Miami has hosted FIME for many years. It may be far from the big-name hospitals and medical schools of New York, Boston and Washington, but the southern coastal city is still a hotbed for innovation, particularly when it comes to technologies and surgeries that improve patients’ quality of life.
One of Florida’s leading urologists, Dr. George Suarez, worked for years to bring a prostate cancer treatment known as high-intensity focused ultrasound (HIFU) to the United States. It works by using sound waves to heat and destroy tissue at a precise focal point, at temperatures of up to 90 degrees Celsius.
Suarez likens the procedure to using a magnifying glass to focus the sun’s rays and burn a leaf. For patients with localized prostate cancer, the procedure can be done on an outpatient basis without any surgery, cutting, suturing or radiation. Suarez, who is medical director of the Prostate Cancer Institute of Miami, explained to us:
There is no pain. There is no bleeding. It is completely non-invasive.
Although this technology was first researched in the United States in the 1950s, nothing became of it for decades. HIFU gained approval in Europe in 1995. “I realized the importance of this technology. And I had the foresight to say, how do I get my hands on it and how do I make this happen?”
Suarez was the medical director of the clinical trials in the United States for HIFU. It was initially rejected by the U.S. Food and Drug Administration, but HIFU for prostate tissue ablation eventually gained FDA approval in 2015, when the U.S. federal agency approved the Sonablate 450, developed by SonaCare Medical.
Suarez said the procedure’s risk of impotence and incontinence are far lower than the standard therapies of radical prostatectomy or radiation. HIFU can be repeated, and studies have also shown that HIFU does not risk spreading the cancer, unlike procedures such as uterine morcellation, he added.
Suarez has performed well over 2,000 HIFU surgeries—more than any single doctor in the world—and often travels internationally to train physicians in the procedure. “Living in south Florida, I should be fishing or boating or doing something else,” joked Suarez, 60. “I often tell people, ‘If you see me at a golf course, come and get me because I am lost.’”
Improving Gallbladder Surgery
Dr. Tushar Barot, a general surgery resident at Mount Sinai Medical Center in Miami, saw a problem with gallbladder removal—namely a high complication rate due to bile duct injury. This potentially dangerous or even fatal mistake can happen when the bile duct gets cut or pinched during surgery, leading bile to leak into abdomen or blocking its regular flow. It often happens when the operating doctor cannot see clearly the area around the gallbladder and bile ducts.
Barot’s research showed that Mount Sinai’s complication rate for laparoscopic cholecystectomies was 5.7% —which he felt was too high. Some 750,000 of these operations take place annually in the United States. “So we implemented a six-step protocol in our hospital to see if we could do something to reduce this complication and essentially create a culture of safety where we could make this procedure safer for everybody,” Barot said.
The first step involved clearing fat and fibrous tissue from an area known as the hepatocystic triangle, then separating the lower one-third of the gallbladder from the liver. “Two and only two structures should be seen entering the gallbladder,” he explained.
Then, surgeons allow for an intra-operative timeout, followed by extra attention to any aberrant anatomy. The fourth step of the protocol allows for “liberal use of intro imaging” followed by identifying the danger zone. Barot’s final step: Get help from another surgeon. A total of 173 patients were enrolled in the nine-month study from 2014 to 2015 to see if these steps could reduce complications. They did. According to Barot:
We dropped our complications from 5.7 percent to 0 percent using that protocol.
Larger, long-term follow-up studies are needed, he added. Eventually, Barot hopes that others will take advantage of the six-step protocol in their hospitals.
New Generation Disc Replacement
Another innovation that was dreamed up in Florida is a lumbar disc replacement known as ActivL. It is the first FDA-approved spine surgery technology in a decade. For patients with lumbar degenerative disc disease or lumbar disc herniations, it offers an alternative to spinal fusion surgery, which involves fusing vertebral bones together and can lead to more stiffness and pain.
The technology was co-developed by Dr. Rolando Garcia, who was the first surgeon in Florida to perform a spinal disc replacement back in May of 2000 and was the co-lead investigator of the FDA trial for ActivL.
ActivL has chromium endplates with spikes that affix to the patient’s vertebrae and an ultra-high molecular weight polyethylene core that enables natural forward and backward movement of the lumbar spine. Garcia, an orthopedic surgeon with Orthopedic Care Centers in Aventura, Florida explained:
One of the greatest advantages is that ActivL recreates the motion of a normal spine by allowing the plastic inside of it to move and mimic the motion of the human spine.
“It also offers advantages in terms of its shape which allows the surgeon to better fit the implant to the patient,” he added. Since ActivL was FDA-approved in June of 2015, he estimates he has performed about 100 surgeries using the disc replacement.