Value Addition

We recently shifted our Urology operation theatre to a newer OT complex. The current OT is a modular one, with state of the art equipment (some installed and some in the process of procurement) and laminar air flow and HEPA filters to reduce surgical infections as per NABH guidelines. While we were in the process of procuring new operating room tables, lights, anesthesia equipment etc., the current equipment from the existing OT was transferred so that the OT-transfer process could be started and teething problems sorted out. Thus, came a question to my mind – What exactly is value addition?

A lot of definitions float about the internet explaining value addition in complex economic terms. The bottom line is – If you can add something worthwhile to ‘XYZ’, you are doing value-addition to the ‘XYZ’. So, does simply moving to a new OT complex add value to our department? Or will the value addition happen only when the new operating table and ‘to-be-procured’ equipment such as ultrasound (with PCN and TRUS guided facility) and ‘flexible cystonephroscope’ arrive? Or does value addition depend on any equipment at all, versus the skill that a surgeon brings to the table? I feel that all three are necessary. While the skill of the surgeon is most important in starting a new procedure, or improve upon an existing one; many a times this cannot be done without the necessary infrastructure in place. You want to do retrograde intrarenal surgery, you cannot do it without a flexible ureteroscope; you want to do laparoscopic partial nephrectomy, you need laparoscopic bulldog clamps and preferably a laparoscopic ultrasound probe; you want to do robotic radical prostatectomy, well, you need a surgical robot! In the background comes the OT complex per se – ensuring sterility of the operating environment and the necessary protocols and checklists to reduce surgical errors. With this ‘background’ infrastructure, I include the OT nursing staff as well, because the OT complex is only as sterile and as safe as its nursing staff ensures.

So how have we added value to our department in the last one and a half years? Here are some examples –

1. Retrograde intrarenal surgery (RIRS) is a routine procedure in our department now. We had the equipment beforehand, but we were holding back due to technicalities. RIRS brings incision-less stone surgery to the patient and is invaluable in cases of small renal calculi, post-lithotripsy residual stones and pelvicalyceal pathologies requiring a visual inspection and biopsy for diagnosis.

2. We routinely perform advanced upper tract laparoscopic procedures in our department currently. This includes fairly large renal masses requiring radical nephrectomy with or without tumor thrombectomy, small renal masses requiring partial nephrectomy (which I feel is one of the most complex laparoscopic renal procedure) and donor nephrectomy for kidney donors.

3. Arterio-venous fistula, both radiocephalic and brachiocephalic, for chronic kidney disease patients are done using the extended arteriotomy technique (pending publication) with a peer-matching maturation rate of 85%.

4. Urodynamic investigation for patients with neuro-urological problems and other relevant diseases has been started in the department. This helps in assessment of the lower tract and can be essential for guiding treatment in these cases.

But we are nowhere close to the summit and a lot of work is to be done yet. With the surgical field advancing so rapidly in the recent years, we hope to further advance our department with new skills and latest equipment to harness the best out of us. I thought I would list out my wish list here, in the ascending order of complexity –

1. A flexible cystonephroscope is a versatile equipment. It eases the process of DJ stent removal and can be invaluable in preventing extra punctures during PCNL by examining and helping to remove stone fragments in difficult to reach calyces.

2. We plan to add another fluoro-uro-compatible operating table in our OT complex. This will open up our restraints in terms of performing fluoro-requiring procedures, thus expanding the surgical pie, so to say, and reduce the waiting time for these procedures.

3. Documentation is of utmost importance in the surgical field. Not only is it required for medico-legal purposes, it is an integral part of medical training for residents and helps in sharing one’s work with peers through medical conferences, webinars and publications. For surgical procedures, documentation is done via the recorder for the Endovision system and this is on our bucket list.

4. It is rightly said that ultrasound is the extension of medical examination. So, we plan to introduce in-house ultrasound facility in our department. This will open up a Pandora’s box of ultrasound guided procedures, including transrectal prostate biopsies, MRI-machine and cognitive-fusion prostate biopsies, ultrasound guided percutaneous nephrostomies and PCNL and laparoscopic ultrasound (for partial nephrectomies, in future), to name a few.

5. There is hope that the surgical robots will become more competitive in their prices, now that newer models such as Mantra and Versius have entered the market. I feel some procedures are made for the robot, and I hope that patients can get the benefit of the technology and surgeons can get the benefit of the ergonomics at an affordable cost in the recent future.

My wish list is but a stepping stone to bringing our department to the new era. Though we are working on it, I have not included the residency program in my wish list, because I feel that it is so high in its value and so important for the department, that it would have been injustice to club it with the rest. I hope that my plan works out as I see it, cause that is the true ‘Value Addition’ that I can do for my patients.