Mastering Minimally Invasive Techniques: Perspective on Robotics With Dr. Sammy Elsamra

In a recent interview for GU Oncology Now, David Ambinder, MD, a urology resident at New York Medical College/Westchester Medical Center, spoke with Sammy Elsamra, MD, of Rutgers Robert Wood Johnson Medical School. Dr. Elsamra was a prominent panelist and presenter on topics related to robotic surgery in urology at the Eighth Annual North American Robotic Urology Symposium (NARUS), which took place in Las Vegas, Nevada, February 22-24, 2024.

Together, Drs. Ambinder and Elsamra explored the frontiers of robotic surgery, including its practical applicability, patient benefits, and evolving role in modern surgical practices.

Dr. Ambinder: You were a big part of the NARUS agenda this year. What were some of the most notable takeaways from the meeting?

Dr. Elsamra: This year, we witnessed a single-port (SP) radical prostatectomy live. We observed a Hugo radical prostatectomy that was performed overseas. There were also many innovations with regard to robotics. The NARUS meeting offers a lot of practical applicability.

One of the sessions I was involved with focused on robotic cases on call, addressing emerging cases robotically, which I found to be very applicable and beneficial. Additionally, it was a good reminder to see some partial nephrectomies and other techniques that are up-to-date—things that are not earth-shattering but highly applicable and can make an impact on your practice right away.

Dr. Ambinder: You moderated a couple of the live sessions. What does the audience gain from these sessions, which are unique to NARUS and quite valuable for many people?

Dr. Elsamra: I am particularly interested in the live sessions. One of my mentors, Arthur Smith, was against live surgery. Certainly, there are limitations to it. Nothing in this world is all good or all bad. Live surgeries do have potential downsides; bad things can happen, and there could be delays in patient care due to the live surgery. However, the excitement and enthusiasm that people have to watch live surgeries and interact with a panel of experts who are viewing it, and who can then interact with the surgeon themselves, asking questions directly, is palpable. This real-time interaction allows for direct insights from the surgeon, which you cannot get from a video or recorded session. That is a huge benefit, and it is very engaging.

Dr. Ambinder: You spoke about the acute care scenarios. I wanted to delve more into that topic. What were some of the discussions during that session?

Dr. Elsamra: We discussed certain cases in which a take-back robotically makes sense. The traditional thinking of an operative take-back needing to be done within 48 hours or after 4 to 6 weeks has evolved, especially if the index case has been done robotically. The inflammation and tissue changes observed in open surgeries are not present when the surgery is performed robotically.

From a patient recovery standpoint, it makes sense to go back in. For example, we presented a case that involved a ureteroenteric anastomotic leak in a patient who was obese. Managing her with follow-on frosty tubes, a pigtail drain, and a red rubber catheter in the stomach for months could be avoided by going in robotically, finding the ureteroenteric anastomosis, and repairing it, sparing her the morbidity of a big open incision.

We also discussed a couple of prostatectomies—one for bleeding and another for a urine leak requiring repair. Robotically, these issues were well visualized and managed, saving patients from further complications. It is important to note that such procedures require the right setup, teams, and support, as well as the right attitude from the surgeon.

Dr. Ambinder: If we can touch a bit on your personal journey, you have achieved a lot in the field of robotics. You are particularly known for your inguinal lymph node dissection and how you have advanced that area. How did you get into that specific area?

Dr. Elsamra: It was partly luck and partly my willingness to explore slightly unconventional approaches where robotics can benefit. I am particularly skilled in robotics, so I tend to lean on that skill set.

I encountered a series of patients with penile cancer who needed prophylactic inguinal lymph node dissection. Before my first case, I went to an anatomy lab and coordinated with Robert Wood Johnson Medical School for a cadaver dissection session. Together with a device rep, we performed a laparoscopic inguinal lymph node dissection on a cadaver, then converted to open after completion. This experience enhanced my understanding of the anatomy, making me feel comfortable performing the procedure on patients. So, I proceeded with my first laparoscopic procedure.

I had not encountered the procedure much during my residency or fellowship, but that initial experience was invaluable and propelled me forward. Subsequently, I transitioned to robotic approaches based on suggestions from colleagues, which proved to be more efficient and beneficial.

Dr. Ambinder: For many surgeons emerging today, this might seem new. What advice would you give to young robotic surgeons graduating? How can they continue to improve their skills?

Dr. Elsamra: It is crucial to avoid becoming stagnant. Build a solid foundation through reading and understanding. Even if a procedure seems unfamiliar initially, be open to trying new approaches. Attend meetings—NARUS, the American Urological Association Annual Meeting, World Congress, and so on. They offer invaluable opportunities to connect with peers, understand challenges, and learn from others’ experiences.

Keep an open mind about new techniques and innovations. Not every change will suit your practice, but many will prove beneficial if you have the courage and will to adapt and grow. My own approach to surgeries has evolved significantly since fellowship, and flexibility and adaptation are key to improving outcomes and efficiency.

Dr. Ambinder: Where do you envision robotic surgery in 10 years?

Dr. Elsamra: As someone deeply biased toward robotics, I foresee an increasing percentage of the population being offered minimally invasive surgery with outcomes that are equivalent to open surgery.

Over the past decades, we have witnessed a shift from predominantly open surgeries to laparoscopic procedures, extending the accessibility of minimally invasive surgery. With the advent of robotics like the SP and XI systems, a significant portion of the population previously ineligible for minimally invasive approaches can now benefit from them.

The smaller footprint of the SP allows surgeons to perform procedures that were previously challenging to accomplish robotically. I anticipate this trend continuing, with more patients having access to minimally invasive surgeries, resulting in shorter recovery times and equivalent outcomes.

With additional innovations in Enhanced Recovery After Surgery protocols and techniques, I believe the robotic approach will dominate abdominal and pelvic surgeries in the future, offering patients a shorter convalescence and better outcomes overall.