The Methodist Hospital6565 Fannin Street

Houston, Texas 77030methodisthealth.com

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METHODIST DEPARTMENT OF UROLOGY 17

MITIE also serves as a research center for procedural innovation and technology development, where multidisciplinary teams of scientists, bioengineers and surgeons collaborate to break new ground in robot-assisted surgery, image-guided operations, biosensors, virtual procedures and other leading-edge techniques.

“When it comes to sheer volume of physicians and students, our program is one of the largest,” says Dr. Brian J. Miles, a board-certified urologist and medical director of robotic surgery at Methodist. “Clearly, we have one of the most effective teaching centers in the country. In the world, for that matter.”

LEARNING WITHOUT BORDERSAlthough MITIE is a top-notch teaching facility for robotic surgery, Methodist understands that coming to Houston for continuing medical education may not always be practical. Now, with advancements in robotics and communications technology, it may not be necessary at all. Today, physicians

like Dr. Miles can share their expertise with other surgeons and observe robot-assisted surgical training from almost anywhere in the world.

By toggling between multiple camera views, educators can see inside the patient’s abdomen, watch the doctor’s hands in action, and zoom out to evaluate a robot’s position over a patient. In some cases, they can take control of the robot to demonstrate finer points of certain techniques and procedures. Physicians can review video footage of the session in real-time and compare their work to videos of optimal procedures. With remote proctoring, physicians can show, demonstrate and communicate as if they were in the same room.

EVALUATING INDIVIDUAL SKILLSThe current methods for evaluating robotic skill first look at the number of robotic procedures a particular surgeon has performed. While an excellent measure of experience, this does not represent skill and technical acumen.

To ensure an accurate assessment of surgical skills, Methodist developed the Global Evaluative Assessment of Robotic Skills (GEARS) program. GEARS reviews physicians across six areas critical to robotic surgery, and then provides immediate feedback about areas that need improvement. This allows feedback to be delivered in real time — even in the middle of a training session.

The GEARS curriculum has been in development since 2009, and has been used to help practicing physicians get up to speed on the latest robotic techniques and acquire specialized robotic skills.

This world-class facility and these innovative programs reinforce Methodist as a force in medical education and skills evaluation. This dedication to learning, sharing and mentoring has allowed Methodist to consistently deliver upon one of its guiding values: “to be the best at what we do and a model for others to emulate.” n

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1 MESSAgE frOM THE CHAIrMAn Our legacy, research and innovation

2 THE METHODIST HOSpITAL Leading Medicine for our patients

4 pATIEnT CArE World-renowned expertise and dedication

5 KIDnEY STOnE MAnAgEMEnT Innovative treatment and prevention

6 rObOT-ASSISTED SurgErY Advancements in techniques and technology

10 CEnTEr fOr rESTOrATIvE pELvIC MEDICInE Comprehensive care for complex disorders

13 A pATIEnT’S pErSpECTIvE An inside look at compassion and care

14 rESEArCH AnD EDuCATIOn Breaking new ground and sharing expertise

T A B L E O F C O N T E N T S

M E T h O D I S T D E pA R T M E N T O F U R O L O G y

Dear Friends and Colleagues,

It has been an honor to lead and work with The Methodist Hospital Department of Urology for the last 12 years. Since 1998, the Department of Urology has ranked consistently as a top program in U.S.News and World Report’s “America’s Best Hospitals.” This year Methodist was ranked as the best hospital in Texas due in part to our continued success as a multidisciplinary, cross-institutional faculty of talented urologists from private practice, employed models of care, academicians and researchers. “Diversity with respect” describes our collective approach to problem-solving in patient care, education and research.

Methodist’s Department of Urology offers comprehensive treatment covering the entire spectrum of urologic disease and disorders of the urinary tract. In this age of technology overload with robotic-assisted surgery, laser ablation of tissue and stones, along with organ regeneration, we never lose our perspective as physicians caring for our patients. At Methodist we are committed to our I CARE values, which define us — integrity, compassion, accountability, respect and excellence. While proud of our state-of-the-art facilities and equipment, I offer our attention to patient-centered care as the vital reason our department excels year after year.

The patient care experience at Methodist is enhanced by our exemplary staff, from the operating rooms to the inpatient and outpatient floors. Drs. Goldfarb, Lapin and Lewitton have practiced urology at Methodist for many years and describe in this issue why they choose this hospital over others in the Texas Medical Center for their urology practice.

The Methodist Center for Restorative Pelvic Medicine (CRPM) is a multidisciplinary program helping meet the needs of patients with incontinence and pelvic organ prolapse. Our department participated actively in the formation of CRPM, where urologists collaborate with urogynecologists, colo-rectal surgeons and plastic surgeons to tackle difficult reconstructive cases using minimally invasive techniques whenever possible.

The Department of Urology is a leader in minimally invasive and robot-assisted surgery for prostate, kidney and bladder cancer. Methodist was one of the first institutions in Texas to embrace minimally invasive technology, including robotics, and actively practice and teach its application to urological surgery. The Methodist Institute for Technology, Innovation & Education (MITIESM) is a comprehensive education and research institute dedicated to simulated clinical environments and research. Our programs re-train experienced urologists alongside residents-in-training to assure safe and competent practice. MITIE is an exciting place to work, where innovation applied to imaging and navigation is being fostered to complement minimally invasive surgery.

The education of our residents and fellows in urology remains a primary focus for our teaching faculty in a joint residency program with the Scott Department of Urology at Baylor College of Medicine. We remain committed to the best urology education possible by combining the diverse expertise of the institutions’ faculty.

Advancing medicine requires active research in the clinic and laboratory. The Department of Urology actively participates in more than 25 clinical trials, including several Phase I studies along with active bench research in cancer of the prostate and kidney, voiding dysfunction, and neurogenic bladder disorders. Urology residents and fellows actively participate in all phases of research, encouraging their bright minds to consider academic urology for a future career.

The Department of Urology seeks to enrich urological care through innovation, education and a passion for patient-centered care. I hope you enjoy reading our annual update.

Sincerely,

TIMOTHy B. BOOnE, M.D., PH.D. Professor of Urology, Weill Cornell Medical CollegeChair, Department of UrologyThe Methodist Hospital

Message from the Chairman

Dear Friends and Colleagues,

It has been an honor to lead and work with The Methodist Hospital Department of Urology for the last 12 years. Since 1998, the Department of Urology has ranked consistently as a top program in U.S.News and World Report’s “America’s Best Hospitals.” This year Methodist was ranked as the best hospital in Texas due in part to our continued success as a multidisciplinary, cross-institutional faculty of talented urologists from private practice, employed models of care, academicians and researchers. “Diversity with respect” describes our collective approach to problem-solving in patient care, education and research.

Methodist’s Department of Urology offers comprehensive treatment covering the entire spectrum of urologic disease and disorders of the urinary tract. In this age of technology overload with robotic-assisted surgery, laser ablation of tissue and stones, along with organ regeneration, we never lose our perspective as physicians caring for our patients. At Methodist we are committed to our I CARE values, which define us — integrity, compassion, accountability, respect and excellence. While proud of our state-of-the-art facilities and equipment, I offer our attention to patient-centered care as the vital reason our department excels year after year.

The patient care experience at Methodist is enhanced by our exemplary staff, from the operating rooms to the inpatient and outpatient floors. Drs. Goldfarb, Lapin and Lewitton have practiced urology at Methodist for many years and describe in this issue why they choose this hospital over others in the Texas Medical Center for their urology practice.

The Methodist Center for Restorative Pelvic Medicine (CRPM) is a multidisciplinary program helping meet the needs of patients with incontinence and pelvic organ prolapse. Our department participated actively in the formation of CRPM, where urologists collaborate with urogynecologists, colo-rectal surgeons and plastic surgeons to tackle difficult reconstructive cases using minimally invasive techniques whenever possible.

The Department of Urology is a leader in minimally invasive and robot-assisted surgery for prostate, kidney and bladder cancer. Methodist was one of the first institutions in Texas to embrace minimally invasive technology, including robotics, and actively practice and teach its application to urological surgery. The Methodist Institute for Technology, Innovation & Education (MITIESM) is a comprehensive education and research institute dedicated to simulated clinical environments and research. Our programs re-train experienced urologists alongside residents-in-training to assure safe and competent practice. MITIE is an exciting place to work, where innovation applied to imaging and navigation is being fostered to complement minimally invasive surgery.

The education of our residents and fellows in urology remains a primary focus for our teaching faculty in a joint residency program with the Scott Department of Urology at Baylor College of Medicine. We remain committed to the best urology education possible by combining the diverse expertise of the institutions’ faculty.

Advancing medicine requires active research in the clinic and laboratory. The Department of Urology actively participates in more than 25 clinical trials, including several Phase I studies along with active bench research in cancer of the prostate and kidney, voiding dysfunction, and neurogenic bladder disorders. Urology residents and fellows actively participate in all phases of research, encouraging their bright minds to consider academic urology for a future career.

The Department of Urology seeks to enrich urological care through innovation, education and a passion for patient-centered care. I hope you enjoy reading our annual update.

Sincerely,

TIMOTHy B. BOOnE, M.D., PH.D. Professor of Urology, Weill Cornell Medical CollegeChair, Department of UrologyThe Methodist Hospital

Message from the Chairman

Since 1998, the Department of Urology has ranked consistently as a top program in “America’s Best Hospitals” by U.S.News & World Report.

About The Methodist Hospital

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about The Methodist hospitalHISTORY

The Methodist Hospital in Houston, Texas, has earned an international reputation for

excellence in patient-centered care. Located in the renowned Texas Medical Center®,

Methodist is one of the largest private, nonprofit, academic medical centers in the United

States. From its humble beginnings as a 19-bed community hospital in 1919 to the

global destination it is today, Methodist offers patients cutting-edge medical treatments

and techniques, sophisticated diagnostic technology, and groundbreaking research.

ACADEMICS

In 2004, The Methodist Hospital formed a partnership with Weill Cornell Medical

College and New York-Presbyterian Hospital. This primary affiliation enables the

three internationally renowned institutions to collaborate to ensure a rapid exchange

of ideas, providing high-quality patient care, cutting-edge clinical and biomedical

research, and the most innovative medical education and training of future

physicians and biomedical scientists. These three institutions share the highest

commitment to providing the best care for patients — as well as the best training

for young physicians through residency programs for graduate medical education.

Methodist also has affiliations with Baylor College of Medicine, University of Houston,

Texas A&M University and The University of Texas Medical Branch.

MILESTONES AND AWARDS

Methodist is consistently recognized nationally for patient outcomes

and medical proficiency. The Methodist Hospital ranked among

the country’s top hospitals in 13 specialties in U.S.News & World

Report’s 2012 “Best Hospitals” issue, more than any other hospital

in Texas. For seven consecutive years, FORTUNE® magazine has

named Methodist one of the “100 Best Companies To Work For®.”

The Methodist Hospital System is the only health care organization

in Texas to be recognized.

FORTUNE is a registered trademark of Time Inc. and is used under license. From FORTUNE Magazine, February 7, 2012 © 2012 Time Inc. Used under license. and Time Inc. are not affiliated with, and do not endorse products or services of, Licensee.

METHODIST DEPARTMENT OF UROLOGY 3

7,200 36209inTernaTional paTienTs

FroM 93 counTries in 2012

More Than acgMe and gMec sponsored residency and Fellowship prograMs

sponsored Medical residenTs

philanThropy MaKes a diFFerence a contribution in any amount can make all the difference — in medical education; research; equipment, technology and facilities; clinical programs; and helping those in need. To join Methodist’s mission of healing people and saving lives, please contact The Methodist hospital Foundation at either 832-667-5816 or donor@tmhs.org, or visit methodisthealth.com/foundation.

methodisthealth.com

THE METHODIST HOSPITAL RESEARCH INSTITUTE (TMHRI)

Private physicians can choose to treat their patients in any hospital which suits their needs. Drs. Stephen Lapin, Michael Lewitton and Richard Goldfarb, urology specialists at Houston Metro Urology, consistently choose Methodist because it offers the highest-quality patient care and access to the best resources. “Methodist is really good at getting us state-of-the-art equipment,” says Dr. Lapin. “Not only were we one of the first centers to have a robot, but now we have multiple devices and the latest version of the robots.”

DEDICATED FACILITIESMethodist reserves an operating suite for the urology department’s exclusive use. In other hospitals, urology surgeons often share facilities with general surgery, orthopedics and other departments, reducing the time and resources available for each department. Working in a specialized operating room means doctors spend less time and energy familiarizing themselves with a new setup before each procedure, allowing them to focus on optimal surgical outcomes.

SpECIALIzED STAFFNurses in the Methodist Department of Urology operating room specialize in urology,

so they are uniquely positioned to offer focused insight and expertise. According to Dr. Lewitton, “You’re surrounded by people who know what’s going on. So if there’s a problem, they can handle it.” This arrangement improves the quality of the work environment, patient care and results.

FOCUSED ON RECOvERYThe urology-specific recovery environment at Methodist is an added benefit for patients. Located on the 12th floor of the Fondren building, the urology recovery wing formerly catered to visiting royalty. “It’s more like a hotel,” says Dr. Lapin, “with large suites and wall-to-wall carpeting and chandeliers. I think the environment helps expedite patient recovery.”

For physicians who can work in any other Houston hospital, the driving force for practicing at Methodist is, by far, the people. Dedicated, knowledgeable and friendly, the nurses and staff of the Department of Urology form a cohesive team and warm place to work. For patients, it helps provide an ideal place to heal. n

great patient care is foremost in a physician’s mind, and that means finding a hospital just as committed to quality, compassion and integrity. For doctors in houston, that hospital is The Methodist hospital.

Quality of Care, Quality of Life

Patient Care

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METHODIST DEPARTMENT OF UROLOGY 5

“This disease is a lifelong condition. So we want to do more than just surgically treat kidney stone patients,” says Dr. Wesley A. Mayer, a Methodist-based specialist in minimally invasive urologic surgery techniques. “We want to manage their condition and help keep it under control, thus reducing the need for surgical intervention whenever possible.”

Because kidney stones have recurrence rates as high as 50 percent, surgery without close medical evaluation and follow-up may not always be the best option. Urologists at Methodist treat patients’ immediate surgical needs; however, if a patient has experienced problems before or has a family history of kidney stones, or if there is any significant complexity or size to the stone, then a metabolic evaluation will be performed. In as many as three-quarters of the cases, simple changes to a patient’s diet can make a world of difference in controlling stone formation and eliminate the need for future surgical intervention.

COMpREHENSIvE TREATMENTDr. Mayer is spearheading an effort to establish a comprehensive stone management clinic at Methodist by visiting other major care centers around the

country to collect best practices and new methodologies. “Currently, nothing like this exists in the region,” Dr. Mayer says. “Patients will come here for all aspects of kidney stone treatment because we are switching from being problem-solvers to problem-preventers.”

INTERDISCIpLINARY AppROACHSoon patients will be able to experience a comprehensive, interdisciplinary approach to kidney stone management. In one visit, patients can meet with their nephrologist, urologist and other specialists to determine the best course of treatment.

The prevailing opinion at Methodist is that simply treating kidney stones with surgery is not managing the patient or the condition properly. It takes a team of specialists to sit with patients and discuss all of the factors involved before recommending a course of action. This approach not only alleviates the immediate need; more importantly, it helps a patient manage kidney stones over the long term. n

Kidney Stone ManagementThe accepted practice for many years has been to treat kidney stones surgically, then monitor patients closely for a period of months to look for signs of trouble. while the physicians at The Methodist hospital are among the top in their field when it comes to these traditional methods, Methodist also recommends a more comprehensive approach.

Kidney Stone Management

Robot-Assisted Surgery

a guiding principle at The Methodist hospital is the constant pursuit of excellence. an example of this system-wide commitment is Methodist’s work to advance robot-assisted surgery, especially as applied to kidney and bladder procedures.

Leading the Way in Robot-Assisted Surgery

METHODIST DEPARTMENT OF UROLOGY 7

“We have the highest concentration of robotics experience in Houston,” says Dr. Alvin Goh, a fellowship-trained urologist who specializes in minimally invasive surgical treatments at Methodist. “We have specific skills in advanced robotic procedures, from prostate, kidney and bladder cancer surgeries to kidney-sparing operations and urinary reconstructive surgeries.”

As robot-assisted surgery continues to gain acceptance within the medical community, Methodist is uniquely positioned to lead the development of new procedures and methodologies.

SURGICAL ADvANCES IN KIDNEY-SpARING TECHNIQUESThe American Urological Association recommends that any patient with a renal mass of less than four centimeters be given the option of a kidney-sparing operation. Despite this, many physicians still recommend a total nephrectomy, especially when confronted with a particularly complex renal mass.

“Radical nephrectomy carries an increased risk of chronic kidney disease, which has been associated with cardiovascular disease,” says Dr. Wesley Mayer, a leading expert in minimally invasive surgical treatments for urologic disease. “Partial nephrectomy has been shown to decrease these risks with oncologic outcomes similar to radical nephrectomy. It is for these reasons that our focus is in renal preservation when clinically possible.”

Methodist surgeons’ experience with robot-assisted surgery allows them to address complex tumors previously treated with complete kidney removal. Not only does this cut recovery times, it also allows cancer patients to tolerate chemotherapy and radiation sooner than after an open partial nephrectomy or full kidney removal. This can be critical when time is a factor in maximizing positive outcomes.

INNOvATIvE SOLUTIONS FOR BLADDER REMOvAL AND RECONSTRUCTION Methodist also leads the development of minimally invasive techniques for robot-assisted bladder surgery. Traditionally, bladder cancer surgery has been a maximally invasive open procedure with an incision of 15 to 16 centimeters. Recovery time can stretch for months, with increased risk of death.

In recent years, the growing acceptance of minimally invasive robotic techniques for bladder removal has helped reduce morbidity significantly. But in most cases, bladder reconstruction is still being handled as an open procedure, which counteracts many of the benefits of using less invasive techniques for removal. Methodist saw this as an opportunity to apply leading-edge robotic techniques to both bladder removal and bladder reconstruction.

Now the entire process — from removal to reconstruction — can be performed robotically and intracorporeally, with a single significant incision to remove the specimen at the end of the operation.

“The reason people haven’t gone this route is because it is technically challenging, so when they are first learning, it takes significantly longer than open surgery,” says Dr. Goh, who helped pioneer the techniques. “At Methodist, we have developed more standardized techniques so that we can do the entire procedure robotically. Whether diverting urine or creating an illeal conduit as a bladder replacement, the entire process can now happen inside the body.”

Because of this approach, bladder reconstruction patients experience shorter hospital stays and a quicker return to normal activity with less pain and need for medication.

Robot-Assisted Surgery

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SINGLE-SITE ROBOTICS Most robotic surgery necessitates up to six small incisions for proper entry and instrument manipulation. Currently, Methodist is working to develop modifications and upgrades to make single-site robotic surgery more feasible.

A recent development crosses the robotic arms for better access and mobility. The operating physician may then map the crisscrossed arms to his or her natural operative view, so that the surgeon’s right hand is controlling the robot’s left arm and vice versa. This technique is already being used to great success for simple, non-cancer-related procedures such as pyeloplasty, adrenalectomy and the complete removal of nonfunctioning kidneys. Few surgical centers offer these operations as single-site laparoscopic procedures, with even fewer offering robotic single-site surgery as an option. n

METHODIST DEPARTMENT OF UROLOGY 9

Methodist’s Department of Urology is working to develop modifications and upgrades to make single-site robotic surgery more feasible.

ADvANCEMENTS IN ROBOTICS: NEW TECHNIQUES AND TECHNOLOGYThe Department of Urology at Methodist has always leveraged advanced robotic techniques and technologies. But Methodist physicians also look past the technology’s current capabilities to investigate what future applications there may be. This forward thinking often results in direct collaboration with industry professionals to refine tools and recommend new methods.

GOING GREEN AND MINIMIzING ISCHEMIAWhenever a surgeon performs a partial nephrectomy, control of the renal hilum is critical to minimizing blood loss. The conventional protocol has always been to clamp the entire kidney. While this is a good method for controlling blood flow, it is not always the best approach for preserving healthy tissue — especially when the surgeon is confronted with a patient who may only have one functioning kidney.

To help better identify blood flow, the robots used at Methodist employ a green-vision camera and a green fluorescent dye called Indocyanine Green (ICG). When surgeons administer ICG to a patient, they are able to toggle the operative view of the robot to the green-vision camera and clearly see segmental perfusion of the kidney in stunning detail. This allows surgeons to clamp only the blood supply feeding the mass in question, effectively minimizing ischemia to the kidney during the procedure.

REAL-TIME INTRAOpERATIvE ULTRASOUNDAnother advancement in robotic surgery involves real-time intraoperative ultrasound probes. Robotic or laparoscopic ultrasound probes return immediate results as an operation progresses, rather than having to send multiple specimens to a lab and wait for preparation and analysis. This aids in better operative planning and allows a surgeon to know exactly where a mass lies in relation to the critical structures within the kidney.

Center for Restorative Pelvic Medicine METHODIST DEPARTMENT OF UROLOGY 11

The Center for Restorative Pelvic Medicine Elevates Patient Care The center for restorative pelvic Medicine (crpM) at The Methodist hospital combines expert physicians in fields such as gynecology, urology, colorectal surgery and plastic surgery to provide a single-center location for the diagnosis and treatment of complex pelvic-floor disorders.

Established by Dr. Timothy B. Boone and Dr. Keith Reeves, the center is one of only a few of its kind in the country and has been extremely successful since its inception. “The whole vision was one that many of us may have had,” says Dr. Sophie Fletcher, one of the urologists who works with the CRPM, “but we owe it to Dr. Boone and Dr. Reeves for making it happen.”

The CRPM continues to attract remarkably talented and experienced physicians, thanks to its distinctive approach to total pelvic wellness. Dr. Rose Khavari, a urologist specializing in male and female incontinence and neurourology, recently joined Methodist and the CRPM. Dr. Khavari recognizes the benefit of working with this diverse group of physicians. “We are unique in that we have all of the subspecialties represented by fellowship-trained experts in their fields.”

COORDINATED CARE In addition to quality physicians, the patient care coordinator at the Center for Restorative Pelvic Medicine adds another level of expertise for patients. Once a patient has either contacted the center directly or has been referred by a physician, the coordinator organizes appointments so the patient can see two, three or even four doctors on the same day. “The CRPM helps organize meetings

and appointments so patients come in and get everything done in one day,” says Dr. Khavari. “Instead of going from doctor to doctor to figure out what’s going on, everything happens here, much more efficiently.”

ROBOTIC ADvANCEMENTS IN pELvIC RECONSTRUCTIONAdvancements in robotic surgery have improved many procedures for pelvic reconstruction, making the surgery more efficient and easier on both the surgeon and the patient. For example, sacrocolpopexy typically is performed as open surgery using a long horizontal incision, which significantly increases recovery time. “Patients stayed in the hospital for days and experienced a lot of pain,” says Dr. Khavari. “Now we do it robotically, and it takes about an hour with minimal blood loss, and the patient can go home the next day.”

pROMOTING OvERALL pELvIC HEALTHWhile many physicians focus on their own specialty, CRPM physicians understand that ordinary symptoms may have an underlying connection to other conditions. Dr. Fletcher and Dr. Khavari, for example, educate their patients on pelvic laxity, specifically on how prolapse, urinary incontinence and fecal incontinence are often related. This can prompt patients to reveal additional symptoms that point to other

METHODIST DEPARTMENT OF UROLOGY 11

The Center for Restorative Pelvic Medicine Elevates Patient Care The center for restorative pelvic Medicine (crpM) at The Methodist hospital combines expert physicians in fields such as gynecology, urology, colorectal surgery and plastic surgery to provide a single-center location for the diagnosis and treatment of complex pelvic-floor disorders.

Established by Dr. Timothy B. Boone and Dr. Keith Reeves, the center is one of only a few of its kind in the country and has been extremely successful since its inception. “The whole vision was one that many of us may have had,” says Dr. Sophie Fletcher, one of the urologists who works with the CRPM, “but we owe it to Dr. Boone and Dr. Reeves for making it happen.”

The CRPM continues to attract remarkably talented and experienced physicians, thanks to its distinctive approach to total pelvic wellness. Dr. Rose Khavari, a urologist specializing in male and female incontinence and neurourology, recently joined Methodist and the CRPM. Dr. Khavari recognizes the benefit of working with this diverse group of physicians. “We are unique in that we have all of the subspecialties represented by fellowship-trained experts in their fields.”

COORDINATED CARE In addition to quality physicians, the patient care coordinator at the Center for Restorative Pelvic Medicine adds another level of expertise for patients. Once a patient has either contacted the center directly or has been referred by a physician, the coordinator organizes appointments so the patient can see two, three or even four doctors on the same day. “The CRPM helps organize meetings

and appointments so patients come in and get everything done in one day,” says Dr. Khavari. “Instead of going from doctor to doctor to figure out what’s going on, everything happens here, much more efficiently.”

ROBOTIC ADvANCEMENTS IN pELvIC RECONSTRUCTIONAdvancements in robotic surgery have improved many procedures for pelvic reconstruction, making the surgery more efficient and easier on both the surgeon and the patient. For example, sacrocolpopexy typically is performed as open surgery using a long horizontal incision, which significantly increases recovery time. “Patients stayed in the hospital for days and experienced a lot of pain,” says Dr. Khavari. “Now we do it robotically, and it takes about an hour with minimal blood loss, and the patient can go home the next day.”

pROMOTING OvERALL pELvIC HEALTHWhile many physicians focus on their own specialty, CRPM physicians understand that ordinary symptoms may have an underlying connection to other conditions. Dr. Fletcher and Dr. Khavari, for example, educate their patients on pelvic laxity, specifically on how prolapse, urinary incontinence and fecal incontinence are often related. This can prompt patients to reveal additional symptoms that point to other

Center for Restorative Pelvic Medicine

problems the patient may be having. “When I see a patient, they fill out a questionnaire that asks about colorectal, urinary and pelvic issues,” says Dr. Khavari. “Right off the bat, it is a group approach, a comparative approach to every single patient who comes into the clinic.” Instead of simply treating the symptom and sending the patient on their way, the center’s doctors focus on finding a complete diagnosis and creating an individualized yet comprehensive treatment plan for each patient to ensure long-term total pelvic wellness.

Ultimately, the CRPM focuses on providing care for the whole patient. As Dr. Fletcher puts it, “For the most complicated cases — patients with injuries that seem almost impossible to fix — we’ve come together with three or four surgical subspecialists. By coordinating them in the center, we’ve been able to take an approach toward these patients and really help them, whereas anywhere else in Texas they would not have been able to get that kind of care. On the other hand, on some of the simplest cases, we’ve been able to come together and help just as well by coordinating surgeries to make sure they are on the same day, ensuring things go a lot more smoothly.” And that makes the CRPM truly an environment of respect, compassion and comprehensive care. n

23P H Y S I C I A N S

T H E C R P M H A S

“Instead of going from doctor to doctor to figure out what’s going on, everything happens here, much more efficiently.” Dr. Rose Khavari

METHODIST DEPARTMENT OF UROLOGY 13

A New Lease on Lifeellen Kuehnle is a mother of two very active children. between school, athletics and other extracurricular activities, the Kuehnle family is constantly on the go. so when the symptoms of bladder overactivity began to affect Kuehnle’s lifestyle, she turned to The Methodist hospital for answers.

Kuehnle met Dr. Sophie Fletcher, a urologist at the Methodist Center for Restorative Pelvic Medicine (CRPM). Learning that Kuehnle also suffered from multiple sclerosis, Dr. Fletcher began working with Kuehnle’s neurologist to determine whether her bladder overactivity was MS-related or simply a common symptom of aging.

Dr. Fletcher found that Kuehnle also had uterine prolapse and fecal urgency, a common occurrence as women age, especially when they have had multiple pregnancies and suffer from MS. In order to adequately treat every underlying issue, Dr. Fletcher engaged fellow CRPM physicians Dr. Kelly Gilmore-Lynch, colorectal surgeon, and Dr. Hailey Hall, in obstetrics and gynecology, to develop a treatment plan.

The team concluded that Kuehnle would require three surgical procedures to alleviate her suffering. With the help of a CRPM medical coordinator, the surgical team combined the procedures into one operation. Kuehnle would endure a single surgery under one round of anesthesia, and one hospital stay and one recovery period.

Thanks to the joint effort, Kuehnle’s life quickly normalized after surgery. “I don’t have to worry about finding a bathroom in every single store and I feel more confident and secure,” says Kuehnle. “Now I can be the mom I want to be to my children and the wife I need to be to my husband. Our house can be a home again.” n

“Now I can be the mom I want to be to my children and the wife I need to be to my husband. Our house can be a home again.” Ellen Kuehnle

A Patient’s Perspective

P H Y S I C I A N S

85%PAT I E N T S W H O W I L L D E F I N I T E LY

R E C O M M E N D M E T H O D I S T

botox and the neurogenic bladderThe same action that makes Botox® an effective treatment for fine lines and wrinkles also makes it an extremely useful alternative to treating bladder overactivity in patients suffering from conditions such as multiple sclerosis and spinal cord injury.

Dr. Sophie Fletcher is a urologist at The Methodist Hospital who currently uses Botox to treat bladder overactivity. “With an overactive bladder, the bladder muscle contracts without the patient wanting it to,” she says. “When the bladder muscle contracts, it expels urine. So the patient has absolutely no control over it.”

Before Botox, treatment options were limited to daily medication or reconstructive surgery. Because

medications are taken orally, their side effects are systemic — dry mouth, dry eyes and constipation. For MS patients, these symptoms are compounded by taking medications often with the same side effects. The surgical option, though effective, requires at least six hours of operative time and a recovery of 10 or more days.

A recently completed FDA study conducted with Allergan, the makers of Botox, found that when Botox was injected into the bladder wall, it eliminated the effects of overactive bladder for up to nine months.

Botox is delivered in a clinical setting and does not require an incision. Patients are in and out of the clinic within minutes and may return to normal activity almost immediately, a clear improvement in quality of life and in urinary function for patients struggling with the embarrassment and inconvenience of bladder overactivity.

Though reconstructive surgery still may be necessary in some cases, this likelihood has been reduced dramatically. Last year, Methodist performed three reconstructions — down from 10 to 15 cases per year before FDA approval of Botox as a

treatment option. n

a collaborative laboratory environmentThe Methodist Hospital and Baylor College of Medicine are collaborating to create the NeuroRegeneration and Bladder Sensory Laboratory, a unique research facility studying complications of the lower urinary tract and bladder issues brought on by spinal cord injury, diabetes and multiple sclerosis, among other conditions.

“It’s a great arrangement. Methodist provides the space, Baylor provides the equipment,” says Alvaro

Research and Education

P E R Y E A R

10 -15NuMbER OF OvERACTIvE bLADDER

SuRgERIES bEFORE bOTOx APPROvAL

P E R Y E A R

3AvERAgE NuMbER OF OvERACTIvE bLADDER

SuRgERIES AFTER bOTOx APPROvAL

J O I N T R E S I D E N C Y P R O G R A M E N S U R E S A S T R O N G F U T U R E

As part of its focus on excellence in research, patient care and education, The Methodist Hospital has partnered with the Scott Department of Urology at Baylor College of Medicine to implement a five-year residency program specifically tailored to urologic training. The joint program at Methodist accepts four residents per year and is now in its second year. The structure of the residency program leads residents at their own pace through progressively increasing responsibilities to ensure they receive maximum patient contact.

Beginning with rotations in general surgery, the residents gain experience in managing surgical patients and learning

basic surgical techniques. Gradually, the residents are exposed to increasingly complicated cases and rotations to refine diagnostic techniques and develop skills in open, robotic and endoscopic surgery. By the fifth year of training at Methodist, the chief resident leads the house staff, coordinates administrative and educational activities and, with faculty, plays an active role in the management of patients. At the end of training, the residents should be able to deal comfortably with all situations encountered in a busy urologic practice. Because the residency is not a pyramidal system, each resident whose performance is satisfactory is assured of completing formal academic training and becoming eligible for certification by the American Board of Urology. n

Munoz, Ph.D., lab leader and assistant member at the Methodist Hospital Research Institute. “And the joint appointments between the faculty and staff from Baylor and Methodist make for a very strong lab.”

The NeuroRegeneration and Bladder Sensory Laboratory will feature more than 1,000 square feet of laboratory space, with nearly as much square footage dedicated to clinical use. The lab will be fully operational in 2013, and basic research already is underway. One study examines the role a family of proteins called purinergic receptors plays in producing bladder contractions and sensation.

A better understanding of these proteins and their role in ion movement across cellular layers of the bladder promises to help doctors find new and more effective ways to treat a host of bladder dysfunction problems. n

breaking new ground with clinical Trials INNOVATIVE OPTIONS FOR ENLARGED PROSTATECurrent treatment options for men suffering from an enlarged prostate offer two choices: prostate surgery or daily medication for the remainder of a patient’s life. The Methodist Hospital now participates in a nationwide study of an innovative treatment option.

The Phase III clinical trial follows more than 300 men treated with a new medication designed to reduce prostate size. Physicians use ultrasound to visualize the prostate, and then deliver a transrectal dose of the study medication directly into the prostate. Participants are closely monitored at regular intervals over the course of one year. Interim follow-up suggests the treatment will be safe and effective.

The study is still enrolling patients. The medication has also shown promise for treating early-stage prostate cancer. Plans to launch a clinical trial are underway.

ON THE HORIzON: TRIALS TO WATCHThe most common complication associated with a radical prostatectomy is a loss of urinary continence. Methodist is studying the use of a new pharmaceutical compound to treat urinary incontinence in men undergoing robotic-assisted radical prostatectomies. When used within 10 days after surgery, this drug has shown promise in relaxing bladder muscles, allowing

patients to maintain better urinary control. n

METHODIST DEPARTMENT OF UROLOGY 15

Research and Education

Advancements in Education and Skills AssessmentThe Methodist institute for Technology, innovation & education, or MiTiesM, is a 35,000-square-foot, interactive, simulation-based procedural training center. as one of the largest teaching hospitals in the country, The Methodist hospital created MiTie to help physicians stay up-to-date on the latest high-tech procedures and developments.

Ewing Werlein Jr.

Chairperson

John F. Bookout

Senior Chair

Marc L. Boom, M.D.

President & CEO

David M. Underwood

Vice Chair

D. Gibson Walton

Vice Chair

Gregory V. nelson

Secretary

Robert K. Moses Jr.

Assistant Secretary

Carlton E. Baucum

Treasurer

Joseph C. “Rusty” Walter III

Assistant Treasurer

Morrie K. Abramson

Emily A. Crosswell

Mary A. Daffin

Connie Dyer

Gary W. Edwards

Eric Haufrect, M.D.

President of the Medical Staff

Mark A. Houser

Bishop Janice Riggle Huie

Lawrence W. Kellner

Rev. Kenneth R. Levingston

Vidal G. Martinez

Dr. Thomas J. Pace III

Keith O. Reeves, M.D.

C. Richard Stasney, M.D.

Advisory, President-Elect of

the Medical Staff

Elizabeth Blanton Wareing

Dr. Stephen Wende

Rev. B.T. Williamson

Advisory

Sandra Gayle Wright, Rn, Ed.D.

Life MeMbers

Jack S. Blanton

Ernest H. Cockrell

James C. Dishman

Charles W. Duncan Jr.

Isaac H. Kempner III

nat S. Rogers

The MeThodisT hospiTaL board of direcTors

Ewing Werlein Jr.

Chairperson

John F. Bookout

Senior Chair

Marc L. Boom, M.D.

President & CEO

David M. Underwood

Vice Chair

D. Gibson Walton

Vice Chair

Gregory V. nelson

Secretary

Robert K. Moses Jr.

Assistant Secretary

Carlton E. Baucum

Treasurer

Joseph C. “Rusty” Walter III

Assistant Treasurer

Morrie K. Abramson

Emily A. Crosswell

Mary A. Daffin

Connie Dyer

Gary W. Edwards

Eric Haufrect, M.D.

President of the Medical Staff

Mark A. Houser

Bishop Janice Riggle Huie

Lawrence W. Kellner

Rev. Kenneth R. Levingston

Vidal G. Martinez

Dr. Thomas J. Pace III

Keith O. Reeves, M.D.

C. Richard Stasney, M.D.

Advisory, President-Elect of

the Medical Staff

Elizabeth Blanton Wareing

Dr. Stephen Wende

Rev. B.T. Williamson

Advisory

Sandra Gayle Wright, Rn, Ed.D.

Life MeMbers

Jack S. Blanton

Ernest H. Cockrell

James C. Dishman

Charles W. Duncan Jr.

Isaac H. Kempner III

nat S. Rogers

The MeThodisT hospiTaL board of direcTors

METHODIST DEPARTMENT OF UROLOGY 17

MITIE also serves as a research center for procedural innovation and technology development, where multidisciplinary teams of scientists, bioengineers and surgeons collaborate to break new ground in robot-assisted surgery, image-guided operations, biosensors, virtual procedures and other leading-edge techniques.

“When it comes to sheer volume of physicians and students, our program is one of the largest,” says Dr. Brian J. Miles, a board-certified urologist and medical director of robotic surgery at Methodist. “Clearly, we have one of the most effective teaching centers in the country. In the world, for that matter.”

LEARNING WITHOUT BORDERSAlthough MITIE is a top-notch teaching facility for robotic surgery, Methodist understands that coming to Houston for continuing medical education may not always be practical. Now, with advancements in robotics and communications technology, it may not be necessary at all. Today, physicians

like Dr. Miles can share their expertise with other surgeons and observe robot-assisted surgical training from almost anywhere in the world.

By toggling between multiple camera views, educators can see inside the patient’s abdomen, watch the doctor’s hands in action, and zoom out to evaluate a robot’s position over a patient. In some cases, they can take control of the robot to demonstrate finer points of certain techniques and procedures. Physicians can review video footage of the session in real-time and compare their work to videos of optimal procedures. With remote proctoring, physicians can show, demonstrate and communicate as if they were in the same room.

EVALUATING INDIVIDUAL SKILLSThe current methods for evaluating robotic skill first look at the number of robotic procedures a particular surgeon has performed. While an excellent measure of experience, this does not represent skill and technical acumen.

To ensure an accurate assessment of surgical skills, Methodist developed the Global Evaluative Assessment of Robotic Skills (GEARS) program. GEARS reviews physicians across six areas critical to robotic surgery, and then provides immediate feedback about areas that need improvement. This allows feedback to be delivered in real time — even in the middle of a training session.

The GEARS curriculum has been in development since 2009, and has been used to help practicing physicians get up to speed on the latest robotic techniques and acquire specialized robotic skills.

This world-class facility and these innovative programs reinforce Methodist as a force in medical education and skills evaluation. This dedication to learning, sharing and mentoring has allowed Methodist to consistently deliver upon one of its guiding values: “to be the best at what we do and a model for others to emulate.” n

12

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36,586$21.6 MILLION

440,000

1,500+

550

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THE METHODIST HOSpITAL rESEArCH InSTITuTE

b Y T H E n u M b E r S

stories

members

inpatients in 2012*

in niH FUnDinG in 2012

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credentialed researchers

number of articles bY methodist researchers

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*Projected 2012

1 MESSAgE frOM THE CHAIrMAn Our legacy, research and innovation

2 THE METHODIST HOSpITAL Leading Medicine for our patients

4 pATIEnT CArE World-renowned expertise and dedication

5 KIDnEY STOnE MAnAgEMEnT Innovative treatment and prevention

6 rObOT-ASSISTED SurgErY Advancements in techniques and technology

10 CEnTEr fOr rESTOrATIvE pELvIC MEDICInE Comprehensive care for complex disorders

13 A pATIEnT’S pErSpECTIvE An inside look at compassion and care

14 rESEArCH AnD EDuCATIOn Breaking new ground and sharing expertise

T A B L E O F C O N T E N T S

M E T h O D I S T D E pA R T M E N T O F U R O L O G y

The Methodist Hospital6565 Fannin Street

Houston, Texas 77030methodisthealth.com

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