Ralph Clayman: I’m going to share with you just a few thoughts and some experiences that I have. Quite frankly, I believe I’m the warmup act for Dr. Belldegrun who’s really done this to the Nth degree. I am a piker in his presence. So I’m going to cover five areas, seminal whys, creativity, innovation, failure, and success. The seminal why is something that I really love and it is something that if you’re a pain in the ass, this is a question you frequently will ask. It’s birth by clinical consternation or empathy and spurs the imagination, but usually, it’s a question that really ticks off the most senior person in your group. As in, “Why don’t we have a flexible scope?” And somebody says, “Shut up and learn how to use the rigid,” and on and on like that. Possibly that question that generates the most negative response and the most senior person on the team is absolutely a seminal why. Don’t get upset, write it down, and then when you finally finish the program, pursue it.

Creativity. There’s a lovely book on your Creative Brain Set that Carson has done and basically talks about seven potential attributes, if you will, and two pathways. One is a deliberate of reason and evaluation, and the other five are spontaneous, and she writes about the ability to flex in and out of these different pathways. I don’t believe anybody has all seven attributes. I believe that all of us are excellent in one or two of these areas, and what you really want to do is then work with people who fill in your gaps and then you have an amazing team.

One of my favorite ones is the ability to transform, which is the redirection of often negative results or negative energy, which basically speaks to never getting discouraged, never ever getting depressed when things are going the wrong way. I think Winston Churchill’s a perfect example of this and he said, “Success consists of going from failure to failure without a loss of enthusiasm.” So from that standpoint, there are no useless results. Each failure is actually new knowledge. Edison said this, he knew 900 ways not to make a light bulb before he found one way to make a light bulb.

I see no as merely the first step on the creative pathway. Each change in the planned course of events is an opportunity for discovery, it’s not the slamming of a door. If you drown your sorrows over a beer, you can discover the tubing for cardiopulmonary bypass. That’s what C. Walton Lillehei did. And by the same token, if you left your lunch on the benchtop and turns putrid and looks horrible the next day when you come in, you may discover penicillin, which is what Fleming did.

Going from creativity to innovation, John Kao basically described innovation as, “Where creative thought and practical know-how meet to realize value by doing new things or by doing old things in new ways.” And he cited six essentials in order to do this. Three are emotional, which is do you have a vision of the desired future that defines the purpose of your innovation? What’s the purpose of the journey? Is it compelling? Is there a sense of urgency to it? And the other three are practical factors. Do you have the time and energy to seek the new? Do you have the protected time? Can you carve that time out? Do you have a way for your disruptive innovation to co-evolve with your day to day work? Do you have a laboratory or place where you can take these creative ideas and test them out? And lastly, do you have an effective model for innovation stewardship where once you have worked things out, you have people with whom you can work to make them real?

I’ve had a lot of failures. There’s a lot of things I have that were lost in translation. Everything from a blood ID wristband, which was the first patent I did and never went anywhere further, one-handed ureteroscopes, mesh stents which turned out to be a great way to not drain the kidney but actually to biopsy the ureter, endowires, porous Foley catheters, and also the world’s greatest recipe for margaritas that I could not remember after we had perfected it.

But there have been successes and these were found in translation. And I’ll just touch on this briefly, the Acucise device that we did with applied urology and then the development of the LapSac and the high-speed electrical tissue morcellator that made the lab nephrectomy possible. But again, the circumstances were there. In the late 1970s when I was a resident in Minnesota, Ahmed Orandi in Fergus Falls, Minnesota had developed a very effective method of transurethral incision of the prostate. Then in the mid-1980s balloon dilation of the prostate came out and that became very, very popular. It was simple and easy to perform, but it had no efficacy so it fell out of favor. So the seminal why was, “Why can’t we simultaneously balloon dilate and perform a transurethral incision of the prostate in the office setting?” And with that, the goal was to cut the anterior commissure of the prostatic urethra, stay away from any potential rectal injury, do it in the office, and the balloon would stay up [inaudible 00:05:24] for 10 minutes and tamponade any bleeding. So that was the plan.

I met with Said Hillal the last time or the first time maybe that the AUA was in Boston. That was about 15 or 20 years ago. We met with venture capital, we got funding for this idea, and it worked great if you were an old male beagle. It failed in humans. And the reason it failed is we were not smart enough to realize that the human prostate is far different from the beagle prostate because it’s hourglass shape, and as such, every time you tried to cut the anterior commissure, the wire slipped off and would cut into the lateral lobe creating bleeding but no relief of obstruction.

And so the question is, “What do you do with this?” And this is transform. Find a narrowing that was more circular and that was the UPJ. People were doing endopyelotomies, UPJ was difficult to immobilize for the incision, and the incision while it was out to fat often was spiraling in nature and took a while to complete. So the potential of the cutting balloon catheter was there to give you the ability to immobilize and cleanly cut the UPJ via retrograde approach under fluoroscopic control. And that’s exactly what happened with applied. They downsized the prostate cutting balloon to this. It worked. We did it, first case in December, 1990, and this just shows you the device up with the wire lateral and then extravasation after the balloon has been inflated and the wire has been activated. Outpatient, no need for prestinting, retrograde approach, less costs in the antegrade or pyeloplasty at that time until eventually, obviously, the robotic pyeloplasty came in and swamped that out.

The other seminal why was, “Why can’t we remove a kidney laparoscopically?” I must admit, I had this similar experience to Dr. Moll in getting exposed to gynecology when I was at Washington University and marveled at laparoscopic surgery and the fact that this individual was doing it in the office. We started doing a bunch of laparoscopic cholecystectomies with Nat Soper at Wash U. Many of you have seen this slide. In 1990 we thought we were slicker than you could possibly imagine. We had done six kidneys in seven pigs and it only took us about 2.8 hours per kidney, came up with this sack, and then with several people, and this is the whole thing, you need a team like Lou Kavoussi, Nat Soper who was in general surgery and now is chair at Northwestern, and then we had some wonderful engineering partners in Fred Roemer and his team, Paul Thompson and Ed Pingleton to help us with the LapSac and the morcellator. And then in June 1990, we were able to proceed to actually do this for the first time in an 85-year-old woman.

And as people have pointed out, you know, “Dr. Clayman, you did the wrong thing, you should have biopsied this and left this lady alone because that was an oncocytoma.” But that was a LapSac and the morcellator and the only thing in the case that went according to plan, quite honestly, was a morcellation that took 15 minutes to do. And this is the incision she had. Today, people are still making incisions, drives me nuts, will drive me to my grave on that, that we took something that was minimally invasive with little tiny holes, and now people are still making big incisions because surgeons do what surgeons do. But these were found in translation, but they’re now lost in translation if you will because there’s progress. Nothing lasts forever and you just keep on moving on.

So in conclusion, think about the seminal why. Think about the time that somebody made you feel like you are the dumbest person on the face of the earth and threatened to fire you because of your bad thinking and that horrible question you asked. Everyone’s probably had that experience. Think about what would happen if you pursued that now. Know your creative brain set. Feed where you’re powerful and fill in the gaps with other people. Think about innovation and the things you need both on an emotional and environmental basis in order to be successful to take your creativity to the lab. Don’t worry about failures. Try hard, fail, try harder, fail better. The successes are few, but it’s definitely worth the effort. On the words of Steve Jobs, “The people who are crazy enough to think they can change the world are the ones who do.” Thank you.