First, there was open surgery. Then there was laparoscopy, surgery performed by inserting a long, thin tube with a high-resolution camera, light, and specialized instruments through a few small incisions. Then there was robotic surgery, also completed with few tiny incisions; and now, there is a single-port robot, a tool for surgeons to operate with just one tiny incision.

Meanwhile, in the realm of imaging: first there were x-rays, and then came CT scans. Then there was MRI, and now PSMA- PET. Once, pathologists only looked at cancer cells with microscopes. Now they can perform genomic analysis on individual biopsy samples – which means a surgeon might not need to remove the entire organ, but just the cancerous tissue within it. And this, for the patient, means preserving more function, having fewer side effects, and recovering more quickly.

Surgery is becoming more minimally invasive than ever before.

“We are in a new surgical era at the Brady,” says Mohamed Allaf, M.D. “We are seeing miniaturization of surgery.” Prostatectomy and some kidney surgical procedures are performed using only one tiny access point. “We’re even using this single-port approach in reconstructive surgery. These are patients who have had either trauma, like a gunshot wound or car accident, or who have had previous surgery, sometimes with radiation. They have a lot of scar tissue. Just a few years ago, we had to make a big incision and remove the scar tissue just to make space – to fix a blocked ureter, for example. Now we can navigate and operate in small pockets in the body. We can sneak in, fix what needs to be fixed, and finish our work with the faintest trace.”

Surgery Without a Scalpel

Brady surgeons are performing and perfecting more “ablation-guided interventions,” as well. Instead of a scalpel, they are “zapping, freezing, or steaming” cancerous tissue, says Allaf. “Dr. Arvin George has started a focal therapy program for select patients with prostate cancer using ablative energy: high-intensity focused ultrasound (HIFU), using ultrasound waves to kill tissue; microwave energy; or freezing it with cryotherapy. He’s using water vapor (steam) on localized prostate cancer in the VAPOR2 trial. This is not just less invasive; it’s noninvasive, with minimal side effects, and it's better for the patient.”

In carefully selected patients, Brady urologists use this same tissue-vaporizing technology, called aquablation, to destroy overgrown tissue and relieve urinary symptoms of benign prostatic hyperplasia (BPH). Another form of ablative energy – the laser (in the HoLEP procedure)—is “the gold standard” for removing excess tissue within the prostate, Allaf notes.

Ablating kidney tumors.

Hopkins is one of a few centers using ablative energy to kill kidney tumors. “The alternative is surgery,” says Allaf. One patient, who had been told by his doctors in Canada that he would need major surgery to remove his kidney, was evaluated by Brady urologists and considered a good candidate for ablation. “The procedure took an hour and a half. He walked out of the hospital, flew back to Canada after percutaneous ablation of his kidney tumor, needed no recovery time – and he kept his kidney.”

This procedure is done in collaboration with interventional radiologists, and this is another big change that Allaf sees in urologic surgery.

Analyzing information

Why are information scientists involved with patient care? Because this is the era of big data, says Allaf. Thousands of individual pieces of data – from imaging, PSA tests, genomic analysis of biopsies, pathology reports, and blood and urine biomarker test results – are now available for each patient. Brady urologists use computers to sift through that data to craft nuanced, individualized care plans. In prostate cancer, for instance, “There’s a lot Allaf. “A computer can look at all the pixels and tell us a little more about what we’re seeing. When we take biopsies, we get a big genomic analysis from the pathologist.

We can analyze this information and predict how best to get rid of the cancer in the least invasive way. We’re minimizing surgery, but also quantifying it.”

Using 3D models

“With Dr. Ghazi’s models, if we have a difficult case we can rehearse an intervention,” says Allaf. “We can figure out the best approach for the individual. This is unique and exciting, and it’s truly precision surgery: using the 3D models integrated with a quantitative approach, and then implementing the best technology for that patient’s cancer.”

These 3D models are also being used to improve surgery in very young children with bladder exstrophy – a rare condition requiring a complex reconstructive operation developed by Brady pediatric urologist Robert Jeffs, M.D., and refined by his successor, John Gearhart, M.D., and surgeons Chad Crigger, M.D., M.P.H., and Heather Di Carlo, M.D. To correct the congenital abnormality of the bladder and the pelvic bone structure, these surgeons are using intraoperative, 3D MRI-guided pelvic floor navigation and dissection.

Using tracers to see the invisible

Allaf has just completed and is analyzing data from a clinical trial of robotic prostatectomy using a PSMA tracer – the same type of tracer used in PSMA-PET imaging. It highlights prostate-specific membrane antigen (PSMA), a molecule that sits on prostate cancer cells. In the study, PSMA-containing cells show up on the screen as bright green. “The green we see is so dramatic,” he says, “but sometimes there’s just a greenish hue to the tissues. We can’t discern if it’s green enough.” Allaf envisions routinely using computer vision to zoom in on a hazy area and quantify the amount of green. “If you don’t see it, it doesn’t mean it’s not there. But even if the human eye can’t see it, the computer can detect it. All of this is leading toward an approach to surgery that we’re very excited about.”

A similar tracer – blue, not green – is being used in bladder cancer surgery at the Brady. The technique is called blue light cystoscopy, and it’s also done with computerized guidance. “The surgeon puts a dye into the bladder an hour before the cystoscopy,” Allaf explains. “The dye is absorbed by the cancer cells, making it invisible to the naked eye. However, it emits a blue light, allowing us to view the cancer more effectively. Even just a few years ago – like all of these advances – this would not have been possible.”