The Medical Innovators Interview #5 Professor Roman Zachoval
Prostate screening, bladder disease and mapping the urinary microbiota are all hot topics in this month’s Medical Innovators Series interview, Combat Medical’s Guy Cooper is in conversation with head of the Czech Urology Association Professor Roman Zachoval, of Charles University in Prague.
Our Medical Innovators Series investigates developments in the medical and clinical worlds with the people right at the cutting edge. If you’re a fellow medical innovator who would like to be featured, please get in touch – we’d love to speak with you.
Which area particularly interests you within urology at the moment?
I’m focused on onco-urology, especially prostate cancer. It wasn’t always like that. I started with functional urology many, many years ago when I finished university and started as a resident and with my fellowship, and I still do a lot of it.
Ours is the leading department in the Czech Republic for the surgical treatment of male stress-urinary incontinence, so we do a lot of urinary sphincters, tapes and slings, mostly adjustable. I’m a big fan of adjustable devices. This also includes neuro-urology, as we are also the country’s only urological-care provider with a rehabilitation unit for spinal cord-injury patients. We visited institutions in many countries like Great Britain, France, Germany and Switzerland and tried to recreate what they were doing.
Innovation in urology in terms of incontinence has gone backwards rather than forwards. Meshes have vanished and a lot of places have taken this to mean that slings are also not to be used. We are back to sphincters from AMS which were invented in the 1970s and doing Burch colposuspensions again. So where’s the innovation around incontinence today?
I have to partially agree with you that there’s not been much so-called clinical development in recent years, but there are lot of things going on in the scientific field. The urologists are in collaboration with the scientists to try to improve all the diagnostics and treatments that we have for functional disorders like incontinence and hypocontractility of the bladder, including the new drugs for bladder overactivity or underactivity. So I think there are a lot of things going on scientifically, but there’s not much yet in real clinical practice.
Twenty years ago we used to do TURP all morning and TURB all afternoon with a monopolar loop on a resectoscope. There have been huge innovations since then. If we talk prostate, there are a thousand different ways of ablating the prostate tissue now for BPH [benign prostatic hyperplasia]. And then, of course, the robot was supposed to be for neurosurgeons or cardiac surgeons and all those other guys in a much sexier part of the world than urology. But somehow the urologists have stolen a march here and there are some wonderful innovations surgically – yet at the functional end we’re still using Botox for hypermobility in the bladder. Where’s the next thing coming from?
Coming back to functional urology, BPH is still part of that. Robotic surgery is mostly used for the oncological diseases, but BPH is still a matter of functional urology and we have a lot of new techniques for it. And it’s questionable that TURP will be the gold standard for the surgical treatment of BPH for much longer – it may be replaced soon by new innovative approaches like laser therapy. We are also the only department in the Czech Republic that uses lasers for BPH – greenlight laser, mostly for small prostate, and holmium laser enucleation of the prostate [HoLEP] for the medium size and large prostate. So I think this is a real improvement for the patients.
I collaborate closely with Dr Cesare Scoffone from Torino. We’re good friends. We work together and he has done a thousand procedures, so I have to learn a lot from him – it’s good to have a tutor like him. But it’s not only about lasers. We’ve had Rezum for two or three years and I’ve been using it for 18 months. I’m quite satisfied with it, and my patients are, too. I haven’t evaluated my results yet, but just going from experience with a few dozen patients, it really works. We have just got a new five-year, multi-centre follow-up study showing it’s comparable with TURP or laser methods for efficacy and complications, but it’s minimally invasive. It’s a one-day surgery and can be done in outpatient surgery.
From speaking to your colleagues globally, it seems that doing less but in a more targeted fashion is the surgeon’s aim at the moment – taking away less tissue, but the right tissue. What about visualisation? The hand can’t remove what the eye can’t see. Yet we’re still looking down a scope. It’s better than the naked eye and cameras have got better, but where do you think visualisation is going?
I think it’s improving stepwise all the time. Many years ago, visualisation wasn’t as good as it is now. And the improvement in the technique itself of the visualisation, the digitalisation, the fibre optics and so on – it’s so much better than we had before. And we also have this new 3D laparoscopy technique, robotic surgery and enlargement of the operating fields with loupes.
Do you use some augmented visualisation in your tumour surgery?
We use narrow-band imaging as standard when we perform resection of the tumours. Hexvix we don’t use much because of the cost – that’s a problem here in the Czech Republic.
So, moving on to onco-urology…
In recent years I’ve been doing more of it – it’s a field that has been improving and developing.
Well, I’ll challenge you on that one then for bladder – 40 years ago we treated bladder tumours with transurethral resection and either BCG or chemotherapy. We’ve moved on enormously in so many other areas but we are still treating this one with transurethral resection of the tumour and either BCG or chemotherapy. Is that it?
I do think there are new approaches in the site. We resect a lot of small tumours en bloc – we don’t cut them into pieces. This is not the usual oncological approach – it’s actually specific to urology to cut the tumour into small pieces and remove it…
… and reseed it for future work. I think that’s an issue.
Yeah. Oncological surgeons in other specialties always want to remove the whole tumour, not cut it into pieces.
Would it help if you had a little surgical bag to put your en bloc in? I’m designing one on a beer mat as we speak!
Yeah – we should talk!
I’ll write that one down. We can call it the Zachoval Cooper approach or the Cooper Zachoval… we’ll have to argue about the billing! So let’s look at it a slightly different way then. What’s your big academic research area at the moment?
In functional urology it’s mostly research in spinal cord-injury patients. We’re trying to find their urinary microbiota and see if it influences the natural course of the disease.
OK, you’re talking about this with a former orthopedic surgeon. This is new to me – explain what you’re looking for here?
Microbiota is a microbiome – the spectrum of bacteria or viruses in the tissue, urine or blood that you are examining. We’re trying to find out what this microbiome is. If you try to find out what infection is in urine, you take a sample and you send it for microbiological testing. It used to be thought that they were only about 10 to 15 common bacteria in urine. But in recent years, using special methods rather than the standard ones, we’ve found there are many more than this – there are dozens there in small amounts.
And microbiota is a very popular scientific issue now everywhere. You can examine not only urine, but also sputum, stools – it’s a big issue in gastroenterology. And it looks like these bacteria can influence the natural course of diseases.
So the patient’s natural biome or perhaps an infective biome may lead to either protection from or worsening of cases of specific cancers, including prostate and bladder cancer, and anything else you can throw your hat at?
Yes. It’s more about the bacteria worsening the problems or maybe increasing resistance to some kinds of treatment. For example, for overactive bladder, you can give drugs, you can do botulinum toxin or neuromodulation. And if these methods are not effective, that might be due to some types of bacteria, which you can identify with the new techniques.
So the treatment of those bacteria or their eradication or even propagation might lead to different curative states?
Okay. Goodness. Every day’s a school day. This is like being back at university. I suppose, if you interview a professor, you’re going to learn something! So can you tell us more about your work in the field of male stress-urinary incontinence?
I’m in a few working groups that are trying to improve implants for the surgical treatment of male stress-urinary incontinence, both sphincters and tapes. I’m a big fan of adjustable devices and also using telemedicine in the future to operate the sphincters. They are currently operated manually, but this is an issue for patients with impaired manual dexterity and cognitive problem. At the moment we’re not doing much with telemedicine in urology – the other specialties are probably more advanced than us – but sphincters might be the first devices that we can operate by remote control.
So you can have an app on your phone or, as you say, telemedicine, so everybody knows that at 10am it’s pee time and you have to go. Joking aside, when I worked for AMS, we had many discussions about this in the related area of impotence implants – an app on your phone might be a way forward. And there’s also the serious point that an awful lot of these devices fail.
Yes, of course a lot of do at the beginning, and it’s always little bit disappointing, but it takes time to make things work well. But now you can see in diabetes, in ear surgery and other areas, that these remote-control devices really can work.
Well, thinking about incontinence as a disease of more elderly people, if they have cognitive or physical disabilities then this can stop them from using a manual device properly. We know that using a sphincter with an implant for control can be incredibly difficult. There’s a story, probably apocryphal about a patient in South Africa who said he couldn’t operate his sphincter and that it was incredibly painful trying. It turns out that instead of pressing on the pump, he was squeezing his testicle. So if we can remove some of the technical challenges, we can aid patients with exactly what we’re looking for. And that leads me onto funding… so, I’ve recently won the European super lottery, as I’m sure you’ve read, and I have €100 billion of research money that I’m more than happy to donate to Charles University in Prague. What are you going to spend it on?
A lot of things!
You can only have one…
That’s tough, too many choices. Can I have two? [laughs] As a surgeon, I’d like to have a robotic system for making procedures perfect. We operate by robotics now mostly, and they have improved laparoscopy, but there are still some disadvantages. You don’t have a feeling of the tissue when you operate the system and so on, so if you can make the system really perfect, enabling the use of all the human senses, then I would probably invest the money in that.
With robotic surgery, we’ve long had the stranglehold of Da Vinci from intuitive, but Versus from CMR Surgical is starting to be placed now and there’s the new Hugo system coming from Medtronic. What would you want to develop – visualisation, haptic feedback, 3D reality? Do you want to be completely removed from the operating theatre and be in a room on the other side of the world?
Yeah. Just working from a home office [laughs].
So, after the pandemic, all urologists will have a robot installed in their spare bedroom and they’ll work from home [laughs]. What do you think will come next?
I would invest in onco-urology research. In recent years it’s really moved forward and we now have a close collaboration with the oncologists. We’re also looking at treatments with the clinical oncologists for prostate cancer and bladder cancer. There are a lot of new drugs that can influence these urological cancers. So it would be something around this – perhaps research in oncology for prevention, to decrease the risk of these diseases, minimise the treatment burden and so on.
A lot of your colleagues are discussing urinary biomarkers and specifically in uro-oncology because we still tend to have a fairly blanket approach. The discussions about chemotherapy choice in bladder cancer in our area tend to go along the lines of, “Well, everybody uses mitomycin because everybody uses mitomycin. Or if mitomycin is too expensive, we use epirubicin because it’s the same as mitomycin.” I suspect it isn’t. Or “We use gemcitabine because that’s available and inexpensive, and it’s the same as mitomycin and epirubicin.” I suspect it isn’t. So this looks like an area where more research is needed.
Yes, I agree. And I would go to the step before it. I’m involved in raising awareness of urological cancers and I’m working on prostate screening project, which is the hot issue in the EU at the moment and also in the Czech Republic. There should be a pilot project for prostate screening here in Europe, and I’m trying to push it forward.
Is that a biopsy screening or urinary biomarker screening?
No, just PSA screening.
We can request a PSA screen in the UK aged 50 or over. I was 50 this year and both my father and grandfather had prostate cancer, and I can remember enough genetics to have a passing interest in my PSA at the moment.
According to what I know, there is actually no systematic prostate screening in any European country. Some state institutions send you a letter when you are between 50 and 70 and say you should go to your GP or urologist for a PSA test. Setting up a screening programme is the way forward, at least in developed countries where you have the possibility of financing it and getting high patient recruitment, over 50% of population. I think it can be successful. It’s just another aspect of the fight against cancer.
And what should we do for bladder cancer? You hear British urologists cry out when there’s any news story telling people to see a doctor if they find blood in their pee, because the clinics then explode with urinary tract infections, prostatitis and god knows what else. What else should we be doing?
I’m not sure. I don’t want to judge just the British healthcare system, but here in the Czech Republic we proceed according to the recommendations that all patients with haematuria, either microscopic or macroscopic, should see a urologist for endoscopy and ultrasound or CT scan. These checks can reveal some small cancers. So I think the issue in Great Britain is that there are not so many urologists for the population, compared to the Czech Republic and Germany.
In Germany it feels like every butcher’s and baker’s has a urology surgery above it. When you go to German urologists’ meetings, there are thousands upon thousands of them.
And even more in Italy!
Final question then. I’m going to give you the keys to the DeLorean from Back To The Future and you’re going to set the date to 2050 and land in the urology theatres of Charles University. What will they look like?
We’ll still be doing surgical procedures and still operating in the OR. But it will be mostly minimally invasive procedures, probably in the outpatient department, just day surgery, because there will be much more awareness and prevention. We’ll be diagnosing the diseases in their early stages and we’ll have much more medical treatment of urological cancers. So the surgical part will be smaller than today, with more targeted therapy and more medical, chemotherapy, biological treatment. But we’ll still have skilled doctors and nurses in the hospital.
To quote from a recent James Bond film, regardless of all of the technological advantages, you still occasionally need somebody to pull a trigger. There will always be room for surgeons because you always need somebody to remove something surgically.
There will still be a need for surgeons, yes! And we’ll have more lawsuits, of course [laughs].
We’ll always have a need for lawyers as well! Is there anything else you’d like to add?
In the last two years all of us have missed the physical contact of real-life meetings and congresses and the social events that go with them, so I hope the virus won’t kill all that off. Because of course it is extremely nice to have a video call with you, but maybe if we were having a beer, it would be even more pleasant!
We’ll be at EAU22 in July, so come and see us at our booth. And thank you very much for your insights. It’s really interesting to have these conversations – it’s easy to get so involved in your own day-to-day that you forget to see what the broader picture is. And we’ve certainly talked about a couple of things I’d never thought of.
Thank you – it was a pleasure!