My experience as a Vattikuti-MIME fellow in Robotic urooncology at Max Institute of Cancer Care

Vattikuti foundation in collaboration with Max Institute of Medical Excellence (MIME) provides an excellent opportunity to train the novice urologist in the field of robotic surgeries in urooncology by offering a clinical fellowship for one year. The remarkable feature of the application process is the absolute transparency in the selection of a fellow which gives full merit to the curriculum vitae of the applicant.

Dr. Ashwin Sunil Tamhankar (MCh, DNB Urology), fellow in Robotic Urooncology who did his fellowship under the guidance of Dr. Gagan Gautam and Dr. Harit Chaturvedi in Urooncology department at Max Institute of Cancer Care, New Delhi in February 2017 shares his experience

“This team consisted of Dr Puneet Ahluwalia as another consultant and Mr. Surya Ojha as a dedicated robotic nurse practitioner and many more people who are responsible for a successful robotic program. As mentioned earlier the selection was based on the curriculum vitae along with an interview by the mentor. The main dilemma from a fellow’s perspective is always an element of hesitation for deciding on joining fellowship program. I was not an exception for this. For a novice who has completed his or her residency recently, it’s a difficult call to be taken especially when someone is not exposed to the robotic surgeries during the urology residency. It’s the enthusiasm and commitment of the mentor which gives reassurance to the candidate.

As a fellow, one has to have an open mind at the beginning of a fellowship program. As you are going to enter a new challenging field in your career path, your eagerness to learn this skill is most vital. One should approach this as a clean slate; ready for the beautiful painting by the joint efforts of a fellow and a mentor. One should decide about certain goals from this fellowship right from the beginning. These can be clinical learning, surgical training, academic and research development. Finally one has to focus on the future path. I have elaborated my experience from this one year fellowship pertaining to these five aspects.

Being a part of exclusive uro-oncology unit, we had multiple referrals for the cases in uro-oncology which included predominantly prostate, bladder, kidney cancers and few cases of testicular and penile cancers. One can be thorough in managing these patients in every stage and in following them on long term basis by the end of the fellowship. I think that the management of prostate cancer patients is so varied due to ongoing research; one has to streamline the protocols at individual centre considering the evidence and local patient pool characteristics. The basis of a good clinical practice revolves around the concept of patient centric approach. Multimodality treatment concept is another factor which I did learn from the disease management group discussions which form the core of ethical practice. Most important aspect of the decision making is the basic of our medical practice i.e. primum non nocere (first do no harm). One should also understand when not to operate and when not to go for robotic approach. Another valid point which I learnt is the requirement of a thorough preoperative counselling admitting all potential minor and major complication rates including anaesthesia related complications. This avoids the adverse repercussions in post operative phase.

First and essential step of surgical training is to understand the basics of the robotic instrumentation, positioning, port placement, docking and undocking of robot. Patient safety throughout surgery including prevention of all issues related to positioning is always the priority. Core of the successful training is active independent assistance as a bedside assistant (BSA). One has to be an excellent BSA for becoming an excellent console surgeon. The main keystone of the successful robotic program is the level of coordination between console surgeon and bedside assistant. I was actively assisting the cases at the end of one month of my fellowship. Care of the instruments, safe docking and undocking, proper padding of pressure points, under vision instrument insertion, guided tool exchange etc were the points which I leant thoroughly. Preparedness for any emergency open conversion was the most important lessons learnt by me before proceeding to console work.

The console work started after this at about 2 months. This console training is a stepwise process starting from basic non critical steps followed by more critical steps of the procedure. Pertaining to robotic prostatectomy training it starts from the step of bladder drop followed by posterior dissections then lymphadenectomy. The day you perform your first bladder drop, you actually understand the gravity of console surgeon’s skill. Advancing further it involves bladder neck dissections, control of dorsal venous complex, lateral pedicle dissections, anastamoses in sequential manner. Nerve sparing and apical dissection are the most critical steps which should be focussed upon at the end. Before advancing to the next step, factor which is most essential is the confidence of a fellow in performing previous step. In my focussed training of robotic prostatectomy, I have performed each step for several numbers of times. Apart from prostatectomy, as a fellow you get to perform certain steps of robotic surgeries of kidney in the form of mobilisation of colon, lifting of ureterogonadal packet, hilar dissection, tumor excision for partial nephrectomy etc. This gives you the comprehensive hands-on experience of lower tract as well as upper tract. The learning at this stage also depends upon observing and actively assisting certain complex cases like cystectomies and atypical cases like retroperitoneal lymph node dissections, video endoscopic inguinal lymph node dissections, total pelvic exenteration etc. I could get this hands-on training in about 73 cases in my one year of fellowship. In total I did spend about 4470 minutes on console amounting approximately one hour per case. During all these console work patient safety is not compromised. All the steps are mentored by expert BSA and the mentor. In total I had an exposure of 137 cases which included all types of robotic surgeries in urooncology. It’s a very good habit to maintain all the data in your log including all steps of assistance and console work which would include the precise timings. It is most essential to store your videos and analyse those periodically. If you encounter some complication, it is essential to analyse the video and identify the reason for the complication so as to avoid it in future. Another important aspect which I learnt was the importance of the team work. You should learn from each and every member of your team. The level of coordination between each and every team member is utmost vital.        

On the academic front this fellowship is an excellent opportunity to present data and videos on all possible platforms including international conferences. It’s an excellent opportunity to add some feathers in your cap by getting awards in different conferences. We presented about 18 abstracts in different conferences. We presented our papers in European association of Urology (EAU) annual conference in 2018 and EAU Robotic urology section conference 2017. Totally we had five awards for different topics including a third position for the best student award by Max Institute of Medical Excellence (MIME). We did receive one national award (Dr. Sitharaman memorial prize) for the essay which we wrote on the topic ‘future of urological research in India’. We also had national award for the video on robotic intracoporeal conduit in RUFCON (Robotic Urology Forum of India Conference) 2017. Our poster on evaluation of outcomes of continuation of low dose aspirin in robotic prostatectomies was awarded as the best poster for RUFCON 2018.  These presentations made me confident in presenting and delivering to the fullest. I was actively involved in writing guidelines for Urological society of India on certain topics of urological cancers. This was a different learning experience for me while gathering the knowledge on those topics with specific focus on the published Indian literature. Academic growth also involves writing manuscripts, reviews, book chapters. We wrote two book chapters which included updates on non muscle invasive bladder cancer and another chapter on basics of robotics, instrumentation, port placement, docking. We also had two projects approved by hospital ethics committee. One out of that was a randomised controlled trial on outcomes of pre division and post division suturing of dorsal venous complex during Robot Assisted Radical Prostatectomy. We have completed the patient enrolment (n=64) and active follow up is being done at present. Another topic was on pilot study of enhanced recovery after surgery (ERAS) protocol for robot assisted radical cystectomy with intracorporeal conduit. At present we have six manuscripts under evaluation at different stages with international peer reviewed journals. I had an opportunity to visit two places one at the beginning of my console training and another at the end of my tenure. I went to observe Dr. Ashutosh Tewrai at Mount Sinai Hospital, New York for a week during initial days. In the end I had a clinical attachment at Lister Hospital, UK with Dr. Nikhil Vasdev, Dr. Jim Adshead and Dr. Tim Lane for a week. These opportunities help you decide about your focus of interest and guide you for the research ideas.

I think the learning is an ongoing process and one has to develop the skills on a basic foundation. This fellowship gives you a solid base on which you have to build your pyramid. When you join this fellowship you are in a phase of unconscious incompetence, which means you are not in a position to understand your level of incompetence. Once you start acquiring the skill, you know exactly what you are lacking in which is a phase of conscious incompetence. In my opinion this learning curve has a steep up slope after this phase in which you gradually progress to the stage when you consciously put efforts to reach the level of competence which is called conscious competence. Aim of a fellow during the training should always be to start going on this path towards conscious competence. Ideal mentor always keeps on showing you the correct path forever.

My learning in this fellowship actually revolved around concepts of clinical governance i.e. ethical medicine, clinical bench strength i.e. thorough basic knowledge and clinical research. I could actually learn the principles of ‘sevabhav’, ‘excellence’, ‘credibility’ in the purest sense in this one year.      

To conclude, Vattikuti-MIME Robotic Uro-oncology Fellowship program at Max Hospital is an excellent ground for structured training for rapid skill and academic development for a novice urologist. If you have a beginner’s mind which would always be ready to learn without any preconceptions, you would end up with a boundless learning experience in this fellowship. I sincerely would like to thank my mentors Dr. Gagan Gautam and Dr Harit Chaturvedi, the team members of uro-oncology department Mr. majo Mathew (Nurse Practitioner) and Mr. Abhishek Mahaveer- Program Coordinator and each and every person responsible for my training; for making me a better person. I would cherish this excellent learning experience forever in my life. It is an honour to be the first individual fellow of this Vattikuti-MIME fellowship program with Dr Gagan Gautam.”

Dr. Ashwin Sunil Tamhankar (MCh, DNB Urology)

Fellow in Robotic Urooncology,

Max Institute of Cancer Care,

New Delhi