Cleveland Clinic

Innovation is at the cornerstone for care in Cleveland Clinic’s Department of Urology, and it’s enabling experts to deliver more personalized approaches to patients. From developing new ways to screen for and treat genitourinary cancers to leveraging robotic and artificial intelligence platforms — our experts are transforming how urologic conditions are diagnosed and treated.

“In the United States, tens of thousands of patients may be unnecessarily undergoing surgery or receiving treatment for kidney cancer because the benign tumor mimics that of a malignant one on computed tomography (CT) imaging,” explains Christopher Weight, MD, Center Director for Urologic Oncology.

To address potential overtreatment, Dr. Weight and his colleagues are utilizing artificial intelligence-based segmentation to recognize pathologic characteristics of the tumor and its surrounding anatomy. Often disease features are too complex and subjective for large-scale human interpretation. However, tapping into AI imaging technologies that integrate data from CT scans segments with nephrectomy scores could prognosticate disease at a high level.

“We hope that additional investigation into this work will provide an even more personalized approach to kidney cancer care,” he says.

Determining whether a patient should undergo partial nephrectomy versus a more aggressive radical nephrectomy is a big question in the field. Urologic oncologist Steven Campbell, MD, PhD, and colleagues are using semi-automated imaging software to optimize management.

The technology automatically measures renal parenchymal volume in the kidney with the tumor and in the contralateral kidney. “That differential of parenchymal volume provides a split renal function that’s as accurate as a nuclear renal scan, and, in our studies, has actually proven to be more accurate,” he says.

Single-port (SP) robotic surgery is a new generation of robot that is enabling further regionalization of urologic surgery. The surgeon introduces a camera and three other narrow-profile instruments through one cannula; thereby, avoiding unnecessary involvement of other anatomy and leading to improved recovery outcomes.

Over the last several years, the Cleveland Clinic team has pioneered numerous applications using the SP robotic system to assist with robotic partial nephrectomy for removal of cancerous kidney tumors through a small incision outside the bowel sac, called the peritoneum. Additional complex robotic procedures applied the SP approach, such as the extraperitoneal robotic SP kidney transplant and autotransplant, nephrectomy, pyeloplasty, prostate surgery, including transvesical and extraperitoneal prostatectomy, cystectomy, and urinary tract reconstruction.

SP is also appealing for use in pediatric patients because it requires a minimal incision site and enables a retroperitoneal approach. The incision, called mini-Pfannansteil is performed low in the pelvis, away from the abdominal muscle, a cosmetically appealing option for younger patients.

Jihad Kaouk, MD, Director of the Center for Advanced Robotics and Image-Guided Surgery, says there is still untapped potential for robotic surgery, adding that we can look forward to the “smart” application of the system next: “moving the robot from an extension to my hands and eyes, to become a partner in the surgery under human control.”

“Our focus on innovation will keep moving and evolving patient care into the future,” he says.

Articles

Innovation is at the cornerstone for care in Cleveland Clinic’s Department of Urology, and it’s enabling experts to deliver more personalized approaches to patients.

From staging to surgery: How innovation is customizing urologic care

Urologists at Cleveland Clinic have found a new application for machine learning within their field, and they’re using it to improve shared decision making in the treatment of a common urologic diagnosis: overactive bladder (OAB).

Machine learning isn’t new to medicine or to urology, but its potential remains largely untapped, according to the authors of two new Cleveland Clinic-led studies.

“Algorithms can “learn” data patterns and trends and make inferences about the relationship between input and output data and, with this knowledge, make new predictions,” explains Glenn Werneburg, MD, PhD, first author on both of the studies and a fellow in the Department of Urology.

“In the context of our work, these predictions can help inform patient decision making about the effectiveness of a particular therapy,” says Dr. Werneburg.

Many patients with OAB will respond to behavioral approaches or oral medications, but for those who don’t, third-line options, bladder injection of onabotulinumtoxinA (OBTX‐A) and sacral neuromodulation (SNM), are two similarly effective therapies. Since those treatments are invasive, it’s important to know in advance which individual patients are more likely to respond and, if so, to which one.

OAB is common and costly, and improved clinical management of OAB is needed. The condition currently affects about 16% adults of the United States population, and its global expenditure is expected to increase in coming years.

, both female pelvic medicine and reconstructive surgeons in the Department of Urology, developed neural networks using a series of novel approaches. They then applied the networks to the prediction problem in OAB using datasets from the ROSETTA study.

The ROSETTA study, which was sponsored by the National Institute of Child Health and Development, is one of the most complete datasets in the field. The open-label, randomized trial included 381 women with refractory urgency incontinence across nine different U.S. centers to compare OBTX-A and SNM. These findings were published in 

The first study showed that the algorithms were extremely accurate in predicting treatment responses to both modalities; they correctly predicted who was a responder and a nonresponder about 90% of the time. In fact, the algorithms generally outperformed human experts in predictions. The study was published in 

In the design of the second study, Dr. Werneburg explains, blinded expert urologists were given the same training data, and this time tasked to predict patient-reported outcomes.

The top algorithms showed excellent predictive accuracy for patient-reported bladder function improvement for both OBTX-A and were noninferior to expert urologists. The algorithms were also highly accurate in predicting patient-reported bladder leakage improvement for both modalities and were noninferior to experts.

They presented the findings in May 2022 at the American Urological Association meeting, and the study was later published in the 

Plans for a future prospective analysis are underway, wherein the study design will begin with the clinician, and not the algorithm. The clinician will counsel the patient on the options, determine what is important to them, and direct their questions based on the clinical picture and the patient’s history.

They also plan to test if these data can be extrapolated to males with OAB, as their current dataset only includes women.

Machine learning complements, not replaces, clinical judgement

Despite their accuracy, the algorithms won’t replace clinician expertise, says Dr. Werneburg. “Some aspects of the physician‐patient interaction are subtle and uncomputable, and thus machine learning may complement, but not replace, a physician’s judgment.”

Machine learning isn’t new to medicine or to urology, but its potential remains largely untapped, according to the authors of two new Cleveland Clinic–led studies.

Cleveland Clinic urologists show how machine learning could revolutionize overactive bladder care

Efforts to regionalize robotic prostatectomies have opened the door for another innovation in urologic surgery. Patients can now undergo prostate surgery with epidural anesthesia and light sedation, known as twilight sleep, without the need for a ventilator general anesthesia.

Jihad Kaouk, MD, recently completed a series of ten single-port transvesical radical prostatectomies with an epidural anesthesia regimen. He explains how a newer technique—

single-port (SP) robot-assisted transvesical prostatectomy

—has made this anesthesia regimen possible:

“Robotic surgery requires pumping gas into the patient’s belly to create a surgical field in a gas bubble for visualization and maneuvering. Under pressure, it expands and alters the movement of the diaphragm, preventing the patient from breathing spontaneously,” he says. “This has traditionally necessitated the use of a ventilator machine under general anesthesia — with or without spinal or epidural anesthesia.”

“But as we continue to regionalize the surgery limited to the location of the disease, as in the case of the SP transvesical prostatectomy, that gas bubble is no longer in the intraperitoneal space: it’s limited inside the bladder, so it’s not pushing on the diaphragm,” he explains.

Dr. Kaouk, Director of the Center for Robotic and Image-Guided Surgery in Cleveland Clinic’s Glickman Urological & Kidney Institute, worked closely with Mauricio Perilla, MD, of the Department of General Anesthesiology, to prepare, coordinate and implement this approach.

Initial series completed with excellent results

The patients selected for the epidural underwent prostatectomy for either prostate malignancies or enlarged prostate but were otherwise healthy with no other underlying disease or comorbidities. “We wanted to minimize the variables,” says Dr. Kaouk. “This is important when you establish a new approach. Our goal was to show the feasibility, safety, and efficacy of doing an epidural for this type of surgery.”

The teams involved established a plan B in advance of the first case in the unlikely event that the patient moved, vocalized pain or unknowingly reached into a sterile field. “It takes a minimal amount of time to intubate and continue with the surgery, and the team was on standby in case that was required,” he says, but was not needed in any case.

SP transvesical prostatectomy: At a glance

The transvesical approach enables surgical access to the prostate through the bladder, avoiding the intraperitoneal cavity entirely. As a result, Dr. Kaouk explains, patients experience less pain and postoperative ileus because the bowels stay intact. In 2021, Dr. Kaouk and colleagues were the first to report their experience and early outcomes of this technique for radical prostatectomy and pelvic node dissection. It has become a preferred option in select patients with low- to intermediate-risk prostate cancer, Dr. Kaouk says.

Early results demonstrated a significant impact on urine control (50% had immediate continence), short postoperative Foley duration (three days post-surgery), minimal perioperative complications, limited use of opioids for pain control, low risk for transfusion, and fast recovery, with about 87% of patients in an outpatient setting within four hours of surgery.

For most patients, general anesthesia is a safe and appropriate option. But in patients with underlying neurologic or respiratory disorders who may be advised to avoid general anesthesia, epidural anesthesia may be a safe alternative.

Contraindications aside, some patients simply prefer to maintain consciousness if given the option, asserts Dr. Kaouk. “Going forward, an epidural for SP simple or radical transvesical prostatectomy will become an option as part of the medical decision-making process. And we will recommend it to patients when there are possible benefits.”

He continues, “I’ve had patients tell me that they want the surgery but are terrified of being intubated completely under general anesthesia, or there are medical reasons precluding them from use of general anesthesia. So it feels great to be able to give them this option.”

Patients can now undergo prostate surgery with epidural anesthesia and light sedation, known as twilight sleep, without the need for a ventilator general anesthesia.

Robotic prostatectomy without ventilator general anesthesia? SP transvesical prostatectomy is making it a reality

Fertility preservation is currently not an option for prepubescent males who are undergoing gonadotoxic treatment or who have an infertility-causing disease, as they are unable to provide a semen sample. A team of Cleveland Clinic urologists and pediatric oncologists is hoping to change that by offering a testicular cryopreservation service—at no cost to patients.

An experimental approach with great potential

Preclinical studies have shown that autologous transplantation of spermatogonial stem cells (SSCs) from testicular tissue cryopreservation (TTC) has the potential to restore spermatogenesis in animal models. Though still in the experimental realm, clinicians and researchers are excited by its promising results.

“It’s still experimental, but the data published about its utility in primates is promising. We’re not quite there yet in humans, but I think we will be. The science is moving really quickly,” says Sarah Vij, MD, a urologist in the Department of Urology and the study’s primary investigator.

With this in mind, she and colleagues, pediatric urologist Audrey Rhee, MD, and pediatric oncologists Seth Rotz, MD, and Stefanie Thomas, MD, developed a streamlined testicular tissue collection and storage process. They have enrolled and cryopreserved testicular tissue for nearly a dozen young patients so far.

Dr. Vij, who also leads Cleveland Clinic’s Center for Male Fertility, says their goal is to have the tissue available for future use when research and technologies have advanced enough to support transplantation of SSC.

“Although we do not yet have the ability to develop sperm from spermatogonial stem cells in humans, there is hope that this will be available by the time these children are ready to grow their families,” says Dr. Vij.

The project was funded with a VeloSano Impact Award, a Cleveland Clinic cancer research grant.

In addition to obtaining and storing the tissue for potential future use and research pursuits, the team is also assessing the effect that tissue storage has on parental distress during and after treatment.

They plan to capture this data systematically to understand the association between parent experience measures and determine if TTC plays a role in reducing parental distress and/or increasing parental hope.

“For some patients and families, having that conversation about fertility can provide some solace. You’re talking about life after treatment, which can be a hopeful dialogue and alleviate some distress, as difficult as those conversations may be,” adds Dr. Rotz, who leads the Childhood Cancer Survivorship Clinic.

Improved survival has changed the conversation about future fertility

Advances in pediatric cancer treatment have led to a greater than 80% survival rate at least five years post-treatment. This has shifted the conservation among parents and providers about how to best manage the longer-term effects of cancer treatment on quality of life, which includes fertility.

“Every patient encounter is different, and age, sex, and treatment are all variables that shape the fertility-preserving conversation,” stresses Dr. Rotz. “Regardless of the patient’s age, our goal is to have a conversation about fertility and infertility and potential fertility preservation options with all of our new cancer diagnosis patients before we start therapy. It’s never too early.”

Dr. Vij acknowledges that TTC is not inexpensive; it’s novel and still experimental. So to be able to offer it to all patients at no cost is significant.

“We are trying to remove all barriers to entry for interested patients and families.”

A team of Cleveland Clinic urologists and pediatric oncologists has developed a streamlined testicular tissue collection and storage process. They have enrolled and cryopreserved testicular tissue for nearly a dozen young patients so far.

Cleveland Clinic

Articles

From staging to surgery: How innovation is customizing urologic care

Cleveland Clinic urologists show how machine learning could revolutionize overactive bladder care

Robotic prostatectomy without ventilator general anesthesia? SP transvesical prostatectomy is making it a reality

Testicular tissue cryopreservation offers hope to prepubescent males at risk for infertility