Crouse Health: Leading the Way in Robotic Surgery — Past, Present and Future

By Sherry Christiansen

Wednesday, February 26, 2020

As modern medical technology continues to see exponential growth, the Crouse Institute for Robotic Surgery remains a leader in the industry, largely due to its pioneering spirit and team-centered approach.

 
Since its inception in 2008, the Crouse Institute for Robotic Surgery has evolved to become the largest multispecialty robotic surgery program in Central New York. Crouse Health has a sizable team of highly skilled, experienced surgeons, each committed to the use of the newest, most advanced surgical technology available today. Surgeons at Crouse Health continually enhance their minimally invasive surgical skills in order to offer their patients the highest level of care possible.

Surgeons and administrators at Crouse, particularly those who were instrumental in laying the initial foundation for the program’s infrastructure, share their perspectives on how Crouse became the market leader in this highly competitive and continually evolving field of modern medical technology.

 

History of Robotic Surgery

Central New York was not the birthplace of robotic surgery, and the da Vinci Surgical System was certainly not the first robot designed to assist in performing surgical procedures. According to the American Journal of Robotic Surgery, a robot was used for the first time in a procedure over 30 years ago, when the PUMA 200 was utilized for needle placement during a CT-guided brain biopsy. There have been many advances in robotic technology since that first robotic-assisted procedure back in 1985. Each improvement led to the first da Vinci Surgical System, which was approved by the Food and Drug Administration in 2000. This early da Vinci model broke new ground as the first robotic surgery technology approved for general laparoscopic surgery

The Making of a Leader

Eventually, the Crouse Health team began to contemplate what it would take to establish a successful robotic surgery program of its own. When approached by its highly skilled staff of surgeons who had learned about the many benefits of robotic surgery, administrators at Crouse saw the promise of such a program and committed the resources to building it, in partnership with its surgeons.

Po Lam, MD, a board-certified urologist at Crouse Health, performs close to 200 robotic procedures each year. His fellowship training included endourology, laparoscopy and minimally invasive surgery at the University of Oklahoma Health Sciences Center. Dr. Lam was instrumental in getting Crouse Health’s robotic surgery program off the ground.

“In 2006, Crouse did not have a robotic surgery program. I met with Paul Kronenberg, MD, [CEO of Crouse Health at the time] to ask him if we could start a program,” Dr. Lam says. “Since then, the Crouse program has grown significantly.”

Dr. Lam, as well as GYN/oncology surgeons Mary Cunningham, MD, and Douglas Bunn, MD, conducted much of the initial research to learn about program start-up costs. They also estimated the number of cases it would take to make the investment in the technology, training and other expenses worth the initial expenditure.

“At that time, the technology cost between $1.2 million and $1.4 million,” Dr. Lam says. “This was a significant investment, but adding the technology made sense because of the tremendous service we would be able to offer to the community.”

After Dr. Lam and the other Crouse surgeons presented data on how and why the hospital should consider a new robotic surgery program, hospital administration gave the technology their stamp of approval, fully supporting the surgeons’ vision of bringing the leading-edge technology to Crouse.

The purchase of the hospital’s first da Vinci robot in 2008 was just the beginning.

“It’s vital to undergo the right preparation and training before using robotic surgical technology. Crouse Health provides great training for the surgeons, both the experienced surgeons and the new surgeons and residents, as well as the rest of the team.”
— Po Lam, MD, board-certified urologist at Crouse He

Meet the Team

Crouse Health features the largest multispecialty robotic surgery program in Central New York.

General Surgery

  • Akbar Ahmed, MD
  • Kenneth Cooper, DO
  • Jeffrey DeSimone, MD
  • Steven Gelb, MD
  • Taewan Kim, MD
  • Benjamin Sadowitz, MD
  • James Sartori, MD

Colorectal

  • David Nesbitt, MD
  • John Nicholson, MD

Gynecology Oncology

  • Rinki Agarwal, MD
  • Douglas Bunn, MD
  • Mary Cunningham, MD

Gynecology

  • Stephen Brown, MD
  • Nikole Bucsek, MD
  • Carla Liberatore, MD
  • Myron Luthringer, MD
  • Navpriya Oberoi, MD
  • Byuong Ryu, MD
  • Shane Sopp, MD

Urology

  • David Albala, MD
  • Po Lam, MD
  • Hadley Narins, MD
  • Nedim Ruhotina, MD
  • Harvey Sauer, MD
  • Jeffrey Sekula, MD
  • Daniel Welchons, MD

Bariatrics

  • Kenneth Cooper, DO
  • Jeffrey DeSimone, MD
  • Taewan Kim, MD

Teamwork

John Nicholson, MD, colon and rectal surgeon at Crouse Health, graduated with honors from SUNY Upstate Medical University in Syracuse in 1973. As a highly skilled surgeon, Dr. Nicholson was one of the first in the area to be trained on the da Vinci system.

“Crouse Health’s state-of-the-art technology wouldn’t be what it is today if it hadn’t been for the efforts of the staff and the support of the administration,” Dr. Nicholson says. “When the robotics program first launched, it was considered a badge of honor for nurses to be on the robotics team, so those who were selected worked very hard to ensure that the program was successful.”

While the robotic technology is the same at every hospital, the quality of the surgeons using the technology is what really matters.

“Crouse Health has the right staff and the right surgeons with the right training,” Dr. Lam says. “That is the recipe for success.”

The Crouse Institute for Robotic Surgery has continued to progress since its inception.

“Every few years a newer version of the technology is available,” Dr. Lam says. “Our administration helps us stay up to date on the newest technology, which allows us to offer the most advanced care possible to our patients.”

“Our robotic surgery program is physician driven, with an active steering committee and talented physicians, PAs, nurses and technicians, all trained to perform optimally as a team. The robot technology is just another tool for the staff. The physicians’ talent and engagement is what really drives the program, creating an environment where the staff providing patient care can really excel.”
— Seth Kronenberg, MD, Chief Medical Officer and Chief Operating Officer, Crouse Health

Expanding the Team

Benjamin Sadowitz, MD, FACS, a board-certified general surgeon, joined CNY Surgical Physicians (now known as Crouse Medical Practice – General Surgery) in 2015. He completed his fellowship in advanced gastrointestinal and hepatopancreaticobiliary surgery at Florida Hospital Tampa. Currently, Dr. Sadowitz largely specializes in robotic general surgery, which includes gallbladder, hernia, colon, appendix and anti-reflux procedures.

Dr. Sadowitz has firsthand experience of just how efficient the teamwork is at Crouse.

“About 18 months ago, we grew from two to four robotic systems at Crouse. Logistically, we needed to train a significant number of staff members to get all four systems up and running,” Dr. Sadowitz says. “We had a large group of OR staff — technicians, nurses and physician assistants — undergo training. Our robotics coordinator, Lisa Miller, our Director of Perioperative Services, Jill Hauswirth, and our head physician assistant, Cathy Burkett, were instrumental in identifying and eliminating training roadblocks.”

“The expansion was a huge initiative for Crouse,” says Dr. Sadowitz. “All four robotic systems were up and running by January 2019.”

“There used to be limitations when the robotic technology first came out. For example, patients with scar tissue from previous surgeries may have been disqualified. Now, there are fewer limitations because the technology is much better.”
— Po Lam, MD, board-certified urologist at Crouse Health

Crouse Institute for Robotic Surgery Today

Presently, Crouse Institute of Robotic Surgery providers perform over 1,750 robotic surgery procedures each year.

“Our four robots are not only in use full-time during the weekdays, but the robotic technology is also used after hours and on weekends,” Dr. Sadowitz says.

Seth Kronenberg, MD, Chief Medical Officer and Chief Operating Officer at Crouse Health, continues to support the legacy that his father, former CEO Paul Kronenberg, MD, started in 2008.

Dr. Seth Kronenberg has been a member of the senior administration at Crouse Health since 2014. He chose Crouse because of its culture of collaboration with the medical staff.

“Physicians here have a voice in the decision-making process, a focus which I believe differentiates Crouse Health from other hospitals and health systems in the region,” Dr. Seth Kronenberg says.

While Crouse Health may have been the last in Central New York to implement the infrastructure needed to perform robotic surgery, the hospital has surpassed all other programs when it comes to patient volume and availability of clinical applications. Today, in addition to having four state-of-the-art da Vinci Xi multispecialty robots, Crouse partners with Intuitive, the company that provides the robotic technology. Through the work of the surgeons, OR staff and the unique partnership with Intuitive, Crouse Health has become the regional leader.

“Crouse Health has the highest number of robotic surgeons in the area, including 25 multi-specialty surgeons, each providing the highest level of quality to our patients by using the robotics technology,” Dr. Lam says.

“When using the robot platform for cholecystectomy, a special imaging system [Firefly fluorescence imaging] helps to highlight the bile duct. Such illumination helps minimize the risk of injury to this fragile structure during dissection.”
— Benjamin Sadowitz, MD, FACS, board-certified general surgeon at Crouse Medical Practice – General Surgery.

The Future

Considering recent advances in robotic technology and the accomplishments of Crouse’s robotics team, it’s exciting to imagine what more the future might bring. Dr. Sadowitz believes Crouse may increase the number of robotic surgical systems it uses to five.

“Robotic surgery is fast becoming the standard of care for many surgical conditions,” Dr. Sadowitz says. “More than 40 companies are vying to get into the robotic surgery market, so it makes sense that there will be a role for robotics in every operating room in the country. There will be very few places or areas of surgery where robotics won’t be involved.”

Dr. Lam also sees an exciting future involving the next generation of robotic surgical systems.

“I think the new technology will be more intuitive, with many alert signals to notify surgeons when a situation during a procedure may require additional attentiveness, such as moving in the proximity of adjacent blood vessels. The launch of the newest technology may occur within the next 12 to 18 months,” Dr. Lam says. “At Crouse, we’re prepared to be one of the first to successfully adopt new generations of robotic surgical system technology.”

“We perform a procedure called a total proctocolectomy and ileal-anal pouch — sometimes referred to as j-pouch or an s-pouch. With robotic-assisted surgery, this procedure can be done sparing the anal sphincter, which means the patient will usually not need a permanent ostomy. With traditional surgery, these patients were hospitalized for one week to 10 days. After a robotic-assisted total colectomy, the patient can typically go home in three to five days.”
— John Nicholson, MD, colon and rectal surgeon at Crouse Health

Benefits of Robotic Surgery

Robotic surgery offers many benefits to patients compared to open surgery, including:

  • Shorter hospitalization
  • Reduced pain and discomfort
  • Faster recovery time and return to normal activities
  • Smaller incisions, resulting in reduced risk of infection and less scarring

For the surgeon, benefits of robotic surgery include:

  • An enhanced visual field: Surgeon has a superior view of the operating area. The high-definition camera provides a magnified, detailed view of the affected area
  • Superior dexterity
  • Access to hard-to-reach places

For more information about robotic-assisted surgery services offered at the Crouse Institute for Robotic Surgery, visit Crouse.org/robotics.

Upstate Urology Brings a Better Way to Detect Bladder Cancer to Central New York

By Thomas Crocker

Wednesday, February 26, 2020

To enhance a burgeoning bladder cancer program, the Department of Urology at Upstate Medical University offers Blue Light Cystoscopy (BLC) with Cysview, a method that has been proven to increase detection rates of certain forms of bladder cancer.

Cysview is a photoactivating solution that causes bladder tumors to fluoresce when absorbed. Using it with BLC allows urologic oncologists to detect cancers that might have gone unnoticed under standard white light. Bringing BLC with Cysview to Upstate was a priority for Joseph Jacob, MD, MCR, Chief of the Bladder Cancer Program in the Department of Urology and Assistant Professor of Urology at Upstate Medical University. He joined Upstate Urology in 2017, intent on using his fellowship training to help meet the need for bladder cancer care in Central New York. Part of that meant acquiring advanced technology to improve quality.

“High-level evidence from recent randomized trials showed BLC with Cysview has been proven to benefit patients,” Dr. Jacob says. “This technology has been shown to increase the rate of detection of carcinoma in situ, which is typically flat, often difficult to see and identify, and can progress to more aggressive types of bladder cancer. That higher detection rate is a huge deal for patients.”

Studies have also demonstrated higher detection rates of nonmuscle invasive papillary bladder cancer using BLC with Cysview compared with white light cystoscopy.


“Upstate Medical University invested in Blue Light Cystoscopy with Cysview based solely on a desire to improve quality for patients in Central New York. That makes me proud to be part of Upstate.”
— Joseph Jacob, MD, MCR, Chief of the Bladder Cancer Program in the Department of Urology and Assistant Professor of Urology at Upstate Medical University

 

 

Detection and Removal

Most patients with bladder cancer are candidates for BLC with Cysview due to the typically noninvasive nature of the disease, according to Dr. Jacob. Available at Upstate Cancer Center at Upstate University Hospital since March 2019, BLC with Cysview begins with the introduction of Cysview into the bladder via catheter. The medicine is left to coat the bladder for one hour.

“Cysview is full of molecules that can be absorbed by cells, and the cells can be activated with a certain wavelength of light,” Dr. Jacob says. “In the procedure room, I use a standard white-light camera that allows me to switch to blue light. Under that wavelength, cancers pop out in bright pink that’s quite obvious compared with normal bladder tissue.”

Treatment often takes place concurrent with BLC with Cysview, which can supplement transurethral resection of a bladder tumor, a common procedure for staging and removing bladder cancer. Removing the tumor may set the stage for intravesical therapy, such as immunotherapy or chemotherapy.

“The bladder is an imperfect sphere with areas that require careful scrutiny,” Dr. Jacob says. “Using only white light, we might miss some subtle, small or flat lesions, but BLC with Cysview helps prevent that. If we were to overlook a flat carcinoma in situ, for example, then we would miss the opportunity to provide immunotherapy, which is the treatment of choice for this type of cancer.”


For information about the Department of Urology at Upstate Medical University, visit upstate.edu/urology.

Public Health: Surveillance, Research and Prevention

By Kathryn Ruscitto; Wednesday, February 26, 2020

The current crisis with the emerging Coronavirus, combined with a challenging flu year, reminds us all of the important role of our Public Health officials.

Public health takes the entire health system — including patients, community providers and environmental factors — into account. The CDC and local health departments provide early warning systems. Public health has played a key role in every community across this country, from managing communicable diseases such as HIV to the outbreak of the coronavirus. Laboratories and clinicians report results to local health departments, who then coordinate aggressive tracking and communications across their communities and with the New York state health department.

“The foundation of our work is based on our mission to protect [the] health of our community residents with [a] vision of community partnership. We follow [the] principle of health equity and advocate for [the] CDC’s Health in All Policies (HiAP) [approach] because these impact social determinants of health,” says Indu Gupta, MD, Onondaga County Health Commissioner. “Both as a practicing physician and now as a leader of a mid-size public health department, I always followed these two principles in order to improve health outcomes, and continue to do so now.

“It is important to understand and acknowledge that health care and public health are interdependent, [such that] one’s focus to improve and protect [the] health of one person at a time can result in improving [the] health of the entire community by collaborative partnership with all the members of a public health system. Public health departments play a central role in this. While health systems work at the micro level, public health provides [a] bridge to the community to provide a macro-level perspective and leadership to engage all those [who] impact [the] health of a community!”

Helpful Resources

A report exploring the social determinants that factor into health status can be found at the Onondaga County Health Department website and is an excellent summary of data and actions that have been coordinated across local health systems and providers. While these are identified actionable goals, public health must deal equally with emerging, unpredictable health challenges.

Clinicians across Central New York are part of the public health system and may be the first to experience an outbreak or indication of a systemic gap in care.

Dr. Gupta began her career as a primary care internal medicine physician and appreciates the role clinicians play in the health system. She cares deeply for her patients and understands the importance of assessing the whole person and their environment to understand the best approach to treatment. Onondaga County is in a unique position to have a leader who experienced the provision of clinical care before leading an experienced team of public health professionals.

The coming year will challenge all health providers to think about how they prepare for emerging trends in health. Environmental factors are influencing the increase in asthma, diarrhea and food-borne illness, tick-borne disease, and heat-related conditions.

Key Priorities for Onondaga County

Indu Gupta, MD, Onondaga County Health Commissioner, notes that key priorities of the Onondaga County Community Health Assessment and Improvement Plan for 2019–2021 include:

  • Preventing chronic diseases
  • Promoting well-being and preventing mental and substance-use disorders
  • Promoting a healthy and safe environment
  • Promoting healthy women, infants and children
  • Preventing communicable diseases

You can reach out to Kathryn Ruscitto on LinkedIn or via email at krusct@gmail.com.

 

The Labor and Employment Law Landscape

By Anastasia Semel

Anastasia Semel

Several significant changes to state and federal labor and employment laws are taking effect this year. Employers need to be aware of these laws in order to adjust employment policies and procedures accordingly. Understanding and complying with these laws is essential. Below is a nonexhaustive list of laws enacted to date:

1. Increases In Minimum Wage and Salary Thresholds

Effective Dec. 31, 2019, the minimum wage is $11.80 for employees in areas of New York state, other than New York City, Nassau, Suffolk or Westchester counties. Additionally, New York state’s Minimum Wage Act and applicable regulations raised the minimum salary threshold to $46,020.00 annually ($885.00 weekly) for exempt executive and administrative employees in areas other than New York City, Nassau, Suffolk or Westchester counties. 

New York state does not have its own minimum salary threshold for exempting professional employees; however, the federal Fair Labor Standards Act and applicable regulations increased its threshold amount to $35,568.00 annually ($684.00 weekly). Employers should confirm that their wage rates and exemption classifications are in compliance with federal and state laws.

2. Salary History Ban

Effective Jan. 6, 2020, New York Labor Law Section 194-a bans employers from inquiring about or relying on salary history, including compensation and benefits, when making employment decisions. More specifically, the law bans employers from asking job applicants and current employees about their salary history and relying on salary history as a factor in deciding whether to hire or how much to pay an applicant or employee. Employers cannot (1) require applicants or employees to reveal salary history as a condition of consideration for a position; (2) request salary history information from an applicant’s or employee’s former employer; or (3) refuse to interview, hire, promote, or otherwise employ or retaliate in any other way against an applicant or employee who exercises the right not to reveal salary history.

If an applicant or employee voluntarily discloses his or her salary history, the employer may take it into consideration. Additionally, if the applicant or employee volunteers his or her salary history information in order to negotiate higher pay when an offer of compensation is made, the employer may take steps to confirm the accuracy of that information.

Employers should train human resources personnel, and anyone involved in the hiring process, on permissible and prohibited questions and actions under the new law.

3. Employee Rights Regarding Reproductive Health Decisions

Effective Nov. 8, 2019, New York Labor Law Section 203-e prohibits employers from (1) accessing an employee’s personal information regarding the employee’s (or dependent’s) reproductive health decisions without prior informed, affirmative written consent; (2) discriminating or taking any retaliatory personnel action against an employee with regard to compensation or the terms, conditions or privileges of employment because of or based on the employee’s (or dependent’s) reproductive health decisions; and (3) requiring an employee to sign a waiver or other document that purports to deny the employee the right to make their own reproductive healthcare decisions.

The law permits employees to bring a civil action in any court of competent jurisdiction and seek various legal and equitable remedies, and it also provides for an additional award of civil penalties against any employer who retaliates against an employee for bringing a complaint.

4. Expanded Worker Protection Under the New York State Human Rights Law

Several changes to the New York State Human Rights Law (NYSHRL) take effect in 2020.

Nondisclosure agreements (NDA) as part of employment contracts entered on or after Jan. 1, 2020 must include an explicit policy that allows the employee or potential employee to speak with “Law enforcement, the Equal Employment Opportunity Commission, the state Division of Human Rights, a local commission on human rights or an attorney retained by the employee or potential employee.” Without this language, NDAs are void and unenforceable to the extent that they prohibit disclosing factual information regarding any future claims of discrimination.

Effective Feb. 8, 2020, employers of any size, including those with just one employee, are subject to the NYSHRL.

Finally, effective Aug. 12, 2020, the statute of limitations for reporting claims of sexual harassment to the state Division of Human Rights will be extended to three years.

Employers should ensure they are in compliance with these laws and consult legal counsel if they have specific labor and employment law questions or concerns.


Anastasia Semel is an associate at CCB Law, a boutique law firm focused on providing counsel to physicians and healthcare professionals. She can be reached at 315-477-6232 or asemel@ccblaw.com.