Jaime Landman: Hi, this is Jaime Landman, Chair of the Department of Urology, UCI, and welcome to Endourology Today. A collaboration between UroToday and the Endourology Society, where we're always going to update you on the latest, greatest coming out of the world of endourology and specifically the Journal of Endourology.

And then today I'm particularly delighted to be with my friend and colleague Michael Palese, who is the Chair of Mount Sinai, downtown, Professor of Urology. And as you will all know, an internationally famous endourologist. and he published a wonderful manuscript that should be coming out very shortly called "Magnetic-Assisted Robotic and Laparoscopic Renal Surgery: Initial Clinical Experience with the Levita^TM Magnetic Surgical System". TM of course, being trademark. So Levita^TM Magnetic System.

As I remember, Michael, I saw this coming out a few years back. We saw it at the AUA in World Congress, Jeff Cadeddu out of UT Southwestern, I think developed this technology. Do you mind telling us a little about the technology?

Michael Palese: Sure. I mean, listen, this was something that we got our hands on pre-COVID actually. So prior to sort of the madness that's occurred across the country. And so we had quite a bit of experience using it for robotic, some laparoscopic, and even then pre-COVID for the single port. So single port surgery, we just started about a little over a year ago.

And so we got a chance to play with it and really kind of figure out where the pluses and minuses were for it. And honestly, I think there is some value. There's no question there's value in using this technology. Particularly in certain procedures, especially, for instance, that single port technology, where the goal is really cosmetically to reduce the amount of trocars that we're using.

This is a fantastic addition to your surgical tools to really be able to sort of move a piece of tissue or move an organ in such a way that allows you to do a better surgery. And so we reported on our experience, which was relatively small at the time. And this was again, we brought this data from pre-COVID, about 10 cases using various different renal protocols.

Jaime Landman: All right. So the reason I was excited, was the same reason I'm sure you were, is that like yourself, I don't see robotics and laparoscopy as minimally invasive anymore because that's the standard for us, right? So we should consider that standard invasive. And minimally invasive is anything that's now a step forward. And by using those definitions, we'll always be striving to do better. And obviously, by using a magnet, you're able to reduce the number of trocars. Do you have any idea if you were able to use one or two per case, was that pretty typical?

Michael Palese: Yeah, pretty typically certainly for the multiport, as I said, in the meantime, we've got multiport, single port, right? So a year ago we didn't have these terms. So multiport robotic surgery, there's an opportunity to remove a sort of an assistant arm at that time. There are some technical issues because you're using a sort of a powerful magnet. You have to be careful because you don't want to get too close to the machine, to the robot itself.

So initially, when we were playing with this technology, we had a little bit of trouble trying to avoid getting the robot arm. Because it does spark sort of a fault, a recoverable fault. So you have to stop and redo everything. But once we kind of got the hang of it and figured out the positioning, it worked very well. So we were able to go from a sort of four forearms down to three arms that made sense. And perhaps even in some certain cases, we needed a fifth arm. So we would put it in there as well. Again, it depends on the scenario you're using it. Again, I think the single port is really where it was a kind of really, a major improvement because you're trying to reduce trocars and you're trying to do everything through a relatively small incision, two and a half to three-centimeter size incision. And so allowing you to lose one trocar, or even, I guess, gain a sort of another assistant arm is fantastic.

The issue with sort of hitting the robot with the magnet was not really the case with a single port, because the single ports designed to obviously look very differently. The fantastic part about the magnet is you can kind of move it anywhere on the body. You don't have to worry about it sitting in one spot, and really can get some very nice retraction using this technology.

Jaime Landman: The two major challenges you reported in the manuscript on these 10 cases were one was that recoverable fault, which wasn't a big deal. And you learned to work around it by separating the magnet. And the other one was just a minor liver tear from the retractor, which I think is a little grasper, right?

Michael Palese: Correct. Or a mini bulldog is really what it is.

Jaime Landman: Right. Other than that, perfectly safe. And did you find it particularly effective? Because I know you did, at the time of publication, a little less pelvic surgery, a little more flank surgery. Was it better for one or the other? Did you notice?

Michael Palese: So yeah, I think for obviously most of my expertise is in flank surgery, retroperitoneal surgery. So that's where I used it. We did use it a few times in several prosthetic procedures, obviously simple prostatectomy, radical prostatectomy.  We found it also very helpful in these instances as well. Another reason to sort of lose or not place one of the assistant ports. Because again, you can move it from side to side, you can use to hold up the prostate. The prostate was very conducive to using this technology, and certainly using the magnet around the flank, around the pelvis even is quite nice. It's quite easy to do.

Jaime Landman: And so this is the first iteration of this technology. You've done a lot more than the 10 cases now I presume, right?

Michael Palese: Correct. Yes.

Jaime Landman: That's actually a good sign because if it wasn't really a value, you probably would have dropped it. So in itself, that screams that it's useful.

So would you say you got a gut feeling let's say from one to 10, 10 being, "Oh, you got to get this. It's like the next best thing from DaVinci robot or some novel technology that you can't live without". To a one or two, "Well, yeah, sometimes it's helpful, but I don't want it." Where does it fall on that spectrum?

Michael Palese: I think the current status of this is it's very useful on certain procedures, not every procedure, right? It's obviously got its own expense. It's got a disposable component. So you want to make sure that if you're using it, you're using it for the right type of a case where you need a good retraction and you want to avoid placing an extra trocar. What I think is exciting about this technology is it's really just the beginning, scratching the surface, of how we use this. Okay?

So ideally if we can actually avoid placing certain trocars, to begin with, and just use these kinds of magnetic arms, who's to say that we can't do this for robotic technology in general, make sort of magnetic arms that don't require really any kind of trocars that go into the body?

So in theory, you sort of just introduce these magnets, and then the arms work themselves with the use of a magnet through the skin. And we're demonstrating the technology is actually very viable, right? This is something you can do. You can transmit this magnetic technology through the skin and actually get a good response without actually compromising, or it seems to be very safe without compromising patient care.

Jaime Landman: If I have a limited budget this year, which we all do, do I buy this? Is it going to make my surgery better and less invasive? Or do I wait until some future iteration?

Michael Palese: I think if you're doing single port surgery, this is a no-brainer to buy. Absolutely. And I think this is a good addition and will also enhance your ability to deliver better care.

Jaime Landman: And the last question I'll have is I remember Jeff Cadeddu, we had spoken about this when he was first working on it. Texas, just like when I started in St. Louis, lots of very obese patients, New York, less obese, California now, even less obese than New York, it's better than the Midwest. Did you have any trouble with those people with a thicker abdominal wall? Because obviously, the magnet has a limited range.

Michael Palese: That's a great question. So, no question needs to take that into account. There are certain patients that you have to get the magnet a little bit closer to the skin, but we didn't find any of our larger patients that that was really an issue. We had severe over 40 BMI patients that we did this on and didn't have any trouble.

Jaime Landman: Very cool. Well, Dr. Michael Palese, world-class expert saying that this is, if I interpret his words properly, nice to have right now, it's going to be very important in the future. And thank you so much for bringing this innovation. I think it's just now in here in December 2020, going to be in the Journal of Endourology, it should be in hard copy in the next few months, and really grateful for your time, Michael. Thank you so much. Stay safe and happy, healthy new year.

Michael Palese: See you.

Jaime Landman: Bye. 

Michael Palese: All the best. Thank you.