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KHURSHID GURU: We'll start [INAUDIBLE]. It's probably nothing new. It's going to tear off. [INAUDIBLE].
SPEAKER 2: [INAUDIBLE] because she sometimes will get consults from gynecology or colorectal if they have a very invasive cancer that needs a complete exenteration maybe sometimes a plastic surgery involved. What's your experience on those complete exens, or very locally invasive to--
KHURSHID GURU: They kind of are more easier because they remove everything, and we remove everything. And then the total-- in both places, mainly, the issue is reconstruction. That's part of where the challenge is in those cases.
SPEAKER 2: What's a panel's experience in those cases-- for those cases [INAUDIBLE] side wall, and you have to do a very destructive surgery?
SPEAKER 3: Yes. So sometimes, the patient will still want to do open if they are really advanced cases. But I agree with [INAUDIBLE] in general. You can almost take any tumor out. It's just a question of how to repair it afterwards.
KHURSHID GURU: It's a lot of reconstruction, right, if we do both sides?
SPEAKER 3: Yes.
KHURSHID GURU: And the exenterations are easier because you're not leaving anything behind. And if you're--
SPEAKER 3: And sometimes it's difficult because you go into a new plane that you don't normally go to. So you may remove muscles and things that you normally go in the other side. But in general, I would say that the issue is not the actual exenteration. It's actually to repair the damage you do.
KHURSHID GURU: Yeah.
SPEAKER 3: And I also said that maybe the gynecological tumors are not difficult to deal with. It's more the colorectal ones that may be complicated.
KHURSHID GURU: Yes. And usually you have people who are radiated or they have gotten chemo. Now they have a lot of this scarring. They're trying to get everything out.
SPEAKER 4: You know, [INAUDIBLE], I wanted to ask you this question yesterday, and I didn't. When you do the lymph-node dissections, do you try to spare the obturator artery at all? Do most people--
KHURSHID GURU: The majority of the time, I try to. But I'll tell you, a lot of times, the nodes are too bulky, and they're close. I don't try to get the nodes. So one of the things that's-- you raise a very good point. So if you look at the videos of people trying to do this, a lot of times, you'd see they would be getting involved is nodal tissue and try not to avoid it. And if you see now, what I think a lot of us are doing is we kind of prefer to dig them out as kind of mass descends with the body nodal stuff, rather than just getting into the node.
You know what I'm saying? Instead of cutting them into-- I like to do this where I'm kind of just losing the stuff. We have named it "release and roll." And we release it, we roll it. Try to not do pieces, and try to see where they're attached, and go to the attachment area. We feel that it's a better way.
Now a lot of times, they're bulky, and they're kind of into the stuff. And they're big, and they're necrotic. It's hard. But this way, you kind of look where they're held rather than just peel them and then go for the next piece. So I try to do that.
Now, It's not always easy to kind of go from that base and look for that base.
SPEAKER 3: I tend to normally spare the obturator vessels because they look so big when I do-- [INAUDIBLE] it's large vessels there, so it's tempting to spare them. But I do think that you may do a better lymph-node dissection if you remove the [INAUDIBLE] obturator nerve and take all the vessels out.
SPEAKER 4: Yeah. What I do is I first start my node dissection at the common iliacs, and I just go right over the internal iliacs, and I identify all the little branches.
And I seem to get away without needing to take it, and then [INAUDIBLE] skinny it completely. But I just wonder because I know many other surgeons in our institutions don't even look for it, and they just take it all in block. And I just want to get the opinions of people here. Do you try to spare it? Is there a benefit to sparing it?
KHURSHID GURU: No a lot of the people I know-- when I was [INAUDIBLE], they wouldn't worry about it because they were [INAUDIBLE] and all that, and they were like, whatever, and they just take the whole thing.
SPEAKER 3: I do think that Bush probably should take the whole thing because I do think that the lymph-node dissection is better. And I don't know that you have any issues taking the obturator vessels, as long as you take the vessels and not the nerve.
SPEAKER 4: I would tend to agree with that. I think [INAUDIBLE] probably could skeletonize both vessels take it right off the takeoff of the internal vessels-- internal iliac. In some men, especially who have that more sticky, globular fat, it can be a real challenge to be able to pick all that tissue free. So I think that in general, especially in the absence of any documented functional benefit of leaving those obturator vessels, particularly in the group where you're not doing nerve-preserving surgery on, I would still recommend just kind of routinely taking those vessels, freeing, the nerve, and taking the vessels, and then tracing them back to their takeoff when you do your hypogastric node dissection, and then just resecuring them right off of the takeoff, and then bringing that all up.
You'll almost always find that there is a reasonable amount of fat. Now, how many nodes are listed in there or not-- it's a little unclear. But as I'll show you this afternoon, that still remains a very vulnerable site for pelvic recurrences.
So anything we can do to do a better job in that area, particularly the proximal at the bifurcation of the vein, I would tend to want to focus more, particularly on high-risk patients. If you're dealing with a very low-risk group of patients-- recurrent CIS or--
KHURSHID GURU: [INAUDIBLE]
SPEAKER 4: Yeah, just be just because you're playing the odds, because I know positive rates can be so low.
SPEAKER 3: But that's one of the problems with the robot. You see things so well, so you tend to like to spare things. And sometimes, you spare things which are probably unnecessary to spare.
KHURSHID GURU: On your CTs, if you try to spare things that you shouldn't be, you don't worry about them because you're seeing them so well.
SPEAKER 5: Jim, when you do some of these patients with high-risk prostate cancer, do you also do a dissection where you just take the obturator artery without kind of looking for it as well?
JIM: I usually try to dissect the obturator artery out. If it is really stuck, I don't have any problem taking it, because I don't know that there's any deficit that occurs as a result of that. If I can pick it clean without too much work, I'll usually do that, and leave it.
SPEAKER 2: Is that true for the excessive pudental artery? You tried to do everything?
JIM: Yeah, I treat it the same way. But if it's stuck, again, it's not no there is no downside, really, to taking it.
KHURSHID GURU: These vessels can, especially for older patients, can be very fragile. We have to be careful. I think Bernie was talking about this yesterday.
SPEAKER 4: I think that this is where the tunnel vision sometimes, especially, for neonates, robotic surgeons like myself, where you sort of stop paying attention to what, in particular, the retracting arm may be doing with the vessels. And you pull back and you realize just how much pressure you've actually put. And on some of these very crunchy heavily atherosclerotic vessels, that can really be a problem.
KHURSHID GURU: Yeah, it kind of works against you-- the robot. You can see too much.
JIM: Or not enough.
SPEAKER 5: Yeah. In my operating room-- I'm sure you know I'm not the only one who does this-- but I never ever retract any vessel with the third arm. The only arms that actually retract vessels are either my second arm with the bipolar, or my assistant comes in with their suction tip when I'm doing like the fossa, you know, the Marseilles, because I have seen videotape of people with their third arm retracting things and completely avulsing the iliac artery. So it's very scary.
Yeah, [INAUDIBLE] that's crazy.
SPEAKER 2: We have a question from Livestream. For the patients with known kidney stone, are there any concerns regarding complications, how those stones can pass an anastomosis, neobladder, ileal conduit? What's the panel's experience of those diversions with kidney stones?
SPEAKER 5: I think ureteral anastomosis, whether it's a Wallace or whether it's a whether it's a Bricker, I think it's pretty patent. I don't tend to have a problem with patients requiring surgery for stone disease. Now, if they're forming big honking stones, then yeah, it's a big problem. Obviously, I get our stone specialist to see them and manage them either percutaneously or endoscopically.
And I base that on the fact that I've had patients with their stent fall off. Like I do these conduits, and I'm bringing the stoma out. I'm bringing the conduit up to the skin. And then in the process, the stent falls off, and all they have available is a flexible cystoscope. And I've been able to drive a cystoscope up the ureter. I mean, it's just pretty wide.
SPEAKER 3: Yeah. I think that we extremely seldom see any issues with kidney stones in these types of patients, or in uritary stones. I don't know whether it's because they are passing or whether they're not forming in the stone-- so whether you don't have the same passage of the uerters, of the artery anymore after this surgery. But this seems to be a very unusual problem, at least in my practice.
SPEAKER 6: Yeah, and I also think it's published that spontaneous stone passage rates are higher in the context of a urinary diversion, like before that factor Dr. [INAUDIBLE] brought up [INAUDIBLE] the upper tract. There is a greater degree of dilation after urinary diversion in general. So that is published that it's the same criteria for stone passage, where you may quote a patient for ureteral stone, at least, is higher in this context.
SPEAKER 4: So heavy having said that you know you balance that off of the much more difficult endoscopic management of an obstructed stone. And while it it's not a real common event, I think that if you encounter a patient preoperatively, where you've identified stones, especially of any reasonable size-- so beyond a few millimeters in size-- I've tended to try and routinely get those removed prior to the reconstruction because if you think you've got a 1-centimeter stone-- a 1-centimeter stone has a reasonable, but not a 90% chance of spontaneously passing. And the retrograde management of those can be very dangerous, especially in these chronically infected systems, these patients can get very sick. So if you have the time, and it's possible to get the stones managed beforehand, I try to clear the systems because you can save the patient and yourself potentially, some major problems afterwards-- so lessons learned from past experience.
SPEAKER 6: Yeah, I think that's a very important point to Dr. [INAUDIBLE] brings up in the context of prior cystectomy. I think you have to be very cognizant of that. But post-cystectomy, I think, it was my comment was related, where spontaneous passage rates may be higher, meaning well after the diversion is done down the line once stone incidents becomes higher.
SPEAKER 5: You would anticipate that stone formation would be higher after diversion-- I mean, considerably higher. So if you've got 11% of the US population with kidney stones, and you solidify their urine, you get demineralization of the bone, you get dehydration, it's an absolute setup for stone formation. But it is not that common.
SPEAKER 4: Yeah. Probably, Stooter's long-term data is some of the best information-- for instance, even in the long-term conduits, where you still will see that maybe 20% or so of patients-- even long term-- that's kind of, I think, where the risk maxes out. The recurrent-infection patients may have a higher risk of struvite-related stones. So you're right. It's not a huge percentage, but potentially, a challenging group to manage when it happens.
SPEAKER 2: So for those of you joining us live, we encourage you to ask questions, either through Twitter or the live broadcast. There is the Ask a Question button, and you'll be able to ask the question to the experts.
And I was just wondering, for those neobladder patients, if you have to do a retrograde ureteroscopy-- you mentioned, it's very difficult, it could be challenging-- and does it matter how you handle the limbs or anastomosis? Or would we some way make it easier? Or any comments on that?
SPEAKER 4: They tend just not to be a straight shot. And so my personal experience is that there's about a 50/50 chance that you're going to be able to access the system that you need to, get the instrumentation up there, and either manage the stricture, manage the stone. There's a lot of twists and turns, particularly as these limbs are made longer to replace ureteral segments.
So up front, I'll tell the patient, we'll give it a try, usually, but there's about a 50% chance we may end up having to go antegrade. I know others that won't even try to go from below. They'll just go ahead and put a perc in, and get it done antegrade, which is certainly reasonable to do as well.
SPEAKER 6: Yeah, especially with the evolution of many PCNL tracks and doing PCNL supine and not always prone. I mean, that area is really advancing. And we're fortunate that we have an ability to collaborate with someone who's a very expert stone surgeon. And I'm amazed at how slick and how easy it is to do some of these antegrade cases.
SPEAKER 2: How about a modified W? Did you have to try that? [INAUDIBLE] modify W? Have you ever tried to retrograde ureteroscope?
SPEAKER 5: I have. And I curse. And I can't seem to find the limb sometimes. It's torturous. I mean, it's hard. I'm not going to kid you.
I once had a patient who-- I went to take out his stent-- he had a ureteral stricture. Earlier experience, he ureteral stricture. And I had to go in there robotically and re-implant it. And I left the stent in there, and it was like a Double-J stent.
And I booked the case as, you know, I'll just do it in the office. And I couldn't find it in the office. I told the OR it'll be a five-minute operation. I'm just going to go in there and take it out with a rigid scope. And like an hour and a half later, I was able to finally get it. But it's hard finding your way up in that limb.
And I think it's true. It's not just the modified [INAUDIBLE]. I think it doesn't matter what kind of diversion. Maybe with the exception of a true [INAUDIBLE], a true W, maybe with the limbs shorter-- maybe it'd be a little easier. But once you get that long A-framed limb, it's hard.
So [INAUDIBLE], if you could explain to everybody where you're at and what you're doing now--
KHURSHID GURU: Yeah, I'm going to just-- hold on one second. [INAUDIBLE]. So what I did is-- let me just go back. So I'm going lateral here, making sure that, laterally, I have-- now, I'm kind of be careful because we use a stapler to fire the pedicle here. And I don't want to get into the pedicle because I'm almost close to the pedical. And I'll show you in a second-- try to grow here and take all of this tissue.
And this is exactly what scares me as I get into these and try to make sure that I've have taken-- so where I am right now, Bernie, is anteriorly, way below the internal chain here. I'm going to go back and give you a little-- I'm sure you're done watching, but I just do this for everybody else.
OK, why are my instruments locked? Camera is locked. OK, [INAUDIBLE] probably pulled off.
So there, you can see ureter. I'm marching along. I haven't gotten to the triangle yet. Cleaned up here, and see this area going here, internal, and went here, went here, went here. And that area was very, very-- we're looking at-- I was just trying to clean the internal track here. This will go with the triangle hopefully-- this little branch.
And we will always know that these are kind of annoying. Laterally here, the nerve here, this here, this here, and kind of cleaned up a little over there, and back here, and then to the triangle. That's the tour, sir.
Questions? Comments? Something we can do better?
So I like to clip that pedicle still because once I take all these things off it, the staple will come off, or something. So for the sake of being sure, I kind of, in the end, put this nice, big, large clip on top of it.
So you see this is the peritoneum on the side wall here, so that's up to where I want to go. Laterally, obviously, the pelvic side wall. So at this point, I'm going to approach.
SPEAKER 2: Yeah. For the folks who missed the surgery yesterday, can you tell us, how do you approach the fossa? And what are you doing with it?
KHURSHID GURU: In the fossa, the key is that 30% of patients have a little branch which goes from the common iliac to the psoas muscle. And you got to to be careful. If it's a larger branch, it can really annoy you and scare you if you don't do this maneuver a lot. But if you do so, you know that it's dead branch.
And a lot of times, it might not be easy to get behind to the fossa without sacrificing the branch. You can leave it in. You leave it in. If you can't, you can't. And there are these small ones which are little branches going to the fossa. It's really very important that you go behind this and--
SPEAKER 5: Khurshid, quick question, do you have one assistant port or two right now?
KHURSHID GURU: Only one assistant-- well, we have the 5-millimeter section port.
SPEAKER 5: OK, because what I do sometimes during this part is my assistant comes in through the 5-millimeter port, and she has her little suction. And that just retracts the vessels medially for me. And that tends to help a little bit.
KHURSHID GURU: When you were talking earlier, I was-- I kind of get scared. This is a branch here. It's a very small branch. I kind of feel like I need to put that tension, myself, upon which I'm going to--
SPEAKER 2: Can you tell us your setting or your Bovie? And does it doesn't matter? Or do you think it's higher better? Or what's your setting?
KHURSHID GURU: This is the new one. I don't know exactly what number it is I put. I always have it a little higher for nodes and all that because I want to-- as we can see here-- so you've got to be careful because if you hit the nerve by mistake, or you go too close, you could almost have those obturator reflexes and get into too much trouble. So you have to be careful what you're doing here.
And like Bernie was saying, like we all, probably, who do this maneuver know that this is probably one of the most dangerous. And it's especially true for robotics because there's no tactile feedback of how much. And I think yesterday, Kareem was also talking about this, that this whole thing-- how much you push these vessels and just [INAUDIBLE] mentioning-- you've got to be very careful of how much you're going to mobilize these vessels, especially in older patients.
SPEAKER 5: I think this is kind of like the advantage of people who've had open surgical training. You know how much you can push and pull on some of these vessels. And, I think, with resident training primarily being robotic and minimally invasive, I think they miss that a little bit. I think they don't realize how much you can push and pull or how fragile things are.
Fortunately, at our residency, I think our residents get a fair amount of open experience with transplant. So they work with iliac arteries, and veins, and calcified vessels all the time. But if it wasn't for transplant, I think I think their training would be significantly impaired. I think they come out really well trained because they work with transplant surgeons.
KHURSHID GURU: Another program also that this area-- when you dissect this area, even if it's a small little vessel and bleeds, you panic because you feel like you might have gotten into one of the major ones.
SPEAKER 4: I think it's important for those that are watching this to see just how significant that packet actually is that's removed from this. Obviously, this is magnified. But it's not just a little bit of fat. There is going to be several lymph nodes in this area.
KHURSHID GURU: Yeah. And another thing is this, Bernie, which kind of signifies this is-- what you're trying to get at is that if you don't do that, you won't see anything from behind here and how much tissue You need to take out here. And it's important.
SPEAKER 2: And for those of you who are watching this online, we encourage you to ask questions either through Twitter or through live broadcast. There's a button-- Ask Question button. We can get the question momentarily.
KHURSHID GURU: And as I get closer here, I watch also that when you pull things, you've got to be careful. And I think, Bernie, you're right. Even if it's smaller tissue and it doesn't look significant, it is significant because of the landing zone and all those issues. You want to make sure that you see the nerve exit that source because that's the only me way you-- it might not be the anatomic [INAUDIBLE] definition, but it's your indicator that you have tried to clean up everything possible here.
Wash and wash around here, wash here. Let's make sure that we have everything. Suction all of that.
SPEAKER 2: Doc Bucker, I remember you were working on a project looking at the pelvic recurrence, whether it recur from the nodes, or cystectomy bed. Or do they recur with a distant metastases? What's the updates on that?
SPEAKER 5: So as part of this-- I guess later this morning or this afternoon's discussion, I'm actually going to present all that information. But there is increasing awareness of the extent of pelvic recurrence in some of the higher-risk patients. These are higher stage, the more aggressive histologies, positive-margin patients, where up to 30% or 40% of people [INAUDIBLE]. And the majority of those recurrences are likely to be nodal recurrences.
So there's clearly some areas that are lighting up as hot zones where we need to pay more attention. And this is where the whole push now for adjuvant radiation therapy, which we're going to be hearing a lot more about, I think, over the next several years-- there's at least half a dozen studies that are up and running, looking at adjuvant pelvic-radiation therapy in these folks to see if we can lower the pelvic recurrence rate as a way of ultimately improving overall survival.
The reality is most of those pelvic recurrences are showing up along with distant mets just because they're high-risk-- very high-risk tumors.
SPEAKER 7: [INAUDIBLE]
SPEAKER 5: So most of those patients are going to undergo some sort of systemic therapy because of the high-risk nature overall. Sometimes, they are in a position where it's just difficult to get to if it's growing into the levators or along the other areas of side wall, involving the vessels. Radiation therapy sometimes will be used along with chemotherapy.
And depending on the timing, particularly for some of these late recurrences-- so recurrence is happening after three years in the absence of distant mets-- so those are the ones that I think we should be aggressively going after-- they're not easy procedures, particularly if you've got a neobladder and the pelvic recurrence that you want to try to get out as well. So it makes up the minority of patients. But I think there is a subset where there is a role for surgery.
KHURSHID GURU: Let's just leave this here. And we go back, [INAUDIBLE] come back if there's anything left.
SPEAKER 2: So Khurshid, I just saw Will have sucked some fluids mixed with some fat in the pelvis. And yesterday, you didn't finish. Would you mention that wash study? Just checking those fluids, is there any tumor seeding?
KHURSHID GURU: What we tried to do was we tried to do a wash before-- like when we put the ports in. Then we did a second wash after the bladder was out. Then we did a third wash in the lymph nodes were done in both sides. You kind of did what Will was doing. We wash all of the area.
And then the fourth was whatever-- like, the suction material was coming out. We took all of that. And initially, our idea was we will just do cytology on this, and it was very simplified idea, but then realized that there was nothing specified that we could have done, and we needed to get something better done. So we went back in talked to our genomics department here, and decided to do whole-genome sequencing on the primary tumors to identify specific markers on these tumors, and then match them with the wash.
So here-- hold as well? So in one of the areas which we were especially interested in was the [INAUDIBLE]-- I forgot to say, one of the things we also send was the filtrate. We got this filter. We basically would circulate CO2.
And we had another kind of exit port, I can say, which basically would take everything filtered out. And whatever was in there-- any cells-- that [INAUDIBLE] the specificity of that filter was pretty high to see if there were any circulating, floating cells.
And we didn't find any of that. We did find that a lot of these patients who had higher-grade disease had [INAUDIBLE] had more of those micro [INAUDIBLE] like spotting outside of their bladder, which was not seen as a soft-tissue surgical margin.
And this was mainly on patients who were aggressive, not in patients who were [INAUDIBLE] and all that. And we kind of felt that was kind of a proposal in the paper that maybe a soft-tissue surgical margin will go from just a pathologist looking at histology slide to a very elaborate sequencing, and then give us a better idea of the disease. And maybe it'd lead to further treatment.
And this was like a very small number of patients, so it wasn't like something earth shattering. It was like a pilot concept, like the [INAUDIBLE] into peritoneal chemo, like all of these things which are coming out now which are very beneficial for bladder also. But you could do a spot test intraoperatively, and you could almost tell which are the people who will, like what Bernie is mentioning-- local recurrence and all that [INAUDIBLE]. It was a pilot idea of why a lot of people kind of didn't believe that it was going to work our boss from [INAUDIBLE] he hinted it was a great concept.
We found this, I think it worked out well for the pilot to do what we wanted to do. But we kind of were looking at it exploring it further. That's the sum of it.
SPEAKER 2: And for folks who missed the surgery yesterday during the left side lymph-node dissection, can you kind of explain what's her general approach for the folks who didn't see that?
KHURSHID GURU: [INAUDIBLE] first. I like releasing from the top down preferably. It also gives me an idea of what is where. So this is a little scary here. So what I do is I dig into this area, but I go and look for it higher up so that [INAUDIBLE] and everything else surrounding it. [INAUDIBLE] I might go around-- like, I think all of us who do a lot of this do it that way. But I don't like this kind of getting to the point where you kind of have this crush [INAUDIBLE] you can't do anything about it. But--
SPEAKER 1: Any comments from the panel? And do you do things differently for the lymph node dissection?
SPEAKER 2: I think that the distal part that's being dissected out here is kind of nicely illustrating. The lateral distal limits which is the crossing of the circumflex iliac vein over the top of the artery, the external artery here. So just distal--
KHURSHID GURU: Yeah, this--
SPEAKER 2: --coming across, that's your distal limit. You don't really need to go beyond that. You don't want to injure that vessel. And then basically, you would take that down medially to across the artery in the vein to Cooper's ligament.
And that basically brings you to the lymph node of [INAUDIBLE], which is what is being dissected out right through here. And it's important to recognize that this lymph node is coming out from the leg, right? From the inguinal area.
So people tend to put the clip, if they're going to clip these, right across within the pelvis. Cooper's ligament restricts them from going any further. The reality is that lymph nodes sometimes is further distal.
KHURSHID GURU: Yeah, we kind of pull it out.
SPEAKER 2: Just as Khurshid is showing you here, he's dissecting into that inguinal canal area. You go as far as you need to to get that entire node. And if you notice that you're starting to cut across the node, then you need to go a little bit deeper.
There are these little vessels. this is a beautiful view, these little branches that sometimes will supply the node, and that those need to be secured. So usually either control them with [INAUDIBLE] or put a clip or something. But you can see he's above Cooper's ligament here. He's not being restricted by the ligament itself that's an artificial boundary that as a surgeon, you got to realize the nodes are coming from the leg above that area.
KHURSHID GURU: Very, very important technical point, that is.
SPEAKER 2: I think the other important thing here which Jim Peabody had just whispered in my ear was Cooper's is the key landmark here. Everything above Cooper's is going to be taken it's immediately below Cooper's ligament where the obturator foramen is located.
And that's where you're going to encounter the nerve and the vessels. And this is the other landmine that's being dissected out here that you always have to look for, which are these accessory obturator veins. This is a very distal vein, which probably is-- you could see he's going to be able to preserve and still get the nodes out.
But those accessory branches can show up anywhere along the length of that external iliac vein. And you need to look for him. And in some particularly nasty patients, there may be more than one.
KHURSHID GURU: Lens [INAUDIBLE]. Thank you, Will.
SPEAKER 1: I saw when you do the obturator node dissection, you kind of stopped in the half, then started more surfactant. So is that typically how you do that?
KHURSHID GURU: I honestly kind of go by region. Kind of I feel, OK, I've done enough there. I need to kind of I-- it will look nicer if I open it from here. Then I have a view it's kind of what I feel is going to be safe. That's kind of how I decide it.
I don't kind of follow just one rule book. I kind of say, OK, this is-- like I did here. And I feel that this is going into there.
I don't like operating like downwards towards. I like operating away from me. So I kind of-- so OK, let me just take this so that by the time I get there, I kind of have a nice view.
SPEAKER 1: So for those of you watching us online, we encourage you to ask questions either through Twitter or the live broadcast by pressing the Ask Question button.
KHURSHID GURU: These are those small branches. I don't want too close to that here. You see that?
Maybe I'll put a stitch. Yeah. It's OK. So can I have two [INAUDIBLE]? Yeah. I mean, so you see that branch there?
SPEAKER 1: Yep.
KHURSHID GURU: Increase the number 20. So I kind of took it off the base. So I don't have like a root to kind of cauterize it.
So I'm going to kind of go with the stitch. It's safer because I think I have it from flush to the vein. that a mega [INAUDIBLE] today?
It's kind of a [INAUDIBLE] thing, right? OK. So hold on. Let's wash this for a second [INAUDIBLE]. Yeah, it's there. Just seeing if I can kind of get away with just putting a clip or something.
SPEAKER 1: It appears to be the new [INAUDIBLE] did the trick at least at this time.
KHURSHID GURU: The question is, the [INAUDIBLE] is not going to stay forever, right?
SPEAKER 1: Yeah.
KHURSHID GURU: Here, can I have the [INAUDIBLE]? Yeah.
SPEAKER 3: I'm sure if you turn the [INAUDIBLE] down, you'll be able to see the hole a little bit better.
KHURSHID GURU: Yes, yes. Well, it's very small. I'd rather just pull a stick now.
SPEAKER 2: I think this probably represents that [INAUDIBLE] branch that you were talking about earlier.
KHURSHID GURU: Yeah.
SPEAKER 2: There are very few other branches that come laterally off of the vessels at this point.
KHURSHID GURU: Yeah, and you kind of [INAUDIBLE]--
SPEAKER 1: What needle is that?
KHURSHID GURU: This is a [INAUDIBLE]. The needle was what? RV1?
SPEAKER 1: RV1.
KHURSHID GURU: I don't like this [INAUDIBLE] needle driver [INAUDIBLE].
SPEAKER 1: Just for the panels, do you guys always keep a [INAUDIBLE] just on the table in case?
SPEAKER 3: Yeah, I have them make two for me, one-- and they're always about four inches long. I make one that has a [INAUDIBLE] tie at it at the end of it just in case I need to get it to [INAUDIBLE]. I don't have time to put a stitch and have another one like this.
SPEAKER 4: So I have one with the pledges on it instead, always at least one. But this type of bleeding, I will actually don't do anything. So I will just--
KHURSHID GURU: Just watch it [INAUDIBLE]?
SPEAKER 4: Put some pressure on it and then just continue because this will not bleed. I don't think that this is an issue, actually. have more risk of doing something when you suture it than to leave this type of bleeding. That's my take.
SPEAKER 1: [INAUDIBLE]
KHURSHID GURU: [INAUDIBLE]
SPEAKER 2: That's experience.
KHURSHID GURU: [INAUDIBLE] doing something stupid, uh?
SPEAKER 4: Yes, exactly. But you said it yourself. So--
KHURSHID GURU: Ha ha.
SPEAKER 2: Khurshid--
SPEAKER 4: The risk is that you have such a big needle, and you have a vein. And you can actually, if you're not skilled you can make a small problem into a big problem at this point.
KHURSHID GURU: Yeah, you can make a bigger mess. Can I change back in my hook and [INAUDIBLE] absolutely right.
SPEAKER 3: Khurshid, can you lay out the anatomy a little bit for us? We just want to see where that vein is in relation to the--
KHURSHID GURU: Once--
SPEAKER 3: --internal iliacs and everything.
KHURSHID GURU: So this is kind of external here.
SPEAKER 3: It's not the common?
KHURSHID GURU: Sorry, the common.
SPEAKER 3: Yeah.
KHURSHID GURU: Common, the vein. This is kind of underneath here.
SPEAKER 3: This branch, this branch, [INAUDIBLE] vein that is [INAUDIBLE].
SPEAKER 4: [INAUDIBLE]
KHURSHID GURU: This is the common vein.
SPEAKER 4: [INAUDIBLE]
SPEAKER 3: Branch-- got it.
KHURSHID GURU: This is [INAUDIBLE] branch coming off [INAUDIBLE] vein. Probably the [INAUDIBLE] going down. And then this is the foramen and then external here. And then this is your internal right here.
SPEAKER 3: Hm. I think those are the veins that frightens many of the pelvic surgeons who work right over the pre-sacrals, those pre-sacral [INAUDIBLE]. With robotic surgery, It's just, you don't even bat an eye.
KHURSHID GURU: No, it's kind of-- all this-- I mean, this scared me a lot. I agree. I cannot--
SPEAKER 1: Can you guys comment to how to control the bleeding during the lymph node dissection? When do you use a monopolar, bipolar, put a clip, put a stitch, or nothing? Just kind of decision making at that point-- what's the rules of [INAUDIBLE]?
SPEAKER 4: I mean, for me, the basic rule is do nothing. So you should--
SPEAKER 1: Not necessarily for this.
SPEAKER 4: No, but in general. But I mean, in general, people are overtreating their bleedings here. The patient's coagulation is amazing.
If you have a good-- you can increase detention or the pressure, intra-abdominal pressure, and you can have an instrument pushing at the bleeding. But almost all venous bleedings are-- almost all, not all-- are small ones, and they will actually coagulate and sort of disappear if you don't do anything. I'm more afraid--
KHURSHID GURU: I think Peter is right. And also, [INAUDIBLE] you reach the end, you'll know that if it's losing a lot, you'll have to do something about it.
SPEAKER 4: Yes.
KHURSHID GURU: We could have done that what Peter said-- left it and come back and looked at it. And we would not have been able to find it probably.
SPEAKER 3: Exactly. But I mean, so the risk is when you try to suture, especially if you're not very experienced, is that the needle or something makes this small problem a big problem.
SPEAKER 1: Yes.
SPEAKER 3: Yeah, what I end up doing as I end up-- I think exposure is the most important thing. I think sometimes junior residents, as they're doing robotic surgery, they want to get control of bleeding immediately, and they feel like they got to stop what they're doing. I try to kind of remind them that, no, no, just don't stop.
Just get good exposure. See what's actually bleeding. And sometimes, what you realize is that if the hole is shallow, the bleeding looks much worse than it is. And if you actually get better exposure, you realize there's not that much bleeding.
And sometimes, you don't do anything. Sometimes you do need to do something. Bipolar, monopolar, I mean, it all depends. But I think exposure is probably one of those important things that you don't just jump immediately to try to control.
SPEAKER 1: You know, that's what I do most of the time. I have a surgeon's seal. And whenever there's even the venous bleeding, if there's a lot of bleeding, I just-- maybe I wasn't ready. I just put a surgeon's seal there and go somewhere else, come back in 20 minutes.
SPEAKER 4: I think that's a very good technique, actually, or you should put some pressure and then do something else for 15 minutes and then maybe come back and see if it's still bleeding or not.
SPEAKER 3: And what I tend to do is at the end of the case, after I get the bladder and lymph nodes out, I always turn down the [INAUDIBLE] peritoneum to about eight or so. And I do the rest of the bowel diversion with low [INAUDIBLE] peritoneum. And if there's any kind of bleeding, you know, it's going to take about an hour and a half to do the bowel resection, [INAUDIBLE] diversion, uretal [INAUDIBLE].
During that hour and a half, if there's any kind of bleeder, you want to catch it at a low normal peritoneum. And so sometimes, the vessels are just spasm. And you know, 5, 10 minutes is not enough time.
But I try to give it as much time as possible.
SPEAKER 2: Yeah, that's what I was trying to show on the video-- internal iliac muscle. But yeah, I'm sorry. [INAUDIBLE] muscle branches coming off of the obturator. Those [INAUDIBLE] get ripped [INAUDIBLE]. But you know what? You do that, and you do [INAUDIBLE].
SPEAKER 1: You know, for Khurshid's paper of the pelvis washing [INAUDIBLE], I just want to mention a few points, see what panels think. So basically, there is some advanced disease, T3 disease, and some nodal positive disease. And before the wash, there was no cells with mutations detected.
And all the surgical margins are negative. Margins are all negative. Some of them has positive wash cells after the cystectomy. And just, they're mutations detected.
Some of them, they have no mutation detected. And those have the mutation detected in the wash. They have a pelvic recurrence, a very small number.
So the thought is that initially, for the robotic surgery, one of the critiques is that you may have break the system like Dr. Bochner mentioned. But the surgical margins are all negative. And the idea is that positive wash may predict this.
| other alternative hypothesis is that there is some pre-existing microscopic disease not related to the surgical margins. So that's kind of the question of pelvic recurrence. What are those coming from? Are they pre-existing, or it's break of the system?
SPEAKER 3: --doing it one way. Yeah, I actually reviewed the paper for [INAUDIBLE] journal when you guys submitted it. And what I got from it was there's probably micro metastatic disease in the lymph nodes because I thought from what I remember reading the paper, I thought you did pick up some positive findings during the node dissection part. And I'm wondering whether it's-- I think we find sometimes micro metastatic disease in the lymph nodes. When we do this operation, we may actually be spilling a few of these cells.
SPEAKER 1: That happened with open as well. It may [INAUDIBLE].
SPEAKER 3: It's possible, but I think the difference is that I think in general-- and I can tell you-- and you know, Khurshid's doing a really nice job. But I can tell you most robotic surgeons don't do in block resection of the lymph nodes like the open surgeons tend to do. Yeah, and they just take them out in pieces. And I think that's where, I think, sometimes you get some spillage.
SPEAKER 2: Yeah, breakage [INAUDIBLE].
KHURSHID GURU: [INAUDIBLE], this thing is really bad.
SPEAKER 3: Yeah, I mean, people are cutting right through in the middle of a lymph node. And it just looks like it's piecemealed. And I think that's where the cancer spills.
SPEAKER 2: So Khurshid, you had just demonstrated some very important anatomy there, that branch to the obturator internists muscle coming off of your obturator vessel-- not that uncommon to have one or two or even more branches that sometimes will go out there. It's important to recognize that if that node packet is pulled too hard and you don't secure those vessels, you can get in and have a very--
KHURSHID GURU: [INAUDIBLE] like-- yeah.
SPEAKER 2: --very troublesome lateral bleeding there. That was nicely shown.
KHURSHID GURU: Thank you. Yeah, it's kind of-- anatomy is kind of-- and that's what [INAUDIBLE] people to do a good lymph node dissection. They kind of don't get the crux of-- and if kind of they understand what they're looking at and what kind of-- what to watch out for, kind of gets better, you start becoming more braver in doing node dissection.
SPEAKER 2: Yeah, it's a lot like [INAUDIBLE] nervous. I think I [INAUDIBLE].
SPEAKER 1: So for those of you joining us, watch this online, and those of you in the room, encourage you to ask questions either through Twitter or live broadcast by pressing that Ask a Question button.
SPEAKER 2: So [INAUDIBLE]. I don't remember seeing [INAUDIBLE].
SPEAKER 1: [INAUDIBLE]
KHURSHID GURU: [INAUDIBLE]
SPEAKER 2: Lateral side [INAUDIBLE].
[INTERPOSING VOICES]
Right, or the vein.
SPEAKER 1: So you can see the obturator nerve is nicely protected. I have this question to Khurshid and all the panel members. What do you do in case any obturator injury? Do you put it back, or what's your experience on this?
KHURSHID GURU: I mean, I've been lucky until now. I mean, this candidate wanted to do the magnification. We may have drafted a few times [INAUDIBLE] or something. We have not--
SPEAKER 2: [INAUDIBLE] crutch.
KHURSHID GURU: --fortunately never [INAUDIBLE].
SPEAKER 1: How about others?
SPEAKER 3: Yeah, it's happened in one of my cases where I looked away for a few seconds and-- not a few seconds. I was checking my email. And then I looked up, and I can't find the obturator nerve anymore.
The resident inadvertently clipped and cut it. I ended up using [INAUDIBLE] proline, and I ended up sewing it back together interruptedly. And you know, the key is, you got to basically put one stitch.
And you leave a little bit of a tail. And with that tail, you can basically twist and turn and put your interrupted sutures. Patient ended up doing fine, but it took six months or something for her to regain function again.
SPEAKER 2: I've seen it happen once, too and we had one of the neurosurgeons come in. It was an open case from years ago. And they just sewed the [INAUDIBLE] back together with three or four interrupted sutures. And the guy did fine eventually too. That's what I would do if I had it happen again.
SPEAKER 4: Washing.
SPEAKER 1: What if there is some gap that is kind of hard to do a tension-free? Can you put that, like, some grafts or anything?
KHURSHID GURU: [INAUDIBLE]
SPEAKER 1: Hypothetically [INAUDIBLE].
SPEAKER 2: I mean, those are obviously pretty uncommon events. You could get a plastic surgeon to see if they could do a nerve transfer in that setting. But you know, there's times when we're dealing with really large tumors that will extend out into the obturator fossa, or you may be doing a post-chemo dissection of people.
KHURSHID GURU: [INAUDIBLE]
SPEAKER 2: Fibrosis. And the reality is is that while there will be some neuro deficit if you end up resecting the obturator nerve, sometimes it's a planned resection as part of a bulky tumor that you need to remove. As long as the femoral nerve roots are still intact, the sciatic nerve roots are intact, the legs are going to be functional.
They're just going to have AD duction issues. And so that's different from an inadvertent injury during the node dissection. But in general, it's worth trying to get help to put that back together.
SPEAKER 1: Dr. Wiklund, is there any comments on that?
SPEAKER 4: Yes. So I exactly agree with Dr. Buchner here. So I think that sometimes when you have large pelvic tumors, they may be only urological tumors-- maybe colorectal or gynecological tumors. They will grow in the areas we actually plant to the resection.
Many patients actually do fine afterwards but not all. So I've been involved in like four or five cases where we have resected obturator nerve. Sometimes the patients have almost no symptoms, but sometimes, they actually have an impaired function afterwards. And I do think you should try to suture it back, although, I don't know that the scientific evidence is very strong to support that the outcomes better if you do it.
SPEAKER 1: It happened to me once that I put a large clip without dissecting the entire length of the obturator. Then I found out it's kind of caught-- the tip caught the nerve. You know, we kind of ask the OR nurse for the [INAUDIBLE] clip.
There is another applier. You can actually release that [INAUDIBLE] clip. It took us about 20 minutes to find it, but once we found that, then we just very easily to kind of put pressure to release that. It popped it open.
SPEAKER 4: But it's very easy to open a [INAUDIBLE] if you have two needle [INAUDIBLE]. The only time I use two needle [INAUDIBLE] is when I have to open a [INAUDIBLE] clip because if you take the tip of the clip, you can actually sort of turn the clip open.
SPEAKER 1: You have any comments, Jim?
SPEAKER 3: Yeah, you know, sometimes they come in, and they put in the [INAUDIBLE] clip on if you're doing a prostate, they go too deep, or they get the nerves. And you just have to basically to use two needle drivers like Dr. Wiklund was saying to unlock it. I've never used the applier. I don't know if we even have it. I'm sure we do, but somebody probably down in the basement-- nobody knows where it is. But I just used two needle drivers to unlock it.
SPEAKER 1: I did try to use two needle drivers, but the nerve is cut right at the tip there and I tried to pull those on the side to side, see whether it would go. Because I was afraid to tear that by just pulling those two tips. So what the plier does is that there is a curve on the [INAUDIBLE].
And when you press that, it will release straight. When you release that, this top will get released from the bottom one. So it actually works much better than I thought. It just-- click it, and it'll release it.
SPEAKER 3: You know, we were talking a little bit about tumors that are invading into the obturator nerve. I had a patient that had a squamous cell carcinoma in a diverticulum. And I took him to the OR probably a month later from the time, you know, for scheduling and everything.
And by the time I took him to the operating room, he had tumor thrombus. He had a tumor directly invading into the iliac vein, and I had to do a tumor thrombectomy. But fortunately, I didn't clip the ureter or anything like that.
So I did the node dissection. I was doing the note dissection first, and it was clearly visible that the tumor was directly invading into the nerve, completely occupying the nerve. So when you cauterize the nerve, you absolutely get no reflex whatsoever, no jerk.
And it was directly invading into the foramen. And so I ended up aborting that operation, and I'd like to get the opinion here. I mean, would you guys have proceeded further? I mean, if it's completely unresectable, would you still do a cystectomy on a patient like that?
SPEAKER 4: So only if I think that the symptoms local symptoms would be worthwhile to sort of remove the bladder to relieve the symptoms. And it's [INAUDIBLE] symptoms. Otherwise, I would probably do a diversion [INAUDIBLE].
SPEAKER 3: He was 42 years old, and he's unable to move his-- his obturator nerve was completely occupied with cancer, and it was invading through the foramen.
SPEAKER 4: So maybe then this-- I mean, it's 42 years old. Maybe you should resect everything you can and then the radiation or something. I mean, he's so young, so you may want to give him every chance. But it's not the standard type of--
SPEAKER 3: Yeah, one of the things I decided was if I did a cystectomy on him and I did a diversion, he's going to have to wait months before he get-- or weeks to months before he gets any kind of local treatment. So I thought, he's 42. Time is of the essence. I mean, if he's going to get anything, he's got to get it now. But I'd like to get what you guys would have done differently if any.
SPEAKER 2: He'd had neurologic therapy?
SPEAKER 3: No, no he didn't. He was classified as a T1 in the diverticulitum and no metastatic disease. And so-- and he turned out to be squamous.
SPEAKER 2: Yeah, I mean, it's not unreasonable to try to give him therapy, see if you can make it smaller and more resectable. [INAUDIBLE] going to get it anyway. [INAUDIBLE] out to the side wall [INAUDIBLE] not resectable. Yeah.
I mean, if he's not resectable, kind of try and radiate it, treat it with chemo, do something, and then see if you can go back and [INAUDIBLE]. So the nice thing about some of these squamous tumors are they may be a little more radiation sensitive. And in general, in general, the locally advanced squamous cell tumors tend to metastasize a little bit later. So it is sometimes worthwhile going after.
But that's if it's resectable. If you've deemed it not resectable, It's fixed, it's growing through the obturator foramen, which is a known pattern of progression of some of these tumors, I would do what you can systemically, even add radiation therapy if you can to downstage it as much as you can and potentially make it resectable following that. And as Peter had mentioned, at that point, you may end up having to do much wider type resection.
But it may be worth-- in the typical TCC patient, I would say no because their outcome would be so poor from their distant risk. But for a squamous cell in a younger person, it might be worth it. But you got to down stage it.
SPEAKER 3: So how would you attack-- I mean, if it's growing beyond the obterador foramen, I mean, who else would you involve to go in there and try to completely resect something?
SPEAKER 2: So the ortho guys, you know, they live in that area. It's amazing what they resect. We go to the fascia of the obturator internus muscle. And we feel that we've reached the box, and that's the level of resectability where there's people at your institution who make a living resecting the buttocks.
And for them to strip the arbitrator fascia and take the muscle down to bone even, you've got great help there to be able to do it. It now has become more of an issue of should you do it as opposed to can you do it. You know, between a vascular surgeon and an orthopedic surgeon, yourself, and a plastics person to cover the defect, now the blue towels on the table are actually-- that's your barrier of resection. So I think the big issue here is, can you get a response to get this shrunk down? Tough case.
SPEAKER 3: Yeah, we've given him chemo, and he's had growth. He's going right through it.
SPEAKER 2: [INAUDIBLE]
SPEAKER 3: Yeah, yeah, yeah.
KHURSHID GURU: [INAUDIBLE]
SPEAKER 3: The medical oncologist is looking to give him some checkpoint inhibitors in combination with radiation therapy to see if there's some kind of synergy there.
SPEAKER 2: [INAUDIBLE]
SPEAKER 1: There's a question from livestream. What is your typical anesthesia setup? Do you use arterial line, central line? Anybody use SPY, TAP block? Any comments?
SPEAKER 3: None of the above.
SPEAKER 1: None of the above.
SPEAKER 3: None.
SPEAKER 1: Typically just general anesthesia.
SPEAKER 2: Yeah. I routinely will use an epidural. Most anesthesiologists, they'll feel more comfortable with an A line, no central lines.
KHURSHID GURU: I think that's what we do here.
SPEAKER 2: Yeah. And you know, the epidural, I guess, would be plus or minus-- really, the way that the smaller incisions are made for the robotic cases is there's probably not much of a benefit. And there is some immediate perioperative issues with hypotension from the vasodilation. But the epidurals, that probably outweighs the potential benefits with the small incisions, especially the little fan and steels.
SPEAKER 1: So now you're finishing the fossa. Do you have--
KHURSHID GURU: [INAUDIBLE]
SPEAKER 1: Do you have any comments for the right side versus the left side? Which side is more difficult? Or is there any different-- how do you expose this right versus left side?
SPEAKER 2: Side-- the rest is working on [INAUDIBLE].
SPEAKER 4: Well, for me, I always start on the right side like Khurshid is doing because they do the pre-sacral dissection. And so I think that takes a little bit longer time to do the right side because down the right side, you actually start the proximal medial part on the left side.
So that's already done. When you come, you normally have dissected all the way down so the internal hypogastric artery from the right sides. So I think it's a little bit faster on the left side. You have to do the triangular [INAUDIBLE], which is done different because on the right side, you have the [INAUDIBLE] coming out there instead.
KHURSHID GURU: Camera is back out again. I don't know why.
SPEAKER 1: You try using the 30 degree down [INAUDIBLE] for dissection?
SPEAKER 4: Yes, the question is if you should use 30 degree down for left [INAUDIBLE] dissection. Yes. I think, I mean, if you have the new XI, I think it is easier to have the 30 degree optics for the surgery because you can go up and down as you like, basically. So if you have an older robot, I normally use the zero degree.
SPEAKER 5: I noticed it's actually down with the [INAUDIBLE].
KHURSHID GURU: [INAUDIBLE] zero right now.
SPEAKER 5: [INAUDIBLE]
SPEAKER 4: Yeah.
SPEAKER 5: Right, Khurshid.
SPEAKER 1: You go into the bowel work right now?
KHURSHID GURU: No, I'm going to just take a look at the node dissection there [INAUDIBLE] left for me to do.
SPEAKER 1: OK.
SPEAKER 5: [INAUDIBLE]
SPEAKER 1: You know, speaking of locally dense disease, I had an aborted one, and I kind of did an aggressive one. So there is an 84-year-old with a disease to the pubic bone. And we kind of [INAUDIBLE].
We chop it off over the bone. And it's T4B. And the patient was fine but had recurrence in six months.
It's a huge tumor, a 6 centimeters tumor. In three months, scan was fine. Six months was large tumor.
And the other gentleman is a, you know, CKD [INAUDIBLE] 3, some cardiac disease that we aborted. Then the patient went on immunotherapy. So my question to the panel is, what is the main factors, you have a disease, whatever, it's resectable or not resectable? Is it worthwhile to proceed, or what is your thought process in OR?
SPEAKER 4: Europe I think that as Bernie Buchhner is saying that there is a subset of patients that have a local aggressive disease but don't metastasize, you know, like the squamous cell differentiation, the tumor, where it is worthwhile. I had several patients where I have actually used hammers and things and take out part of pelvic bone. And they have not recurred afterwards.
Day 2: Robot-Assisted Radical Cystectomy with Pelvic Lymph Node Dissection and Intracorporeal Ileal Conduit
Part 2: Pelvic Lymph Node Dissection
Day 2 (part 2 of 3) of the Masterclass on Bladder Cancer at the Roswell Park Comprehensive Cancer Center featuring a robot-Assisted Radical Cystectomy with Pelvic Lymph Node Dissection and Intracorporeal Ileal Conduit. 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.
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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.