Maximizing Minimally Invasive Procedures at White Plains Hospital Provides State-of-the-Art Care to Urology Patients

By Michele C. Hollow
Wednesday, October 28, 2020

Urologic surgeons at White Plains Hospital have garnered many firsts in Westchester County and the surrounding area. One of the highest-volume programs in the region, they’ve become leaders in implementing robotic and other minimally invasive procedures, performing as many as 95% of their prostate removal surgeries robotically.

Group cover photo was taken before the COVID-19 pandemic.

Robotic surgery technology was established at White Plains Hospital in 2005, and 15 years later, the hospital has burgeoned into one of the most comprehensive robotics programs in the region. The mantra shared by a team of urologic surgeons at White Plains Hospital is to use the least invasive procedures whenever possible. They employ robotic technologies and other advanced techniques which result in better patient outcomes, less risk to their patients and shorter surgeries and recovery times.

“Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years,” write the authors of a 2018 retrospective in F1000Research. As a case in point, according to a study in JAMA, robotic procedures accounted for 1.5% of radical nephrectomies in 2003, with the fraction rising rapidly to 27% by 2015.

With similar long-term outcomes to conventional surgeries, robotic procedures offer numerous immediate benefits to patients, including shorter recovery times, reduced pain, smaller operative scars and quicker return to daily life, according to the National Institutes of Health. Patients at White Plains Hospital are seeing the benefits firsthand.

The multispecialty urologic surgical team at White Plains Hospital often collaborates with other experts to bring the best care to their patients in an innovative setting, including five state-of-the-art operating rooms opened in 2016, all equipped for minimally invasive surgeries.

White Plains Hospital’s urology team uses the state-of-the-art da Vinci Xi surgical system to treat a broad spectrum of urologic conditions, including prostate, bladder and kidney problems.

Leaders in the Field

The first facility in Westchester County to obtain two robotic surgery systems, White Plains Hospital routinely deploys its da Vinci Xi surgical systems to treat a broad spectrum of urologic conditions, including prostate, bladder and kidney problems. Services include surgery for benign and malignant tumors, reconstruction of congenital urologic disorders, procedures to treat urinary incontinence and urinary difficulty, and treatments for pelvic organ prolapse. Recovery times are shorter and patients can return to work or their normal routines faster than with traditional surgeries.

Board-certified urologists, Charles Glassman, MD, Seth E. Lerner, MD, Nicole Fleischmann, MD, and Aaron Hagge-Greenberg, MD, have worked together for a number of years and some have been affiliated with the Hospital for decades. They are the first urology practice to officially join White Plains Hospital Physician Associates (WPHPA).

Each of the surgeons has extensive experience in his or her field. Dr. Glassman, director of the urology group, started his practice on Maple Avenue more than 35 years ago.

“Although fellowship trained in pediatric urology, because I was one of very few urologists in Westchester performing adult radical prostate cancer surgery at the time, I rapidly built up a large adult practice,” Dr. Glassman explains. “Over the years, as the field of urology expanded, I recognized the need to bring more specialized experts into our community.”

Dr. Seth Lerner was the first to be recruited because of his skills as a urologic oncologist. As director of the White Plains Hospital Prostate Cancer Program, he is acknowledged as an expert in robotic and minimally invasive surgeries in urologic cancers.

Recognizing a need to support the expanding field of female urology, the group then added Dr. Fleischmann. Now Director of Female Urology, Dr. Fleischmann adds an expertise in women’s urinary and pelvic concerns, cooperating closely with her gynecologic colleagues on complex cases.

Finally, Dr. Hagge-Greenberg, Director of the Urologic Service, was added because of his advanced training and experience in the field of stone disease, as well as minimally invasive treatment for benign prostatic hypertrophy.

Dr. Glassman continues to be a generalist in both adult and pediatric urology, focusing on the care of patients with benign prostatic hypertrophy and male erectile dysfunction, as well as screening patients for prostate, bladder and other cancers.

Changes in Pediatric Urology

As a regional hospital, White Plains Hospital does not see a lot of pediatric urologic oncology patients. But the practice actively serves the community for acute pediatric problems as they arise. Where the typical pediatric urology patient ranges in age from 5 to 10 years old, it is not uncommon for the treatment to extend to both infants as well as teenagers.

“In our busy emergency department, we are often called upon to evaluate and treat acute pediatric urologic injuries, infections and diagnostic dilemmas,” notes Dr. Glassman. “Some of these, like testicular torsion, require immediate surgical intervention.”

Not infrequently, he is asked to evaluate newborns with genital anomalies. In the office, Dr. Glassman regularly deals with common pediatric issues, such as undescended testicles and pediatric hernias, that often require surgical correction.

Integrating robotic surgeries for children occurred slightly later than for adults. Laparoscopic pediatric urologic surgery had been performed since the 1960s, according to a report in Frontiers in Pediatrics, but, given the fragility of pediatric tissues and the visual limitations of laparoscopy on a small operative field, laparoscopy was not widely adopted for complex pediatric conditions.

With the introduction of the da Vinci surgical system, many of these concerns were addressed. In one early example, robotic pyeloplasty in children improved on laparoscopic pyeloplasty by reducing complications and improving success rates.

Still, the volume of surgeries for children, compared with adult patients, remains low, deterring some hospitals from purchasing a robot for use in pediatric urology. That’s what makes the investment in robotic surgery at White Plains Hospital a unique benefit for the region.

A Focus on Men’s Health

White Plains Hospital is known for specializing in minimally invasive procedures to treat benign and malignant prostatic gland tumors, male incontinence, enlarged prostate, and erectile dysfunction.

Routine in-office vasectomies are common. For instance, Dr. Glassman performs an average of three to four procedures in his office setting each week. This 10-minute operation is completed under local anesthesia with positive patient outcomes.

Male sexual health is also an important part of the practice.

“We offer numerous options for erectile dysfunction,” Dr. Hagge-Greenberg says. “That includes everything from medications and injection therapy to prosthetic devices to restore erectile health. These may be used as a follow-up to therapy for prostate cancer.”

When urinary incontinence affects men, it is often linked to prostate concerns.

“We offer minimally invasive treatments for enlarged prostate and prostate-related urinary incontinence,” Dr. Hagge-Greenberg says. “Among the novel therapies we offer are the UroLift and the Rezum procedure.”

In the UroLift for benign prostatic hypertrophy, implants are placed to hold prostate tissue away from the urethra. This can help with many issues from incomplete voiding to urinary incontinence to sexual dysfunction, according to product literature. In the Rezum in-office procedure, hot water vapors are introduced into the prostate, shrinking inflamed prostate tissue and improving urine flow.

When it comes to prostate cancer, Dr. Lerner takes credit for performing the greatest number of robotic radical prostatectomies in the region. The team, with Dr. Lerner at the helm, has performed more of these surgeries than any other program in Westchester County and the surrounding area.

“What separates us from the large academic medical centers in the area is the personalized care we offer our patients,” Dr. Lerner says.

“We look to see which patients are good candidates for these types of treatments,” Dr. Glassman adds. “While we appreciate the benefits of robotic prostatectomies, we first ensure it’s the right treatment for the patient.”

Indeed, patient selection has become one of the key concerns in prostate cancer treatment today.

“I think what we’re doing with prostate cancer is trying to better define who should be treated and who should not be treated,” Dr. Lerner says. “Twenty years ago, we went by the mantra of screening, early detection and early intervention. Now, we realize that a good proportion of men with a new diagnosis may be able to defer treatment for a defined period through the implementation of active surveillance. So while we’ve maintained a high level of care with regard to treating localized disease, whether with robotic surgery or cutting-edge radiation, we manage upwards of 50% of men with active surveillance, thereby avoiding the potential morbidity of treatment.”

These men may eventually need treatment, Dr. Lerner adds, and the high standards applied during active surveillance — regular blood work, exams and MRI scans, including, if necessary, MRI-guided biopsies — allow prompt transition to active treatment as needed.

“We are looking at cancers at the molecular level,” Dr. Lerner says. “We perform genomic testing to further differentiate men with more aggressive cancers from ones that are potentially less aggressive or relatively innocuous. With regards to prostate cancer, we are being more judicious with the applications of targeted screening and more judicious in distinguishing who needs to be treated while maintaining state-of-the-art care for those who do receive robotic surgery or cutting-edge radiation therapy.”

Other Urologic Cancers

In addition to prostate cancers, the surgeons at White Plains Hospital offer treatment for cancers of the bladder and kidneys, among others. Widespread imaging has allowed surgeons to identify kidney tumors earlier, Dr. Lerner says, allowing the option for smaller-scale robotic procedures that preserve the majority of the kidney. As with prostate cancers, some patients with kidney cancer can be managed with surveillance or serial imaging — regular-interval imaging to follow a tumor’s progress.

“There are some patients who can be treated with nonsurgical ablative techniques,” Dr. Lerner adds. “It’s key to see which people can avoid intervention, while those who need it obtain state-of-the-art care.”

Bladder cancer is potentially a chronic condition, with upwards of 70% of patients experiencing recurrence, Dr. Lerner says.

“We are now using blue-light cystoscopic examinations, which can identify more subtle bladder tumors,” he says. “This has been shown to reduce the recurrence rate, and thereby potentially reduce the rate of progression.”

Caring for Women

White Plains Hospital runs a robust treatment program for women, too. Dr. Fleischmann is board certified in female pelvic medicine and reconstructive surgery.

“I perform robotic surgery to lift bladders and fix prolapse,” Dr. Fleischmann says. “I also offer pelvic floor reconstruction and sling procedures for incontinence.”

She uses the da Vinci robot to perform these surgeries.

The newest treatment being used by the team to address urinary incontinence is Bulkamid injections.

“It just became FDA approved in January and has been used to treat women in Europe for about 10 years,” Dr. Fleischmann says. “It’s a minimally invasive procedure — an injection into the opening of the bladder that cushions the insides so women don’t leak urine.”

The bulking agent, which is made up of 97.5% water and 2.5% polyacrylamide, acts as “a scaffold for cells to grow,” according to Bulkamid literature.

A study in the Central European Journal of Urology found that Bulkamid is safe, efficacious, minimally invasive and reliable for the treatment of stress urinary incontinence.

“Because it’s a minimally invasive technique, it can be done in the office,” Dr. Fleischmann adds.

While Bulkamid is new, some of the most common procedures performed at White Plains Hospital are sacral nerve modulations for incontinence.

The majority of their patients being treated for sacral nerve stimulation are older women. According to the National Institute on Aging, part of the NIH, incontinence mostly affects older women, though some men suffer from incontinence, too. The number of cases in both men and women increase as they age.

“With these minimally invasive, low-risk procedures, I can treat women well into their 90s,” Dr. Fleischmann says. “Incontinence is less common for younger women, but it does occur. We can treat those patients, too.”

Another common procedure is called the MonaLisa Touch — a painless and minimally invasive laser treatment for menopausal women who suffer from painful intercourse, sexual dysfunction, vaginal dryness or burning, or urinary incontinence. The MonaLisa Touch procedure revitalizes the wall of the vagina to create a healthier environment.

“Whether women need help with incontinence, prolapse or other female pelvic floor disorders, White Plains can provide the specialized care they need to effectively address their concerns,” Dr. Fleischmann says.

Breaking Stones

Urologists at White Plains Hospital utilize lithotripsy — or ultrasound shock waves — to crush kidney stones of various sizes. Heading this procedure is Dr. Hagge-Greenberg.

The expert team of surgeons make up the first urology practice to officially join White Plains Hospital Physician Associates.

“Every day, urologists treat patients for kidney stones,” Dr. Hagge-Greenberg says. “It’s a common procedure. A lot of the work we do at White Plains Hospital that’s more unique is removing complex, large kidney stones that are dense, hard, or 1.5 centimeters or larger in size.”

To remove these larger kidney stones that can’t pass on their own, percutaneous nephrolithotomy (PCNL) is employed. While standard lithotripsy is a common procedure, the availability of PCNL sets this urology practice apart.

“If you have a large stone, we turn it into a pile of rubble so it passes,” Dr. Hagge-Greenberg says. “Some stones don’t do well with shock waves because they’re too big to get rid of. With large stones, the most efficient solution is the PCNL procedure.”

In PCNL, which is also a minimally invasive treatment, the surgeon removes the stone fragments through a tiny incision.

“We tunnel right into the kidney and access the stones there,” Dr. Hagge-Greenberg says. “We crack them apart with delicate instrumentation and then pull the pieces out.”

This procedure has a high success rate and typically requires between one and two weeks of recovery time.

White Plains Hospital recently acquired the SOLTIVE Premium – SuperPulsed Laser System for innovative new treatment of kidney stone disease, Dr. Hagge Greenberg adds. This will allow urologists to use an approach via the natural urinary passageways to effect a laser destruction of the stone with no need for surgery, allowing for even shorter procedures and easier recovery.

White Plains Hospital was named a 2019-20 Best Regional Hospital by U.S. News & World Report, ranked top 5% of hospitals in the nation for patient experience according to Healthgrades®, and the only hospital in Westchester County to earn the top Safety Grade by Leapfrog Group.

Multidisciplinary Care & Collaboration

All of the urological surgeons at White Plains Hospital work as a team to bring the best care to their patients, in the safest environment possible. (For patients visiting the office for consultations or procedures, they can expect the highest cleaning standards, a spaced out waiting area, and strict social distancing measures, including universal face coverings for staff and patients. Added infection prevention measures at the Hospital — always a top priority — include an ultraviolet robot, Xenex. All areas including surgical suites are now being cleaned and Xenexed a minimum of four additional times during each shift.)

While these individual surgeons all have their own specialties, multidisciplinary collaboration makes the team stronger.

Like her colleagues, Dr. Fleischmann consults and works with other specialists.

“I’m trained as a urologist,” she says. “I also do some things gynecologists do, such as hysterectomies to correct pelvic floor dysfunction. For some cases, I work with a gynecologist. For cancer work, I consult with oncologists.”

Such collaboration yields a total experience that is well more than the sum of its impressive parts.

“We have been doing this many years,” Dr. Lerner adds. “Our combined experience and high patient volumes lead to outcomes that rival those of the surrounding academic institutions. We offer state-of-the-art care to patients with no need to travel far from home.”

The urologists at White Plains Hospital Physician Associates see patients at 170 Maple Avenue, Suite 104, in White Plains, New York.

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