Transcript of What a Robotic Radical Cystectomy is with Dr. Dipen Parekh

January 3, 2023

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Voice over:

This is Bladder Cancer Matters, the podcast for bladder cancer patients, caregivers, advocates, and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit bcan.org.

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle-invasive bladder cancer, the proud owner of a 2006 model year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or, as many call it, BCAN, producers of this podcast. This podcast is sponsored by the Seagen/Astellas alliance and Genentech.

I am pleased to welcome today’s guest, Dr. Dipen Parekh. Dr. Parekh is Chief Operating Officer at the University of Miami Health System, chairman of Urology, and the Dr. Victor Politano Endowed Chair in Clinical Urology at the Miller School of Medicine at the University of Miami in Miami. He also serves as the director of Robotic Surgery at the University of Miami Health System. In 2012, he was awarded the American Urological Association, or AUA, or a Gold Cystoscope Award for his excellence in establishing programs in urologic oncology and robotic surgery and outstanding contributions in transformative research. He serves as principal investigator of the only National Cancer Institute R01 grant sponsored Phase III multi-institutional clinical trial, comparing open and robotic cystectomy for bladder cancer. Dr. Parekh has started several robotic surgery centers and programs of excellence, both nationally and internationally.

Dr. Parekh, welcome. I’ve seen so many questions about robotic cystectomy over the years and I am so excited to have you join me on our podcast to answer them.

Dr. Dipen Parekh:

Thank you so much, Rick. It is totally an honor and a privilege to be a part of this. I just want to thank you on behalf of several thousands of patients with bladder cancer, providing such a wonderful resource to all of them over the years and supporting urologic oncologists and the oncology community as such in its fight against bladder cancer. Thank you for all the great work that you have been doing.

Rick Bangs:

Oh, you’re very welcome. It’s my pleasure.

I want to start with something that’s pretty basic. The question is, what is robotic surgery and how does it compare to open and laparoscopic surgery?

Dr. Dipen Parekh:

The open surgery is a traditional open surgery, where a surgeon uses a knife, cuts open your skin and then gets access, in this particular case for bladder cancer, gets access into your abdomen or abdomen cavity and then accesses your bladder and other organs and then removes them and then does the job. Then once the job is done, you close the skin and the abdominal cavity and the patient recovers.

Typically, all these traditional open surgeries, they do have their own share of morbidity. In order to alleviate the morbidity, laparoscopic technology came into invention, where instead of making big incisions, you actually make small keyhole incisions, put instruments called small trocars and you [inaudible 00:03:51] or fill the abdomen up with gas so that there’s a lot of space inside the belly. Then you put instruments through those trocars, and instead of making a big open cut, your small incisions and instruments through those incisions that the surgeon can manipulate with their hands using a camera to do any surgery that you want to do.

The robotic surgery is an augmentation of the laparoscopic approach. What happens is that through these trocars, there’s a surgical robot with five arms that actually docks on these trocars or instruments that are in your belly. Your belly is full of gas, so that gives you space. There’s a camera, and then these instruments go inside from the robot, but ultimately, the robot is manipulated by the surgeon. In this case, the surgeon sits a few feet away from the actual operating table and the actual patient and then manipulates all the arms, along with the camera and the arms of the robot, to conduct this entire surgery. Then once the surgery is done, you undock the robot from the trocar and then you remove these trocars and then close the keyhole incisions. What we avoid in robotic surgery is large incisions and an open belly that can lead to its own set of side effects and recovery time that is historically a little bit longer than the laparoscopic approach.

The laparoscopic approach was first developed in gallbladder surgery and then found its way to many other organ sites. A laparoscopic approach to doing a cystectomy, or removal of a bladder, was an extremely complex and a challenging endeavor, where you had to have a very steep learning curve and the results are not really that great compared to historic open surgery. What the robot has done has leveled the playing field, where it has made the laparoscopic surgery far more easier because of a 3D visualization of the organs inside the belly or inside the abdomen and the pelvis, and many degrees of wristed motion that are difficult to perform while doing open surgery or pure laparoscopic surgery in deep pelvic cavity. That’s what the robotic process has done to the laparoscopic approach.

Rick Bangs:

Okay. What’s the history of robotic surgery in the GU space, the genital/urinary space? Was robotic prostatectomy first to the party? When did robotic cystectomies first get used?

Dr. Dipen Parekh:

Traditionally, robotic surgery was used, initially it was floated by the Department of Defense with the technology that was then licensed to a company that jumped on the bandwagon. Initially, they tried a lot with robotic heart surgeries and then they found the prostate. You’re absolutely right, the prostate surgery was the first to be used and mastered by urologic oncologist to remove the prostate. Once that happened, then that opened the floodgates to apply the robotic technology into bladder cancer, kidney cancer, many other cancers.

I would say early 2000s is when the robotic technology first came in. Robotic prostatectomy was done around 2000, 2003, and I think cystectomy soon followed. But like every technology, it takes a few years for the technology to be familiar and disseminate widely and the surgeons to work on their learning curve and their skepticism and before there’s widespread options. I think from early 2000 to 2010 was that decade where a lot of people tried this, but then the last decade, 2010 to now, is when many of these robotic procedures have been commonplace.

Rick Bangs:

Very recent then.

Dr. Dipen Parekh:

Yes, very recent.

Rick Bangs:

Last 20 years.

Dr. Dipen Parekh:

Yes.

Rick Bangs:

I think some people might expect that the robot’s actually doing the surgery. We have self-driving cars, so you can understand why people would have that assumption. Does the robot actually do any work on its own?

Dr. Dipen Parekh:

No, the answer is an unequivocal no. The robot has no mind of its own. The robot doesn’t really initiate anything, just the arms of the robot, it’s like your hands and your legs. But even in human beings, our hands and our legs don’t function until our brain tells them to do it. Basically, the same thing applies to the robot. It is completely and totally manipulated by the surgeon who is operating on the robot. The robot itself has no capability of doing the surgery on its own.

Rick Bangs:

Okay. I think you said that in the case of robotic cystectomy, the surgeon would be in the room but a few feet away. Is that correct?

Dr. Dipen Parekh:

That’s exactly right. The surgeon is always in the room, but just really feet away from the patient. Then if there’s any scenario where the surgeon has to leave the robot and let’s say for whatever reason things are not progressing and we have to do the traditional open approach, the surgeon is literally a few feet away and just goes in and scrubs and converts the surgery. The surgeon is always very, very close to the patient.

Rick Bangs:

That would mean that we probably would not have robotic surgeries done remotely in the future.

Dr. Dipen Parekh:

I think we will be able to. I think there’s a big issue with lag times. We do not have the wireless technology where if you made any movements remotely that translated. Generally there was a lag of a few seconds or a few milliseconds and that itself was worrisome in terms of creating complications, but I think with the modern technology that that lag time is almost non-existent. You know that if you look at the video game technology, you could be somewhere in Japan and I could be here in the United States and we could be playing the same game because there’s no lag time. There will be a time in the foreseeable future where obviously their technology will have to be there at the remote site, but there could be someone who could be controlling the technology remotely and either train someone locally to do the surgery or do the surgery themselves remotely.

Rick Bangs:

Let’s talk about the equipment and the technology. Has the equipment, the physical equipment, changed over time? Then you’ve already hinted at this, but what about the software that’s being used? Has that changed?

Dr. Dipen Parekh:

Yeah, the robotic surgery equipment has changed and is now rapidly changing as we speak. For a long time, the company that sold and manufactured these robots and the technology, Intuitive Surgical, had a monopoly and have done a tremendous job in terms of creating what I think is a beautiful, beautiful technology.

There are many versions and many iterations of the robots over the last several years, over the last two decades, from the same company, but now there are other companies that are also manufacturing their own robots. I think Medtronic has its own robot, there are companies in Korea, there are companies in Europe that are manufacturing their own robots. It remains to be seen as to how these robotic technologies compared to the existing one. All I can tell you is that there’s a very high bar, because the current robot that most of the world is used to is a very, very [inaudible 00:11:41] technology. Something will have to either be significantly better or at a very different price point, in terms of being cheaper, to gain traction.

Software, again, I am not the right person to answer this question, but I’m sure that with all the iterations that have happened with the hardware that they have always updated their software as well, to keep track of all the advances in the hardware.

Rick Bangs:

Yeah. In general, what are the fundamental similarities and differences between the open versus the robotic cystectomies?

Dr. Dipen Parekh:

Open surgery is your historic, traditional surgery, where you make an incision and you open the cavity, whether it’s the abdominal cavity or thoracic cavity or if it’s a knee joint, what have you, and then you do your surgery using your own hands and the instruments that are given to you. With the robotic surgery, it’s a laparoscopic approach in terms of the abdominal cavity, but you also have robotic joint surgeries, robotic brain surgeries, but we’ll just stick for this discussion to robotic surgeries for the bladder and the abdominal cavity.

What we do here is instead of a big, large incision, there are small keyhole incisions. We [inaudible 00:12:56] the abdominal cavity to give us more space, we have instruments that go in and out through trocars. The robotic arms, we are able to manipulate this in very difficult areas to access in the pelvic cavity and do the surgeries, do some delicate surgeries. The advantage is that we have significantly more of a magnification, so we use almost 10 to 12 times more magnification of the view, there’s a three-dimensional view. Typically, human hand and human wrist has about four degrees of motion, whereas with the robotic approach, the robot has seven degrees of wristed motion that you can apply. Those are the advantages of robotic surgery in terms of access to challenging areas within the body.

Now, in terms of qualifying patients, there are always a few patients who have so much scar tissue in the abdominal cavity that that precludes a safe performance of robotic surgery. For those patients, we still do the traditional open surgery. There is some setup time, in terms of setting up the robot and docking the robot and docking out of the robot, so that does add somewhat to the duration of the surgery. There is a learning curve that is associated with the robotic technology for all cancers, prostate, bladder, for all the cancers, so one has to overcome the learning curve. But typically, the size of the incision is significantly smaller compared to the typical or traditional open surgery that involves cutting of many muscles and a large incision.

Rick Bangs:

Okay. What about my choice of urinary diversion? Can I get a neobladder if the surgery is done robotically? Can I get ileal conduit or an Indiana pouch?

Dr. Dipen Parekh:

Yes, the answer is yes. The robotic approach has absolutely no bearing in the type of urinary diversion that you want or should get, but there are two ways of doing it. There are some surgeons who prefer to remove the prostate and the bladder and the lymph nodes and then make a small incision to do the urinary diversion by an open approach, but now, there are a lot of surgeons who can actually do the entire ileal conduit or a neobladder through the robotic approach itself.

Rick Bangs:

Wow.

Dr. Dipen Parekh:

Again, it also has its own learning curve, but there are many groups in the country that are doing that successfully.

Rick Bangs:

Wow, so a hybrid approach too.

Dr. Dipen Parekh:

Yes.

Rick Bangs:

What training would you have, as a surgeon, to work on the robotic equipment?

Dr. Dipen Parekh:

Most trainees today who get trained in urology or urologic oncology are very well versed with both the robotic and open approach. If you ask me, some of the more recent challenges we have seen in training programs is actually lack of exposure to traditional open surgery. It’s that many times, for whatever reason, if the patient is not an ideal patient for robotic surgery or there’s a malfunction of the robot, there are many training programs where trainees are not exposed to how to do open surgeries.

But I think there’s more than enough training available now for trainees to be familiarized on the robotic equipment. Most of them go through that process, and before they do or they perform robotic surgery independently, they’re expected to be proctored by an expert for a set amount of cases before they start on their own.

Rick Bangs:

Would I be trained in open and then the robotic, or is it done in parallel?

Dr. Dipen Parekh:

In parallel.

Rick Bangs:

In parallel, okay. If I want to find a surgeon, how would I do that? Somebody who can do robotics, how would I find that surgeon?

Dr. Dipen Parekh:

Again, I think the most important thing is to find a great surgeon. It doesn’t matter if that surgeon is doing open surgery or robotic surgery. To specifically find a robotic surgeon, I think most of the time websites are a good way of looking at someone’s profile. But I think the most important thing is when you’re actually with the surgeon and talking to the surgeon about your procedure, I think it’s fairly acceptable to ask about the surgeon’s experience in that particular procedure. It’s not uncommon to ask about how many procedures they’ve done, do they feel comfortable, their learning curve. I think it’s very, very expected and accepted to ask some of these questions of your surgeon before you decide on who your surgeon is going to be ultimately.

Rick Bangs:

Yeah. Where is robotic cystectomy offered today? Is it primarily done in the larger urban academic centers, or is it fairly widely available in the community today?

Dr. Dipen Parekh:

Cystectomy as such, for bladder cancer, is for the most part done in high volume academic centers. There are a few high volume private practice centers where there’s some outstanding surgeons who do cystectomies, but generally bladder cancer care or cystectomies for bladder cancer is performed at high volume centers. That’s where I would go for robotic cystectomies as well.

Rick Bangs:

Right. Now, the prevalence of robotic cystectomy, is it increasing? I would assume it might be.

Dr. Dipen Parekh:

It is. Yeah, no, it is. Like I said, the first decade, from 2000 to 2010, there was a huge uptick in terms of adoption of robotic surgery. The same, it continued this decade as this past decade as well, and now we are almost reaching a plateau where I think it’s very commonplace for surgeons, not just here in the United States, but all over the world, to be very familiar with robotic techniques for doing cystectomies as well as diversions. Many, many surgeons all over the world are doing this successfully.

Rick Bangs:

Okay. Let’s switch gears, I want to talk about your study. Full disclosure, I was on your data safety monitoring board. Why did you want to do this study about robotic versus open cystectomy?

Dr. Dipen Parekh:

Yes. There’s a very, very important motive for doing this surgery. Like I mentioned, robotic surgery literally got started in around 2003, 2004. The early two or three years were very early days and there was a lot of skepticism about the robotic technology, about the lack of tactile feedback, about how you may potentially compromise cancer-related outcomes and adversely impact patient survival after doing robotic surgery for cancers. There were a lot of question marks and appropriate skepticism in the oncology community and in the general community.

Prostate is a much more forgiving cancer compared to bladder cancer, where if someone is to fail from a surgery for prostate cancer, it can take many, many years, sometimes more than 10, 15 or 20 years, for the failure to really manifest. Bladder cancer is far less forgiving, it’s a significantly more aggressive cancer. Many times, the first shot is the best shot for many of these patients. If there were indeed limitations to robotic surgery, in terms of lack of tactile feedback, in terms of the ability of the robotic approach to reliably remove the bladder and the lymph nodes and have acceptable positive margin rates and to give and reliably remove the lymph nodes to give oncologic outcomes that are either at least equal to open traditional open surgeries, I think there’s a big question mark around there all the time.

A lot of skepticism was reserved in terms of the big question was should we be even doing robotic surgery for aggressive cancers. The only way to answer that question was to do a Phase III randomized trial, because that’s what you do when you have to test any new drug or any new modality for anything else. There’s no reason why we could not have done the same thing for the robot. But as it happens in many surgical devices and new surgical technologies, initially, when you try to do something like this, people generally think that this is such a new technique, it is unfair to compare something which is new, something that people are still in their learning curve, to something that is so traditional and been around for many decades, so it’s an unfair comparison. These new technologies are allowed to go on without any scientifically rigorous studies. Then the pendulum shifts so much on the other side, where that surgery just becomes a new standard. Then by that time, people question, why do we even do that at this point, it’s too late.

That exactly happened for prostate cancer, but because bladder cancer is less forgiving and generally more aggressive, there was a lot of skepticism, and appropriately, so from many experts within the oncology field, within the bladder cancer field. That was the main reason why we wanted to do this study. Also, the previous studies, previous comparative studies between laparoscopic and open surgery and robotic and open surgery, even for bladder cancer, the focus was mainly on the short-term endpoints that were predominantly perioperative mobility. People looked at length of stay, looked at complication rates, how long did it take for these people to start eating their diet, and then the complication rates, the quality of life, and that’s it. They really did not test it for any oncologic outcomes, there was not one study.

There was a time in the first eight or 10 years after robotic surgery came into vogue, that there were about three, 4,000 robots across the world and hundreds of thousands of surgeries were done by the robotic technology, not just for prostate and bladder, but for many other organ sites, but there was not one Phase III randomized study comparing robotics to open approach. That is the context where I wanted to do this study, to really know how does really the robot perform when it comes to oncologic outcomes, a question that no one had ever answered. They’re the main motive to perform this study, because the way you look at this is that if really, oncologically, the robot did not deliver and did not have equal or better outcomes than open surgery or non-inferior outcomes, then it doesn’t make sense to do this, period, because there’s no point if the patient goes home Monday earlier, who cares if you left cancer behind and if you’re not removed enough lymph nodes and the learning curve is too steep.

I think the fundamental question to be answered here was to answer the question of is the robot safe in delivering oncological cancer outcomes. If that is the case, then that will solve that debate forever and then people can build on the existing technology to do bigger, better, more advanced things to make the surgery even more kinder and gentler. But that was the fundamental question that led to this study.

Rick Bangs:

Such an important question. I know tons of patients were, and have been, asking about this on the BCAN Inspire web forum over the years. Who was included in the study? I think you’ve hinted at the objectives, but if you just summarize what the objectives were in addition to who was included.

Dr. Dipen Parekh:

Right. Basically, this was a prospective Phase III randomized study. There were several academic centers that were involved, there were 15 academic medical centers that participated in this trial. It was funded by the National Cancer Institute through the R01 mechanism. These were patients who needed a cystectomy for either a muscle-invasive bladder cancer or refractory high grade T1 bladder cancer that was not responsive to BCG. All these patients were also eligible to get robotic surgery, which means that if someone had any condition that precluded that patient from receiving a robotic surgery did not participate. If someone had a lot of prior abdominal surgeries or could not tolerate pneumoperitoneum to undergo laparoscopic surgeries, they were not included, to make sure that all these patients were balanced.

These patients were also balanced in terms of the stage of the cancer, in terms of the type of urinary diversion that they received, and the actual academic medical center that was picked. We wanted to make sure that at baseline we are comparing apples to apples. These were well-balanced groups that had almost the similar characteristics, in terms of who they were, what their cancer profile was, before we applied the surgical randomization.

Then, once we did the robotic surgery or the open surgery, wherever they were randomized to, we calculated the main endpoint, like I said was the most unique feature of this trial was it was an oncologic endpoint, which is two-year cancer-free survival, a progression-free survival and two-year overall survival, between these two groups at two years. Our hypothesis was that the robot was not going to be inferior to the open surgery and these outcomes will be similar. We were able to prove our hypothesis at the end of the day.

Rick Bangs:

Okay, so that’s the big reveal here.

Dr. Dipen Parekh:

Yes, that was the main finding in terms of we set out with the hypothesis that robotic technology is not going to harm a patient with bladder cancer that needs a cystectomy. We achieved that objective, we proved unequivocally, with a very high powered study with an adequate sample size, that the two-year cancer outcomes and then subsequently the three-year cancer outcomes between the open and robotic surgeries were similar and that the robot was not inferior. That’s a big deal because that then establishes robotic approach as one of the standards of care for patients with bad cancer that need a cystectomy.

Now, while that was our main endpoint, we also did look at some of the other endpoints, like positive margins, which were similar in both the groups. We also looked at the perioperative morbidity, where we found that the incidence of blood loss and blood transfusion was significantly more with open surgery, that patients who underwent robotic surgery typically stayed in the hospital for one day less compared to open surgery, while it just did take one hour more of operating time with the robotic approach.

More importantly, contrary to what some of the previous retrospective studies had shown, they always have a lot of selection bias, we found that the complication rates were very similar between the open and robotic surgery, and we found that the quality of life was also quite similar between the open and robotic surgery. All these false claims that people were making based on retrospective studies, that are well-intentioned, that if you have robotic surgery your chances of complications are lower, that’s just simply not true.

In terms of the urinary diversions, the distribution of neobladders and ileal conduits, were similar between both the open and the robotic group.

Rick Bangs:

Excellent, such important work.

We’ve talked a little bit about this, but there’s this famous saying that it’s the singer, not the song. In this case, is it the surgeon or the type of surgery that’s important, robotic versus open, which is more important?

Dr. Dipen Parekh:

It is the singer, not the song, so it is the surgeon. It is the surgeon, not the approach. The good news is that no matter where you are, you will find a world class surgeon for either open or robotic surgery and go with that. It doesn’t really matter what technique is used as long as you have the best surgeon. Now, if you have both of those available to you readily, which means you have a great robotic surgeon and a great open surgeon, it’s really more about your mindset and your fit in terms of who you feel more comfortable with in terms of who your surgeon should be. But it absolutely is the surgeon, not the approach.

Rick Bangs:

Okay, good advice. What future work do you have planned or might result from your research?

Dr. Dipen Parekh:

The most important point is right around when we published, the entire effort took us about 10 years, the first time I sat and wrote the proposal for the grant was in 2008 and then it took us two or three years to actually get the funding from National Cancer Institute, it then took us five years to do the actual study, to do the randomization and randomize close to 300 patients on the study, and then it takes about a couple of years to really analyze all the details and then report the results. As you know, we published this in the highest impact factor journal in the world, The Lancet, in June of 2018.

Rick, right around that time, a month after we published our study, there were two papers that were published in the New England Journal of Medicine, in 2018 Fall, about the role of minimal invasive surgery for cervical cancer in terms of hysterectomies. Both the studies showed that the minimal invasive approach was inferior in terms of cancer outcomes compared to open surgeries. Typically, cervical cancer is actually even less aggressive compared to bladder cancer. Imagine had we not done the study, we would’ve never unequivocally answered this question and laid this concern and debate at rest in terms of the safety of robotic approach in bladder cancer. I just thought it’s very important for the audience to know that it really turned the narrative or moved the narrative away and I think for once and for all solve this debate and solve this skepticism about the role of robotics in bladder cancer surgery or cystectomies.

Now that that is now established, I think we can move on to many more important and profound questions, either in the [inaudible 00:31:51] of bladder cancer or in the biology of bladder cancer, aggressive bladder cancer, immunotherapy, new agents, so many other areas of interest that we can move into that are I think far more relevant today now that we have addressed and laid to rest the debate of robotic surgery. In a study like this, there’s a lot of secondary studies that come out. We have published subsequent to the main manuscript in Lancet about four or five very important articles looking at a lot of sub-analysis, looking at complication rates, looking at quality of life outcomes, looking at the recovery in some of these patients in a more granular format, a more objective format.

With further follow up, we looked at three-year outcomes. One of the skepticisms was that there’s an altered pattern of recurrence in many of these patients after robotic surgery, which means that when patients with robotic surgery for bladder cancer failed, the organ sites where the cancer showed up was very different compared to open surgery. We looked at that as well and found that there was no difference really between open and robotics. We did a lot of very important work subsequent to that that has been published over the last four to five years.

Rick Bangs:

It’s such important work. Now, what’s the future for robotic and open surgeries and for robotic equipment?

Dr. Dipen Parekh:

I think there have been some other studies that have been done in this space. They just published a study from Jim Catto and his group in England, where they compared a pure straight open surgery to a completely robotic surgery, where both the cystectomy and the diversion was done by the robotic approach. It’s called the iROC study, it was published in JAMA recently. They found that there was some advantages of the robotic surgery, mainly in terms of the number of days in the hospital, but they also mentioned that they don’t really know what the clinical relevance is of that approach in the grand scheme of things, what does it all really mean in a clinical scenario is something that they were not able to comment.

It was interesting that even though they did a pure robotic approach and a pure open approach, if you look at their length of stay in the pure robotic approach, it’s actually still significantly higher than the length of stay we had in our open approach. What I mean by that is that sometimes we can get a little seduced by the headlines of the results, but if you look in the finer print, you realize that there’s a lot of innate heterogeneity and variability in different populations where these trials are done that led to some different results. It is sometimes hard to extrapolate results from one geography to another, just something to keep in mind.

In terms of the future for robotic and open surgeries, the equipment is going to keep on getting better. There will be more and more of tactile feedback, there will be more miniaturization of instruments. But I really believe, at some point, something in the space where we stop using bowel segment or intestines for urinary diversion. The true advance in my mind will be when we’ll be able to create or regenerate urinary bladders using some other tissue rather than using your own bowel, because, as you know, the major cause of morbidity after a cystectomy is the diversion. I sure do hope that there’s more focus on those areas while the future robot becomes more and more user-friendly for the surgeons.

Rick Bangs:

Okay, something to look forward here.

Dr. Parekh, thank you so much for your time today. I think you’ve helped us answer some very important questions about the effectiveness of robotic cystectomy versus open and whether patients should search first for the type of surgery or the surgeon. In case people would like to get in touch with you, could you share your Twitter handle?

Dr. Dipen Parekh:

Yeah, my Twitter handle is my entire name. It’s @dipenjparekh.

Rick Bangs:

Okay, excellent.

Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226. That’s all the time we have today, thank you for listening, and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Parekh.

Dr. Dipen Parekh:

Thank you. It’s my pleasure being here, thank you so much for having me.

Voice over:

Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network, or BCAN. BCAN works to increase public awareness about bladder cancer, advance bladder cancer research, and provide educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit bcan.org.