Robotic Surgery Expands to Kidney Surgery

Story courtesy of Henry Ford Hospital

da Vinci is a breakthrough robotic system designed to transcend the limitations of both traditional open surgery and conventional laparoscopy – thereby expanding the surgeon’s capabilities and providing patients a minimally invasive option for many complex procedures. da Vinci® Partial Nephrectomy represents a state-of-the-art, minimally invasive approach to surgically remove kidney tumors while preserving healthy renal tissue necessary for normal kidney function.

The da Vinci’s high-definition 3D vision system, fully wristed instrumentation, intuitive motion and ergonomic design provide unsurpassed visualization, surgical dexterity and control. This allows the surgeon to perform all the steps of a partial nephrectomy – including careful dissection, tumor identification and excision, and renal capsule reconstruction – with far greater surgical precision, ease and efficiency compared to conventional laparoscopy.

Currently, most surgeons remove kidney tumors with an open incision and at times choose to remove the entire kidney, rather than only the diseased portion, due to the limitations of conventional laparoscopic technology and the complexity of the operation.

One of the biggest challenges in performing a successful partial nephrectomy procedure is that the surgeon must excise the tumor and the kidney in less than 30 minutes in order to preserve normal kidney function. This is because blood flow to the kidney is restricted during this stage of the procedure. However, using the expanded capabilities provided by the da Vinci System, urologists can now quickly identify renal tumor boundaries and perform what may be one of the most precise and meticulous partial nephrectomy procedure available today – reproducibly and more safely – in a minimally invasive fashion.

According to Craig Rogers, M.D., Director of Robotic Renal Surgery at Henry Ford Hospital and Director of Urologic Oncology at Henry Ford West Bloomfield Hospital, the da Vinci System provides better access to difficult tumor locations while giving the surgeon greater precision and control for complex surgical dissections and reconstructions. Moreover, suturing with the da Vinci System is significantly easier and quicker. This benefit is important for partial nephrectomy as suturing is used extensively when reconstructing the renal capsule.

When compared to an open surgical approach, da Vinci Partial Nephrectomy offers patients the potential for shorter hospital stays (1.5 day versus 4 days, according to Dr. Rogers), significantly less post-operative pain, less blood loss, fewer complications, a quicker recovery, and less scarring due to small incisions. Based upon his clinical experience of more than 150 da Vinci procedures, Dr. Rogers believes that da Vinci Partial Nephrectomy can provide patients with “an outstanding cancer operation with maximum potential for normal kidney function.”

Henry Ford Hospital’s Vattikuti Urology Institute has a history of innovation in urologic robotic surgery. Dr. Mani Menon, Director of the Institute, was an early pioneer in the field of robotic urology and developed the Vattikuti Institute Prostatectomy (VIP). Dr. Menon and other surgeons at Henry Ford have performed over 3,500 VIP procedures for robotic-assisted surgical treatment of prostate cancer since 2001.

The da Vinci Surgical System is a sophisticated robotic platform designed to enable complex surgery using a minimally invasive approach. The da Vinci System consists of an ergonomic surgeon’s console, a patient-side cart with four interactive robotic arms, a high-performance vision system and proprietary EndoWrist® instruments. Powered by state-of-the-art robotic technology, the da Vinci System is designed to scale, filter and seamlessly translate the surgeon’s hand movements into more precise movements of the EndoWrist instruments.

The net result is an intuitive interface with breakthrough surgical capabilities. By providing surgeons with superior visualization, enhanced dexterity, greater precision and ergonomic comfort, the da Vinci Surgical System makes it possible for more surgeons to perform minimally invasive procedures involving complex dissection or reconstruction. This ultimately raises the standard of care for complex surgeries, translating into numerous potential patient benefits, including less pain, a shorter recovery and quicker return to normal daily activities.

Do You Know How to Choose a Health Care Plan?

Selecting a health care plan used to be an easy and straightforward process. But as the need for health insurance grows and as many employers cut back or eliminate their employee coverage altogether, many individuals are forced to pay out of pocket for their own insurance. With this new responsibility also comes the need to educate ourselves on what kinds of health care plans exist and which ones fit our financial and health needs.

Since many health insurance companies offer open enrollment during the month of November, we decided it would be a great time to talk to the experts about what questions need to be asked and answered before signing on a new plan.

Toni Frawley is the Director of Corporate Product Development at Health Alliance Plan (HAP), which is a nonprofit health plan in Michigan serving 576,000 members and 2,800 employer groups. HAP is a subsidiary of the Henry Ford Health System, one of the nation’s leading regional health care systems.

Frawley helped us look at some of the basic points to consider when choosing a personal health care plan for you or for your family.

EDUCATION

First and foremost is to educate yourself, says Frawley. From premiums and copays and from PPO’s to HMO’s, when it comes to health insurance, there is an entire dictionary of terms and concepts that need to be understood before signing on to a plan. HAP has recognized the need for consumer education and has developed a website which is complete with a glossary of terms as well as an online assessment tool which determines your health and financial needs and provides you with a selection of health care plans to choose from. For more information on how to utilize this tool go to: www.hap.org.

CHOOSING A COMPANY

Once you’ve understood the basic language, next is choosing a health insurance company. But since there are so many on the market, choosing the right one is a daunting task.

“First, look at the health insurance company’s provider network and determine how vast their list of hospitals and doctor base is. Find out if your favorite hospitals and medical professionals are included in their network,” says Frawley.

Next, she suggests looking at the overall mission of the health insurance company because this will drive where they place their coverage dollars. Do they focus on prevention such as early mammography and routine detection tests or do they focus on treating an illness once it has manifested? Also find out if their customer service meets your needs. For instance, can you speak to a live person when you have questions about your plan and coverage? All of these questions will help you filter through many of the companies and narrow your decision.

CHOOSING A PLAN

Once you have focused it down to a few different companies, Frawley then recommends determining how much you can afford based upon your health and financial needs. “Take into account how many times a year you visit a doctor and for what reasons. This will help decide how much your monthly premium and your deductible can be,” says Frawley.

A rule of thumb for most health insurance plans is that the higher the deductible, the lower the monthly premium and the lower the deductible, the higher the monthly premium, says Frawley. HAP has plans that are on either end of the spectrum and some that fall in the middle as well.

Also, keep in mind what your annual prescription drug needs are since many plans offer medication plans that vary greatly in their coverage and copayments. Other services to consider are whether maternity care or mental health benefits are included into the package. Many of these extra services may not be included in a basic plan but can be added on for additional fees.

ALTERNATE PLANS

A popular trend is to create a health savings account which allows you to set aside money into a health account that will pay for future expenses, says Frawley. In order to create a health savings account, you must be first enrolled in a High Deductible Health Plan (HDHP), which is also referred to as a “catastrophic” health care plan that does not cover the first few thousand dollars of your medical bills.

Many employers are also getting creative as they grow tired of dealing with health insurance companies and the expenses of offering benefits, says Frawley. Some employers have instituted “defined contribution” plans which give the employee the money to purchase a health insurance plan that suits their needs. This option frees up the employer responsibilities but also sends the message to the employee that covering health care costs is still a primary service the employer wants to provide to its staff.

Even though the face of health insurance is changing dramatically, one reality that doesn’t show a sign of change anytime soon is the necessity for health care coverage.

For Frawley, hearing repeated stories of accumulating medical debt from a simple accident like breaking an arm is all too common. Just a quick medical condition can cripple you into years of financial hardship and send your credit rating scores pummeling downward.

Shopping around for a health care plan can be overwhelming but fortunately there are more choices to choose from than ever before so that everyone can find a plan that suits their health and financial needs. From family plans to solo plans and from catastrophic coverage to full coverage, with some education and investigation, you’ll too discover a plan that is just right for you.

Health Insurance Terminology

The health insurance industry is practically defined by acronyms and terms not common to most people. Here are some common terms to know according to www.healthinsurance.org.

Health Maintenance Organization (HMO): Health Maintenance Organizations represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician’s own office (as with IPAs.) HMO’s generally require the patient to get a referral from their primary care provider in order to see a specialist.

Indemnity Health Plan: Indemnity health insurance plans are also called “fee-for-service.” These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.

In-network: Providers or health care facilities which are part of a health plan’s network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional’s services under a traditional indemnity plan.

Out-of-Plan (Out-of-Network): This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual’s insurance company.

Preferred Provider Organizations (PPOs): You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care. Most PPOs allow you to see a specialist, or services, within the network without a referral from your primary care physician.

Primary Care Provider (PCP): A health care professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.

Discover You Allergy Nemesis

With Edward Zoratti, MD

With the fall season around the corner, you may think it is a strange time to talk about allergies. After all, flowers are not blooming, pollen is not in the air, and grass is getting cut less. However, according to Dr. Edward Zoratti, the fall season is not the time to discount allergies, it is the time to take notice.

“Fall is one of the worst times, starting in late August the rag weed season begins,” says Dr. Zooratti. “Mold is another concern that starts right when the kids go back to school in mid-September.”

With over 50 million U.S. Citizens suffering from a variety of allergies, there is no down season. In fact, over 55% of our population would test positive for some allergens. There are numerous types of allergens: food, pet, pollen, food, dust, and mold to name a few. It is no wonder that allergies cost the health system approximately $18 billion annually, and is the 6th leading cause of chronic illness.

So, how does one get an allergy? Dr. Zoratti explains, “In general, you are not born with an allergy. You get it over time, whether it is pollen, mold, dust mites… an allergy is an immune response to those substances. You have to be exposed to the allergen first.”

There are genetic connections that may give you a propensity to be allergic, but not a specific allergy. If a parent has an allergy, there is a 48% chance that the child will have an allergy, also. Although, Dr. Zoratti notes, it may not be the same type of allergy. The hot topic capturing headlines these days are peanut allergies. Peanut allergies are causing schools to create new policies regarding snacks, lunch rooms and what your child can take to school in their lunch bag. But, despite the media coverage, peanut allergies are a small percentage of cases, although potentially fatal.

“Most allergies are harmless,” says Dr. Zoratti. “You can develop an allergy at any time in your life, but about two percent of people turn negative to an allergen between the ages of 6 and 18 years. When we see children that are allergic to eggs and milk, they will generally outgrow those allergies. Losing allergy sensitivity is seen sometimes.”

Dr. Zoratti points out severe allergies like peanuts/nuts/fish are rare to outgrow. The same is true for things floating in the air; it is rare to lose those allergies, too. “Once you have sensitivity it tends to remain. The symptom severity goes up and down with grass or pollen allergies. You can have good and bad years in part due to pollen count,” says Dr. Zoratti.

So, as you begin spending more time indoors in the fall and winter months, how do you allergy-proof your home? Well, there may not be one simple solution however, there are some precautions you can make. “For mold and dust mite allergies, decreasing the humidity by 50% will decrease those allergens,” says Dr. Zoratti. “Humidity is a real important factor for dust mites. In high altitude communities, they don’t exist.”

He also points out that tearing up carpet, replacing curtains and other drastic measures, do not seem to eliminate dust mites enough to justify the cost and hassle. “The most effective way is to do hot laundering of your sheets once a week, and use allergy-proof pillows and covers,” says Dr. Zoratti.

There is no good way to eliminate pet allergens, says Dr. Zoratti. “There is just not a good way to allergy-proof your home. Even homes without cats and dogs have a lot of pet allergens. Those allergens get around.”

Dr. Zoratti notes that in one NHANE study, 15% of homes that did not have pets still had high levels of pet dander. However, in a clinical study performed at Henry Ford Health, and published in JAMA, Dr. Zoratti says that there was evidence that having pets early in life may be protective in later life for allergies or asthma. “But, I wouldn’t suggest allergic families buy a pet,” he says.

Directly tied in to allergies is the increase incidence of asthma. “It appears about 2/3 of asthma’s have allergic triggers. A vast majority of these triggers and allergies depend on what is most common in the area,” says Dr. Zoratti. “You become sensitized to what is in your environment.”

To treat or alleviate your allergy symptoms, Dr. Zoratti suggests there are three approaches:

1. Avoidance of the allergen(s) if known

2. Over-the-counter medications such as antihistamines or decongestants for mild symptoms

3. Prescription medications or vaccinations for severe symptoms

Treating symptoms such as eye irritations and nasal problems can be treated with eye drops or nasal steroids, but many of those treatments are simply for symptomatic relief.

A vaccine regimen that includes weekly injections over a six month period followed by monthly injections over 3-5 years have proven effective for some allergies, but it is time consuming, says Dr. Zoratti. This is usually reserved for people with a multitude of allergies. This regimen can help you build up a gradual immunity to the allergen and sometimes offer lifetime relief. However, this regimen is mostly used in people who are failing medication and who are severely allergic.

There is no reason to suffer through another allergy season. Be proactive and visit an allergist to discuss your signs and symptoms. With some simple testing, you may be able to identify your allergen(s) and learn how you can enjoy your first symptom-free season.

Dr. Zoratti is section head of Allergy and Immunology for Henry Ford Hospital. A leading specialist in his field in the metro area, he is board certified in allergy and immunology and internal medicine. He sees patients at the Henry Ford Medical Center-Sterling Heights.

The Dying Days of the Prescription Pad

It used to be that you could always count on one thing walking out of a doctors’ office, and that is that you would have at least one, if not many, slip of paper scribbled on by the doctor telling the pharmacist what medication to fill to make you feel better. Those days are quickly fading. Not that the doctor won’t be prescribing medications for you, but now by the time you walk out of their office, your pharmacist will have already received and probably filled your prescription. This is the future and the future is now: welcome to “e-Prescribing.”

Health Alliance Plan (HAP) and the Henry Ford Health System were among the first in the Metro Detroit area to implement their version beginning in mid-2005. They have just recently finished rolling it out to all of their physicians.

Matt Walsh, one of the members from HAPs’ e-prescribe management team, says, “The program was created to address concerns raised by the Institute of Medicine’s 2001 publication Crossing the Quality Chasm. Mainly the program helps meet the Institute’s guidelines that medical care should be safe, effective, efficient, and patient/doctor centered.”

The program is definitely safer than the old system. Out of the 2.2 million scripts that have been processed by the system to-date, it has caught over 200,000 possible drug-to-drug interaction warnings and over 15,000 allergy warnings.

Now this isn’t to say that in the past doctors were just writing for drugs without regard to safety. Under the standard system of prescribing, physicians did not have access to all the patient’s past prescription data and it would have been impossible for them to look up every possible drug-drug interaction.

Now, in the blink of an eye, the program can scan all of the patients’ prescriptions and flag any potential problems ahead of time. If there is a problem, the physician can then look into prescribing something different or the patient can at least be educated to look out for any possible adverse events.

In addition, pharmacists no longer have to try to ‘decode’ a physician’s hand writing to figure out what they are prescribing. This makes their job much easier and improves safety by reducing the possibility of error.

The e-prescribe system has really improved the efficiency for physicians. “Generating a new script may take a little longer than pulling out a script pad, though the benefits make it more than worth it,” says Dr. David Allard from the Henry Ford Clinic in Royal Oak.

He says that the greatest impact has been on the clinic’s support staff. “They no longer have to spend so much time on the phone with pharmacies working out formulary problems or refill requests. They can now spend that time with the patient in the clinic,” says Dr. Allard.

In just two years the program has found over 80,000 formulary warnings which will direct the doctor to find similar medications that the patient’s prescription program will cover. All this happens right in the patient’s exam room. Therefore, they don’t find out a drug is not covered once they get to the pharmacy, and the doctor doesn’t get a call back from the pharmacist. This saves everyone time.

In addition, all the major pharmacies in the area are tied into the system and they can even make refill requests to the physician on behalf of the patient. The pharmacist sends a message to the physician and they can either approve or disapprove the refill request with the press of a button.

Also, the system can flag the doctor to program benefits the patient may not even know about. Dr. Allard says, “I have had several patients not even know that their plan covers mail-in prescriptions which can often get them three months of medications for one co-pay, saving them lots of money. In the past, patients didn’t like having to mail in the prescription and waiting. But, now I can send the script directly to Medco or Caremark and the patient doesn’t have to do anything.”

As for the system’s effectiveness, Matt Walsh says the numbers speak for themselves: “Over 85% of physicians that use the system say that it has improved their practice, and 72% of them are using it for 80-100% of their prescription writing. Also, over 70% of the doctors state that the system has improved patient satisfaction.”

Currently, the e-prescribe program is processing over 30,000 prescriptions a week and continues to grow as physicians ask to join this very popular system.

Many of the other healthcare systems, as well as individual physicians in the area, are also implementing or have already implemented similar systems. It won’t be long before e-prescribe will be coming to an office near you!

The Future of Prostate Surgery is Here… in SE Michigan!

With Mani Menon, MD

Robots. You hear that word and you may think of R2-D2 from Star Wars, or maybe you think of the robot from “The Day the Earth Stood Still”. Maybe, if you work on the line for the Big Three, you actually think of the big machines that help put the cars together. Most people wouldn’t think about robots in medicine unless it was in some sci-fi show. But, robots are here. And, they are helping patients right here in Southeast Michigan.

Unfortunately, prostate cancer is something that many men will face in their lifetime. In the past, men had only a few options when it came to treating the disease, especially if discovered in its later stages.

These options included chemotherapy, radiation therapy and surgical intervention. Each has their drawbacks, but with the advent of robotic assisted laparoscopic prostatectomy surgery, a procedure that was invented and perfected here in Detroit, the surgical route is now a better option than it has ever been.

Dr. Mani Menon and his team at the Vattikuti Urological Institute at Henry Ford Hospital developed the surgical technique to utilize the daVinci™ Surgical System on prostate cancer. The procedure is aptly named the “Vattikuti Institute Prostatectomy” or VIP.

The VIP is the first minimally invasive system used for a major cancer. It has been used to perform almost 3,000 procedures since it’s development in 2001 and is the foundation for the technique now performed all around the world.

“The daVinci Robotic Surgical System has brought the computer age to the operating room,” says Dr. Menon, describing this new system’s impact on the future of surgical medicine. “Patients can now expect faster recovery times, with very little blood loss, and less adverse events than in the past.”

Historically, surgical intervention for prostate cancer was done through a large incision in the abdomen (large enough to allow the surgeon’s hands access to the prostate) and left many men with complications such as incontinence and impotence. The daVinci system utilizes small cameras and pencil thin tools to minimize trauma and speed up recovery times.

When a patient undergoes the robotic assisted laparoscopic prostatectomy surgery, they are prepped and the robot is moved in to place. The robot’s four arms and their associated devices are inserted into the body through much smaller incisions than were previously required.

While the surgical team monitors the patient, the surgeon is actually several yards away working at a special station. This station has a binocular-like viewing port to allow the surgeon a 3D, high definition view of the surgical site. The surgeon’s hands and fingers are placed into the control devices allowing him to make very precise movements that are then carried out by the robot.

The robot’s computer system performs thousands of safety checks per second and also corrects for any tremors or unwanted movement of the surgeon’s hands. It is this new precision that makes it possible to spare the vital nerves to the area and minimize the incidence of incontinence and impotence.

According to Dr. Menon, “The surgeon and the entire team work in a virtual 3D world and are able to plot out their actions and review them prior to implementing them.” This virtual world also makes the system ideal for teaching the procedure to future surgeons.

“The increased cost of the procedure is transparent to the patient. It ends up costing the hospital about $2000 more than the traditional procedure, but this (cost) is offset through increased volume and efficiency,” said Dr. Menon.

Men have traveled from over 22 countries and all 50 states to have the procedure done here in Michigan. One case involved a man stationed at the McMurdo station in Antarctica who flew to Detroit to have his surgery and returned to work in Antarctica shortly thereafter.

This high-tech procedure is revolutionizing the way physicians can treat patients. If you are facing a prostatectomy now, or in the future, you should be glad to know that several of these $1.5 million robots, and the team that developed the surgery, are right here in your backyard.

Dr. Menon, M.D., is chairman of the Department of Urology at the Henry Ford Health System, the Rajendra and Padma Vattikuti Distinguished Chair in Oncology and Director of the Vattikuti Urology Institute. Dr. Menon is tenured professor of urology at Case Western Reserve University School of Medicine, Cleveland. He graduated from JIMPER Pondicherry and did his residency in Urology at the Brady Urological Institute at John Hopkins, Baltimore.

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