Thursday, July 16, 2009

Who, What, Where, When, and Why...

So basically this is the who is who, what we do, where we do it, when we do it, and why we do it post. Hopefully this information is a helpful tool that gives you a handle on what we do at JBEDS. If you have any questions about JBEDS feel free to email us and we will try our best to respond in a timely fashion.

Director: Raymond J. Leveillee, MD, FRCS-G
Division of Endourology, Laparoscopy, and Minimally-Invasive Surgery
Department of Urology
University of Miami Miller School of Medicine
1400 NW 10th Ave, Suite 509
Miami, FL 33136
(305) 243-4562 (office)

Assistant Director: Nelson Salas, PhD
(305) 243-3531 (office)

Current Address: Elliott Building
University of Miami Miller School of Medicine
1800 NW 10th Ave, Suite 2070A
Miami, FL 33136

Phone: 305-243-3532 (laboratory)
305-243-3531 (Dr. Salas’ office)
Fax: 305-243-3381 (Division of Endourology, Dominion Towers)

Hours of Operation:
Mon- Fri 9-5

General Description:
The Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory was created by Raymond J. Leveillee, MD (brief biography in Addendum), chief of the Division of Endourology, Laparoscopy, and Minimally-Invasive Surgery in the Department of Urology, University of Miami Miller School of Medicine, through the gift of an anonymous donor ($1.5 million for five years). This laboratory is being developed as a joint collaborative effort with the Department of Biomedical Engineering, University of Miami, Coral Gables, FL. The laboratory, which opened its doors on March 01, 2008, is currently comprised of approximately 307 square feet in room 2070A at the second floor of the Elliott Building, University of Miami Miller School of Medicine.

Research Focus:
The overall goal of the JBEDS Laboratory is to develop and optimize both diagnostic and therapeutic modalities within the field of Endourology. Our research focus is on the following:

· Optimization of Computed Tomography (CT) and Ultrasound Guided Radiofrequency Ablation (RFA) for treatment of renal tumors.

Radiofrequency ablation is the current and more widely used minimally-invasive treatment modality for small renal tumors. A radiofrequency electric current is emitted from a probe inside the tumor and is received by a grounding pad on the skin surface. Heat is induced around the probe by the flow of current and is diffused to the surrounding tissue. Tissue coagulation and cell death is achieved within seconds when the tissue reaches approximately 60 oC. This procedure is performed either laparoscopically (ultrasound guidance) or percutaneous (Computed Tomography (CT) guidance), depending on the location of the tumor. At the University of Miami, the treatment endpoint is determined by measuring the temperatures at the tumor periphery with fiber-optic thermocouples. The endpoint is reached when the temperature at the tumor periphery rises above 60 oC.
Despite its success, certain limitations remain that must be investigated in order to reduce risk of residual tumor and increase patient safety. Due to the variety of renal tumor geometries (spherical, ellipsoid, tear-drop), temperature measurements in discrete points may not always guarantee a total ablation of the tumor. Kidneys also have a salt concentration gradient from the center to its periphery, resulting in a possible anisotropy of its electrical properties. Different locations may give different results under the same ablation parameters (irradiation time, power).

· Comparison of optimized CT guided RFA treatment of renal tumors with other available treatment modalities

One of the goals of the JBEDS laboratory is to determine and develop the most efficient, minimally-invasive treatment modality for renal tumors that has the least risk for residual tumor and that most enhances patient safety. Other modalities currently in the market have the potential to be more efficient in treatment renal tumors than radiofrequency ablation. This includes microwave (MW) technology (ValleyLab MW Ablation System, Covidien, Inc.), irreversible electrophoresis (IRE) (Nanoknife, Angiodynamics, Inc.), and lasers. Our investigations will be evaluating these modalities.

· Kidney Stone Ablation – Lithotripsy

Current kidney stone modalities include extracorporeal shockwave (ESWL), laser, and pneumatic lithotripsy. ESWL uses focused ultrasound to crush the stone in the ureter. A main disadvantage is the collateral damage to surrounding tissue, especially when the stone is out of focus. The pneumatic and laser modalities can be affected by the difference in stone composition. Another disadvantage with these modalities is the retraction of the stone calculi to the pelvic region of the kidney.

· Development of a novel biopsy system for renal tumors

Accuracy of biopsies for renal tumors is no better than 80%. Our research will focus on developing a smart biopsy needle that will signal when the needle is in tumor tissue. Efforts will be made to develop a system for both tracking and accurate placement of biopsy needles

Wednesday, July 15, 2009

Robotic Surgery

Yes- you have seen the da Vinci® S Surgery System on fictional TV show Grey's Anatomy, but did you know that it is a new cutting edge tool that JBEDs's very own Dr. Leveillee uses on a frequent basis to treat patients?

Read the Article Below to hear about the draw a DaVinci demonstration drew at UM and doctor's, including Dr. Leveille, thoughts about robotic surgery:

Throughout the day on Thursday, dozens of people stopped to gather in the lobby of the University of Miami Hospital. There was no emergency. Instead, the hospital was showing off its latest device to benefit patients, the da Vinci® S Surgery System in HD. The state-of-the-art robotic system, made by Intuitive Surgical, is only the second such device available to patients in all of Miami-Dade County.
This next generation of the da Vinci offers several key features that clearly benefit both patient and physician. Instead of the traditional 3-arm device, one being the camera, the da Vinci S contains an optional 4th arm. This gives the surgeon the ability to have another set of hands during any procedure. In addition, the camera provides the surgeon with a 3-dimensional view that is also high-definition. The University of Miami Hospital and Jackson Memorial Hospital have 2 robots already on staff, but neither incorporates the high definition capability.
“The resolution of high-def is significantly better,” said Alex Jimenez, clinical sales representative with Intuitive Surgical. “That means for each specialty, a critical portion of the procedure is enhanced.”
The surgeon sits at a console maneuvering two pincher-like devices, while peering through a viewfinder. The viewfinder provides the image from the robotic camera, along with the two-pronged robotic arms that serve as the doctor’s hands inside the patient. That same image is also displayed on a separate screen. There is also a special wrist device that offers more rotation than is possible with the human hand.
The da Vinci can be used for a wide variety of procedures, including prostatectomy (the removal of the prostate due to cancer), hysterectomy, ovarian and uterine removal, mitral valve repair, and gastric bypass.
Raymond Leveillee, M.D., professor of clinical urology and chief of the Division of Endourology, Laparoscopy and Minimally Invasive Surgery, says the benefit of robotic surgery is clear. “It gives us more precision, because of better imaging and 3-D, which allows for a better outcome for the patient.” Dr. Leveillee explained that robotics mean less scarring and less blood loss during the actual procedure, which means better visibility for surgeons such as himself, to save critical nerves in surrounding tissue.
Reduced scarring and bleeding also offer an advantage for gynecologic oncology procedures. Laurel King, M.D., a community physician practicing at the University of Miami Hospital, uses the da Vinci to treat precancerous conditions of the cervix and uterus.
In the lobby, hospital officials were not only showing off the da Vinci, but also allowing anyone to give it a test-run. Jorge Toledo, R.N., nurse director of 8-South at UMH, tried out his dexterity at using the da Vinci’s arms. “It felt very natural. It wasn’t cumbersome at all.”
Hospital officials are also hoping the day’s event will lead to a new name for the device. Visitors were invited to submit names which will then be considered by UMH leaders. The winner, to be announced next week, will receive a restaurant gift certificate.
The da Vinci is also able to serve as a teaching tool, as it incorporates a telestrator feature. A physician or student can point out precise sections on the screen, to explain a procedure or the next step they will perform. The device also has a built-in microphone so the physician can communicate remotely to the rest of the surgical team or with other people observing the procedure.
Between the benefits to the patient and as a teaching tool, many doctors are convinced that robotic surgery is helping to take UM to the next dimension in health care. Dr. Leveillee says “There’s no question that technology improves human lives.”

Article Featuring Dr. Leveillee of JBEDS Laboratory

Watching the surgeons operate, it’s hard to escape the eerie resemblance to observing two grown men play a video game in a darkened room. Standing hip to hip, they manipulate long, narrow joysticks while staring silently up at the television screen. Every now and then, a surgeon grunts “here” or “okay.” But, otherwise, total silence. Even the surgical residents and nurses quietly watching add to the feel of a hushed and darkened video arcade.
What University of Miami surgeons Robert Bailey, M.D., and Gaetano Ciancio, M.D., are doing is no game. The two are removing a kidney from a man in order to save the life of his brother, who is being prepared for the transplant in the surgical suite just steps away. In moments, transplant surgeon Joshua Miller, M.D., will run into the room, place the kidney in a small metal bowl, and race back to begin the two- to three-hour ordeal of restoring the brother’s health.
The procedure, in and of itself, is not unusual. About 50 such “live” kidney transplants are done at the medical center each year. What sets this surgery apart is the fact that the physicians are using a minimally invasive technique that will spare the donor a painful 14-inch incision around his waist, weeks of medication, and the loss of income from staying home and recovering from major surgery. Though one of the more dramatic examples of minimally invasive surgery—physicians hope the reduced discomfort and faster recovery time will encourage more people to donate kidneys—the surgery is only one of numerous such procedures School of Medicine physicians now offer.
Thanks to new technologies that allow doctors to view internal organs through a telescopic camera and long-handled surgical tools, physicians in virtually every surgical specialty at the School of Medicine now do major operations through smaller access openings in the body.
“What we’re doing now is taking an operation that usually involves an extensive incision and doing it through relatively small, half-inch to three-inch, incisions,” says Dr. Bailey, who was recruited from Philadelphia last year to direct the University’s clinical, research, and educational activities in the areas of laparoscopic and endoscopic surgery.
“That offers the patient a lot of advantages because the hospital stay is cut back; the recovery period is reduced; there’s less pain, discomfort, and use of pain medication; and there’s less scarring. If people get out of the hospital and back to work sooner, there are obviously huge financial advantages there.”
Dr. Bailey is a nationally recognized laparoscopic surgeon credited with a number of laparoscopic firsts, including the first such kidney removal in Pennsylvania. There, he created and directed the Center of Excellence in Laparoscopic Surgery at the Allegheny University of the Health Sciences.
With more than 3,000 laparoscopic surgeries and numerous papers and texts to his credit, he was invited in 1999 to create and direct the University’s Center of Excellence for Laparoscopic and Minimally Invasive Surgery.
As director, he is working alongside surgeons in the operating room to teach them laparoscopic techniques and is overseeing the University’s laparoscopic training laboratory, where postgraduate and community physicians learn to perform minimally invasive procedures through computerized and hands-on simulations. He also is encouraging collaboration among the University’s established laparoscopic and endoscopic surgeons and training staff to use the specialized equipment in the minimally invasive surgical suites recently opened at UM/Jackson’s Diagnostic Treatment Center.
And he’s adding a whole new dimension to the University’s kidney transplant program. In the 12 months after Dr. Bailey’s arrival, he and Dr. Ciancio, an associate professor of surgery and urology who has been transplanting kidneys for seven years, performed minimally invasive nephrectomies on 15 donors. In so doing, they made it much easier for mothers, fathers, brothers, and sisters to make the sacrifice that helped another family member live.
“People have been reluctant to donate organs because they were concerned about the pain and how long it would take before they could return to work,” says Dr. Ciancio, who is national chairman of the Minority Organ Transplant and Tissue Education Program. “Once people are aware that we’ve removed many of the negatives, they may be more willing to step forward.”
Because of the lack of available donors, 2,295 people died last year while waiting for a kidney transplant, according to the United Network for Organ Sharing. And while most of the people who undergo kidney transplants receive their organs from individuals who have passed away, those obtaining a kidney from a close relative face better odds of retaining the organ.
Of special concern to transplant surgeons is the fact that while minorities represent about 50 percent of patients seeking kidney transplants, the lack of well-matched donors mean only about 7 percent of kidneys in 1998 went to this group. Dr. Ciancio and his colleagues hope this procedure will encourage more minorities to donate organs.
Betsy Kline, who 15 years ago donated a kidney to her sister, Nancy Varner, admits she’d be willing to do again—especially now that the procedure only involves three bullet hole-sized incisions and a four-inch incision through which the kidney is removed. When the Pompano woman awoke from surgery in the mid-1980s, she found a 13-inch scar around her waist and remembers thinking: “Is it supposed to hurt this much?”
When her sister’s kidney again failed, younger brother John Varner underwent minimally invasive surgery to donate his. “It was like night and day,” Kline says. He reported almost no pain at the incisions and only slight achiness from having air pumped into his abdomen so his kidney could be more readily viewed during surgery. “It really hasn’t been that bad,” Varner said a week after undergoing the procedure. “My biggest problem has been trying not to overdo it because I feel so good.”
While laparoscopic and endoscopic surgery have been available at the School of Medicine since the early 1990s, Dr. Bailey’s arrival signals the medical center’s commitment to expanding research, education, and clinical collaboration in these areas.
Raleigh Thompson, M.D., is confident that the new center will promote cooperation among the School of Medicine’s laparoscopic surgeons. The associate professor and chief of the Division of Pediatric Surgery learned basic laparoscopic techniques performing tubal ligations in the military and has transferred that early experience into one of the busiest pediatric laparoscopic practices in the country. He and his colleagues use the technique as their standard surgical approach to a variety of gastrointestinal repair procedures.
Having a cooperative relationship without competition among different specialists is one of the advantages of being at a university. It gives you the freedom to work together,” Dr. Thompson says. “Sometimes an instrument or technique that develops in one field may be applicable to others. Moreover, you don’t learn laparoscopy in one day or one week. It requires training on simulators and in the OR. Surgeons like Dr. Bailey, Dr. Leveillee, and I can help others do their initial operations without compromising patient care.”
Raymond J. Leveillee, M.D., assistant professor of urology and director of endourology, laparoscopy, and minimally invasive surgery, does virtually all of his surgeries through a tiny incision. Among these are radical nephrectomies and reconstructive kidney surgeries, laparoscopic techniques he has been teaching to the University’s pediatric and adult urologists.
Though technologically advanced, laparoscopic procedures still require great skill on the part of the surgeon. Many surgeons liken it to manipulating spaghetti with chopsticks. Even so, Michael Hellinger, M.D., is convinced that laparoscopy is well worth the extra effort and cost.
“People have looked at cost and found it very difficult to assess. The surgery is more expensive because you’re using more sophisticated instrumentation, more throw-away equipment, and more staplers. The operation takes longer so the cost of the nurses, surgeons, anesthesiology, and others in the OR goes up,” says Dr. Hellinger, an assistant professor and chief of the Division of Colon and Rectal Surgery who performs laparoscopic colon resections for patients with colon cancer and a number of other diseases. “But it is offset by a shorter hospital stay,” he says. “Even more difficult to compute is the intangible cost to society and individuals of reducing a patient’s pain and recovery time, and returning to work in two weeks instead of two months.”
Joan Cochran is a frequent contributor to the University’s alumni magazines. Photography by John Zillioux.

The Surgical Suite of the Future

Today, surgery through tiny incisions! Tomorrow, surgery without doctors?
That’s not quite the scenario envisioned for the future. But it’s not that far afield either—especially in the field of laparoscopic surgery, where the limitations of working within a very contained space benefit from the precise movements robots afford.
With the opening of two new laparoscopic surgical suites at Jackson Memorial Medical Center, a robotic arm will help surgeons by holding the videoscope used to view the patient’s internal organs.
“It’s basically a robotic arm that holds the laparoscope more steadily than a human being could,” says Dr. Robert Bailey, director of the University’s Center of Excellence for Laparoscopic and Minimally Invasive Surgery. “Via about 20 voice commands, the surgeon can direct the scope in any direction he or she wants just by saying ‘move left, move right,’ and so on.”
One of the biggest challenges surgeons now face, Dr. Bailey says, is taking advantage of the technology becoming available to the surgical suite. “In the near future, we’ll be bringing more voice recognition technology into the OR so the surgeon can control his or her environment more efficiently by adjusting equipment,” Dr. Bailey says. “We’re not far from the point where you’ll be able to increase the flow of carbon dioxide, adjust the table for positioning, turn lights on and off, and conceivably call up critical information from a patient’s chart through voice commands.”

Interesting Research Endeavor of JBEDS Scientist Dr. Leveillee

General anesthesia and contrast-enhanced computed tomography to optimize renal percutaneous radiofrequency ablation: multi-institutional intermediate-term results.
Gupta A, Raman JD, Leveillee RJ, Wingo MS, Zeltser IS, Lotan Y, Trimmer C, Stern JM, Cadeddu JA.
Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.
INTRODUCTION: Percutaneous renal ablation is often performed under conscious sedation and without contrast-enhanced imaging. We evaluated intermediate-term outcomes of patients undergoing percutaneous contrast-enhanced computed tomography (CT)-guided radiofrequency ablation (RFA) under general anesthesia (GA) at two high-volume centers. MATERIALS AND METHODS: Prospectively maintained Institutional Regulatory Board-approved databases were searched to identify patients treated with percutaneous RFA using contrast-enhanced CT under GA. A total of 163 masses in 151 patients were treated. Enhancement on imaging or a positive biopsy at 4 to 6 weeks was considered incomplete ablation. Positive findings beyond this interval were defined as local recurrence. RESULTS: The median follow-up was 18 months (range, 1.5-70). Median tumor size was 2.3 cm (range, 1-5.4). Of the 130 (80%) masses with definitive pathology, 70% were renal cell cancer. Five masses had evidence of viable tumor at 4 to 6 weeks posttreatment for a complete initial ablation rate of 97%. Three of these five lesions were endophytic. Five masses (3.3%) showed evidence of local recurrence, and metastases developed in two patients (1.3%). Overall 1- and 3-year recurrence-free survival was 97% and 92%, respectively. Masses that were in the central region and were endophytic had the highest risk for recurrence (hazard ratio, 6.3; p = 0.016). CONCLUSIONS: Intermediate-term outcomes of percutaneous RFA are excellent. GA-assisted, contrast-enhanced CT-guided percutaneous RFA demonstrates a high initial ablation success rate. However, endophytic and interpolar lesions are at higher risk for recurrence.

The generosity that resulted in the development of JBEDS

In addition to being one of the Miller School’s top urologic surgeons, Raymond J. Leveillee, M.D., is an inveterate tinkerer. When he’s not seeing patients, Leveillee loves to modify some of the surgical equipment he works with to further enhance its effectiveness.
That’s because Leveillee, who’s chief of the Division of Endourology, Laparoscopy and Minimally Invasive Surgery in the Department of Urology, is driven to find new ways to fully optimize patient outcomes.
His penchant recently paid handsome dividends—in the form of public praise from a well-known patient, as well as an anonymous $1.5 million gift that created a new laboratory to devise medical technology innovations.
It was one such innovation that helped Leveillee excise a cancerous tumor embedded in the left kidney of Florida State Senator Steven A. Geller. Leveillee, who’s a member of the Prostate, Bladder and Kidney Site Disease Group at Sylvester Comprehensive Cancer Center, destroyed Geller’s malignancy using a technique known as radio frequency ablation (RFA).
Radio frequency ablation involves the insertion of an eight-inch needle carrying electrical current to obliterate cancerous masses by heating them to about 140 degrees Fahrenheit. An RFA-fiber optic thermometer Leveillee developed made it possible for him to use RFA on Geller’s tumor, which was in a location that was difficult to reach.
After Geller was anesthetized and placed in a CT scanner, Leveillee worked in conjunction with a radiologist to insert the RFA needle into the tumor.
Leveillee describes the technique as “a marriage of technology with surgical skills, using the CT scan as an extension of my hands.” He co-authored two assessments of the RFA procedure for the Journal of Endourology.
“It’s miraculous,” is how Geller characterizes Leveillee’s surgery, which was performed on an outpatient basis. “With this procedure, I was in and out on a Wednesday and back at work the following Monday. A more conventional surgery would have hospitalized me six to eight days and left me facing four to six weeks of recuperation after my discharge.
“When I woke up following Dr. Leveillee’s operation, I couldn’t even see the scar,” Geller marvels.
In June, six months after Geller’s surgery, he and Leveillee met at Sylvester for a post-op checkup that indicated Geller was cancer-free. The men also met with newspaper and television reporters to disclose the anonymous $1.5 million donation, which is enabling Leveillee to conduct additional RFA research.
“It came from a philanthropic family that knew I needed start-up funds so I could set up a lab at UM, instead of working on it during the weekends in my garage,” Leveillee says.
The donation made on Leveillee’s behalf led to the formation of the Joint Bioengineering and Endourology Developmental Surgical Laboratory. Leveillee is the lab’s director and Nelson Salas, Ph.D., from UM’s College of Engineering, is assistant director.
“The generous donor who reached out to Dr. Leveillee has facilitated a combined effort between medicine and engineering that will help refine tools needed by the physician,” Salas says. “Our partnership will help increase our understanding of thermal treatment of kidney tumors, so that the process becomes as safe and efficient as possible.”