Robotic surgery in the fight against prostate cancer. Episode 45

Monika Rachtan
Hi, I would like to welcome you very warmly to another episode of our programme "Patient First". First of all, probably for the first time, I would like to ask you to subscribe to my channel. Look for the bell on the right or on the left on YouTube. If you like what I do, I encourage you to subscribe. This will keep you up to date with our programmes. Today we're going to talk about men's health and the importance of choosing the right doctor, which can have a big impact on your sex life after surgery. For the programme, I have invited Paweł Salwa, MD. Good morning, hello, and welcome. I am glad that you accepted the invitation, because when we spoke for the first time, I got the impression that you are an ambitious young doctor who puts the patient first. You not only do your job by operating, but you also care about what happens to the patient after the operation.

Monika Rachtan
When a man comes to you, you take care of his, as you might say, most important organ.

Pawel Salwa
I am not a neurosurgeon. They say that the most important organ in a man should be the brain, but I am a urologist, so I specialise in the urinary and genital tracts, specifically the prostate. I have often been asked why I chose this specialisation. When I was a student, a long time ago, I was interested in this intimate area of life, which is a taboo subject for many, not just men. I never had a problem talking about these topics.

Monika Rachtan
Probably not that long ago, don't exaggerate.

Pawel Salwa
I started my studies 20 years ago, in 2004, and finished in 2010, so it's almost 15 years after graduation. My point is that women, despite having to fight for their rights, are much more advanced in health awareness than men, who rarely talk about their problems, either among themselves or in public.

Paweł Salwa:
Men are traditionally more secretive, so my job is to be a kind of gynaecologist for men. I want to raise awareness of how neglected this area is. The male and female populations are similar, but prostate problems affect almost every man at some point in his life. We are talking about urinary problems or prostate cancer, which is now the most common malignancy in men. Yet not enough is said about these problems.
Monika Rachtan
Well, not many. But we girls go to the gynaecologist when we are 16, you go for that first appointment on the 14th. You get your first period. You should automatically go to be checked. Our mums make sure we go.

Pawel Salwa
You are, of course, right that the gynaecological scope is a little larger than the urological one, because that is where all the prophylaxis, all the cancer prevention and reproductive issues, in other words contraception and so on, are, indeed, a little more. However, the shortage of urologists is extremely high, and this is a result of the way in which urologists have been trained over the years, and it seems to me that this training has not been very intensive.

Monika Rachtan
What is missing?

Pawel Salwa
For example, in my time, when I was finishing my studies, doctors could usually specialise in the most desirable way. This is what is known as a residency, which means that our state, the Polish Ministry of Health, pays the doctor a certain amount of money so that he or she can study for these five years. I would now like to draw your attention to the Mazowieckie voivodship, which was the largest and is still probably the most populous voivodship in Poland, and one of the largest. Year after year, there were either one, or two, or zero specialisation places, that is.

Monika Rachtan
That is, they did not want to educate urologists.

Pawel Salwa
So it is easy to think that if you add two to two, it is easy to answer the question, because who decides about these residency places, these places were decided by the top urologists, so if they arbitrarily decide that no, there is no need for more urologists in Poland, then there are no more urologists. So we have a situation of extreme imbalance, to put it in terms of market mechanisms of supply and demand, because there are a lot of patients and there are no doctors. So in my opinion it is not. I don't want to use the word pathology, but there should definitely be more of these doctors.

Monika Rachtan
We today would like to talk about things that are important for patients. And we are going to talk about how to choose a place consciously, but above all a doctor, because it is the urologist who operates. Not anyone else, not any robot, about which there will also be quite a lot today, who will practically be the other protagonist of our conversation today, but we are going to talk about how. How to choose such a doctor and such a place to be operated on, I think I'll say decently, because that's probably a good word.

Pawel Salwa
Properly or as well as possible, because what we are going to talk about, i.e. treatment of prostate cancer, is indeed the world's gold standard, i.e. performing such an operation to remove the prostate with the assistance of a robot. The most important robot is a robot made by Intuitive Surgical, called DaVinci. But this is not about the name. And in order to perform this type of operation well, you need to have a great deal of experience, because the robot, despite its name, this medical robot, is not a robot. So it's not like a doctor comes in, presses the enter button and the robot does something. No, it is that I make certain movements and the robot transfers these movements in a one-to-one mapping, into the body in a miniaturised form. That is, I make a big, sweeping movement. Without exaggeration, of course. And the robot makes a movement of 5 millimetres. This means that there is great precision in the execution of the operation and, in order for it to be performed in the best possible way, you need to have great experience and the patient, when going to see the doctor for such an important operation, should be prepared with an arsenal of questions that they will ask the doctor in order to recognise whether this is really a person they want to trust and entrust their life and health to.

Pawel Salwa
And we have talked about this behind the scenes, that some patients, a large proportion of patients in Poland, are not yet mentally ready to ask their doctor such an open question. But I encourage them to do so.

Monika Rachtan
So wait, what? I walk into the office, come to see the urologist. The guy is ashamed, afraid of this examination, in general he already knows it's going to be unpleasant. And now he sits down and says Doctor, but before we proceed with the examination. Because I suspect that I might have a problem, I would like to ask you or even after this examination, when the doctor says that an operation will be necessary, the patient thinks well, I want to prepare with this doctor for this operation. And I am supposed to ask him just like that Doctor. Professor, here is perhaps an even better example. And how many robot-assisted operations have you done in your life? Just like that, for the face? That kind of question.

Pawel Salwa
Yes, it's a well-presented scenario as well, but make it a little bit more realistic. Because it's not like the person going to that conversation about the operation is sort of meeting that urologist for the first time. More often than not, it's not like that's the first time he's had contact with a urologist.

Monika Rachtan
He probably goes to him privately beforehand.

Pawel Salwa
He is already prepared. He has usually had some tests already done. He knows that most often we already know that the patient has cancer and is looking for a doctor. So most often, when he goes for such a consultation with one doctor or another, he knows that he is looking for help, help with functional matters, so that he can urinate well, have good sex and so on. He knows what he needs to know, what the game is about, that this game is worth the candle. And then we go to this doctor who tells us, for example, we are proposing to you a procedure of one kind or another, and in the case of what is now, as I say, the gold standard of robot-assisted surgery, there is absolutely nothing insulting about asking Well, doctor or professor, I know this is a new technique.

Pawel Salwa
And what experience do you have in this? And in this there can be no shame. This is the key thing for us if we go to any other professional, after all, I don't know whether to a mechanic, a car salon or a hairdresser. After all, no one is embarrassed to ask: can you do it? Well, it's not just cutting a nail, it's a very complicated operation. In urology, it's actually such a urological crown, one of the most difficult procedures. So it's not like any doctor was born and can do it. Well, we need to be clear about that. We doctors are human beings. Neither half gods, nor gods, nor holy spirits. I often say this to my patients, because we have to learn it too. And in my case, it took me 7 years in Germany to gather this experience to be a good operator, such an experienced one. So it wasn't a weekend trip, like many of my colleagues go on a one or two-day robotics course and then proudly display certificates of having completed a one-day course on social media.

Pawel Salwa
I would hide such a certificate if I were in the place of those doctors, but, of course, that is up to each individual, because let us make an agreement, if I read it, it is an authentic example from some Kurier Lubelski or Kurier Wschodni, I cannot remember. It's about this geographical area of Poland. There's an article in the newspaper where doctors brag about the fact that on Saturday 12 March they were on a course in Belgium, and on Monday 14 March there's the first patient. Would I be bragging about that? I don't know. To me it seems like, I would be that patient. It's not like that, everyone has to learn. It's only the patient's right to know if we're learning on them and they're doing their first ever procedure, or 2500tn like in my case.

Monika Rachtan
How much is a lot? Well, because what is the scale? Does a doctor who says he has done 100 treatments mean he has done a lot of treatments.

Pawel Salwa
This is already something, because for a layperson it is a big deal, whereas this is still the beginning of the so-called learning curve, i.e. this doctor is at the initial stage of learning. And here it is worth knowing, dear readers, that medicine has, like many aspects of our lives, made a great technological leap. Until recently, the standard of treatment for people for this disease we are discussing was to operate on a person with a sharpened knife. This is an archaism of medicine. This is something that was done a hundred years ago.

Monika Rachtan
So if they offer you open surgery, because that's exactly what the procedure is called, do you say no, no, no, run away where the fuck you're going?

Monika Rachtan
I would not want to criticise the whole method, because it is allowed, it is correct, many doctors will do it and so on. I would not give up, because I know what it smells like, what it ends up being. The risk of complications is very high. The risk of incontinence for life, that the patient walks around in nappies or pads for life is very high. What not to say. The number of patients who come to us with this problem after this type of surgery or just surgery too, unfortunately da Vinci, but performed unprofessionally, because maybe someone was just learning, is huge.

Monika Rachtan
Wait a bit longer. A very important emphasis. You told me to walk for the rest of my life in nappies, which means a guy who is 50 years old who undergoes open laparoscopic surgery assisted by a robot. He has the risk that after this operation, which is supposed to cure him of his cancer, he may wear a nappy every day for the next 20-30 years of his life.

Pawel Salwa
And that's a few and that's a few. And I find it professionally difficult, because it's a kind of very complicated but craft. That's why this case is so important. The treatment lasts three hours and we operate with structures that are a millimetre thick. It's easy to talk about, but to do it technically, to separate the millimetre membrane from the tissue where the cancer is. And we have to weigh up at this point that we have to remove the cancer in its entirety, because that is the number one priority. But this sheath is not hijacked, because if we break it, then, as we have talked about, it is unfortunately after the competition and this incontinence problem is very difficult to fix. Of course, there are different methods, there is rehabilitation, which if the patient has a small problem will help, but if the problem is big, because it is easy to guess different scales One patient will fly two drops a day and you can live with that. On the other hand, if the patient flies all over the place, it is usually impossible to fix. And here it is most important that the patient has the so-called one shot. It is one choice. This is not hair at the hairdresser's, which will grow back and can be changed, re-coloured and so on.

Pawel Salwa
Once this prostate is removed badly, there is no going back afterwards.

Monika Rachtan
For guys, incontinence is one aspect they may face after surgery. But the other aspect is the sex life. Well, you know, for women it's important, for men probably even more important. What can happen after such an operation?

Pawel Salwa
It depends on the age. With this sexuality, it is perhaps as such an interesting and curious, perhaps for some the least interesting inclusion, that these curves of male and female sexuality diverge. I don't know if you're aware of this, but as a general rule biologically that's the way we develop, that in women the needs, the sexual capabilities increase with age. This is not a myth, it happens. There are different phrases for it. I don't know if they are pretty or not pretty, but in women it increases and in men it decreases. A man's sexual peak is when he's a teenager. After that, it only gets worse, both in terms of ability and desire, in other words, the so-called libido. So fortunately, it would be a horror story if these teenagers were to have such operations. However, fortunately, most men do, because not all. This disease affects mature men, i.e. the most common patient is around 60, but it is by no means uncommon for a 50-year-old to be a 40-year-old. Any of these age categories should be men who, with all due respect, already have something in their heads and have certain priorities in life.

Pawel Salwa
Mostly he has some kind of family, he has children, he has a job, So this sex is important, very important, but fortunately it is not the most important. Relatively speaking, it shouldn't be, because if we are fighting for life, there are certain outcomes that we have to reckon with that may occur. On the other hand, it is all a question of how likely this is. For example, let's go back to this incontinence, which is a common problem after these operations, let's call them performed imprecisely. In my experience, the vast majority of nearly 100% patients hold this urine. This is such a difference. That is, we understand patients managed imprecisely by an inexperienced operator have this problem commonly, and men managed by an experienced person, the experienced one. That's what the scientific research is for, that's what we'd like to talk about, that it's not peace of fern stories, it's scientifically researched, that is, massive studies have been done based on hundreds and thousands of patients with tens and hundreds of doctors to count how many surgeries a doctor has to do, specifically this prostate. Who was the doctor I drew in such studies to be a professional, to be an expert 500 1000.

Pawel Salwa
If we are talking about this functional outcome, that is, that he holds his urine, that he has a preserved erection. But to reiterate, the first priority of such an operation is, of course, to remove the cancer. There are no compromises here. We want to remove the cancer, but not at the expense of mutilation. And this really does work in the vast majority of cases. It is just that it is not easy.

Monika Rachtan
You are succeeding. Tell me, how many professionals in Poland have made the 500,000?

Pawel Salwa
So I don't have the full statistics, of course, because doctors don't quite share them, or they can't, they can't document it, and that's important.

Monika Rachtan
That is, the patient cannot check it. Let's get this straight right away, it's not like that on the NFZ u website.

Pawel Salwa
It should be. However, I will say it can be checked, because good doctors, if we are talking about the category of doctors who have done, as I have, more than two thousand operations, are doctors who are scientifically present and internationally present. If I publish something, and we publish almost every year, it is on an international, European level. We don't publish it in Polish journals that nobody reads. With all due respect to these journals, only in international reputable journals. And now this doctor should be able to demonstrate this. If someone says he has done 500 or 1,000 operations and has no scientific research of his own, that is suspicious.

Monika Rachtan
I see. OK, so that's how you can verify. All right.

Pawel Salwa
So answering because I haven't answered your question how many such doctors are there? I don't have the full statistics. But in 2022, in October, this global American company, which is a monopoly in the production of these robots, it monitors every procedure. Every procedure performed with such a legal live robot sends millions of pieces of data to America. This is constantly monitored. They have a full list of my treatments when I log in, so I can check in the app at the moment. So if a doctor says he doesn't know how many of these treatments he has had, there's really something in that history that doesn't add up, something doesn't match there. And here we were talking about what this patient is supposed to do when he goes to such a NFZ doctor who talks ugly to him or doesn't want to give an answer or doesn't know the answer. Fortunately, there are a lot of these robots in Poland you just have to go somewhere else, because no answer or a bad answer is also an answer. And I would urge every patient to do so, because I will repeat he is fighting for his health. There is no need to pinch yourself.

Monika Rachtan
Well, exactly. Well, because if we have so much experience, two thousand procedures performed in Poland.

Pawel Salwa
And you were talking in October 2022 about this very American company, I got this statue and then I asked them about this statistic in Poland. And who is next? And I was told very clearly that the next most experienced person after me has an order of magnitude less by an order of magnitude. So these are some low hundreds. This is going to change, because I say, it is no shame to have few of these operations, everyone has to learn, after all, he says openly. It took me 7 years of working in Germany to call myself an expert and to be able to come back here and do these operations of 400 a year, because this is the scale of my activity in Poland.

Monika Rachtan
That is, you do one more than one a day.

Pawel Salwa
I usually do two or three operations a day, but I don't operate every day. I operate on Tuesdays, Wednesdays and Thursdays, and for the past five years I have had a schedule that hasn't even moved one day. Every time, every Monday I have a consultation and qualification of patients for surgery. On Tuesdays, Wednesdays and Thursdays we operate on Thursdays we have checks, on Fridays we have another consultation. And that's the way it's been going for the last five years, because the robots were also the scientific studies showed, they were supposed to introduce standardisation of medicine. We're really talking about a different world of computers, robots, data, calculating what to do to make it right. Because the kind of medicine that is still practised in many places, and we'll see what's going to happen tomorrow, behind what, what doctor comes, what nurse, what anaesthetist, what team there. We fly and we operate you tomorrow. That is what is happening. But it is a mistake in my opinion. In my hospital in the Medicover hospital in Warsaw, where I have been working since the very beginning, and only in this one. It is also such a curiosity if.

Monika Rachtan
You don't drive all over the place.

Pawel Salwa
Poland, I travel all over Poland, I have an exclusive contract, I work in one place. This is such a habit from Germany, which I absolutely recommend to every doctor, because this is also, I think, a source of a lot of frustration and stress for doctors, who then transfer these stresses, frustrations to patients. Well, see how I am supposed to talk to you. Calmly, If I was being rushed by a patient appointment in 15 minutes today, like today, to be here that day, I assumed I wasn't operating that day and doing administrative stuff, because if I was rushing to operate, I would already be sitting here irritated. And in the same way, this doctor, if he leaves at fourteen o'clock to go to another job, to his private office, the third, fourth, fifth, he's puzzled in the corridor, how he's going to answer this patient in a perfunctory way, opaquely, quickly and so that it's either not at all or not at all. And it's doctors, I say to us colleagues we do it ourselves, it's nobody imposing it on you, it's not obligatory to work in five places. Today doctors really don't earn so badly that they have to live here with five jobs.

Pawel Salwa
And that's it.

Monika Rachtan
It is very unpopular to say what you have just said, but.

Pawel Salwa
It may be so. But it seems to me that it is not anything obnoxious. Why should doctors be treated completely differently from all other professions? Does the miner work three jobs? As far as I know, no.

Monika Rachtan
Well, rather not. Thank you very much for those words, because I think I waited 41 episodes for them, so I'm very glad you had the courage to say that. Medicover in Warsaw is a hospital which is a multi-specialist hospital. You came to Poland from Germany, where you learnt your profession really, because studies are studies and practice is practice. As you said yourself, by the way, and you had to find a place where you would like to be. It's your experience that you gained abroad, because it wasn't only in Germany that you worked in the United States. Yes.

Pawel Salwa
I trained there in the States, I trained in the UK in Belgium and in a few other countries. However, I actually had a job for many years in Germany, and that's where I went through my whole career path, because first I was a resident doctor, like every other doctor, and then in Germany. And then, a year before I finished my specialisation, I became an operator, the equivalent of a Polish chief medical officer. As a foreigner, as an immigrant from an unpopular country, because at that time certain political changes had already begun and we in the West had a not very, not very positive press. And yet what was wonderful about Germany was that there you were judged, at least in the place where I worked, by your competence, your commitment to your work and your work, and not by your gender, your nationality and all those other things.

Monika Rachtan
You were young, weren't you?

Pawel Salwa
Correct. Plus. I'm quite young looking supposedly, so it's always been a topic somewhere, a topic of conversation. I'm 39, so it's not like I'm some kind of newly loaded doctor yet. But, but that's the way it looked, it was a serious hospital. And now coming back to Poland, because I worked on it for a long time, it's not like there was a red carpet waiting to be rolled out here again. From the very first day I went abroad I was working in this direction, to come back to Poland with this technology, because it was already a standard in the world at that time, and there was not a single robot in Poland. Relatively speaking, there was one, which didn't work because of some organisational reasons in Wrocław, because in Wrocław the doctors were wonderfully committed, but there was no payment, so they couldn't operate. There were a lot of these operations, very few were performed. But never mind that. Coming back we have, we have a programme. First of all, the patient and any sensible doctor is driven by that. I mean I knew that I wanted to do a major operation, a three-hour operation under anaesthesia, which is not a minor procedure like varicose veins or injecting your face with botox, where you leave the surgery after an hour, but it is a major operation, so Medicover Hospital was the only one for many specialist hospitals at that time.

Pawel Salwa
This is what I like to call it in private Poland, where I was able to perform it. This is a real event, as I define it, I define it as a full-blown facility. I mean it's not a so-called touch hospital that operates from Monday to Friday, on Friday it's locked up by a security guard with three triggers, Because there are places in the country that do major operations. And this often ends in a lamentable way. We have media reports from such facilities, for example in Krakow. I was in that hospital, I had the opportunity to work there, but I refused to do so when I saw the approximately beautiful building, the marbles and the crystal chandeliers. But so what if there were no facilities there or facilities that didn't satisfy me, because there are some facilities there, but they don't satisfy me.

Monika Rachtan
Because the patient doesn't know, totally doesn't know what a back room is. He comes to see a urologist, lays down in a ward where there is a bed, an IV, oxygen, a nurse, an orderly, lunch, and he doesn't know at all what the facilities are.

Pawel Salwa
In our hospital. My understanding of facilities is that we have, firstly, a large operating theatre with an intensive care unit, which we do not need on a routine basis, but in a hospital of letters and in the treatment of such serious things, it is about having the possibility, but not having to use it, because if this possibility, this necessity arose, and we suddenly did not have it, then there would be a problem. That is why you have to be prepared for any circumstance. These are the sort of things that someone asks me: what happens if the robot breaks down? So it's such a technology, my friends, that this robot has never broken down in my whole career, and I've worked on a dozen of these robots. I mean there might be a ripple, some kind of error, but it's never been to the point where it's made it impossible to complete the operation. Someone will ask me what if the electricity is out? That's what we are in a real hospital for, to have generators. And this hospital has these generators, that they switch on and that electricity will be there and so on. On top of that, we have all the other departments of cardiology, interventional cardiology, electro, cardiology, that is, such very complicated heart ablation procedures.

Pawel Salwa
We are also a leader as a hospital or on the podium when it comes to cardiac surgery in Poland, and with operations on a beating heart or a non-beating heart. Serious procedures, that is the kind of machine, the so-called heart lung, that we sometimes hear about on television, that some hospital and miraculously saved someone's life. We have two such machines in the hospital. So this is a hospital that runs. No, it doesn't cherry-pick from the medical cake, we just do the difficult operations and from the most difficult ones too. And there are not one, not two, not 10 cases of patients that I have offered, who in other hospitals, who have been refused surgery because they were too heavy, the surgery too difficult, the cancer too advanced, well here praise be to God that it just so happened that a doctor who has no experience sees a big cancer and says don't undertake it, because that is a much better version than to undertake something that we can't do. Also, praise to him for that. But it's about having that support and in our hospital if there are any problems.

Pawel Salwa
In my practice, what we have talked about behind the scenes is that it happens in private hospitals that if something happens, the patient is sent back to the National Health Service, right? To a public hospital. In my career at the hospital, my patients have never once had to be referred anywhere in this way. And safety, both for the doctor and the patient, is very important. That is the number one point. And this is what I would point out, that the doctor-patient and patient-doctor relationship is a relationship. It's not that someone is at the top, someone is at the bottom. It's an interaction, and I talk about this often, that this trust also has to be mutual. It's not just that I have to inspire trust in the patient, but I also have to trust the patient. If the patient starts the conversation by saying that they are recording the conversation, then there is no trust there. Well, and there are patients, but it does happen, even though it is against all the regulations, against, for example, the RODO Act. It happens fortunately rarely. And I am fortunate that the vast majority of our patients are very cultured people with whom we are many times even friends.

Pawel Salwa
It is, of course, a question of what kind of person one is, because if this is such a well-known quote, then to be a good doctor, one has to be a good person. If someone likes people and wants to take an interest in them, they will act as a doctor in the same way. If someone shies away from these people, it is hard to imagine that he will suddenly put on a white coat and become a master of empathy. I do not believe that. I believe in being, you have to be. We are authentic and you can't fake certain things in the long run.

Monika Rachtan
Tell me how many procedures you perform annually at Medicover.

Pawel Salwa
When it comes to these uro logical treatments it is an order of magnitude of 300,400 per year, it is known that one year one way, the next year another. This is a very large scale. As a comparative example, a very large oncology centre in Poland performed such operations on prostate cancer using the open method, i.e. the old Warsaw centre 50 per year. Personally, I do 300,400 such operations a year with my own hands from A to Zet, and there the entire team does 50 a year. This shows a completely different scale. And why this scale? It's about this issue. Because even if a doctor has done a thousand surgeries, he can do it perfectly well, but suddenly he withdraws from his professional life and does one for one surgery a week, he will leave the case.

Monika Rachtan
So it's not like cycling, that here muscle memory.

Pawel Salwa
Muscle memory will. But it's exactly the same as in competitive sport, which is how we have the form so called built up. If you ride a bike professionally and put it down for a week or a month, every cyclist will say well, that's ploughing fallow and you have to do the form from the beginning. I'm not a great athlete, but the kind of medicine we do, it's like a competitive sport, because it's medicine, as I say, there's no room for chance there. For example, I didn't finish it. This team from the first day I came to this hospital was also one. One of the reasons why I chose this hospital. That there was a management team that you could talk to and say we are doing things differently than you are doing them before. And they were open.

Monika Rachtan
For this talk.

Pawel Salwa
They have been open to it, they have adopted these patterns and I have a dedicated team. For example, one such person who I value and respect very much. At this point I salute many, many people, but these people also need to be appreciated e.g. I have such a nurse anaesthetist, a polite lady called Marzena. I won't give full details because she may not wish to, who has been at every single one of my procedures. Well this is the girl who has been on every procedure for 5 years. And what is that for? It's not about us liking or disliking each other. It's about.

Monika Rachtan
It.

Pawel Salwa
400,000 activities on that operation and if those activities are done wrong, or that person is just learning those activities because they do them 3, 10, 50 times or once they do them.

Monika Rachtan
With one doctor having these habits and another having a different truth.

Pawel Salwa
Time and it is a sub-optimally executed process. Because if we realise again that this operation consists of, for example, 17 big operational steps, but we repeat certain steps on one operation 100 times. I don't know. Pulling the camera out, putting it in, washing it makes a difference. Does the person who has to wash this camera know how to do it? Does he or she do it efficiently, because if he or she does it not efficiently and we lose 10 seconds on each of the 100 times, that's 1000 seconds. And the patient is lying down, the patient is, anaesthetised, given drugs, the lengthening of the operation time is not just someone's whim, it's raising the risk of complications. This is why not only the operator, but the entire team is skilful, perhaps not a guarantor, but the greatest such promises are the chances that the operation as a whole will have a good effect, not only in this aspect of urology, but the entire organism. Because anaesthesia, or anaesthesia, is not without side effects either. It is also not meant to last forever.

Monika Rachtan
Sure, sure, sure. Especially because it's this decalogue and this course of surgery that I think I would like to ask you about, because I think to myself that the patient, when there's anaesthesia in general, he doesn't really know at all, he wakes up, he falls asleep, he wakes up and it's over. But still, people are scared of the procedure. So how would you tell a patient in a nutshell what awaits a man who is about to have an operation? What does the whole procedure look like? What should he expect?

Pawel Salwa
It's hard to say, because it's so short-lived. On the other hand, let's get a few things out of the way. For example, when a patient comes to me for a consultation first, we deal with the full spectrum of this urology, i.e. from diagnosis, MRI, blood tests, biopsy to surgery, we are able to do everything. On the other hand, patients come to us at different stages. A lot of them get there because most patients ask themselves these questions where they are going and why they are going. So most people who come to me are going for it. They only find out. They already know. They go to the doctor who has done the most, unrivalled number of these robotic procedures in Poland. And they want to get this procedure. They go already with the results and such a consultation. Nowadays, most patients have, for example, an MRI scan of the prostate, so in fact at this consultation it is an unpleasant test that all men are afraid of, and it is of very little medical value. It's an examination of really low diagnostic value, which is a finger test, an examination of how it is. If we have an MRI unnecessary, I don't need to examine these patients in this way because I have an examination that is of much higher value, much higher quality.

Pawel Salwa
So it's a nice conversation, it's a conversation. We talk for an hour or so, because that's how much time I have per patient. It's not 15 minutes, because it can't be told in 15 minutes. My consultation, every single one, takes about an hour of time. Where do we talk to each other about all this? I show the patient their MRI. This is where I trained in these MRIs in the United States, because in Europe, the training was on. They were simply, I will say frankly, at a poor level. They were of poor quality. You had to go all the way to the United States to learn it properly. Hardly any urologist looks at these MRIs, because it is not easy. However, in order to perform this operation well, it is not only necessary to have precision, i.e. a tool that allows you to do it. This tool is a robot, but not only. You need to have the experience, but why do we go there, how do we have a preconceived plan? Because if I do, there is my anatomy professor, Professor Cisek, who used to say that if someone doesn't know anatomy very well, they go at this job like a mole blindly and only the diagnosis rolls.

Pawel Salwa
Well I don't think either of us would want to be operated on like that. No well it's a horror story. If I imagine a doctor not being able to look at my imaging studies, just reading a description where it says.

Monika Rachtan
Wait, this is standard in Poland this.

Pawel Salwa
The standard in Poland for me is a horror story. I would. I know that this is a very high bar, but I am not talking about society. I know that it is not a utopia that not all doctors will be able to do everything. I am not postulating that at all. I am saying what I would choose for myself. If I have my life, one thing, my health, one thing, then I pay attention to that and it seems to me that you have to take yourself quite seriously on this subject. And what we talk about in these backstage conversations. If it's intoxication. But I don't know a woman who cares about her appearance and will go to a random beautician or a random hairdresser, just to see a signboard on the street. And I like the signboard. I go in and give myself a haircut. I don't know, dye it, but it's much more important.

Monika Rachtan
But on the other hand, you know, in Poland there is such a belief that the doctor is God, that he is responsible for my life. After all, what patient? A guy in his 50s or even 60s or even 70s, he's going to get that plate. He's going to leave it there at home or not at all and not even get it. After all, wait. I remember a situation like that, when one of my family members had a suspected cancer and got a description and we were going to a professor oncologist who said Monika, it's just remember the plate. I had to write a request to the hospital so they would give me the disc and wait 7 working days for the image to be ripped onto the disc. I paid 15 zloty for them to play it there and I only got it. This is not standard in Poland. That's in general.

Pawel Salwa
I mean, let me tell you. It is just that with us there is no room for chance. We when a patient calls us, again as I said, as a surgical team. And there can be no random doctor, no random nurse, no random instrumentation. In the same way, if we call the hospital and we have a random receptionist lady who doesn't know anything about anything, it already starts to make an image with us. To sign up to see me for a consultation and for an operation there is only one phone number and only one lady answers. My personal wife, who has been the cashier of our company for five years, is herself a veterinarian by profession, so she has a certain background. And she doesn't do anything else but just to tell the patient on first contact that Mr Andrew, or Mr Wojciech there, you need to have a record with you for the consultation. The description is also worth having, but it is not at all crucial here, because this description can say that on the left something and on the right nothing. It is as if we were going to war.

Pawel Salwa
I often compare it like this to patients. Like if we get a map from the military, somewhere on the right are the Russians. Well, that's cool, cool information. We know they are on the right. Only there's a big difference whether they're chicken, top right, middle right, right or bottom right and so on and so forth. So such a patient hears from us that they have to come with a record. And then they often say but ladies, I read, ma'am, we didn't get the plate. And then my wife explains that this is first of all a sacred right of the patient. This result is the patient's, it's the property of the patient, it's the duty of the hospital and every medical facility to release this record. And that's it. Fortunately, I will console. It is very rare that anyone makes an issue out of it. If he does, so do we. Right away the answer It has to be said that this is a patient's right. If you give the right comment to such a member of staff, they begin to understand that they know they are talking to an informed patient and cannot allow themselves these slogans that are not true, because we simply have to.

Pawel Salwa
No, no, I am not, God forbid, urging a demanding attitude. I am urging people to know their rights and to exercise them. Well, because here there is no room for shame or embarrassment, or that they are embarrassed to ask the professor how many operations he has done, because this is our fate. And I will repeat this is not to be later, not to be rebuilt, not to be reversed.

Monika Rachtan
Well, we have a wife who picks up the phone and says you need to come in for an appointment to see you with a record. The patient comes in, shows up for that appointment, there's a consultation, Then they probably make an appointment.

Pawel Salwa
Some date for surgery. Exactly. So I talk about those risks. What specific patient do we have? The chances of curing the cancer, for that continence, that there is a very good chance. The erectile issue, because if it's about that erection, it not only depends on how I do the operation, but it also depends on the patient's conditions. When we have the opportunity we will talk about it, because it is an interesting topic. We agree a date for the operation, I put the patient on the surgery programme and then we have again a dedicated hospital stay coordinator for that patient. After the conversation we first send an email where the patient has everything in black and white. When patients start taking notes with me at the consultation I always ask them to stop, because they will get it all in writing, not handwritten by the doctor that you can't read, but it will be sent by computer by email with attachments. Everything in black and white. Then a dedicated person again one permanent member of staff calls the person, then emails the person so the person knows what time to which surgery to come to the hospital. What about the car park, what about the case arrives.

Pawel Salwa
The patient's stay for this operation is 5 days. On the first day we do all the preparations for the patient. So again in the vast majority of cases it is not that we say ladies, here's a list of tests and do it yourself somewhere, get referrals and so on. It's also something that I had to fight for a long time, That we. Because I download, otherwise, I download. I get patients from all over the country and all over the world, so it's very difficult to prepare them remotely. So we do everything on site. They arrive the day before at the surgery. Any blood tests, urine tests, ultrasound, whatever is needed. We do these patients on site we prepare them for the operation and it's always the day before, the patient. This is also dictated by law, by the way, that the patient should. At least twenty-four hours more for such a final thought, i.e. I sign the consent for the operation today and the operation is tomorrow. He can always change his mind. It almost never happens. This is one of those stories of two thousand patients. I remember one such one. Their life was really spilling over into sexual issues because they were so scared of the fact that there might be something, some kind of danger, but that's 1 2 thousand, so that's the margin.

Pawel Salwa
In general, this is something that seems not worth talking about, but the patient must. This is the very truth that once in two thousand something happens and we have to be prepared for it. And the patient has that day before and you're very welcome, there's no problem because it's, as I say, a mutual decision. It's not like it's just the doctor or the patient who decides, it's you have to get along together and feel that chemistry, because if it's not there it always causes problems.

Monika Rachtan
I.

Pawel Salwa
Then the next day is the surgery. The procedure takes place under what is known as general anaesthesia, or colloquially under this anaesthetic, which means the patient is asleep. The patient does not feel it. It's a well done anaesthetic, and that's what our anaesthetists do with us. We are really very satisfied with them. I very often emphasise that to the best of my knowledge we have not had a single serious lateral anaesthesia complication to date. This is something that every person dreads.

Monika Rachtan
That he would not wake up. And it does.

Pawel Salwa
It never happened. Every patient not only that they survived, but they survived in good shape and a good anaesthetic is really comparable on a safety level to a plane flight. And that's what I tell patients so often too. Yes, this is something to look at. Every one of us feels some mild anxiety when getting on an aeroplane, even if we've flown 10 times or 100 times. If it shakes there, you get scared, but we know in the back of our minds that we're unlikely to crash. It's really a once in a million thing. And it's the same here. You have to feel anxious because it's hard, it would be different. I have such a history of my life that I personally have had several of these anaesthetics, and each time, as a patient and as a patient, you feel uncomfortable. It is not a pleasure, but it is something to be endured, and a good anaesthetic passes like a five-minute dream, after which the patient wakes up and, in the vast majority of cases, says after waking up that he feels much better than he expected. The day after the operation, which is the next day, the patient gets out of bed, walks, moves, can eat everything, drink everything.

Pawel Salwa
We again you, your patients, mostly male patients examine you, check you up and so on. And this hospital stay lasts. As I said more 5 days. At the time of discharge, the patient is in such a state that he can get behind the wheel of a car, drive home to himself.

Monika Rachtan
It is a very big plus that you write off a man who is fit, who is.

Pawel Salwa
It's fit, it's not absolutely lying down. Of course, there are various strictures, because this is not the moment to go play tennis, ride a bike or have sex, because six weeks is such a most common period when we recommend a sparing lifestyle. It is not a laid back lifestyle. A person can function completely normally. On the other hand, I would let go of the hard sports during these six weeks, and indeed of sex, because here you can hurt yourself. We have one such patient so far, fortunately, who did not observe this, he enjoyed it and had an erection very quickly. What is it? I have patients who have an erection even during the hospital stay, or I don't know, two or three weeks after the operation. It's my urology doctor colleagues as if I invite them here, they'll say it's not true, it's impossible. It's such a difference. It is possible, and we have a very large number of such patients, whereas we then have to ask them to refrain from this intercourse, because it is about forces, it is about certain forces that are involved during intercourse, right?

Pawel Salwa
To make sure you don't cram something in there, it's not that the activity itself is somehow not good. It's simply that when you imagine what sex looks like, you realise that there are forces there that are certain, involved and you can hurt yourself.

Monika Rachtan
It's probably hard to convince these men. Healthy, full of strength.

Pawel Salwa
They are very sensible. They really are.

Monika Rachtan
Tell me, how is it possible that in Medicover you have 400, 500, 300 a year? It depends on the year of the operation that you have to pay for and these people are, and other facilities have 50. That's the total you just have to sum up because.

Pawel Salwa
It's about patients coming to us who know why they are coming to us, because they want that result. They are looking for the result, they know what the risks of this operation are and they want to avoid it. And if the patient makes the minimum effort and reads what this entails, that you need a good machine and you need a good operator, then they come to us. Because we deliver these results, as they say in such corporations. So let's agree, if the patients didn't have satisfactory results, we wouldn't have had 400 patients a year for 5 or 6 years. Because if. The whole world. If a facility is doing a bad service, it goes down momentarily. Because the quality of the service has to match. And here it is simply a matter of having this cancer removed, of a man holding his urine and having these erections, if they were before the operation. And now if I offered two thousand Poles of a certain age, with a certain disease, fortunately they talk to each other with their environment and the vast majority of patients come to us on the recommendation of other patients.

Pawel Salwa
Almost everyone. And it's at the moment It's no longer the case that a person has one friend or family. It's often two, two, three or more people. And now think about it, if you were to go to a major surgery and four people you know, where those you trust, who have no interest in encouraging you somewhere or discouraging you, say go there because it's the best address, or I don't know, a very good address. Well I would listen to that advice. Well I do that in my life.

Monika Rachtan
I do that in my life too. When it comes to recommending doctors and specialists, I always, always ask. And I always try to take that advice, because that's what life is all about. It's just that in Poland I don't think it's so common yet. And on the other hand, we are very much urging you to take such advice, because the word-of-mouth works everywhere. But listen, I'll still ask you about these erections, because you said it was worth talking about. What can go wrong with an operation done by a person? Because let's remember all the time that a doctor operates, not a robot. When it comes to your sex life.

Pawel Salwa
So it is. It is, as they say in my children's story, complicated. There are a few aspects in medicine and in life. In the body, everything. There are a number of factors, but it's not like it's zero-one black, red or green. A number of factors influence it and when it comes to erection, the main factors that influence what that erection will look like after surgery. This is firstly just how we perform the procedure. And now technically this part of the procedure is very difficult. Why? Because we have the prostate, which was the glass. It is to be removed as a whole, but it is covered with a kind of wallpaper one millimetre thick, such a sheet, and in it run those nerves responsible for erection. And these are not nerves of the kind we imagine, that a wire goes along the sides. The wire is a micro, such a mangled network of nerve connections spelled with a one-millimetre error. And now we have to, on the one hand, separate this membrane from the prostate first, to preserve it, and it can't be pulled too much, because if we pull the nerves, they are broken or they tear.

Pawel Salwa
If we help it with current, because we have a function like bleeding and we use the wrong current, or we use current at all, it's already wrong. That is, how we handle this tissue is insanely difficult technically and that's why you have to have this experience of 500,000 treatments, because it's relatively easy to say, but to do it technically is terribly difficult. With this robot it is difficult. So now, if we imagine a doctor trying to do it from a metre away on laparoscopy tools that are like billiard cues and in them trying to do something there, it's just a very difficult surgical technique. So it's technically even more difficult. So this doctor just has very little chance of laparoscopy or open to preserve it. Well, because even if one of us, I don't know, inspects the meat, let's try to separate a millimetre of that membrane from a piece of meat without tearing it. We're not going to do it with our hands, or a knife or a fork or any such tool. The robot allows me to do it fractionally millimetre by fractionally millimetre. And that's the technical part of it.

Pawel Salwa
On the other hand, you can't overdo that membrane, because that's where the cancer sits. And we told ourselves that the first honest test is to remove the cancer completely, so it's just difficult. So. Participation, doctor participation is very, very important. It's how is he going to do it? Whereas that's the first, most important factor, another key factor in this, is how that sexual function, erection works in that man before the operation. Well, because if it's working very well in him, that's a great starting point for it to be so after the operation. But if what we have mentioned, a standard 60-year-old patient comes to me, that is normal. It's not the disease, it's the media. Unfortunately, these advertisements in total not the media inject us men and make us a bit of a cripple, telling us about these erectile preparations, that this is such a sine qua non of masculinity and so on. I find this terribly irritating, because it is a terrible injustice being done to men at the moment, because let's imagine I have to stand up for men, a little bit being a man and their doctor, that if a woman has breast surgery and is without the breast, right, it would be a scandal for someone to say that she is not feminine, that she has lost her femininity because she has no breast.

Pawel Salwa
But you can freely in the public space say the truth that. In these adverts, that the definition of masculinity is whether he has, so to speak, a bough on fire or not, whether he has that erection or not, because if he doesn't then he's no longer a man it's horrible, sort of in a primitive way us men, because we're really made up of more than the member itself. I hope most of us are made up of that and it's just very hurtful. But going back that standard man in his 60s has erection problems and they don't stem from any at all. They don't necessarily stem from a disease. They stem from the very ageing of that body. Because the period of reproduction is, as we said to ourselves, the period of teens to 30 years. And then there is the peak of these capabilities. And then a 60 year old human being. The standard in biology is that they no longer reproduce today. Of course it happens if he has a younger wife or partner. But as a rule of thumb, that man at the age historically how we were created evolutionarily, should not decay already at that age.

Pawel Salwa
And now medication is adding to that. On top of that there are diseases, diabetes, hypertension. Hypertension medication alone causes impotence or a weakening of that erection. So if we have a patient who has an erection before the operation, then there is something to fight for and then we have a very good chance. But if the patient does not have these erections before the operation. Here there are no miracles, these erections will not be restored and. And that is why I say that it does not all depend on the doctor. Or we have a patient who admittedly has an erection once a month, but would very much like to have one preserved. Then I have to tell him honestly that, Mr Andrzej or Mr Wojtek, the risk is very high that this erection will not be there, because it no longer works in your case de facto. And the operation will not improve the matter. We are fighting to preserve the status quo, that is, if the patient comes with a functioning one. With this working erection, we have a very good chance of doing so.

Monika Rachtan
It's awfully cool what you said. I think I need to do another episode about men's sexual health and all that.

Pawel Salwa
These myths, because they are a nightmarish amount of myths. Another one that's so interesting, this nuance of medicine that most doctors don't even really know about. There's the issue of male sexuality consisting of orgasm, ejaculation and erection, because that's what people confuse. For most male men, ejaculation and orgasm are one and the same. And they are not the same thing. Orgasm, as most women know, happens in the head also male orgasm happens in the head. Whereas ejaculation, or the discharge of semen that is during orgasm is a symptom. That is, we have a sort of signal from the brain that goes down, at the bottom we have a pump and the pump pumps. And it so happens that this pump is the prostate. So if we don't have this prostate then there is no pump, so there is no ejaculation after such an operation. But the orgasm is there, i.e. the pleasant, pleasurable feeling is preserved. So after such an operation, the man has an erection, can have sex, but there will be no discharge of semen, so he can no longer conceive naturally.

Monika Rachtan
But it's all interesting what you're saying, because I keep thinking about this man who goes to the National Health Service, for an operation, and I think nobody has time to talk to him about it at all. I also imagine this wife, the woman whose husband comes back to her after the operation, and this wife finally says to him well what do you not love me anymore after this operation? Well, you know, these are such difficult conversations. We talk very freely here, we talk about medicine, we are fully aware and open to this subject, but it is in these homes that all sorts of strange situations happen later.

Pawel Salwa
As I talk to patients, they come around.

Monika Rachtan
Pairs to you.

Pawel Salwa
Very often, very often, rarely. Rarely does any man come without some sort of companion. Most often it is either a wife or a partner. There are children, very often children very rarely. I think I've had two cases like that, and they're quite disturbing, that they come with their mothers, because I think it's too much for a grown man to come with his mothers, but it's happened twice. However, I appreciate it very much, I praise it and I always invite these accompanying persons, sometimes more than one, if the man wishes so, because it is really an important topic for the whole family in the relationship and, as I told you now, I also tell the couples about it and I also tell them things such as that in order to be satisfied, in order for both of them to be sexually satisfied, it is not at all necessary to have an erection after the operation, the fact that a given patient may not have an erection after such an operation does not exclude him from sexual activity, it is only that the repertoire may have to be changed or enriched. And we talk about this too. We talk about toys, too, that's all there is.

Monika Rachtan
I'm glad we had this conversation at all today because I think this series Sexual Health, Male. Maybe we'll do Sexual Health, Family, I'll think about that and ask your permission because I think that would be very interesting. The three most important things, because our 60 minute consultation has to be over in a minute. The three most important things for men to remember. Women from our conversation today.

Pawel Salwa
So that. The most important things are that prostate cancer is very treatable. It's not a disease where you have to bury your head in the sand and be afraid of that scenario because a lot of men don't want to be diagnosed because they have this whole oncology pathway in their eyes of some chemo, some lying in hospitals, being infirm sick and so on. That needs to be disenchanted. We really are able to cure the vast majority of patients in the sense that this 5-day stay ends his adventure with prostate cancer. Of course, there are times when something needs to be done further, but we have a very good chance of doing so, so don't bury your head in the sand. Secondly, with prostate cancer, if we want to treat it, we have to think about what our life will be like after. That we risk continence and erection. And that strictly depends on how we will be enchanted, with what device, by what operator. And such a decalogue of those questions that a patient should ask when going to see a doctor is straightforward: What method do you want to operate on me? How many times, how many operations have you performed using this method yourself?

Pawel Salwa
For example, a robot.

Monika Rachtan
All by themselves? There are also some doctors who do not entirely and independently.

Pawel Salwa
This is a huge topic and for a separate story, as it were, but it's the kind of thing you have to ask straight out. That it is, that this doctor has actually done this whole operation, how many of these operations they have done and what equipment they have, because this is another thing that raises a hair on the head of the listeners. But in Poland we also have a market for so-called unauthorised robots, which means we have an official company that produces these robots, services, manages, controls what I said, the modern world. But there is also some bush company that has decided that it is going to trade these robots, and it does it like this.

Monika Rachtan
Some other robots have been appearing in space recently.

Pawel Salwa
Other, because there are other brands, but there are also robots, the so-called unauthorised ones, which means they understand that someone buys a used robot in the States, brings it to Poland and it has no service. Only Mr Krzyś or Mr Staś passes from this authorised company. And he and they say yes we can service it, they conquer and it's legal in Poland.

Monika Rachtan
And he will pay for it. Yes. Amazing. The Minister will be with me soon, or the Minister will ask me about it, because it's a very interesting topic. It was a very interesting conversation. In general, we were supposed to talk about characters, about prostate cancer, about operations, and we talked about many important aspects of our health, of our lives