Mr Ben Challacombe, Consultant Urologist, Guy's and St Thomas’ Hospitals, London
AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Here the subject is Mr Ben Challacombe, a consultant urologist at Guy's and St Thomas’ Hospitals in London. Mr Challacombe is an expert in robotic surgery, runs the International Robotic Fellowship Programme, and was also involved in the first, televised broadcast of a robotic partial nephrectomy in the UK.
A podcast of this interview is available here:
How did you get to where you are today?
Most of the things in my life have started with Guy's Hospital. My parents met at Guy's Hospital - which is a good start. I went to school in south London and was interested in sport. As a student I was linked to sport at Guy's Hospital when it was UMDS Guy's and Thomas's.
At school, I was playing water polo for Guy's. I did medicine there - during my time it went from UMDS to KCL - and qualified in 1998. I then did a gap year in the Army, which was interesting. I tested some of the qualities that one might think were useful for a surgeon. But perhaps I also potentially developed some qualities that maybe are not useful for a surgeon in the modern age. I then did a BSc in Anatomy.
A lot of surgeons do anatomy or physiology as an intercalative year - surgical science would be what I would do now. I did house jobs at Guy's and Worthing - an SHO rotation as it was then. I worked for Sir Barry Jackson, President of the Royal College of Surgeons, and Martin Jordan, President of the Apothecarists and a whole load of ‘bigwigs’.
I ended up on the SPR rotation, which covered the whole of south-east England: Ashford, Tunbridge Wells, Maidstone, Dartford. I spent a couple of years at Guy's, Tommy's, and then a year in Australia. After that, I worked at the Royal Marsden. In 2010, I got a consultant job at Guy's and St Thomas’ Hospitals and I haven’t moved since.
What attracted you to urology?
I say this to my wife when we're choosing things that she thinks are super important - she's a surgeon too. When you're choosing the colour of your tiles for the bathroom it seems important, but you'll probably be quite happy with whichever one you choose, as long as it isn't a crazy colour. That's my view on surgery.
It was a matter of coincidence, at the right time. I was all set to be an orthopaedic surgeon - rugby boy, big guy - maybe orthopaedics. At that time I was working with an up-and-coming consultant who was then Mr, and is now Professor Dasgupta. He offered me a research job. It was an inspirational moment - I was just thinking about doing one thing, and someone said: 'How about this?' I loved urology. It was fantastic fun with loads of really good role models - people I wanted to be like.
There were lots of big ops, little ops, keyhole ops, telescopic, robotic, cancer, non-cancer, benign, young people, old people, lots of technology. Urology really had a whole spectrum of things that I thought I'd find something that would be interesting, stimulating, and enjoyable.
Who were your role models?
My first role models were really when I was with a firm - we used to have firms and would work for them for ten or twelve weeks. I remember these two amazing general surgeons, Mr Owen and Mr Mason and Jeff Kaufman, teaching us on ward rounds and thinking: ‘Wow, these guys are so amazing - they can do all these different operations’. That was when I was a student.
Then, during our final years, there was a guy teaching us for revision. He let us do a few stents - we were literally putting a few wires into people's urethras. It was really cool to be doing stuff. He was called Jimmy Allen; a consultant urologist. Then, when I was a house officer, three months of my job was doing urology and I was with a guy called Rick Popert.
I remember him saying: 'Right, you've worked hard, and got all the ward-round work done. There's a list tomorrow. Why don't you help me do the first case?' or, 'Why don't you do the first case?' I was like: 'Oh, my God. He's going to let me do this first case’. It was a cystoscopy and a biopsy - I was so excited about it.
It was the first time someone had ever really appreciated that even though you are young, you might be able to actually do something. I will never forget those moments or those people. I let people do stuff now because it's probably the same for them.
Then, there was Prokar Dasgupta. And all my senior colleagues in the urology department are inspirational. Professor Khan, Prokar Dasgupta, Tim O'Brien - he's now head of the British Association of Surgeons. I'm lucky that in urology, a lot of people are nice people. And we've got seven female colleagues now, who are all amazing, as well. It's a good family.
What changes you've noticed within urology?
My slant is all to do with keyhole surgery. When I worked with Rick Popert, he did open prostatectomy. It was a crazy operation. You couldn't see anything, if you were helping. It was like guddling around under this pool of blood, and you were sucking stuff out and hoping. Then, he'd pop out with this prostate and say: 'Da-da’, and you’d just cobble it all together and close the skin.
I compare that to now, where I've got a dual console Xi £2.4 million robot. I'm showing somebody the micro-planes around the edge of the prostate and exactly what level I want to do the nerve sparing for that individual patient, planned with an MRI scan. That is just so different.
You might look at that in the same way as bladder cancer or kidney cancer. A lot of operations that people thought couldn't even be considered done ‘keyhole’ are now standard keyhole, done robotically. Technology is the real big thing. It's the robotics for me, and the laser stuff for the BPH and enlarged prostate.
What does robotic surgery involve?
Robotic surgery is a type of laparoscopic surgery - what most people would call keyhole surgery. For me, it generally involves some small cuts on the abdomen. But it could also be on the chest if you're doing thoracic robotics, or even putting things into the mouth or other cavities.
Instead of long, straight laparoscopic instruments that are relatively crude in terms of their range of movements, there are small arms that go in, which have much higher degrees of freedom - they can basically mimic your own wrists inside the body.
On the end of those arms, you have a range of different tools, scissors and tweezers, and things that can put clips on and staple things. And instead of a laparoscopic lens, it's a double lens, giving you a 3D view.
You've got 3D view, scaled motion, no tremor, articulating instruments - all very controlled and precise. It allows the standard surgeon to do things that only the world's best laparoscopic surgeons would be able to do. The downside is that it involves somewhere between £1.4m and £2.4m to buy one of these robotic systems.
This isn't new. This is 2003/2004. There are now 72, maybe, even 76 in the country. The vast majority of certain types of operations are now done with this robotic assistance.
What was it like to be involved in the first randomised trial of robotic surgery?
That was my Master of Surgery thesis. For those of you who want a life of surgery, have done a BSc, an MBBS, an MRCS, an FRCS, a Master of Surgery - we threw that in, which was two years with Professor Dasgupta - we were looking at a very early robot.
We were looking at the ability to precisely put a needle into a kidney and whether that could be done better by the robot. We were also looking at whether you could use the patient. In this case, we used a model of the kidney, a high-fidelity model, moved the model to America, and controlled the robot from England.
It showed that whether you were in England and the patient model was in America - or vice versa - you could actually do it either way over a tele-link, and much more accurately than the human hand. Subsequent to that, other people have tried different parts of surgery remotely - tele-surgery. Now, there's a big telementoring piece coming up, so it was good to be part of those early days.
How did you come to perform the first live broadcast of robotic partial nephrectomy in the UK?
People can have fairly heated views about doing live surgery - the pros and cons and whether it’s a good thing. Basically, you're doing operations on consented patients to a live audience. If you're doing a relatively straightforward operation that everyone has done thousands of times, it's lower risk.
Partial nephrectomy is an operation where you're actively working against the clocks with the clamps on a kidney's artery to remove the tumour accurately and, then, placing two layers of sutures in - and you've got 20 minutes to do this. It is putting yourself slightly up against the pressure to do this.
We had the European Urology Association in the UK coming to London and they wanted a live case. Part of me felt it was actually going to be safer for me to do it from Guy's, than for somebody else to come into Guy's and do it from there, because it was my team and my theatre staff.
We got a 3D-printed model of the case and that helped to guide us. It was pretty stressful with 5,000 people watching you as the kidney starts to bleed a bit.
What were the challenges of running a robotic fellowship programme?
We've had a fellowship programme here since about 2010. It's grown as the number of robots we have has grown, to the point where we've now got three fellowship posts, and this year we're advertising for a bladder, a kidney and a prostate post. They will be able to be fully immersed in each of those disease areas.
At the end of that year, you should be able to do pretty much all of the operations within that specialist area that you came to do - so you can take out a whole kidney, a partial kidney, an open kidney, kidney tumour; a whole range of different things.
They're competitive. For me, it's a great way of having links with lots of units around the world, because my friends in different countries will tell me that they have a good, potential fellow. It’s important to have a person you know and trust tell you that someone is good. They come for a year and we look after them, and sometimes they come with their families.
They come to your house for a barbecue and you make them feel part of the team - you show them whatever they want - a football match, cricket match, rugby match. And it's a great honour to have people come from around the world to work in your unit.
Then I have friends who I collaborate with on papers. We collaborate on research areas. Lots of Australians, New Zealanders, Italians, Portuguese, Americans, Jordanians, Singaporeans, Malaysians - we've had a real range of countries. Last year was probably the proudest moment for me when we had three female fellows all at the same time.
It was a way of breaking that metaphorical ‘ceiling’ - that we can attract not just the best men, but also the best women from around the world to come to us. We've now had four female fellows. It's great.
Robotic surgery versus open or laparoscopic surgery. What's your opinion?
The limitations are cost, availability and training. Not everybody's got one, mainly for cost reasons, but sometimes it's because smaller hospitals can't get access if a larger hospital that's a referral centre has access.
The training is important because as Professor Prokar Dasgupta would say: 'A fool with a tool is still a fool’ - as in, it doesn't matter how smart your car is, if you can't drive then you're still going to crash. It's important that people are trained well with appropriate techniques. I think we've learnt from some disasters.
When you look back to when laparoscopic surgery came in, there wasn't even a training programme. Everyone just had a go. Literally, they were just given the gear and went for it. Now, that would never happen in robotics.
People have got very structured programmes of modular training, simulation, wet lab, dry lab, mentoring, all of these things in order to make people safe when they start. There are some things that the robot can't do. The tactile feedback isn't good.
You can't feel the tissue, but we do have brilliant vision and you get some visual cues that help you with that. You can also use some sensors, perhaps, intraoperatively. I use ultrasound scan or ICG dye - various things that can help with that.
The randomised control trials of one surgeon who is very good at open, versus one surgeon very good at robot, have not shown big differences. But if you look at the country as a whole - if you go on to the British Urology website and look at the outcomes for radical prostatectomy now, compared to ten years ago, they're amazing. They're so different.
Now 92% of the country uses robots. Whether that's just luck, or the fact that you've got more centralisation or, probably, a bit of centralisation and robotics together, the robot's made a big difference to the quality of what we're delivering.
Why hasn’t robotics taken off in other surgical specialities?
There's an historical reason for this. Then, there are political reasons. The original Da Vinci robot was designed to be either in space or in warfare. That was the reason for the original design of this kind of robotic system, where the surgeon could basically be remote from the robot.
It was designed that you might have the robot up in space and you'd be on the ground directing the robot. Then people realised that wasn't such a great idea, because who's going to start trying to dock a Da Vinci robot in the middle of Iraq or Afghanistan in a war? It was never going to work.
The concept was there and they had the robot. Then, they looked at what things it could do, and you needed an operation that was really common, and quite difficult, and that was helped by the ability to suture well.
Prostates had all that. American men were getting screened for PSA. There were hundreds of thousands of men a year in America having radical prostatectomies done open - often very badly. It's a very easy win, an easier operation to do when you’re good at it. Plenty of people to have the volume, to become accomplished at it.
Lots of training programmes had started. In the UK, people think that the majority of robots right now are urological but that's not the case. I'm head of Robotics at Guy's and Tommy's and we are in the process of buying our fourth and fifth robots - and they are not going to be used for urology.
We've basically got two robots for urology, one for thoracic, and we're going to get two more for upper GI, lower GI and gynae. Guildford's the National Centre for Gynae Robotics. Royal London has got a robot that just does GI. Royal Free has got a robot that only does kidney work - nothing to do with prostate.
People are diversifying. We've also just bought a CLR robot, which is a new type of robot. It's a bit cheaper. It's £850,000, which might still sound a lot, but a lot of hospitals find under a million isn't as difficult for them to access as over a million.
That robot could be used for hernias, appendicectomies and intermediate-range surgeries really skilfully. Urology had to almost prove that it was worth it but, now, everyone is interested in robotics, and from all the other specialties.
In the future, will robotic surgery be performed fully by AI without the surgeon's involvement?
All surgeons are aware that with technology ‘be careful what you wish for’. You get a robot, and you start getting some force feedback, some haptics, some programming that will allow easy steps to be done autonomously.
It won't be long before, potentially, that could be rolled out. I can't see that happening within at least ten years. The programming needed to make an autonomous robot that can do a technically complicated operation is huge.
It will gradually come, but it could be 20 years, plus, before you get a robot which is that good. If you’re talking about chopping out a piece of knee to do a prosthesis, or drilling a hole in the right piece of a head - that it can definitely do, much more quickly, and we're almost there with that. But in terms of the autonomous, soft-tissue surgery, it’s much more difficult.
What qualities make a great surgeon?
You need ‘hard’ qualities and ‘soft’ qualities. ‘Hard qualities’ are your attributes - you need to understand anatomy, and you need to keep reviewing anatomy - not just in a book or on a CT scan, but anatomy in a laparoscopic view, a robotic view, an open view, an endoscopic view.
All of the different ways that I can envisage the urethra from a book, I can also envisage from a robotic view, or when I'm inside the urethra with a telescope. You've got to know anatomy and physiology and pathology really well. Ultimately, I have got two major skills nowadays. I do three operations and I try to do those really well.
I also really enjoy, and am hopefully good at, talking to people. Sometimes people say: 'Surgeons - do they have to talk to people?' But you spend your whole life talking to people - pre-consenting them for the operation, talking them through the options about the operation, talking to them on the day of surgery, looking after them on the ward, reassuring them.
Enthusing them to get out of bed and move around and helping with them being settled down. Telling them afterwards about the pathology. Telling them when things have come back. Some really good conversations, but also some really tricky conversations.
You've got to be a good communicator with patients, but also with your other colleagues - with your oncologists, radiologists, pathologists, specialist nurses, nurse leaders, physios, occupational therapists. I call those ‘hard’ skills.
If you look at ‘soft’ skills, you've got to be determined, reliable, punctual, organised. You can't have someone who doesn't answer any emails - who forgets everything, who never gets back to anybody. It doesn't matter how good a surgeon they are, they're going to need massive help to be a surgeon if they're like that. You need to be physically fit. You can’t do a nine-hour robotic operation if you're not fit.
You've got to look after yourself and have integrity. You can't go drinking during the week if you've got an operation the next day. You can't stay up late at night watching TV if you've got an operation the next day. You've also got to be compassionate, thoughtful and caring. You do have to care about the disease and to want to make people better from the disease.
Without sounding like you're going to put a splint on the broken leg of a robin you’ve found in the garden, you do have to have a passion for the area that you work in. You need to be able to stand up for the patients that you're looking after, as well, which sometimes means that you're not just going to lie down and say: 'Yes, that's fine. You go first. You do that operation’. You say: 'No, my patient is septic. They are getting unwell here’.
I am their advocate. If we don't get to the theatre and do that stent, this patient could die. You need to be able to step it up when required. So it's a mixture of those hard and soft skills. Not everybody has all of them and you need to understand them. There is no one who's got the full package, really - that's impossible. No one scores 100%.
You famously operated on Stephen Fry for prostate cancer and together wrote a piece in Nature, titled: 'Both Sides of the Scalpel'? What was it like operating on such a high-profile patient?
It’s the first time I've ever done a consultation where I wasn't really sure who was more scared - me as the surgeon or him as the patient. I was probably more scared. He knew that he'd been referred to somebody who'd been recommended, whereas I was meeting not just someone who was famous, but someone I was a fan of.
I used to love Fry and Laurie, Blackadder, all those things I'd seen him in. It was just bizarre to have somebody that you'd only ever seen on TV come in and say in the same voice: 'Right, hello. Morning. Right', sit down and then just start chatting. He made it very easy, actually, because he's so clever that he had actually considered this.
He’d considered: ‘I'm pretty famous, and this doctor might be unable to speak much, so I'm going to make it easy for him’. He said some really interesting things.
He said: 'I'm not an expert. You're the expert. I've read a lot of books, but I'm not reading books about prostate cancer. You tell me what I need to know. You act as my advocate. You tell me what could go wrong. We communicate together. I'm not going to ask you questions other than the things I don't understand, or if you haven't told me something’.
He said that right up front, and it really made a difference. Then, we got on like a house on fire. I stopped trembling and we started talking about the operation and what needed to be done. He likes cricket and I like cricket, so that was great. It's great to find some common ground, that wasn’t about me being a fan of his, or him wanting to learn about prostates.
We would often text each other when he was going through the process about various things that were going on with cricket or the England team. It was nice that we had some common, ‘outside-the-issue’ ground, that we could talk about, once we got to know each other.
Stephen Fry having prostate cancer generated massive awareness which resulted in a big rise in diagnoses. What was it like as a urologist at that time?
It was weird because I bore the brunt of some of this awareness because I'm multidisciplinary team lead and head of urology cancers. Suddenly we had this massive peak of people coming through. It was slightly due to me, because we'd done some awareness, and Stephen had got involved.
Actually, I spoke to him about it and, at first, he was really upset because he thought: ‘Oh, my God, I've doubled the waiting list for everyone in the country’. I said: 'Actually, Stephen, this is really good. It needed to happen. You've made it very easy for people to go and have that conversation with their GP’.
Wives were harassing the blokes to get a test that they'd never bothered doing, and now the wives felt like they could start those conversations. I said: 'You've probably saved thousands of men's lives by this'. So I had to work an extra three or four extra weekends that year to get through all the cases that we did - so did everyone. Ultimately, it's a good thing.
What advice can you offer aspiring surgeons?
You don't get a lot of exposure at medical school to some of the areas of surgery. With ENT, urology, and plastics, you might not get much exposure at all. If you're interested in something, you can get that experience.
The enthusiastic bird will get the worm. You can email some people. You can ‘cold’ email people to ask if you can pop into their clinics. Who's going to say 'No’. I would never dream of saying, 'No’, if someone's actually got the wit to contact me.
When you go to surgery and to theatre, don't just sit there and say: 'Right, so what's this operation?' If you actually say: 'I hear you're doing a re-do hip replacement today. I read about that. Which hip are you using? I was learning about them last night’. The surgeon will say: 'Wow, that's amazing. This guy, this girl, they're actually interested in it. They've done a bit of work beforehand’.
I remember getting shouted at by a big professor at St Thomas's when I turned up to watch something and hadn't looked at the angiogram - he shouted me out of the room. I never, ever went into another theatre as a student without knowing what was going on.
Even if you’re speaking to the registrar, say: 'Right, tell me, what's happening?' Look, prepare, be alert, be enthusiastic, but not overly enthusiastic. Be aware of the situation. If something's going badly, if it's a difficult operation, that's not the time to say: 'So, could you tell me the pathology of this disease?'
Imagine the next day, if someone has gone up to the ward and said: 'Actually, I know you've just arrived, but I've seen that guy who's on ward X and he looks really good’ - that feedback tells me they're engaged.
Offer to get involved in an audit project. Ask the registrar: 'Are there any projects in this area that I could get stuck into?' I've got a friend in urology, who I know through the rugby club. He got himself attached to urology. He did an elective with us. Then, he wrote a couple of papers with us, just through chatting and coming along.
We've got a couple of other stories like that, of people who've just linked themselves in. If you hang around the department, people will get to know you and you'll get some projects. If someone gives you a project, try and deliver.
If you deliver on the first one, they're likely to give you another one. Then, you'll build a relationship and when you come to your forms, you can immediately show commitment and dedication to the speciality. Don't think: this speciality is not for me because it's too hard.
I say that particularly to the women out there. My wife's a general surgeon. We've had three kids, but really, she's had three kids. She's had three maternity leaves. She's come back. She's got a job at Tommy's doing general surgery.
You can do whatever you want. You can do a PhD, have kids, have a family, work part-time, work full-time. The modern world is allowing us to do all of the things that were previously thought not to be easy to do. They're still not easy to do now, but they're achievable if you put your mind to it.
Reflecting on your career, what have you learnt?
There's the non-clinical stuff, which is when you've realised you're in trouble - like if you stayed up all night, then something upsets you and you want to pick an argument with someone. Don't. Realise that you're tired. Realise that you might be stressed. Realise that if you're thinking: ‘Should I say this?’ The answer is almost certainly, 'No’.
If you’re asking yourself if you should send an email, the answer is: 'Definitely, no.' If you’re asking: ‘Should I tweet this?’, the answer is: 'Absolutely, completely, definitely, no’. Get on well with people. Accept the fact that you're not going to get on brilliantly with everybody, but that you've got to all live together and work together.
On the clinical side, operations don't always go well. You don't always get all the cancer out. You don't always stop all the bleeding. People don't always make it. Sometimes the cancer comes back. Learn what you can learn without making mistakes. If you can learn from a YouTube video of common laparoscopic tips and tricks to prevent errors, watch it.
Watch it five times. If that makes you stop an actual error on an actual patient just once, it's worth it. Listen to the stories that people around you say in the mortality, morbidity meetings. Don't just say: 'Wow, they did what? How did they ever do that?' Sensible people make mistakes - sometimes bad mistakes.
But we can use a lot of technology to listen in, and try and learn from each other. Also, accept the fact that you will make mistakes. If you're a consultant and you do three years of operating, you will have a disaster. If you're obviously having a disaster every month, that's not quite so good.
If you're operating 300 majors a year like I do, you'll have a disaster every two or three years. That's ten years of practice. I can still remember three or four disasters. You've got to have a mechanism for coping with those as well, because if you can't ‘get back on the horse’, then you're no good to anyone.
And then there’s all the money that's been invested in you, to try to help you become who you are.
That's not to belittle this and say: 'You're just going to park it in the corner.' René Leriche says there's a dark room somewhere that all surgeons have where they bury their disasters.
You need to be able to reflect and learn, but you have to move on, because you've got to operate on the next person the next day, and if you're still crying about the person from last week, you're no good to the person tomorrow.
I can't teach somebody that until they’ve experienced it, but what I can do is support people who are going through it, recognise colleagues who are going through it, and try and help them to find that solace after their own disasters.
I know who to call. I know who I speak to. I know who I sit down and have a cup of coffee with and go through it with, and, sadly, that's from having made a few of these big, unfortunate errors or complications.
Have you any habits that help prevent you repeating mistakes?
I'm quite superstitious. I choose Jonny Wilkinson. When you approach the kick, you do it in exactly the same way. When you're a bowler for cricket you have the same run-in, you pace it out. When in football you take the penalty, you might do it in the same way.
I try and do the same stuff. I strap the patient to the table in the same way. I put the ports in, in the same way. I've got to the point where I want to have the same hat. I'm looking at the same pants because I'm worried about breaking this set of routine things.
It's on the verge of being a bit bizarre at times. I have a structured setup. If I'm teaching someone an operation and they're in the middle of doing it, and I take over and don't really know what stage they're at because they've gone in a different order, I find it very difficult to help them.
If you're teaching someone, having structure and repetition is useful. It makes you more slick because you can make each stage slicker and more finessed as you go through. We record videos of our cases.
We reflect on those. We work as a team to look when things go wrong to try and learn from them. But it’s got to the point where I try and make the same cup of coffee every morning. I do all of these things just to try and make it feel normal - rather than feeling unusual and alien - so I can just focus on the op.
How do you maintain a healthy work-life balance?
You want to be contactable but you don't want to be over-contactable. When I go away for the summer holidays it takes me a couple of days - I'm still texting and WhatsApping people about various things. It takes me a few days to deal with all the stuff that's been going on.
Then, it's really good to just get completely out of it for the next ten days. Obviously, people ring you all the time and text you all the time - weekends and everything else - so I'm not brilliant at completely switching off on the normal week, but I'd rather know my patient has a problem than not know.
That’s part and parcel of being a surgeon. It's not like, say, pathology, where you can just decide you're not looking at anything else.
I do a lot of exercise. I cycle to work every day. I stay fit. I love it. I go on sponsored bike rides. I force myself not to answer my emails or text anybody for the whole eight hours - I'm on the bike for the day.
I make myself do challenges. I read. I like reading a lot of para-medical books - books which have a medical slant to them. When Breath Becomes Air is one of the most amazing books I've read. Cutting for Stone which is a book about African medicine and surgery - it's an unbelievable book.
Books by Atul Gawande about Complications. They're things you can relate to. I read thrillers and books on geography and history as well, but these books always end up being in a discussion with fellows or a discussion with family. It’s really important that you stay mentally fit.
Not drinking too much, not drinking too much coffee, not getting into anything you shouldn't do, because it's a marathon, not a sprint when you're a consultant. You've got to live, basically, thirty years of this.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.