Vanderbilt University Medical centre is Tennesse’s largest medical centre, it serves a local population of around 2 million, has 2600 medical staff and the surgical unit has an income of 2 billion USD per year.
The Urology department is Chaired by Professor Joseph Smith, and is one of the countrys leading academic centres. It has 17 Attending Surgeons and runs one of the top Fellowship programmes in Urooncology and Robotic Surgery. Robotic surgery was started by Professor Smith in 2003 and currently the department has performed over 4000 robotic prostatectomy’s with Professor Smith performing over 3000 himself. Currently they are being referred around 800 new cases per year. The department also has a very established robotic cystectomy, partial nephrectomy and laparoscopic programme.
Over a week in March 2012, and as part of the Urology foundation Robotic preceptorship we took our Robotic team from Kent and Canterbury hospital to visit this unit. Our team of 4 consisted of 2 Consultants, our nurse patient side assistant and senior scrub nurse all of whom were able to get a broad experience of robotics relevant to their area of expertise from a world leading centre
The hospital currently has six Da Vinci Robots, 4 for Urological use, 1 for general surgery and one in the paediatric hospital and they can do over 20 robotics cases a week, there were 15 scheduled for our week there. Within the state of Tennessee there are currently 30 Da Vinci machines serving a population of around 4 million. Although Professor Smith has a large referral base from the state he also has many national and international referrals.
On the first day after a warm welcome we had an introduction and tour of the department, organised our scrub suits and met up with Professor Smith in clinic where he saw 45 patients, booking 15 for robotic prostate surgery. We also attended the departments monthly Morbidity and Mortality meeting including data from 4 other surrounding hospitals. This gave us an insight into local Urological issues and they were keen to get a UK point of view. Their complications and logistical difficulties were reassuringly similar to UK practice.
On the Tuesday we had 6 robotic prostates to choose from in 3 separate theatres. Our nurses were taken under the wing of the Urological theatre Sister and were given a behind the scenes tour, with additional information regarding setting up and running a complex robotic schedule. We were introduced to the patient set up, positioning and anaesthetic issues. All cases were started by the resident (who had had a 6am start) or Fellow all of whom were only six months into the job but were confident in doing the complete case, emphasising the quality of the training programme offered at Vanderbilt. Port placement and docking was similar to the UK setup. The Fellows were supervised by the Attendings who would work between 2 theatres taking over where necessary. Specific points of technique would be demonstrated well and clearly to us enabling plenty of discussion on specific parts of the operation. Assisting the cases were dedicated “surgical techs”, trained nurses specific for this role enabling the surgeons to standardise their teams and freeing the residents for console training. We saw a mixture of low/intermediate and high risk disease including extended lymphadenectomy for this last group of patients. Over the week the faculty were able to show us techniques for more challenging cases including obesity, large prostates and more complex cases including a patient with a previous fractured pelvis.
On the Wednesday morning we were shown by the senior resident the ward and were introduced to the specialist nurses. We had a session on how the patients are managed pre and post operatively and followed the Nurse while she went over the postoperative instructions to the patients from the previous day, including recovery of continence and penile rehabilitation. Around 98% are discharged on the first post operative day and we witnessed the process of how this is achieved , even for patients that have travelled long distances. We found this area of care a useful part of the week and picked up many points that can be introduced to our patients locally in the UK. We have been able to update our patient information, change our discharge leaflets and provide additional information in our own preoperative patient forum, in addition to updating our rehabilitation programme for incontinence and Erectile Dysfunction. In the afternoon we saw 2 further robotic prostates. We paid particular attention to their rehabilitation programmes for incontinence and erectile dysfunction, their patient information booklets and their preoperative seminars for patients and wives prior to surgery.
On the Thursday we were introduced to further members of the faculty and concentrated on a complex robotic partial nephrectomy in a VHL patient. As we are not yet currently performing this locally this was very useful to see. Time was taken by the Attending to explain all steps of the operation, particularly paying special attention to setup, port positioning and docking, again the surgical techs assisted but also gave us useful pointers in starting up a robotic partial nephrectomy service. Our nurses also saw some robotic gynae with a radical hysterectomy that was underway in a neighbouring theatre. This was followed by a robotic nephrectomy, which was interesting to see. With all the operations the majority was performed by the Fellow’s leaving us plenty of time to discuss the technicalities of the surgery with the respective Attending, all of whom were very welcoming to us and supportive of our visit.
Friday, unfortunately the robotic cystectomy was cancelled for medical reasons, however we were left with further prostates, one in a patient with a previous fractured pelvis adding a further degree of complexity to the case. Again this was with a different Attending, thereby getting to see different ways of doing the case and experiencing different viewpoints, although it seemed that the technique was roughly standardised across surgeons there. Overall the week gave us a superb opportunity to witness a world class robotic centre in all aspects of the patient pathway, and thanks to The Urology Foundation it has enabled us to make changes and improve our service locally in East Kent. Robotic surgery has always had a team orientated approach therefore we have found that all members of the team have benefited from this visit.
Nashville, as the centre of Country music is a city that has lots to offer outside work. It is known as the “music city” and has much to offer its visitors. We were able to see plenty of music, and experience some of the key places, with a special mention to the Friday night when Professor Smith took us to the Grand Ole Opry, the home of country music, to see some of the biggest stars performing, the was a great evening and a memorable finale to our visit.
We would like to thank Professor Smith, the faculty at Vanderbilt and The Urology Foundation for organising and supporting this preceptorship and hope that other centres benefit as much as we have.
Ben Eddy, Edward Streeter, Julie Pain and Caroline Gower