Page 37 - NEWSLETTER_30

ΣΥΝΈΝΤΈΥΞΗ
the end of the cystoscope. Interestingly, the battery was small and there were just little wires into the battery so that you could have light. Of course, all of that changed when we got modern endoscopy. But instead of having a small box with the battery in it, we got (initially) a bloody great big metal machine, which was about a meter tall by a meter wide and it was very comfortable for the nurses to sit on while the surgeon was doing the work. What do you have with a robot? You have a machine that holds telescopes and one or two instruments for you. But, because they are stuck in this machine, it costs 2 million pounds, as distinct from a registrar or resident, who costs a few euros to stand and hold a retractor for you. Is this progress? The answer is yes. It is progress in some ways. So consequently, if you have something that doesn't require a huge incision and a laparotomy, it makes an enormous difference. But in a sense, it is just as much an anaesthetic aid as it is a surgical aid. I think you need to look at these things in context. There is, for example, a lot discussion about people who had a robotic radical prostatectomy and developed a stenosis of the anastomosis. What do the robotic surgeons, who caused it, do? They go back through the same operating site, through the scar tissue created by the procedure, take it to bits and put it back together again in the same scarred area. I do it with the transperineal approach, the same way as for a patient who had a pelvic fracture-related urethral injury after a road traffic accident. The difference is that instead of going to the anastomosis through abdominal pelvic and anastomotic scar tissue and trying to do it all over again, I go in through healthy tissue in the perineum, all the way up to the fibrosis, and then excise the fibrosis from below where it's all healthy. My results are much better. I know my results are much better because I have been doing this for 40 years. Most robotic surgeons haven't even been doing it for 40 weeks. So, their idea of long-term results is whether it is okay by Christmas.
T.S.: Are paediatric patients, such as complicated bladder exstrophy or hypospadias cases, referred to your Center? What are the peculiarities that a surgeon can face when treating paediatric cases like these, which are not encountered in the adult setting?
Prof. Anthony Mundy: This is a very difficult question to answer. These days in the UK, and indeed in most of the developed world, there are well-developed pediatric services. Contemporary practice over the last five to
ten years is different from elsewhere in the world, where there is no such treatment or, even worse, where people have tried to fiddle around dealing with the more severe cases, like exstrophy for example, when they really don't have any experience or instrumentation. So, you have a huge spectrum of potential problems. Indeed sometimes, you are very lucky and you will get a patient with exstrophy, who comes from the middle of Africa, who has never had any treatment at all. The advantage is that they have survived being very young and they are now either young adults or actually adults, so you can operate on them very easily. That actually brings you back to the point, that very often paediatric patients are actually paediatric problems in adult patients, who have been made substantially worse by their previous surgery. Certainly, experience in Reconstructive Urology is really all about doing that sort of procedure, taking everything to bits and putting it back together again. Sometimes you will find organs in the wrong place and sometimes you have to deal with the bowel. I recently did an operation on somebody with a congenital absence of the vagina, who had had six previous abdominal operations. I spent four hours doing the abdominal surgery before getting sufficient access to do the rest. Every now and then you have other pathologies to deal with. For instance, when you come across serious diverticular disease or a tumor of the sigmoid and you have to do a colectomy. You need to be able to do the whole spectrum of abdomino-pelvic surgery, at least up to a certain point. Fortunately, these days, because of MRI scanning, you can normally get such a brilliant assessment of the anatomy, that you can anticipate the need for help in advance.
F.N.: What advancements do you anticipate as the next step in the field of Reconstructive Urology?
Prof. Anthony Mundy: I have no idea! Except if the actual answer is that there aren't any. Because all we end up doing is going backward. My big advantage is that I have been doing it for 40 years. So, 99 times out of 100, I've seen it before, done it before, or at least it is so similar that I can respond accordingly. I gained the experience of doing surgery before modern medications became available. I'm able, as with the gastric flap ureteroplasty, as I described earlier, to get out of a problem, if I get into it. I don't think things change. Health and diseases don't change. At least they don't change, except on the grand scale. If you
Tεύχος 30 | Iούλιος-Αύγουστος 2024
37