, uh, research, um, topic is using single ports. So recall that we had multiple ports in for our surgery. Um, the latest form of this from Intuitive, it's what's called a single port robot, um, was introduced several years ago and combines, uh, 3 fully wristed elbow instruments with a flexible camera through a, through a 2.5 centimeter cannula, um. You know, initially, the incision itself was a little bit large for, um, uh, pediatric populations, but people figured out kind of ways of how to, um, take advantage of this. But that's kind of what the Singapore idea is. Um, And so, um, you know, we can turn, uh, multiple incisions into a single incision. So people have looked at, um, using that single port, um, putting it in the, uh, suprapubic region. Um, again, down at the bikini line there, um, which then turns your four incisions as you see on the left-hand side here into one incision. Um, so again, all this is done in order to try and, um, and improve, um, a cosmesis for our patients. Sorry. Um, The da Vinci market is a crowded market with large and small companies trying to take on intuitive surgical. Um, here is a list from several years ago, um, of, uh, different robotic systems in various stages, um, with the closest current competitor being the Sen Hansen system and the Hugo Robotic Systems from Medtronic. Um, there is a hominious system for the gynecological procedures. Um, but I think, um, it's going to be difficult for a lot of these companies to, um, take on Intuitive, um, with their 20-year head start. Um, I kind of liken it to the current state of electric vehicles with, uh, Tesla's competitive uh lead there, just with how much, um, uh, lead time they've had over other competitors. Um, as I mentioned, the Sanhan system, uh, from Transenteric differentiates, differentiates itself from the da Vinci system with, uh, reusable 3 and 5 millimeter instruments. So, you know, this may be something that, um, uh, may be applicable for pediatric patients with their smaller, uh, port size. Um, Senhance claims to have haptic feedback with their instruments as well as an eye tracking camera control system. Um, although this, uh, the acceptance of this system has been a little bit slow. Um, you know, relative to the da Vinci system, but it definitely has some advantages, so this may be something in the future as well. Um, the Monarch endoscopy platform, this is kind of cool. Um, this is made by RS Health. Um, it's been FDA approved for a flexible bronchoscopy as well as a ureteroscopy. Um, you can put imagery from pre-op scans over, um, overlaid there to help identify, uh, to help identify the tip. Um, and this is using what really looks like game controllers. Um, and so you're driving the scope using, um, You know, this game controller like, so I wouldn't necessarily discourage your children from playing video games since, you know, they might become our future robotic surgeons. Um, and lastly, AI, you know, AI is everywhere, um, even in robotic surgery itself. Um, uh, so people have bad, um, models, um, having them watch robotic surgery, um, and able to point, um, to the model, what is Safe and what is not safe. Um, and so this is definitely something coming down, um, in the future here. Um, so that's something that we'll need to, um, uh, take a look at as it becomes more, um, of a, uh, a, a, a real thing. Um, some closing thoughts, a robotic surgery represents the future of, uh, pediatric surgery. I hope I've shown that, um, it has a shorter length of stay. It has less morbidity than open surgery. Um, and here at Phoenix Children's, it is now available on our Arrowhead campus. Um, I'm hoping that, um, in the future, we'll have it at every, uh, campus, um, and so that, uh, we may, um, help benefit all of our patients there. Um, you know, with technology, good, bad, or indifferent, if you're not investing in new technology, you're going to be left behind there. Uh, so I think Phoenix Children's has done a great job with that, um, and I hope they continue to, um, uh, you know, listen to these, um, words here. Um, so thank you for your attention, um, and your continued support with our efforts to bring world-class, uh, care to our patients. Uh, this is a photo, uh, right after, uh, we completed our very first robotic surgery, um, at Arrowhead Hospital, uh, last month there. Um, so at this time, I'd be happy to answer any questions that you may have. That's your. Let's see. Question? Yes, when it comes to liability, I'm trying to compare it with the airline industries. When there's anything mishappen, is it that The robotic company liable or the surgical team just random question. You mean like, um, like something that happens in surgery itself? Yes, yes. Um, I mean, they're actually very good about support, um, you know, I personally I have never had issues with the robot from a technical standpoint, um, but, you know, there's always, um, engineers available to phone in. They can remotely, um, help figure out what is going on with the robot, um, and then take steps to, uh, fix that. Um, again, I've never had any issues related to the robot, um, from a technical standpoint. OK Thank you. Any other questions, please, you can either unmute yourself or, or put questions in the chat. Hey, Doctor Wen, this is Mark Pyle. I'm a community pediatrician. This is off topic, but hoping I can just bounce this off of you. We're have a lot of the families who come in who have refused vitamin K in the hospital, and then they want a circumcision. It's kind of fraught here in our organization about how we're handling that. Um, what are your thoughts about that? Is it safe to, to do in the office? Is it something you'd recommend that we send to you guys so you can do it operatively to manage bleeding if that does happen? No, I mean, that's a, that's a great question. We actually just had, um, talked about that earlier today with our group. Um, you know, there, excuse me, there is definite risk, um, in the newborns who do not receive a vitamin K injection as far as risk for bleeding, um. Uh, out of 5 of us in the group, um, 3 will not do newborn patients who have not had vitamin K. The other 2 will. Um, and, um, you know, those 2 that do, um, you know, talk about with the family, explain the risks, document it, but there is a real risk with that. Um, and so for me personally, I would prefer, um, taking them to the operating room, um, to have their circumcision under at the family once, um, when they get a little bit older. Great, thank you. Yeah. And again, the, these questions don't have to be about the robot. I'm happy to answer any, you know, urology questions from the, from the, um, doctors here. Doctor Wen, I do have a question that may help our referring pediatricians. It's, um, they are referring to us for a surgical procedure and would like it to be non-invasive with the robot. How would they go about that? Um, they can put it in their documentation or contact us. Um, you know, we can, um, talk with them about it. Um, if it's something that we feel strongly that should be done with the robot, we can definitely kind of go over that with them. Um, but I mean, we still do, you know, open surgeries as well. And so obviously, not everyone is appropriate for a robotic surgery with potential other comorbidities. So again, that's a discussion. That we can have with their referring physician. Um, if they wanna put in their notes or, you know, contact us, um, through the hospital, um, always happy to talk with them. Wonderful. Thank you. Doctor Wen, this is Doctor Eliop and. I'm one of the pediatricians here at Yuma. Uh, how are you? Good. How are you? Good. It's been a long time since we chatted. Uh, so, um, question in regards to, um, authorization from insurance for the robotic surgeries. Does your team handle that first before you take them for the surgery? Yes, it's always, uh, these cases are always authorized, um, from the hospital before we proceed. Um, it's interesting though, because there's not a specific code for robotic surgery. Um, and to be honest with you, from a billing standpoint, um, I don't think that there's anything extra, um, financially for the hospital unless something has changed when we do robotic versus say, like a laparoscopic surgery. Um, you know, the, the, the benefits are for the patients and hopefully with a shorter length of stay. And so, you know, that may be a financial incentive, but, um, there's, we don't get more money just from using the robot. Yeah, um, and is it both for commercial prayers as well as access insurances that, you know, you don't see any um differences from the insurances, uh, denying or accepting robotic, um, procedures? Correct, yeah, I, I have not heard of any cases that we wanted to do with the robot, um, that we could not do and had to go with an open approach instead. So I don't think that there's a difference with the different payers. Awesome. That's great. Thank you so much. You're welcome. I don't see any questions in the chat. So if there are no other questions, I just, I wanted to thank everyone for joining us today. We really value your time and the participation, and we especially wanted to thank you, Doctor Wen. Great information, very insightful. We really appreciate you presenting this information today. My pleasure. Again, if, uh, we're always available, uh, via by phone, uh, messaging, uh, happy to help out in any way we can. Well, thank you. Goodbye everyone. OK, have a good day. Bye. You too. Thank you.
