Chapters
Transcript
SPEAKER 1: We're going to pack it also. Suction all right. [INAUDIBLE].
[SUCTION]
Can I get a hook back?
SPEAKER 2: And one other question to the panel members, do you routinely use some hemostatic, like surgicel snow or you know, snow or anything [INAUDIBLE] for the nephrectomy bed, or not at all?
SPEAKER 3: Cystectomy bed.
SPEAKER 2: Or whatever, is there some bleeding [INAUDIBLE] bundles?
SPEAKER 3: I do, although not around the anastomosis.
SPEAKER 4: Yeah, I don't routinely do it, but if it looks like it needs it, I'm not opposed to doing it.
SPEAKER 5: When I do intracorporeal diversions, I don't leave any hemostatic agents. I just feel that when you're opening up the bowel, even though it's supposed to be sterile, got you're opening up the bowel. There's contents there. You got surgicel or fibrillar, whatever you're using. I just think it's [INAUDIBLE] for a pelvic abscess, so I don't ever leave it in there. But again, with robotics, you're not really having that much of an issue with bleeding anyway.
SPEAKER 2: Restarting a lymph node dissection?
SPEAKER 1: Yes. So I kind of try to leave maximum stuff on top of the ureter so you can see kind of.
SPEAKER 4: So how far up do you want to take the ureter here? What's your-- do you have a landmark?
SPEAKER 1: I kind of dissect from far away so that it's not in my way while I'm doing the node dissection. And if I have to come back and take it a little bit, then I will. I start from right here, from the bifurcation up.
So if I have to go up for the node dissection, I'll come back and do it. But right now, I'm happy to stop here first. Throw that back down. Yeah.
SPEAKER 2: And I have a question to the panel members. What's your approach for the lymph node dissection? Do you always do extended? Do you do presacral? Do you go all the way to the IMA or just select depending on the stage? Dr. Wiklund, you want to start?
PETER WIKLUND: So my standard lymph node division is to start at our bifurcation. So I will almost always do presacral. But I mean, if I do a very old or very comorbid patient or maybe previous radiotherapy, or I will do a little bit less. Of course, I don't think-- I think the most important part of the lymph section is from the hypogastric and down, basically.
So it's less evidence to suggest that you need to go really high up. I think the more important part is that you do a good cleanout distal from where you have the-- halfway down from the common iliac, basically, and down.
SPEAKER 1: So Peter, I have a question for you. In these neobladder in young guys, you still do the presacral if it's not really beginning because of the [INAUDIBLE]?
PETER WIKLUND: Yes, I do. If you do the presacral with the robot, you see very nicely the sympathetic nerves. They are in a special plane between the lymph nodes and the sympathetic nerves. You can easily push them up on the sigmoid, so you don't need to resect the sympathetic nerves, the hypogastric ones, even if you do the presacral node dissection.
SPEAKER 1: What about others?
SPEAKER 3: Well, I do it open, but I go usually up to the aortic bifurcation unless there's some reason that you don't want to do that, morbidity to the patient and so on.
SPEAKER 2: Would you do it differently if the patient is a CIS vs. T3?
SPEAKER 3: Sure. I probably would go to the mid common iliacs then. But I go pretty high on most people with muscle-invading disease unless there's a serious reason why you don't want to. Aortic grafts and stuff like that make it a piece of work, and certainly a lot of my patients have those.
SPEAKER 1: This is a question for everybody. Has anybody changed practice after the European trial came out?
SPEAKER 6: No, I haven't. I think that's an important trial and obviously a wonderful effort. But I think we're anxiously awaiting for the somewhat similar trial but some differences in the S10-11 cooperative group trial in the United States. I think the patient population enrollment is a little bit different. The standardized templates that are being compared are somewhat different. And clearly, patient numbers-- the power of the trials will be different.
So I think the German trial is important. It's provided good information. But I think the US trial will hopefully inform us in somewhat of a different manner, So I'm anxiously awaiting the results of that trial.
SPEAKER 1: Yeah, me too. Yeah, so other people may comment about this or have any on what Dr. Messing just said? What about [INAUDIBLE]?
SPEAKER 4: Yeah, I get up high onto to the common, up to the bifurcation, usually. Should you start laterally typically like you've done to set up the lateral plane first?
SPEAKER 1: Honestly, I start higher and then try to go distal. And it's kind of almost like the style saw when I was a fellow with the Mansoura group. They kind of start higher, and then they kind of peel everything off anteriorly and just relieves everything. And if they ever come back with something, they would come back for more.
SPEAKER 4: So you set up your lateral plane?
SPEAKER 1: Yeah, I set up whichever one is easier for me to identify everything. I kind of not stuck to one way of doing it, but it's interesting thing how different people look at this differently.
And I have had-- like everyone had different comments. Obviously, we do extended-- I try to extend it. And all that what Dr. Messing said, these are all the similar things why we want do extend it if we can. But everywhere, people use a different approach.
Now we have a lot of people here we have Dr. [INAUDIBLE] there in the crowd from Japan. So we should kind of hear out what they do in Japan, and obviously, Dr. Rao and Dr. Suud from India. So if we can kind of get an idea of how people perceive this and what do they do.
SPEAKER 7: I go up to the common iliac as you are doing. I do have a reservation about presacral when we are doing the nerves pairing. But probably I agree with Peter Wiklund, as he says that he can dissect those sympathetic nerves.
But as on today, I avoid doing presacral if I have done the nerve-sparing cystectomy. But the external dissection, most of the time, is up to the common iliac, up to the bifurcation and then go down, as you are doing there.
SPEAKER 1: Yeah, but I think what Peter said is very important also, is that below the internal and the dissection around the obtunator are almost the first landing zone. I don't hear Bernie saying anything about that.
SPEAKER 7: Bernie is not here.
SPEAKER 4: He just stepped out for a second.
SPEAKER 1: Oh, he just stepped out.
SPEAKER 2: [CHUCKLES] So you're using the hook. You have any comments why you like hook, or other panel members, would you use different instruments?
PETER WIKLUND: [CHUCKLES] So this is something-- so we are-- we started the cystectomies together, courses I made long, long time ago. And I've always teased him about his using the hook, because I think it's a useless instrument. But he continuous using it anyhow.
[LAUGHTER]
SPEAKER 1: It's kind of a animal of this Harvard kind of-- I was-- when we started, obviously, Peter started with the same time that at four-- we were-- I was a resident, Dr. Peabody started and Dr. Mannon.
But this was kind of one of the few instruments. And we trained in it, and we got comfortable with it. And that was the reason. And why should you use it? Because they're most from laparoscopy to robotics. So they were really compressed with the hook in laparoscopy.
We did it because we got trained in this, so we-- everybody is the animal of their training, so they kind of-- by the way, Peter, it'll make you happy that I started using the scissor not that often, but I do use it a lot more than I used to before.
SPEAKER 7: Khurshid?
SPEAKER 1: Yes, sir.
SPEAKER 7: How many instruments you use when you do cystectomy in neobladder? And another question is what about using a robotic stapler? What is your experience? Have you used them? Or have you use them in particular plane?
SPEAKER 1: They're cost prohibitive, honestly, for us, because very expensive. So when I look at the costing, we decided not to go with it. So we-- I mean, our [INAUDIBLE] program is probably one of the oldest in the country.
So we are very happy. We have wonderful team like Dawn [INAUDIBLE] control. And I'm sure you've seen the [INAUDIBLE]. They're excellent. So we never felt the need for it.
And it's very expensive. The instruments-- we are working on a study looking at doing with least amount of instruments to cut the cost. I remember years ago, looking at Peter [INAUDIBLE] used to do an anastemosis with one. Only one [INAUDIBLE] had a driver. And now I kind of feel like that's the way to go.
It bothers me with the neobladders, because I'm so much used to both [INAUDIBLE] drivers, but the prostates have changed to that model.
SPEAKER 7: So how many instruments you are using? [CHUCKLES]
SPEAKER 1: Yeah. Yeah. Go ahead, somebody in the panel. I think you'll see a scissor, hook, a left side grasper. I used the [INAUDIBLE] today and then the Cobra Grasper for a retraction.
SPEAKER 7: So five or six?
SPEAKER 1: Yes.
SPEAKER 2: And typically, there is a system [INAUDIBLE] in the right upper quadrant and the 15 in the right lower quadrant which comes with staplers. There are two--
SPEAKER 1: Now that's kind of different for different people. I think Peter's using something different here, a different algorithm. I don't know how Bernie is doing it now. I know Sadir, what do you do?
SPEAKER 2: Dr. Guru has the assistant sit on the patient's right side. And some other surgeons have the assistant on the patient's left side, which is the opposite. And does anybody have any comments, which one is easier, on the left side, as far as handling the bowel for the neobladder, the bowel anastomosis or just surgeon preference?
SPEAKER 7: I prefer to use the assistant on right side. This is how we are doing for bladder. But for prostate, we use on the left side, as assistant on left side. Most of the time, they do just a sparing prostrate. But for bladder, we use assistant on right side.
And we use an extra port for fighting the stapler on the left side. And that's our own [INAUDIBLE] or 15 remember where we have. So we'll end up then using around six port site.
SPEAKER 4: I think you can do it either way. It just depends on what the surgeon preference is. We have the assistant on the right side for all our cases. That's just what we get used to and have done. But you can do it the other way too.
PETER WIKLUND: So we would also typically have the assistant on the right side. I do think that it's easy to staple the intestine from the left side. So In our practice, the assistant would go always to the left side to staple, because the stapler comes more parallel to the part of the ilium that we are using.
You can staple from the right side. I think maybe Khurshid is going to staple from the right. I'm not sure. But I personally don't like the robotic stapler so much, because I think that what is happening is that you have done the stapler. And then the assistant will have to help you with the intestine, to pull the intestine up on the stapler.
blood I think that's actually a more complicated part and more the part where you have to be very careful with the intestine. So I think I'd rather do that with my robotic instrument than have somebody holding a stapler, because they need basically only to put the stapler inside. And then the robot will push up the intestine on the stapler. So I prefer that.
SPEAKER 2: Dr. [INAUDIBLE], what's your assistant's son?
SPEAKER 8: So yeah, so my assistant's on the right. I use the six-port protocol. What I do is I kind of jerry rig the lateral left port. I put a 12 in there. But I tunnel an 8 millimeter port through it, So it's going to be used as a fourth arm. And whenever I'm going to do the bowel resection, the bowel anastomosis, they take the 8 millimeter arm, and then they come in with the 12 stapler. And so I do it all through the six.
SPEAKER 2: Can you hear me?
SPEAKER 9: Can I talk? Can I talk?
SPEAKER 2: Yeah, please.
SPEAKER 9: For Japanese, we-- the assistant do from left side the main part, because we [INAUDIBLE] from the right side. In the [INAUDIBLE] not other university is a different way. So maybe according to the [INAUDIBLE] position, that's why we like the [INAUDIBLE] from right side. And the assistants mainly work from the left side. It's the Japanese way.
SPEAKER 2: And typically, Dr. Guru--
SPEAKER 1: Were you talking about while you studied as negative for on frozen? Right, Ahmad? Can you hear me?
SPEAKER 5: Yes, we can hear you just fine.
SPEAKER 1: Oh, am I muted? No.
SPEAKER 8: No, you were good.
SPEAKER 2: No, we hear you OK.
SPEAKER 1: So the urethra is negative, so we're going to-- right, Ahmad? The urethra is negative so we're going to do the neobladder.
SPEAKER 2: Now we have a question from Twitter, what are the main things to look out during a lymph node dissection to prevent vascular injury? It's kind of a [INAUDIBLE] question, but what are the basics?
SPEAKER 1: Are you asking Peter that question?
[LAUGHTER]
SPEAKER 2: That's rather from the Twitter. That's just--
SPEAKER 1: From the Twitter?
SPEAKER 2: Yeah.
BERNIE: Well, so exposure is probably the key. You can say that with any surgery, but especially when you're working on big vessels that want to bleed. You have to know the anatomy. That includes where the small branches are located that can potentially be problematic. That includes the left common iliac vein, the lower part of the cava, the psoas branches that come off of the external iliac, the internal obturator vessels that head out to the obturator internist muscles.
You need to know where the obturator vessels are as well. Those tend to be the sites where most of the bleeding comes from. The dissection over the hypogastric vein, as well, I think you have to understand where the takeoff, then, of particularly the obturator vessels are so that you can resecure them in order to get the hypogastric nodes down. But those tend to be the areas, I think, of greatest concern.
Exposure is the key. Over-retraction is a problem. And that tends to happen when you're not really seeing things well.
SPEAKER 1: Yeah, exactly.
SPEAKER 2: Any other comments from the panels? So what about for those salvaged cystectomies where the patient have chemoradiation, everything, like, stuck? What's your experience on that?
SPEAKER 1: Be careful.
SPEAKER 5: I just had one last week, and it's one of those few times where I've actually said, look, I'm not going to injure this guy. And I'm just not going to do a node dissection on that one side. It was completely plastered, and I felt like I was going to onion skin.
And maybe five years ago, I would've been able to-- I would've gone in there and been a little more aggressive with it. But I guess I grew a little wiser and grew some white hair and I just said, I just-- I don't think it's worth going in there and trying to be heroic. And so I didn't do one side.
BERNIE: The degree of scarring is really kind of time dependent. At least that's been my experience, so the early failures of the chemo rads, the ones that come back as non-responders, because the radiation has been delivered fairly recently, usually within six weeks is when you're re-biopsying these people. If you find invasive disease and go in and operate, you don't find a lot of that more chronic scarring.
The patients that go on for a couple of years and then develop another one is when you begin to run into the scarring that Karim had just mentioned. The other thing to consider when you're doing salvage cases is that, in general, when we do extended dissections, we don't see a huge amount of severe lymphedema of the lower extremities. It's in the previously radiated patients that you do extended nodes on--
SPEAKER 1: We see that too.
BERNIE --where you may end up with some pretty severe edema. So those are the ones that I would tend to limit the dissection of the nodes to below the bifurcation of the common iliac vessels, if possible. And obviously, if you've got involved nodes higher, you need to get those out, if that's why you're operating. But if there aren't any gross involvement nodes above that, I would basically stay below the bifurcation of the common.
SPEAKER 2: So Doc [INAUDIBLE]. You were on the break when we had a discussion of the European trial regarding the lymph node dissection extended versus standard. What's your take or comments on that?
BERNIE: So we're going to discuss that in the lecture that's going to be coming up. But my sense is that--
[INTERPOSING VOICES]
--the numerical findings of that trial were exactly what we expected. There were differences. They just statistically weren't significant because of the power of the study. So we'll go through that in detail. You've got to look beyond that p value and understand what that node dissection can deliver, how the study was designed, including the underpowered nature of the study, and what they actually found.
And I would say that that study backs up the use of an extended dissection. And we'll go through exactly why later at the lecture.
SPEAKER 2: Yeah.
SPEAKER 1: They're all more on the same corner. And I think we feel the same way. We haven't kind of--
SPEAKER 2: And they also include the T1 disease, which is probably less beneficial from the extend to lymph node dissection.
SPEAKER 5: But just hypothetically speaking, so if the SWOG study comes back negative, would that change your practice? Would you stop doing an extended node dissection?
BERNIE: Yeah. So the SWOG study is designed actually-- and again, we can talk about this later in the lecture, but the design of the SWOG study is actually even more underpowered. And we'll go through why. Because of the on-table randomization that occurs, you eliminate anybody with involvement of the common iliac nodes, which means now you're putting in an incredibly low-risk group of patients.
And I'll run through numbers from decades worth of mapping to try and get a sense as to what the node dissection extending it could actually deliver. I don't think it's more than a 5% benefit in an overall group of patients with muscle invasive disease. Both studies are looking for double-digit improvements in outcome.
SPEAKER 1: That's a lot.
BERNIE: --which is-- there's zero data that you're going to get a double-digit improvement. But a 5% to 6% improvement in recurrence-free survival is probably what you would predict. It's exactly what came out in the German study. And so we give chemotherapy for months for a 5% to 6% improvement. So this takes us 15 minutes to do an extended node dissection, 20 minutes, whatever.
SPEAKER 1: And it's not taking me that. [CHUCKLES]
BERNIE: So my sense is that-- and again, we'll go through this, but there are some major issues with the way that the studies have been developed that will have to come out. And people are going to have to go beyond just looking at a p-value that in no way is going to be significant. So we'll talk about it, but there are some major issues with both trials.
SPEAKER 2: I do remember I saw one of Dr. Bochner's patients, who you did an extended node dissection with node positive in the upper, above the bifurcation. The patient was cured. I think the question is number to treat, and how many node dissections you have to do to save one of those patients actually cured by dissection of the node.
BERNIE: Well, we know that number. I mean, we know that you probably cure about 30% of patients with N3 disease, N3 disease, not post-chemo N3, but N3 disease. And that's from memorial data. That's from several other Scandinavian data that shows that as well. So a third of that population that's at risk is what you're going to basically potentially save.
And we know that probably only 15% of a group of muscle-invasive patients are going to be at risk. You'll save a third of that at-risk population, at most. That's about 5%. That's how we came up with that estimate, and we published that 10 years ago.
SPEAKER 5: But that's-- these are chemo-naive patients. I mean,
BERNIE: Yes.
SPEAKER 5: So if they've had neoadjuvant chemo, you wouldn't expect them to have the same third of patients--
BERNIE: Correct, no. Positive nodes after neoadjuvant chemo is very different. That's correct. But if we're asking what the surgery potentially deliver, I think asking for 15% improvements in recurrence-free survival is not backed up by any data. To power a study so that you have 400 randomized patients, you need 2,000 to 3,000 patients to find the actual benefit.
SPEAKER 2: I have a question to the panel members. Does everybody go behind the [INAUDIBLE] to make sure get [INAUDIBLE] that's a routine for everybody?
BERNIE: Yeah.
SPEAKER 5: Yes. It also is kind of a virgin plane too. So sometimes if things are stuck medially, sometimes if you go into that fossa, you can find your operator nerve. And it kind of sets up your dissection as well. I think it's helpful, either before or after the medial dissection.
BERNIE: This is an important area that Dr. Guru is showing right now, because this is potentially an area where some lateral branches could get-- you could get into a little bit of bleeding here. And as Karim just mentioned, you have to understand the location of that obturator nerve, because if there's bleeding in that area, plunging a clip down into that area has the potential for injuring the obturator nerve as it exits the psoas muscle here.
SPEAKER 1: So that's what I want to show right now. It's actually a great point.
SPEAKER 10: So my teaching is that you should never put the proximal clip when you [INAUDIBLE] of dissection, never, because then you avoid this problem.
BERNIE: Yeah.
SPEAKER 1: Is your suction not working? Let me help you do suction and then--
BERNIE: Peter, at what point do you approach that more proximal portion right there at the bifurcation? Do you usually do this first as you begin to start freeing up the external vessel, go antegrade? Or do you do this retrograde?
PETER WIKLUND: So I would do this retrograde. So what I'd do is I'll actually go up the highest. I'll go up all the way to the [INAUDIBLE] bifurcation, normally. That's where I start. And then I will dissect the plane between the sympathetic nurse and the lymph nodes. I will move the nerves up on the sigmoid.
And then I'll take the presacral all the way over to the left side. And then I'll go up, down. I'll go to the cava and just push everything down, down, down the whole way. But there will always be part of the [INAUDIBLE] triangle which I come back to at the end of my dissection.
SPEAKER 1: So you come back to the [INAUDIBLE] at the end?
PETER WIKLUND: Yes, because it's difficult to go down deep there while you-- for me, anyhow. So I think it's easier to-- but I'll try to take everything in one package, except this part, which I then do at the end.
SPEAKER 1: Could we have suction?
BERNIE: We're going to show some mapping data later on during the lecture part, where we've mapped out all pelvic recurrences over about a 15-year period. And this particular area is a hotspot where we're finding recurrences. It's those nodes right at the bifurcation of the vessels, laterally, where people tend not to go down and get that. And it's just a simple extension of what we're dissecting in the distal part. Those notes need to come out.
PETER WIKLUND: The most common problem is that a lot of people only go medial, so they do the lymph node dissection on the medial side of the vessels. And if you don't go lateral down, you will never get these nodes out, because you'll just pull, and then half of the nodes will sit in the [INAUDIBLE], or the close of the triangle of [INAUDIBLE].
SPEAKER 1: OK, let's do a little suction now. Could we have our suction back? Yeah, so let's talk a little about it. I think what everybody is talking about is, obviously, I can feel the bone here. And you can see the nerve exiting the object. Or you can see that's what I think Bernie, you were talking about the clip thing.
BERNIE: Yeah.
SPEAKER 1: You see the vessels, they are going in here like that.
BERNIE: Exactly. And you can see either the take-off of the hypogastric or those posterior/superior gluteal veins that are going posteriorly.
SPEAKER 1: Up here.
SPEAKER 2: Yeah, it's right there.
BERNIE: Yeah, just right, just medial to the nerve off of the vein.
SPEAKER 1: Suction, please.
BERNIE: Yeah, right in there. And these vessels, you have to be exceedingly careful that you don't over-retract the vein, because if those-- if you have an avulsion injury, what happens is that that proximal portion or the distal portion of the vein ends up [INAUDIBLE] into the muscle. And it's very difficult to control in that area.
SPEAKER 1: Yes.
SPEAKER 2: Do you plan to go higher up?
SPEAKER 1: Yeah.
SPEAKER 2: How high do you plan to go?
SPEAKER 1: Usually, I don't go-- I probably-- see the thing is. I don't do the sacrals in patients who I don't see kind of I'm doing a nerve spare, and I'm going to do a neobladder, unless it's indicated very seriously that I should really do it.
What I usually do here is maybe a little different than Peter, that I come back for this area. Dawn, can you hold this?
SPEAKER 5: See, I always tend to do the presacrals almost on many of my patients, just because I think I tunneled the left [INAUDIBLE] underneath the you know, underneath the [INAUDIBLE]. And so you kind of need to do a little bit of the presacral dissection anyway. I kind of feel like while you're in there, you just do it all.
I know Khurshid doesn't. He doesn't need to tunnel that left [INAUDIBLE] or he does--
SPEAKER 1: Yeah, but I do it for the conduit. I mean, it all honestly depends on the case.
SPEAKER 6: I think that term "presacral," too, can be somewhat ambiguous. I mean, we're using the term here a fair bit in the group. But it's a matter of how you roll the package, because some of that presacral-- we're talking over the sacra promontory find. I think that's the true definition of presacral.
But you're talking about some right internal iliac lymph nodes, some left common iliac lymph nodes.
SPEAKER 1: This is where your [INAUDIBLE] bifurcation, right? You see what, Peter, you're talking about, so the ease of this. You see?
BERNIE: Yeah, but that would not be considered presacral lymph nodes. This is what Kamal is talking about.
SPEAKER 1: Exactly.
BERNIE: Those nodes are overlying the left common iliac vein. Those are considered part of the left common iliac vein packet, the left common packet. It's below the bifurcation there--
SPEAKER 1: So we're talking about these ones here.
BERNIE: Correct. As the left common vein meets the right common artery, it's in between that are the true presacral lymph nodes. And that's the easiest part of the dissection there, because there's only one small median sacral vein that you have to control. This is the part that you have to be cautious of, because immediately underlying that right common iliac artery is the left common iliac vein that's coming into view here.
SPEAKER 1: You see that?
BERNIE: Yep, perfect dissection. And it's within this area that you'll get small little perforators that come off that left common iliac vein that have to be controlled. So the amount of tension that you put on that packet with your left hand here has to be exceedingly cautious, because if you pull too hard and you get into bleeding before this area is exposed, you're going to have a very long morning.
SPEAKER 1: Yeah, because you can't find them easily. See that vein you're talking about, Bernie?
BERNIE: Yeah. Yeah, the left common iliac vein, exactly, as you're anteriorly dissecting.
SPEAKER 1: See that? Right there.
BERNIE: Yeah.
SPEAKER 1: Oh, it's probably behind it.
BERNIE: Yeah. And there aren't a lot of branches that come anteriorly off this vessel. They're usually a little bit more laterally displaced. At least that's been my experience.
SPEAKER 1: Yeah. Yeah. But it's also the angle, right? With the camera, which angle we're giving it versus which angle you would open, open you would different. And the angle you have here is different. Here, the camera is looking at it straight. Why is that? [INAUDIBLE].
SPEAKER 2: He's using a fourth arm, the Cobra, to grab the sigmoid to the left side. Do you do that? Is that what you guys routinely do? Do you use another assistance or anything?
SPEAKER 5: You grab the peritoneum.
SPEAKER 2: Yep.
SPEAKER 1: Now it's nicely lifted up.
SPEAKER 2: Yep. Question from the Twitter said, how do you place port differently for the recurrent disease?
SPEAKER 1: How do you what?
SPEAKER 2: How do you place ports differently in the recurrent cases? I don't--
SPEAKER 1: I don't think I can handle that.
[LAUGHTER]
SPEAKER 2: Probably started-- I don't quite understand that maybe for--
SPEAKER 1: [INAUDIBLE]
SPEAKER 2: Yeah, I'm not sure what they ask for recurrent disease.
SPEAKER 5: I wouldn't know. I've never had a recurrence.
[LAUGHTER]
SPEAKER 1: That's the best surgeon.
[LAUGHTER]
BERNIE: Or a complication.
SPEAKER 5: Yeah, or a complication.
SPEAKER 2: No complications.
SPEAKER 5: Never.
SPEAKER 2: Never complications, someone else [INAUDIBLE].
SPEAKER 1: I [INAUDIBLE].
[LAUGHTER]
OK? I'm just kidding.
SPEAKER 2: Have you guys ever tried to go higher to the IMA for selected patients with aggressive disease with gross nodes?
SPEAKER 1: I don't know if, robotically, Peter has. I haven't gone higher.
SPEAKER 2: With gross nodes through the common iliac, you try to go higher?
PETER WIKLUND: Well, I do, but not so much in bladder cancer, because I don't think it's so useful to go out there. If the disease is up there, most-- occasionally do it. I do it more like as if it's testicular cancer or sometimes in prostate cancer, where we chase the nodes all the way up to the [INAUDIBLE].
But if you put your ports a couple of centimeters higher, you can incise the peritoneum, and you just continue upward, specifically the right side is very easy to reach up to the [INAUDIBLE] like this.
You don't have to do anything. You don't have to change. You don't have to do this very complex port placement. You can just have standard placement. Just move all the ports a little bit higher. Yeah.
SPEAKER 1: I don't do it, though.
BERNIE: So that's been our experience is where we're getting out at least the aortic bifurcation. Usually, the IMA take-off is a couple centimeters just above that area,
SPEAKER 1: Just move up.
BERNIE: Yeah, the ports are just, as Peter mentioned, they're just moved up, and it gives you perfect access to them. And you could see that, I mean, Dr. Guru, here, is essentially right in that area as well. It wouldn't take much to just free up a little bit more of the sigmoid [INAUDIBLE] in there, and you could get up a little bit higher.
SPEAKER 1: Watching this, yeah.
SPEAKER 6: I think the question here also that's important is outside the context of somebody that had AM1 retroperitoneal disease and post-chemotherapy.
SPEAKER 1: Yeah, what are you helping.
SPEAKER 6: But what's the indication to really go to the IMA in general if the--
BERNIE: An extended node dissection as classically defined goes up to the base of the IMA. It takes basically-- clears off the aortic bifurcation and goes up a centimeter or two.
SPEAKER 1: [INAUDIBLE].
BERNIE: That's the classic description of an extended--
SPEAKER 1: Everybody happy with this work? OK. Move to the other side. And we just add the two sides.
SPEAKER 2: Yeah.
SPEAKER 1: There's a [INAUDIBLE] silence, and there's a lot, so I'm kind of, oh, my god. What's going on there? Could you send these guys coffee?
[LAUGHTER]
And how about those pills I told you to put in that coffee?
[LAUGHTER]
SPEAKER 5: Yeah, this is why I do this first, because this is so tough to do after you've done the bladder, but--
SPEAKER 1: Yeah, it's--
SPEAKER 5: It requires willpower. [CHUCKLES]
SPEAKER 1: Eh, it's OK. I just slow down a little bit because--
SPEAKER 2: So I want to extend the question a little bit higher to the retroperitoneal lymph nodes enlargement, a node with more risk [INAUDIBLE] a serious current cystectomy and retroperitoneal and a node dissection. Dr. Bochner, do you want to share your thoughts on this?
BERNIE: So distant nodal disease in the retroperitoneum is considered metastatic disease. And those patients are all treated with systemic chemotherapy and then selected based upon their response to chemotherapy for consolidative post-chemotherapy surgery. And it's a select group of patients with minimal disease and outstanding response to chemo. And in that setting, the patients that are going to do well are the ones with minimal residual viable disease. So it's a true select group of patients, I think, that are going to be considered for that.
So I think to Karim's point here is that this is sort of what we're expected to do as local regional control experts dealing with invasive bladder cancer, that this node dissection, I think, whatever we decide the extent is is a critical part of what we need to do as part of a cystectomy. And it is tedious, and it can be tough, because you're working on some big vessels.
But this is what I think we buy into when we take on patients with invasive disease. You need to be willing to do this. And we know that not doing this-- and again, we can debate what the full extent needs to be. I think all of us would agree that a thorough node dissection is important to be able to do on these folks. But whether you do it before or after, you need to have your technique down, because this is the hard part of this procedure.
SPEAKER 1: Yep.
SPEAKER 6: And I think according to T1 patient's tumor, the comment probably applies to T1 patients also, the thoroughness of this dissection and the extent we're talking about.
SPEAKER 10: In patients who are not eligible for a neoadjuvants platinum-based chemotherapy, are you proceeding directly to cystectomy or you give them gemcitabine? You accept that, and you go ahead with a neoadjuvant first?
BERNIE: Yeah. For surgical candidates, there currently is level 1 evidence for a survival advantage for patients receiving cisplatinum-based chemo. And anything short of that carboplatinum-based or other single-agent regimens, there's no data for a survival advantage.
So in that setting, if they're not going to be able to get that, you have two options now. One would be an immunotherapy protocol of neoadjuvant, [INAUDIBLE], nivolumab, pembrolizumab, your choice. But those are all being studied, so that'd be under protocol design. Or taking them to surgery, which would be the standard answer for a nonplatinum-based candidate who has non-metastatic disease and is otherwise a surgical candidate. Yeah.
SPEAKER 1: Yeah, one of these bowels [INAUDIBLE] we haven't opened here. [INAUDIBLE], please.
SPEAKER 10: What do panel members do to decrease the risk of lymphoceles? We used to do a lot of clips, and now people are using less and less clips. Do you use glue? Do you use anything else?
SPEAKER 5: I don't. I just use clips here and there. I don't leave a drain. I don't look for lymphocele. That's the other thing.
SPEAKER 1: Sorry, Karim?
SPEAKER 5: I don't leave a drain, and I end up using some clips. I use about the same amount of clips you use for your [INAUDIBLE].
SPEAKER 1: I don't use clips too. They fall off, and by the end of the case, they're all gone.
SPEAKER 5: Yeah.
SPEAKER 10: Anybody prefers metallic clips?
SPEAKER 5: No--
SPEAKER 2: That's why I use it open.
SPEAKER 10: OK.
[LAUGHTER]
SPEAKER 1: Roger got the message?
SPEAKER 3: And I use a lot of them, and you can see where you went. But I mean, I use them because I don't buzz the lymphatic. I clip them.
SPEAKER 5: Yeah, I agree with Dr. Messing.
SPEAKER 3: Whatever, but the lymphoceles, after cystectomies, you can't tell the difference between that and ascites, anyway. I mean, it's all intraperitoneal, [INAUDIBLE]. So it'll get absorbed over time.
When you did what-- I don't do very many prostates nowadays, but we do those retropubically, and then lymphoceles could be an issue in the retroperitoneum.
BERNIE: One of the questions about whether an extended dissection increases your risk of a lymphocele, that was answered in the randomized study, the German study. And in the 400 patients, 200 in each arm, there were 10 additional lymphoceles that needed to be drained in the extended arm.
SPEAKER 1: Wow.
BERNIE: That's it.
SPEAKER 1: That's it. Yeah. Well, honestly, a lot of times they're asymptomatic, and you don't see them till you scan them for follow-up.
SPEAKER 5: So Khurshid, what you could see really nicely dissecting beautifully right now is the femoral branch of the general femoral nerve. And this is something I never really appreciated in open surgery, but you see it really nicely robotically.
I mean-- and I've only started noticing it over the last two or three years, where patients come in with a little bit of thigh numbness-- right there.
SPEAKER 1: Also, sometimes, when they branch, they're kind of tough to preserve a lot of times.
SPEAKER 5: Yeah.
SPEAKER 2: And since we're doing the tedious lymph node dissection, I have question to panels. [INAUDIBLE] that is show that increasingly robotics technique is done than 10 years ago. And we have panels here only doing open or mainly open or only robotic or some half and half. What's your perspective in the next 10 years, and what's it open versus robotic? And we know the--
SPEAKER 3: Unless you get an outcome that's like that hysterectomy study or cervical cancer study, which seems pretty bizarre, our residents, at least where we are in Rochester, they clamor to work with me, because I'm the only one doing major open cases. Tom Frye does a few. So they get to see very few of them.
I'm sure in practice, they're going to do robotic surgery exclusively. If they come across something that needs an open case, they'll probably either have one of their partners do it or send them out. I think in the United States, the residency training, maybe Karim can say something different, but I think almost everything is done robotically.
SPEAKER 5: Yeah I would--
SPEAKER 3: A few cases, which aren't, but ours is [INAUDIBLE]. That's--
SPEAKER 5: I think that robotics will be increasingly utilized. I still think the really good open surgeons like Bernie and everybody else here on this panel are going to still be busy with their practice. I think the bigger issue is-- and I see it coming down the line-- I think we're going to end up doing fewer cystectomies, honestly. I think with immunotherapy and combination therapies coming in the pipes, I think we're going to do fewer and fewer.
And the ones that we are going to do are going to be more and more advanced disease. So we're going to kind of follow the same path that we've had with prostate cancer. We're going to do less Gleason 6 or no Gleason 6, and we're going to be doing more Gleason 8, 9, 10s. And I think for bladders, the same way, unfortunately.
SPEAKER 3: I'm not convinced of that [INAUDIBLE]. Unless we combine it with some sort of early detection and better treatment for nonmuscle-invading disease, I think you're in the same soup. And Bernie probably could answer, and Khurshid can, about the residents now versus seven years ago in terms of their abilities to do open surgery. And I think they could talk more. That's a select group of good residents, because they're coming to do it on fellowship. But I think they have much more experience in robotics.
SPEAKER 1: This is a really important discussion what Dr. Messing also is saying here. And I think we should learn from everybody. There's a great panel experience here, starting from A to Z, because the end of the day, almost everybody here has been in academia, have had residents and have had fellows. So why don't we start from one end and hear the opinion. I think-- Bernie, you to take a crack at it?
BERNIE: Sure. So there's no question that there's been a huge shift in the skill set of the residents that are graduating. 90-- if you're not from a Canadian program, because in Canada, they're still doing a fair amount of open surgery, but in the States, I mean, there are some programs where almost 100% of residents' pelvic surgical training is being done with a robot.
So they have to-- that's how people, I think, are going to end up practicing, which is fine. There's no question that with these tools and the techniques that many of the people on the panel here, including yourself, Dr. Guru, that have developed this technique and helped to perfect the technique.
You can do this operation well. You can do it safely using these tools. We're not reinventing the wheel on the biology of the tumor. You're adapting what needs to be done to the tools. And so that's what this whole panel has been discussing.
So there's no question that this, I think, has to be in the armamentarium of the graduating residents who are going to be practicing. This is what their comfort zone is like. It's all robotically inclined at this point.
And the good news is, as Ed had alluded to, that we haven't really seen the big know full stop, red flag type study that gynecologic oncologists found. If you follow the proper surgical techniques, you can do this correctly. But as we've been discussing, it takes work. This is advanced robotic surgery, especially as we get to the reconstruction. And so a lot of people are going to have to ask themselves, do they have the skills? Are they able to do this correctly?
What we don't want to do is see a setback in cancer outcomes or functional outcomes because it's just hard for people to do this.
SPEAKER 1: [INAUDIBLE] is bad, yeah.
BERNIE: Yeah. The leaders here are able to do this. They understand it. Like Peter, he came from a background of open surgery, did a lot of this before making the transition. So the key is that we continue to put the patient right at the forefront of what we're trying to do here, and make sure that we're doing at least as good a job as we did open, and hopefully, better over time. That's what we're here for.
SPEAKER 1: Exactly right. I think it's also important-- I want to say one more comment-- that it's also important what Dr. Messing also alluded to, that what happens to the people who get trained and then have no open experience. And is it that this is the norm for them? And maybe it is.
Maybe they don't need open surgery. Maybe they can do redo because their basic starting skills are so better than what we had.
PETER WIKLUND: Yeah, I think that, I mean, the difference between robotic surgery and open surgery is not that great, actually. It's very difficult to show in the clinical trials that there is a difference. I think that the main difference is you see a little bit better with a robot. And you have different types of access. But I mean, the difference is small.
SPEAKER 1: It's still an operation.
PETER WIKLUND: Yeah, I mean, it is that you're supposed to follow exactly the same surgical plane. You should have the same outcomes. You can maybe do a little bit better nerve sparing.
I think I'm going to do prostate part of this dissection with the robots. But in general, it's very similar. I think I'll do a cystectomy still faster open than with robots, even if I'm fast, because I have done so many open.
The first time it happened to me, I actually converted a patient recently because there was so much-- it was a prostate cancer patient with a prostatectomy. And we were doing adhesions. And after like one hour, we could not get [INAUDIBLE]. I said, let's open the patient.
But then once I had taken down all the adhesion, I actually closed the patient and put the robot and did the robotic prostatectomy, because I'm personally more comfortable to find the planes that I want to find with the robot. So for me, it's better. And I think that we will see this in the future that you actually do combination. So if you're trained with a robot, let's have somebody help you open. And then you can do your part with the robot anyhow.
So we will change this. We are in an area where this will change. But I mean, nowadays, at least in my practice, almost everyone who is trained now to do prostatectomies, they are trained with a robot, and they're not trained in open surgery. So they will practice as they are taught, basically, with a robobt.
SPEAKER 3: And again, we'll run out of surgeons at some point who know how to do this as an open operation. Feels to me like we're heading in that direction.
BERNIE: Yeah, I think you're right. I think there's a limited number of programs, really, that are putting people out. For many of us, as we trained residents, it took every available case to get somebody to the chief level where you felt your final product was ready to go out. And that was with a single technique.
Now they're splitting, and the split isn't even even between two different techniques, which take a couple of you know it's very different getting your hands in here as compared to using the visual cues with a robot. They're just different techniques, and so--
SPEAKER 3: And they were doing a lot of prostatectomies open and a lot of nephrectomies open. And now all the hands-on skills have sort of gone by the wayside. And in our program, they get most of their open surgical training doing female urology reconstructive surgery and pediatric surgery. The open surgery for oncology is very limited.
And there's the worry about what if you get into a situation where you have to convert? Are you going to be able to do that? Happily, those don't happen very often. And I think if you're well trained and you understand the planes, you can stay out of trouble, for the most part.
But it's inevitably going to happen at some point that people are going to get themselves into trouble. And if you don't have a backup plan, if you don't have the skill to open somebody and-- that's kind of a scary situation. And our residents, we did an open prostatectomy last year, and the previous one, I think, was in 2009. So it really has--
[LAUGHTER]
--nobody-- it's the history of urology section, that they go to hear about that. We've done some open cystetomies, and we still do open nephrectomies once in a while. But people just don't-- the residents aren't able to do it on their own by any means. The chief residents graduating couldn't be left to do a case with minimal staff supervision. The staff has to be in there every inch of the way.
SPEAKER 1: [INAUDIBLE] kind of in the program. It's kind of almost starting from us as residents, from 2001, 2002. Do you see a difference in resident level as they go through the years?
SPEAKER 3: In terms of their ability to do robotic surgery?
SPEAKER 1: [INAUDIBLE] to kind of say, OK, my basic skills are now not open. They are robotic. And it might be reverse, that for me to have open skills, that's special.
BERNIE: Right. It is. And that trust transition probably eight or nine years ago. I mean, when you trained with us, you also went for three or four months to Mansoura and got a big dose of open surgical experience there. And we were still doing, at that point, 2004-2005, we were still doing most of our cystectomies open. That was kind of the transition phase. And a few years after that, all the kidneys went to-- all the partial nephrectomies went to robotic approach.
I think that the hard work that's been done by a lot of people, including the randomized trials that are available now is that we have two reasonable options on what we can offer patients. Following the same surgical tenets, it looks like the outcomes are going to be about the same, whether it's recovery, cancer outcomes.
And so I remember the first time after our randomized study data was published, and as I was sitting with a new visit, and they were asking about robotics. And I discussed the trial findings. And they looked up at me, and they asked the question, and sort of the clouds parted and the angels began to sing, which was, well, Doctor, there's really not that much of a difference. What do you feel most comfortable doing?
And ultimately, that's exactly what patients should be asking. So if your skill set is open and you can do this better open, do it open. The patients are going do the same. That's what we've found. That's what the studies have shown. But if your skill set is robotic, and you can do a good job robotically, offer it robotically. And that I think that's really kind of where the state of the science is at this point.
SPEAKER 3: Patients, maybe less so now, although maybe not, looked at the robot as some kind of magic wand, that if you used it, it'd be better. And I think a lot of robotic surgeons early on didn't try to talk patients out of that idea. They let that be believed and went along with it I think that was a disservice, especially early on in people's experience when you're trying to figure out the technique.
SPEAKER 1: But Dr. Peabody, I think that glad that it didn't happen for broader-- I I can tell you of multiple patients who came to me a second opinion from Rochester, and I said, well, I don't think I could do it as well as Dr. Messing. The only difference is he would do it open. I think broader people didn't do that. So it kind of was a good service for the patients.
SPEAKER 3: Yeah, I think that might be a surgeon's specific thing too.
SPEAKER 1: Yeah.
SPEAKER 10: Another question to the panel about surveillance of the blood during the neoadjuvant chemotherapy. How many of you guys survey the patients and if they find a mass, do you resect it before the cystectomy? Or do you change the chemotherapy [INAUDIBLE], and do you take the patient directly to the cystectomy?
PETER WIKLUND: So we would do, typically, a scan after two courses. And if we don't see a response, we will take them to cystectomy at that point. If they respond, they will have the last two courses.
SPEAKER 4: Is it just a CT, Peter, or you do PET scans? Do you do a PET scan?
SPEAKER 2: The question, do you do PET CT scan or just regular CT?
SPEAKER 5: Well, the PET CT can't show what's in the bladder, so you have to do an MRI or maybe a CT urogram [INAUDIBLE] in the bladder.
PETER WIKLUND: I mean, I think you should also do the same technique you did before you start chemo. So you see, with the same technique, if you have a response or not. I don't know, but that's how we do it. I don't know if that's very evidence based.
SPEAKER 3: I scope them before the cystectomy, but it's mostly to know about the urethra.
SPEAKER 1: Yeah, me too. I can [INAUDIBLE] there's the same thing.
SPEAKER 3: I mean, if it's a small tumor, I'll take it out, but it wouldn't change my mind about doing the cystectomy. If it's a big tumor, I'm not going to spend an hour and a half whacking away.
BERNIE: And the reality is that there's zero evidence that trying to TUR a residual tumor prior to taking the bladder out is going to have any patient benefit. So we wouldn't do that either. Unless, you're considering a bladder-preserving strategy.
SPEAKER 3: Yeah, right, that's different.
BERNIE: That's totally different. Exactly.
SPEAKER 1: Also, Bernie, if you do that, the inflammation is too much post-operatively, and you didn't achieve anything, right?
BERNIE: Yeah, there's-- I don't like doing anything that isn't directly going to benefit patient outcome. And so if the plan was to do neoadjuvant chemo followed by cystectomy, our practice pattern has been to do a scan after completion of the chemo.
The people we tend to scan at halfway through are either the large borderline lesions that if they grow, they may become unresectable, or the unusual predominant histologies, where we're really not sure about response rates. And those are the patients that we'll tend to go ahead and scan in between. But if you're not considering bladder preserving as the next step, as long as the scan doesn't show progression of disease, I usually just go ahead at that point.
Now, I will always do a [INAUDIBLE], as Dr. Messing had mentioned, at some point during the care, to make sure that the urethra has been visualized. Sometimes I'll just do that on the table at the time of cystectomy, and I'll let them know. If I see something overtly involving the urethra, we'll fall back on whatever plan B has been discussed, as far as diversion types go.
SPEAKER 5: Now I do do-- I don't know what your [INAUDIBLE]-- you guys all do an aggressive TUR prior to the start of neoadjuvant chemo, meaning, do you want to try to render them as minimal disease in the bladder before you start if you think that the bladder is the sanctuary site for some of these cancers?
Because we know that 39% of all the complete responders from neoadjuvant chemotherapy, we can attribute that to an aggressive TURBT.
BERNIE: I don't think we ever trump biology of the tumor. And so my sense is that people live or die based upon whether their tumor has spread and whether it's sensitive to the systemic therapy that we give. Whether we render it, the local disease, free or not, it doesn't really-- it doesn't trump the biology of what's out there.
So in general, unless it's a trimodal approach, again, bladder preserving there, a complete macroscopic TUR is essential, I think, to improving the trimodal bladder preservation outcomes. But if you're headed to cystectomy, you see a large, invasive mass, getting enough out to be able to make the diagnosis and then getting them on to chemo, it is really enough.
Our ability to go back and make them, the bladder, a P0 by going in and resecting it does not change the biology of that patient's tumor. If it's spread, if it's chemo-resistant, they're the ones that are going to get into trouble.
SPEAKER 10: I wonder how many of your patients who were supposed to get chemo surgery next transfers from this plan to trimodality because of their health issues or they changed their mind?
BERNIE: I think everybody, at some point, has a practice that includes some kind of bladder preserving strategy, because there's a group of patients that are just simply too ill to be able to tolerate surgery or flat out refuse it. And we know that trimodal therapy can work in the properly selected patient-- low volume disease, unifocal disease. lack of CIS, no hydro, all the things that have been published, the ones that can undergo a macroscopic complete resection.
So that's the group that has about a 70% complete response rate with good trimodal approaches. So a third of those, roughly 30%, are not going to respond. That's under the best selection criteria. As you widen those selection criteria out and include larger masses, hydro, inability to completely resect the mass, now your complete response rates drop into the 30% range.
So selection is key, I think. And sometimes you don't have a choice. Sometimes patients are just going to make a decision. They're not going to follow your advice, or you're not going to get clearance to take them to surgery. And so there's optimal therapy, but people are not a bladder walking in on two legs in our clinics. They're full of lots of other moving parts. So those parts don't work.
SPEAKER 3: So one thing I want to add to that is that I still think it's very selected, but a partial cystectomy has a role in this disease. And you have to watch all the rules. Those people, I'll certainly go in after chemotherapy and re-biopsy their bladder like crazy to make sure that you could do that.
But I think it's not a bad treatment. We update it from my own personal series over unbelievably selected patients. But they do very well. And the problem is that it's very selected. But they clearly have a better life than someone who's had a cystectomy, even the most perfect neobladder.
SPEAKER 5: What's your surveillance after the partial cystectomy?
SPEAKER 3: Every three months for the next--
SPEAKER 5: [INAUDIBLE]?
SPEAKER 3: Five [INAUDIBLE] the first time, but then after, just watching them, and obviously, imaging, especially with [INAUDIBLE] disease.
SPEAKER 10: How much is the time that you say a neodjuvant, four cycles of GEMSAS? There's a good stress dose per patient to show how much he will do good after the cystectomy.
SPEAKER 3: Well, they obviously do better if they're P0.
SPEAKER 10: If can handle the chemotherapy without complications, because I think it's a good stress test for them if they can handle chemo.
SPEAKER 3: It is a good test, except the GEMSAS or a cisplatin in general doesn't test pulmonary function. And so this isn't like testis cancer, where they could take any joke you could throw at them. These are people who are elderly.
There's a reason they got bladder cancer in the first place, right? I mean, the median age is 73. Their life expectancy is much lower than the equivalent 73-year-old man, much, much lower if you're a woman who gets bladder cancer, not dying of bladder cancer. So these are people who come in with a high comorbidity burden. And I don't think that we really test the pulmonary issues. Everything else, it will test, but pulmonary, it doesn't.
SPEAKER 2: So we have a question from Twitter, which could be perfect for Dr. Bochner. In case of patient with kidney transplant, what's the extent of lymph node dissection? He just had a--
BERNIE: So yeah, the renal transplant patients will obviously make it difficult. It's really not even advisable, I think, to try and do much of a node dissection on the side that the graft has been placed. So there's usually too much reaction. It's very difficult to identify where the renal vessels have been implanted. And you really don't want to devascularize the graft urethral blood supply as well.
So usually, the ipsalateral dissection on a patient is not going to be done. The contralateral side usually will. And you can usually do some nodes above that area, above where the graft-- but it can be challenging. And so I think it's just a limitation. When you stick a kidney right on top of your lymph nodes, you're not going to get those nodes out.
SPEAKER 3: The other thing I do is I get a transplant, say, a surgeon to be there while I'm doing that part of the case, if I do it. And I agree with Bernie. You don't do big, bold dissection there. But I make sure that they know what's going on. They [INAUDIBLE] vessels for you and so on.
PETER WIKLUND: I would agree also. I think, I mean the potential benefit of doing a lymph node dissection is we're discussing 4% or 5% or something, and this is one side. So we're down to very few-- a small chance that you actually help the patient. But you have a high risk of actually doing something not so good for the patient, so I would refrain from doing a lymph node dissection on that side.
SPEAKER 3: So Khurshid, as we're watching you do this, we were chatting away as you very nicely secured a branch there. So was that a psoas muscle branch? Because it looks like--
SPEAKER 1: It was not a-- it was kind of a branch going from the node up here. One branch was there, which was kind of stuck. The node was stuck. And then there is this one branch here, so I took the node, and watching for the nerve, like you said earlier, kind of got to be careful with that nerve.
And all I'm trying to do is take the other end of that vessel so that-- because usually, if you cut arterial, it kind of seals itself. But I always like to-- these are the ones that kind of draw you back into the hole.
You're right. I kind of took that branch and-- it was stuck behind here, so I took it here, went here. That's the nerve. We go there, and there is-- give me suction there. Is there anything? Trying to slowly clean all of this so that it--
BERNIE: In general, the area-- so the branches that are coming off the external vein here or the artery are usually heading directly lateral out to the psoas. And you'll see these even along the common.
SPEAKER 1: Yes. That's exactly what here, as they go up, we kind of see that.
BERNIE: But in the deeper part of that triangle, especially after the obturators come off of the hypogastric branches is where you could potentially get into a branch of the obturator.
SPEAKER 1: Big trouble.
BERNIE: Yeah. And that'll be below the--
SPEAKER 1: I just want to show there what you're talking about. You're talking about those, where the bone suction is.
BERNIE: Exactly.
SPEAKER 1: Because this is bone. She is hitting bone. And if you cut them, you don't have any access. Right?
BERNIE: Yeah, I think this is an area right here where people just-- the exposure that you're showing now, I think, is what everybody needs to learn to be able to do to dissect out this triangle safely. These are the--
SPEAKER 1: I see the suction is hitting the bone, so there's nothing else to take there.
BERNIE: Exactly. But you need to see the artery--
SPEAKER 1: These are the most dangerous in the whole case.
BERNIE: Yep. You need to see the artery, you need to see the vein, and you need to see the nerve. Once you see those structures is when you can then safely get the rest of those nodes out.
SPEAKER 1: Yes. I mean, that's one of the problems. A lot of people don't do this dissection and those vessels. But if you see them nicely and slow down where you have to slow down, sometime they're stuck. Like this side is a lot more stuck than the other side. And so you just slow down. That's probably the key. I mean, this is not something which you can race through. OK.
SPEAKER 2: We're getting close to the urinary diversion. A few years ago, Drs. Herr and Hartman wrote a commentary saying, is the urinary diversion the Achilles heel for the robotic surgery? We know that more robotics is definitely done, but intracorporeal urinary diversion seems to be challenging.
So I don't know. What's the panel's comments on what's going on right now and what-- is it getting better for the intracorporeal diversion? Do we achieve the same outcomes as open neobladder?
BERNIE: So if you look at use patterns, even before robotics came in, I think conduit diversions, in my opinion, were underused. And the vast majority of patients still in the country, open or robotic, are getting conduits. And despite all the progress we've made on conduit reconstructions, again, overall, we're finding that there are still a lot of conduits being done robotically. We haven't necessarily seen that transition. And maybe that will change over time as people get more comfortable with the intracorporeal techniques.
As far as functionality goes, there really hasn't been a ton of really good prospective data comparing what those functional outcomes are when we do these either intracorporeally or whether we're doing hybrid procedures. So I think we need to continue to collect that data so we can convincingly say that we are doing the same.
But when Jim and I were on a consensus panel a couple of years ago and we looked thoroughly at the world's literature, there just wasn't enough information to even make a conclusion at that point. There hasn't been a ton produced since then.
SPEAKER 1: So the person who kind of gets a lot of credit for intracorporeal is Peter Wiklund. Kind of, Peter single-handedly found the [INAUDIBLE] for neobladders.
Obviously, I started conduit like five years later, a lot longer later. And I do the different type of neobladder. But yes, I think, Bernie, you're right. At the end of the day, all of this will define where we stand with this operation, right? You have comments about the intracoporeal and this [INAUDIBLE]?
PETER WIKLUND: So I think that, as already said, that what it's published is almost nothing. So we really cannot say anything scientifically based. For me, it's the same with the rope and open. When I look at my data, it doesn't really change a lot.
And I think it's depending on the same thing. We're back to oncological outcomes. So if you follow the same plane, you'll spare as much urethras before you do the same nerve-sparing [INAUDIBLE], you will have the same outcome. It's not-- this is just another instrument of doing surgery. It's not really different in that respect that you would expect good or bad.
SPEAKER 1: Especially the complications that came, right? Because you're not changing the operation. All you're doing is instead of hand, you're using a tool.
PETER WIKLUND: No, you have to take part of the intestine, and you have to incorporate it in the urinary diversion. And there's a lot of things are the same regardless how we do it. So I think that the outcomes are not going to be widely different.
BERNIE: I think that in large respect, if we do exactly the same thing, we should get exactly the same outcomes. But as we've, I think, learned even from the prostate experience as we moved from open to robot, we felt we were doing the same things. And then we found that we were over-dissecting the apex early on. And our continence rates, which should have been better, actually weren't initially, until we recognized that the better visualization actually changed the extent of the dissection that was being done.
So theoretically, it absolutely makes sense that we should be seeing the same thing, but what we need to do is we've got to put that data out there and make sure that we're comfortable with that.
SPEAKER 1: So there's a randomized controlled trial right now going in the UK, right?
PETER WIKLUND: Yes. There is a trial ongoing, which is recruiting well, I think.
SPEAKER 1: Yeah, I heard it's recruiting really well, and that might be the first clue. I mean, but Bernie, I completely agree that at the end of the day, it is a similar operation, but it's also where the learning curve is there.
PETER WIKLUND: Yes
SPEAKER 1: And I think a lot of us know that that's going to come in the way. Now we don't have a way that we could've measured open learning curve, because we didn't have a measurement. So we don't have anything to compare it to.
BERNIE: Right, but I think that as long as people are watching you do this, Khurdish, they have to understand that they're watching somebody who's done over 600 of these. This is just a very experienced surgeon that we're seeing right here.
SPEAKER 1: Yeah. I think but at the end of the day, what's the most important key is we want to do no harm to our patients and don't want to give them care which is not optimum.
All right, now let's take this out and let's do a little wash. Let's look around. Did we miss any nodes? Did we have any vessels which we didn't take?
SPEAKER 5: Khurshid, do you turn down the pneumo after you're done with the DVC, and you're doing the node dissection.
SPEAKER 1: We turn it down to, like, 14.
SPEAKER 5: 14?
SPEAKER 1: Sorry, 12, yeah.
SPEAKER 5: 12, OK.
Day 1: Robot-Assisted Radical Cystoprostatectomy with Bilateral Lymph Node Dissection
Part 2: Pelvic Lymph Node Dissection
Day 1 (part 2 of 3) of the Masterclass on Bladder Cancer at the Roswell Park Comprehensive Cancer Center featuring a robot-assisted radical cystoprostatectomy with bilateral lymph node dissection, possible bilateral nerve sparing, and neobladder ICUD. This includes a panel discussion with Peter Wiklund, MD, Mount Sinai Health System; James Peabody, MD, Henry Ford Health System; Karim Chamie, MD, University of California; and Bernard Bochner, MD, Memorial Sloan Kettering.
Created by
Related Presenters
Chair, Department of Urology
Director, Robotic Surgery
Director, Applied Technology Laboratory for Advanced Surgery (ATLAS)
Robert P. Huben Endowed Professor of Oncology
Professor of Oncology
Khurshid A. Guru, MD, was appointed Director of Robotic Surgery at Roswell Park Comprehensive Cancer Center in October 2005.