Surgeons: Craig Rogers and Chandru Sundaram

Moderators: Ronney Abaza, Riccardo Autorino and Fabrizio Dal Moro


Craig G. Rogers MD, FACS

Dr. Craig Rogers received his medical degree from Stanford University and completed his urology residency at the Johns Hopkins Hospital. He completed a fellowship in urologic oncology at the National Cancer Institute. Dr. Rogers has helped pioneer the development of the robotic partial nephrectomy (RPN) procedure. Dr. Rogers specializes in surgery for kidney, prostate, and adrenal tumors. He performed the first live webcast of a complex RPN and the first live surgical demonstration of RPN surgeries at the AUA National Meetings, fostering international interest and adoption of this new technique. He has demonstrated techniques of robotic kidney surgery at numerous national and international meetings.

Dr. Rogers helped establish research consortiums with other major centers to evaluate outcomes of robotic kidney surgery. He published the first descriptions of RPN for complex tumors and patients. He has authored over 200 publications and numerous book chapters and is a reviewer and editorial board member for several urologic journals. His presentations nationally and internationally about robotic kidney, adrenal, and prostate surgery have won national and international awards. Dr. Rogers is innovative, helping to develop robotic ultrasound probes, robotic bulldog clamps, and other novel techniques that have become routinely used during RPN. Dr. Rogers is the Department Chair of Urology as well as the Fellowship Director. He also serves on the Program Improvement Committee of the Urology residency program.

 

Chandru Sundaram, M.D.

Dr. Sundaram is the service line chief of urology at the University Hospital, and tenured Dr. Norbert and Louise Welch Professor of Urology at Indiana University, apart from being Vice Chair (QI) and Program Director. He was director of the fellowship in minimally invasive urology at Washington University in St. Louis before moving to Indiana University in 2002. He is a member of the exclusive American Association of Genitourinary Surgeons. He was until May 2020 on the Board of Directors of the American Urological Association and Society of Academic Urologists.

Dr. Sundaram is the Executive Editor of the Journal of Endourology after having been on the Editorial Board of the Journal of Endourology for several years. He was the founding co-editor of the first peer reviewed online video journal, Videourology 2010- 2019. After long-term service in multiple capacities in the Endourological Society, Dr. Sundaram is presently Treasurer and member of the Executive Committee. Dr. Sundaram has over 170 peer-reviewed publications and is actively involved in several urologic organizations. Other positions he has held include Presidents of the following: the Indiana Urologic Association, North Central Section of the American Urological Association and the Society of Urologic Robotic Surgeons. He has been visiting professor, invited faculty and speaker at multiple institutions and at national and international meetings.

Dr. Sundaram's area of expertise includes robotic and other minimally invasive surgical approaches, with extensive robotic surgical experience since 2002. He specializes in kidney cancer and other conditions of the kidney, adrenal tumors and prostate cancer.

 

Ronney Abaza, MD

Dr. Ronney Abaza is Director of Robotic Surgery at OhioHealth Dublin Methodist Hospital.  His practice and academic interests are dedicated solely to robotic surgery.  Dr. Abaza is one of the most experienced robotic surgeons in the world having performed over 5,000 robotic urologic operations. Dr. Abaza is an innovator in robotic surgery as the first in the world to perform robotic surgery for adrenocortical carcinoma, kidney cancer with caval thrombi, ureteroileal anastomosis revisions after cystectomy, and renal autotransplantation.  He has presented his work at national and international meetings, including more than 150 presentations at various meetings on robotic surgery, and has won numerous awards for his research.  He is director of a robotic urologic surgery fellowship program entering its 10th year. Dr. Abaza has authored over 120 publications in the fields of robotic surgery and urologic cancers. He is editor of the only textbook dedicated to robotic kidney surgery. Dr. Abaza frequently serves as faculty at medical society meetings and for educational courses both in the U.S. and internationally. He has performed live robotic surgery for the American Urological Association (AUA) Annual Meeting, the World Congress of Endourology, ERUS, NARUS, IRUS, and SRS, among others.  He is father to three children ages 17, 14 and 12, and he and his wife recently celebrated their 22nd anniversary. He is an active member of the Muslim community in Central Ohio and has volunteered for and served on the board of multiple non-profit organizations.

 

Riccardo Autorino MD PhD FEBU

Dr. Autorino works as Associate Professor of Urology, Director of Urologic Oncology and Associate Member of Massey Cancer Center at Virginia Commonwealth University in Richmond, Virginia. Native of Italy, where he received his MD degree and did his Urology residency, he completed a fellowship in advanced laparoscopy and robotic surgery at the Cleveland Clinic in 2014. Dr. Autorino received many awards, mostly related to his editorial activity, including best reviewer award for several top tier Urology journals. In 2012, he earned the prestigious Italian Society of Urology (SIU) Matula Award, as urologist under 40 with the best CV. In 2017, he was the recipient of the Hans Marberger Award at annual EAU Meeting. Moreover, he served as AUA/EAU Exchange Academic program Visiting Scholar in 2009, and he was recently selected to be a 2021 AUA/SBU Exchange Academic program Scholar. Dr. Autorino is member of the several all the major scientific organization (AUA, EAU, Endourologic Society, SIU) and international member of the Association of Academic European Urologists (AAEU). Dr. Autorino has been involved in different fields of urologic research mainly related to minimally invasive treatment of genitourinary cancers, and to the implementation of new technologies in the field of uro-oncology. He led several multi-institutional collaborations. He has published more than 400 PubMed indexed peer reviewed publications and edited several books and journal monographies. He has a Scopus h-index of 53. He serves as associate editor for Minerva Urologica and Central European Journal of Urology, and he is editorial board member of multiple journals. He regularly serves in the Program Abstract Review Committee of major urological meetings.

 

Fabrizio Dal Moro, MD, FEBU

Dal Moro was born in Venice (Italy); he completed medical school, and urology residency at the University of Padova, Italy.

He is a board-certified European urologist (FEBU).

He is currently Associate Professor at the University of Padova, Director of the Urologic Clinic at the University Hospital of Padova.

Dal Moro has authored or co-authored many original peer-reviewed scientific papers, over 10 book chapters, and 2 Text-books (Atlas of Urologic Anatomy – Volume I “Orthotopic Urinary Diversions” – Volume II “Surgical Anatomy”). He has received many awards, including the First Prize for the Best Video during European Association of Urology Congress (Stockholm) in 2014 with “CORPUS: novel COmplete Reconstruction of the Posterior Urethral Support after robotic radical prostatectomy”.

Dal Moro’s primary focus is on innovation and minimally invasive surgery for uro-oncologic diseases, with a large robotic surgery experience treating patients with prostate, urinary bladder and kidney cancers. In addition to the above, he usually performs other non-oncological robotic procedures such as pyeloplasty, hysterosacropexy, among others.

Dal Moro’s research encompasses the anatomic studies of urologic organs, the study of patient outcomes, novel robotic techniques including strategies for improving postoperative urinary continence (e.g. CoRPUS technique), a new procedure for creating an original robotic intracorporeal orthotopic neobladder (Ves.Pa. neobladder), the development of new devices (e.g. a patent for an original hemostatic adjustable tie) and novel bio-materials.

He is active as a tutor in several robotic training programs, proctor in E-BLUS (European training in Basic Laparoscopic Urological Skills) examinations and coach in non-technical skills courses. More recently he conceived and realized the web-platform “urodraw.com” for teaching and learning urologic surgical anatomy using only surgeons’ original works of art (sketches and drawings).

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello and welcome. I am delighted you're able to join us for the SURS and the Endourological Society Webinars on Robotic Surgery. Please join us in a couple of weeks on December 11th for one of our webinars on innovative robotic techniques. We have had robotics webinars almost every other week for the last several months since COVID struck, and please review those and view those on the Endourological Society as well as the SURS website where it is freely available at those sites.

Dr. Chandru Sundaram:

However, today I'm excited for our webinar on robotic adrenalectomy. We have with us excellent moderators as well as surgeons. I'll be joined as a surgeon by Dr. Craig Rogers, the Chair of the Department of Urology at Henry Ford. He's one of the pioneers in robotic surgery; also Dr. Ronney Abaza, Director of Robotic Surgery at Dublin Hospital in Ohio; Dr. Riccardo Autorino, Director of Urologic Oncology at the Virginia Commonwealth in Richmond, Virginia; and Professor Dal Moro Director of the Urology Clinic at the University of Padua in Italy.

Dr. Chandru Sundaram:

We will start in a few minutes, but before that a few housekeeping points. Dr. Clint Bahler, who's been extremely helpful for us during these webinars, will fill you in on those.

Dr. Clint Bahler:

Welcome. Here's just some details on the CME credits that are given out, and also we want to point out that this activity is supported by Intuitive Surgical. The disclosure statements for our experts are here at the bottom of the page as well.

Dr. Clint Bahler:

The format for today, we're going to break the hour into three sections. We'll have 20 minutes with Dr. Dr. Chandru Sundaram and then 20 minutes with Dr. Craig Rogers, and finally throughout the whole time, however, we would love for you to participate using the chat function below, and we have a panel of experts that will be answering your questions there. Hopefully, there will be a good conversation. Then the last 20 minute block is set up for those discussions.

Dr. Clint Bahler:

For CME, look out for an email that goes to your registered email address for instructions on how to claim your CME. Of course, we welcome you to join the Endourology Society. One of the biggest benefits for that is on my last slide, so that you can join us in Hamburg, Germany, we hope, in 2021 for our next annual meeting. Thank you so much.

Dr. Chandru Sundaram:

Thank you, Clint. In the next few minutes, I'm going to share with you a talk on the technique of robotic adrenalectomy. Over the last two decades, adrenalectomy has evolved as far as I was concerned, and my technique started off with laparoscopy and then moved on to robotics several years ago.

Dr. Chandru Sundaram:

Let's start with two illustrative cases, one on the right and one on the left. This is a 56-year-old female with a 3.6 centimeter right adrenal mass. On laboratory testing, she was found to have Cushing's syndrome. That's the CT scan of the mass of the right adrenal gland. It's important to review the CT scan, not only to look at the characteristics of the mass but also to determine its relationship to the kidney as well as the renal vessels. You may be lucky to see some of the adrenal vessels as well, but usually not.

Dr. Chandru Sundaram:

Here the trocar positions. This was an additional trocar which I normally don't add. I usually have a four arms in. You could do away with the fourth arm, and you could do away with one assistant trocar, just have one assistant trocar. But here is the initial picture of the inferior vena cava. We normally don't get as thin patients as this. You'll have to work to get the inferior vena cava. However, what we do is we start right at the top, right next to the inferior vena cava and the liver. You'll find the cava there. Once the cava is visualized, you can go just below the liver all the way until you see the diaphragm.

Dr. Chandru Sundaram:

We start right on the top, mobilize the liver as high as you can go, and visualize the diaphragm above the adrenal gland, and that's what's being done here. As you go laterally, you can see the muscle fibers of the diaphragm. The key to adrenalectomy is not to focus on the adrenal but to focus on the boundaries around the adrenal gland, which will be the boundaries of your surgery. You see the inferior vena cava there and you work your way up until you see the adrenal vein.

Dr. Chandru Sundaram:

The adrenal vein is not often seen laterally. You have to sometimes roll the inferior vena cava and find it posterolaterally, so posteriorly. Here you see it laterally, so that's great. The question is whether you tackle the vein immediately or not. For a pheochromocytoma with a unstable blood pressure that's certainly an option, but otherwise I tend to leave that until you get a little bit of dissection done as you can see here.

Dr. Chandru Sundaram:

Next question is whether the adrenal vein should be tackled with a clip or with bipolar diathermy. I think both are acceptable. In the right side, I usually add a five millimeter clip. On the left side you really don't need a clip. You can just do bipolar diathermy. Here's a clip. But oftentimes, the adrenal vein is so sharp that applying too many clips is impossible. My usual strategy is to place a clip medially and coagulate laterally. You want to coagulate it really well because you don't want back bleeding from the adrenal gland, especially since the arterial supply has not been taken down yet.

Dr. Chandru Sundaram:

Once the adrenal vein has been taken down, you see the diaphragm again there medially above the adrenal gland. You can also see some of the normal adrenal gland right up there in the corner. You can take that down, see there's the adrenal gland and this is a bipolar diathermy being applied there. There are small vessels oftentimes from the liver and from the inferior cava there as well. All this can be controlled with diathermy easily.

Dr. Chandru Sundaram:

You can see now that the entire diaphragm has been exposed. The big take-home point is mobilize the liver adequately and get to the diaphragm. The upper part of the dissection has been completed. Then you work your way down along the inferior vena cava. What you see there is actually some of the sympathetic ganglia with the nerve fibers that go towards the adrenal gland, and that can be divided. When I started doing adrenalectomies, I used to be concerned that those were lymph nodes. They are actually ganglionic tissue and ganglia there.

Dr. Chandru Sundaram:

Once you do that, you can see the upper pole renal artery there. That's critical. It's important to stay just above the renal hilum. This is the inferior margin, the renal vein and the renal artery inferiorly. You just coagulate just above the hilum. Again, there you see some ganglionic tissue here right there. This again is the renal vein, and the real artery branch is right there. You coagulate all the little vessels that go between the renal artery and the adrenal gland. Most of the vascularity of the adrenal gland is medially and some inferiorly.

Dr. Chandru Sundaram:

Here you can see the upper pole artery going into the kidney, and you can see the kidney here, the upper pole of the kidney. That again is a boundary for an adrenalectomy, medially inferior vena cava, laterally the upper pole of the kidney, inferiorly the renal hilum, and superiorly the kidney and the liver and the diaphragm. Once you stay within these boundaries, you really don't need to see the adrenal gland, and you could do a good operation, get the entire adrenal gland along with the periadrenal tissue in this specimen as is seen here. Now this can be bagged and removed through one of the trocar sites by a little extension. The end of it this is what you should see: the diaphragm, the posterior abdominal wall, the kidney there laterally, the renal hilum inferiorly, and the liver superiorly. That's really what you should see at the end of a right adrenalectomy.

Dr. Chandru Sundaram:

Now moving on to a left adrenalectomy. This is a 58-year-old with a 1.6-centimeter, left adrenal nodule. She had clear hypokalemia, hypertension, required multiple medications for hypertension, and she had a adrenal vein sampling done to lateralize the hypersecretion of aldosterone to the site of the adrenal nodule, which is on the left side. Here you can see the right side adrenal vein being cannulated. In most patients, I would do an adrenal vein sampling in patients with a primary hyperaldosteronism, unless they are really young and the nodule is definite with severe hypokalemia and so forth.

Dr. Chandru Sundaram:

Now let's move on to the surgery. The first is mobilizing the spleen and the splenic flexure of the colon. The spleen is being mobilized. I think the key here is to mobilize the spleen and the tail of the pancreas completely. That's what's being done here. You get between the Gerota's fascia and the pancreas, which is now medially seen, and the spleen is higher up.

Dr. Chandru Sundaram:

Once this is completely mobilized, it's important for you to mobilize a spleen more than you would with a nephrectomy, for instance, and I'll tell you as to why we do this in a minute. Again, this can be done with three arms or the fourth arm. In this case, we're using a fourth arm for lateral retraction. Again, this is not entirely required if you want to minimize the number of trocars.

Dr. Chandru Sundaram:

You see on the top here a bit of the stomach seen, and once you have mobilized the spleen completely, beware of the stomach that will visualize itself that you could see high up. You see the stomach right there, and down below you'll see the diaphragm in a minute. That's the diaphragm above the adrenal gland. The spleen has been completely mobilized. The stomach is seen right here in the corner. Once you do that, you can come up from the top, bottom, right on the crus of the diaphragm, and that's exactly what's being done here.

Dr. Chandru Sundaram:

During this dissection, you may see branches of the inferior phrenic artery or vein, and any of the branches going towards the adrenal gland can be sacrificed. You work your way down on the crus of the diaphragm medial to the adrenal gland, coagulate all the little blood vessels that go to the adrenal gland in this region. Now you see the adrenal vein. You've come down, you can see the adrenal vein there. Again, this is the top down approach. You don't need to if you're more comfortable doing the bottom-up, which is mobilizing the entire colon, finding the gonadal vein, to find the adrenal vein, and then go up that way, that's certainly acceptable.

Dr. Chandru Sundaram:

You could see the adrenal vein there, and that's being coagulated at this time. As you can see, at this time you've never seen the adrenal gland itself. It's just the boundaries we're interested in. That's coagulated adrenal on the left side. The adrenal vein does not need clips, but in this case we have added another clip just for me to sleep well at night, but it's certainly not essential. For our donors, which I actually did a donor kidney just now, we do not typically clip the branches of the renal vein, the tributaries of the renal vein.

Dr. Chandru Sundaram:

Now once that is done, we are going laterally. Again, you see right here is the sympathetic ganglia again. It's very predictably seen just above the renal hilum. You take that down, then the medial dissection is done, the inferior dissection is being done just above the renal hilum. Once you do that, again, you get to the posterior abdominal wall, coagulate those little blood vessels there, and keep proceeding laterally until you get to the upper pole of the kidney, like you saw on the right side.

Dr. Chandru Sundaram:

The principle basically is the same. Structures are a little different. There's no cava on this side. There's a spleen instead. Now you can see the renal artery. I think the key especially in doing a wide as a dissection as we do, it's important not to get the hilar blood vessels, or even an upper pole blood vessel. You see the kidney right there, the upper pole of the kidney. Again, you go on the upper pole of the kidney. Again, why do you do this? Because you ensure the entire adrenal gland is taken. In the unlikely event that this is a cancer, very occasionally you see a Cushing's adenoma ending up as a adrenocortical carcinoma. You want to do a complete job.

Dr. Chandru Sundaram:

Also, doing so results in bloodless fields. You're not messing with the adrenal gland, you're not violating the gland itself, and causing bleeding. You see here's the renal hilum, and then you trace the upper pole of the kidney and detaching the adrenal gland and the periadrenal tissue as you do so. The obvious question is whether you need to do it laparoscopically or robotically. I think you can do it both ways. Certainly, it's a matter of how well you're trained or what's your preference as far as your background and training is concerned. I would tell you that for difficult larger drills, especially on the right side, definitely robotics tends to add a bit of safety in case you get into the cava and you cause severe bleeding. With the robot, it's not a big deal. You suture it up.

Dr. Chandru Sundaram:

Our poll question says, laparoscopic adrenalectomy with a lot of robotics as well, which is what I would have hoped to see. Now you see the completion of this. You see the adrenal gland, you see the periadrenal tissue being taken along with adrenal gland, and that's being detached. This is just a classic typical right and a left adrenalectomy technique using the top-down approach, and this again you see the bed, the diaphragm, the pulsations of the aorta below the crus of the diaphragm, the renal hilum there down below, and the upper pole of the kidney as well laterally there.

Dr. Chandru Sundaram:

This is what you should see at the end of a good adrenalectomy. All the boundaries are freely exposed, and the adrenal gland along with the periadrenal tissue is placed in a bag for the retrieval. You can see here how the nodule is in the middle, but there's lots of tissue right around it once it's been removed. That would conclude my section of this talk, and we'll now hear from Dr. Dr. Craig Rogers. He's certainly a pioneer in this field and the Chair of Urology at Henry Ford. Dr. Craig, I'd be delighted to hear your technique and learn something from you.

Dr. Craig Rogers:

Thank you, Dr. Sundaram. Awesome surgery. Really enjoyed watching it. I'm going to similarly show some different approaches surgeries that show a potpourri of instruments, and I'm going to focus mainly on technique. Obviously, the adrenalectomies I'm going to show are all functioning tumors or by size and CT criteria warrant adrenalectomy. Just to reiterate a few points. You can't say it enough. Exposure is key and adrenalectomy isn't that hard if you set yourself up well and that's really exposure. To Dr. Sundaram's point of a top-down approach, it really is to get exposure. Then I would recommend approaching the tumors as if they're all a pheo. I approach them all the same way. I get exposure, ligate the adrenal vein, don't touch the gland a lot, don't push on it. I'd say dissect the patient away from the tumor, and then I'll talk a little bit about partial adrenalectomy at the end for hereditary adrenal disease.

Dr. Craig Rogers:

This is just a picture of the idea of whether it's the spleen or the liver. Just get it out of the way. If you release those attachments, you're going to see. When I see people get into trouble in an adrenalectomy, it's because they're working in a hole, stuff's in the way, the liver, the adrenal. Don't work in a hole. Get it out of the way. This is an example of a left robotic adrenalectomy. First is getting the bowel down, so getting wide exposure. I'll talk while we're showing this. I essentially place my ports the same as I would for a partial nephrectomy as if it was an upper pole tumor where you cheat the ports a little higher just to get better visualization to the top portion of the kidney.

Dr. Craig Rogers:

Now the bowel has been taken down, and I'm just making a plane in between the pancreas and the kidney. You'll notice kind of a breaststroke motion where the left hand bluntly is pushing the spleen away. These are taking down the lateral attachments of the spleen, looking behind to make sure you don't get stomach. The suction is pushing the kidney away. I'm looking over the top for stomach. I will sometimes put either a sponge or just a cottonoid in to help accentuate that space between the kidney and the spleen. Also, it lets me push on it without worrying about my Maryland poking the spleen or poking the pancreas. Again, that breaststroke motion.

Dr. Craig Rogers:

Now that I've gotten a top-down approach, I go to the bottom, frame a reference, find the renal vein, and then I'm going to detour, follow the renal vein, and before I get to the kidney, just open Gerota's to expose the left adrenal vein. Similar to if you were dissecting the hilum for a partial where you just spread on both sides, then I'll come under it. This is using a Robotic Weck Clip Applier. Many ways to take this. Your assistant can put a clip, but I love this angle. My assistant could never do this angle. Just one example of how the robotic articulation can help you here.

Dr. Craig Rogers:

Do I need three clips? Probably not. I'll show you I use the vessel sealer now, which could just come right through this. But it's more to show you, you can adapt this to whatever your preference is. I'd recommend, once you take the adrenal vein, if it's a functioning tumor, especially a pheo, I'll give my anesthesiologist a heads up that, hey, we've taken the adrenal vein.

Dr. Craig Rogers:

Now I'm going to open Gerota's, and this is just an estimate of where I think the junction of the top of the adrenal and the kidney is. It doesn't have to be exact. What I'm shooting for is parenchyma, right here. I've gone a little bit lateral. I'm going to get down until I see the kidney, and I'm going to dissect along the border of the kidney so I'm dissecting the lateral border of the adrenal. I'm pushing the adrenal away from the kidney and I'm going to get down to where I see a lip here of the kidney. That allows the suction to come in and lift the kidney up or your fourth arm can lift the kidney up.

Dr. Craig Rogers:

We've taken the adrenal vein. Now all that we're going to do is set up the arterial blood supply. Here's one artery that's going to be coming off the renal artery to the adrenal. We're clipping this in a way where we're protecting the renal hilum. This is just going to give a little bit more mobility of the adrenal vein away from the kidney. Now you could also do this at the end. I just prefer on the left side, get the top, get the adrenal mobilized off the kidney. Now the only thing left is the arterial blood supply and the adrenal is mobilized that it can be lifted up on stretch, and you can either buzz or clip your way along little packets or pedicles, which these are all going to be arterial blood supply now.

Dr. Craig Rogers:

I used a multi-fire there just because it's faster. Occasionally, if you can get underwater quickly on an adrenalectomy or if it starts bleeding, especially on a pheo, I just want something that can clip-clip-clip. Everything's set up on a pedicle now, and notice I'm making little packets and windows, a big clip can come along. I love clips. I know I could just burn this, but the things that could get me in trouble I feel is this medial arterial blood supply. I usually will just lift it up just you'd do a hilar dissection with the vessels on stretch. The whole adrenal is just dangling by the arterial inflow now. Like I said, I would probably use a vessel sealer for this now, and I'm going to show that in a later case. That's the last attachment. Once that's out, we'll put it in a bag. All right, then it goes in a bag and we extract.

Dr. Craig Rogers:

All right I'm going to go to the next video. This is a left side but with different instruments. This is a hook. We use the hook at Henry Ford sometimes where I feel like for when you're plucking vessels, it just gives me a little more control. I think it's a little faster sometimes as well. Same idea, getting the spleen out of the way. Notice the left hand you're using the shaft of the instrument to distribute force across the whole length of the instrument, so you're not getting focal pressure on the spleen that could create a splenic hematoma.

Dr. Craig Rogers:

Here I'd say is overkill. I shouldn't even be seen. You don't need to see the ureter. This isn't a bottom-up approach like you'd approach a kidney. I'd say this is over-dissection. You can just go above. I've gotten the spleen down, gotten the pancreas down, and now I'm going to carry this back into my upper pole dissection again. Think of it like layers of an onion. Now I'm going to go back one layer deeper to get the pancreas away.

Dr. Craig Rogers:

Notice how the left hand not only is distributed over the shaft of the instrument, but you can delicately grab tissue that's not pancreas to get a little bit of upward lift, or if I was afraid of poking it, I could put a cottonoid there to backhand it. Again, the breaststroke motion, kidney, pancreas, holding the tissues in a way where you're not going to get a pancreatic injury, a pancreatic leak, and I'm on the lookout for stomach. There it is. You want to make sure you've got an OG tube in. If the stomach's billowing in your way, you're not going to see this as well.

Dr. Craig Rogers:

Then take the splenorenal ligament. You want gravity to be your friend. Once you take this down, the whole spleen falls, it takes the pancreas with it, and now you've got a wide open view of the whole area of dissection of surgery. Then for the arterial supply to the adrenal, we're going to have a pericardiophrenic supply coming in laterally, coming in there. Just getting that exposed so that can be taken, also getting to the musculature, psoas and diaphragm, getting that all exposed. You can see some blood supply that's going to be coming in here right there. I don't have to take the blood supply now. I'm going to orient myself to find the adrenal vein.

Dr. Craig Rogers:

We'll get a little bit more exposure here, and in dissecting, I'm going to go ahead and open Gerota's here and take that into the renal vein. I have to open this anyway to expose the renal arteries to take to expose the adrenal arterial blood supply, so you can see those arteries coming into the adrenal tumor which is above us. There's the psoas muscle, again, showing what we're going to clip later. Top is done, back to the renal vein, following that until we get to the adrenal vein. The adrenal vein is in view on the right.

Dr. Craig Rogers:

All the arterial pedicles have been teed up there. All those could be clipped if I wanted to. Although they say ligate the adrenal vein early, that can create some congestion. I tee things up that I could clip the arterial supply before the vein if I wanted to. Again, exposing the top edge of the renal vein, really no need to expose the renal vein circumferentially. You just want the top edge, find the adrenal vein coming off it, and again in this case I'm going to go ahead and clip it, same as before. That's telestrating to the resident, go here, clip here, all right.

Dr. Craig Rogers:

Then the hook can be used the same as a scissors and cut if you want to come through it. I don't have to switch instruments. Here's vessel sealer. We now use the Vessel Sealer Extend, which is the same instrument. It requires a different generator, the E-100, which makes it about twice as fast as what you're going to see here on the screen. I love this instrument now because I'm an impatient person. It just goes one or two seconds, beep, and you're done, and it really makes this dissection, whether it's this plane dissecting between the kidney and the adrenal, the lateral border of the kidney, and I'll use this on nephrectomies as well when I'm doing adrenal sparing.

Dr. Craig Rogers:

You can see in the foreground a little bit of adrenal edge here. I really don't want to see the adrenal at all. If I'm seeing gold nuggets staring at me, that means I'm too close to it, especially if it might be malignancy. But just keep in mind, the adrenal is very unforgiving. It does not like to be touched. You start touching it, it starts bleeding, you're under water before you know it, and then it's not a pretty surgery when you aren't in the right plane. I try to stay away from it. If I see it, I course correct, go a little farther away.

Dr. Craig Rogers:

Now we're only attached by the arterial blood supply, and we can just lift the adrenal up and finish the job. In the background I've got a little cottonoid, so you're seeing white beyond. I know that there's nothing beyond this and vessel sealer can just go in. I've put a clip down and vessel sealed above. I now have more confidence in the vessel sealer. I don't need to do that.

Dr. Craig Rogers:

I will use a multifire, whether it's a titanium or now I often will use the Multifire 5 Weck Clip Applier if I'm going to clip a whole array of pedicles quickly. For something bigger like this, vessel sealer does just fine up to I believe seven millimeter vessels. A few last attachments. I also like how this instrument gives me good articulation, and it gives me a more robust bite. It's just faster. In the bag, we're done with that side.

Dr. Craig Rogers:

Let's go on to the right side. This is a bigger tumor, and because it's bigger, I really want exposure up top. I'm going to be spending extra time getting that liver out of the way. I'm just reflecting the upper bowel. We don't have to take the whole colon down. I mainly just want to see the vena cava. We jump up, we're seeing kidney, adrenal, vena cava, and I'm going to start mobilizing the edge of the liver with the goal of just continuing to get that liver up, up, up, out of the way, because the top of this big adrenal tumor is going to be tucked way under the liver. I don't want to be dealing with the liver if we have any bleeding issues.

Dr. Craig Rogers:

Let's say I did have to put a suture on the vena cava if the adrenal vein tore, I'd rather have both hands. I could just box it out with the elbow of my right hand, and for most adrenals on the right side that would work fine. When the stakes are higher, the tumor is bigger, I'm going to treat this almost like I would an IVC thrombus case where I'm actually getting exposure to the caudate lobe of the liver, taking the short hepatic, really getting this liver out of the way, and you'll see why when you start to see this tumor.

Dr. Craig Rogers:

Then going laterally to the diaphragm, reflecting the liver off the diaphragm. So far the technique has been I'll pull the kidney, but I'm trying not to really manipulate the adrenal tumor at all. Now I'm going to come medially, expose the vena cava, split-and-roll technique. I want to see the lateral border of the vena cava. To help keep the liver out of the way, I put a sponge back there just to get a little upward retraction. Also, it's there if we had any bleeders or anything like that, but it's tucked out of the way. It just helps give me lift.

Dr. Craig Rogers:

Now it's getting the lateral border of the vena cava free. This defines my landmarks. I'll take this down until I know where the renal vein is. I know I don't have to be any lower than that. That's the lower border of my dissection, and I'll just follow it up, and I'm using a fourth arm in this case just to get a little better exposure. I'm not pushing on the tumor at all. This has just been no-touch technique, and I'm now setting up the adrenal vein, which in this patient's going to be a little bit larger. For a really large adrenal vein, either a larger clip or even a stapler, whatever is going to set you up the best.

Dr. Craig Rogers:

Now I want to mobilize the vena cava out of the way to help expose. I'm trying to set this all up for the upper corner, which is going to be the bigger adrenal vein. In terms of what you could get in trouble on a right-sided case, it's really just the short adrenal vein coming off the vena cava. I will go ahead and take some of these. This will reduce some of the venous engorgement, and again with the Extend this would be much faster. Again, taking some vessels, and you'll see this is just to get a little better exposure.

Dr. Craig Rogers:

It's not a hard fast rule that you absolutely have to go right to the adrenal vein and you cannot pass go until you take the adrenal vein. There are some times where you just want to set up the adrenal vein safely. As I take some of this on the medial border, now I'm seeing psoas muscle behind this and the vena cava can be pushed out of the way. I'm above it, I'm below it, just getting set up now for what is probably going to have to be a bigger clip or a stapler just given its size. I wouldn't use my vessel sealer for a vessel this big and that short and close to the cava. But now it's well suited for either me or my assistant to come in. Maybe overkill on the dissection, but again, when stakes are higher, I want this totally exposed. This was a gold clip, a larger Weck just for that first one, then the other clips can be smaller.

Dr. Craig Rogers:

Now we're totally home free. The fourth arm can lift up. Really the only thing left to avoid is just being careful about the kidney in the renal hilum. Stretching the adrenal tumor away from the kidney so it's clear where the renal artery is and the branch off the renal artery to the tumor. Finishing up our last attachment. Notice that part, the plane between the kidney and the tumor. Let's say you did that first, what would happen to the adrenal tumor. It would spring north, you'd release its attachment to the kidney. It would now shoot up under the liver even more and make your adrenalectomy even harder. To Dr. Sundaram's point of top-down, there's a reason for doing this, in that if you start on the kidney and release its attachment, you're really hurting yourself for the latter part of the surgery.

Dr. Craig Rogers:

I'll just touch on partial adrenalectomy with very short clips. The whole front part of the surgery is exactly the same, but it's wide mobilization of the adrenal. These are going to be amenable to tumors that are on the limb, like a lateral or medial limb, and it's going to require ultrasound, just as if you were doing a partial nephrectomy. I apologize for the quality of the video, but if you look at the [inaudible 00:36:17] above, it's just showing the adrenal has been completely mobilized, so you can flip it back and forth like a book. Intraoperative ultrasound has defined the tumor. Then this is like an off-clamp partial, right. You can't clamp for this. You can either clip or burn or even staple that edge. As I'm clipping along the bottom, you can see the contour of the tumor's coming into view. This is a hereditary field. Finishing that up and that'll go in the bag.

Dr. Craig Rogers:

Then this is another VHL patient that happened to have a kidney tumor as well. I'll skip. There's the adrenal mass up top. This patient was blocked. We usually give Cardura for a block. Unless the blockade is poorly controlled, then we'll use phenoxybenzamine. The normal adrenal is under this sponge to the left. The tumor is off my scissors to the right, and this is a junction right here of normal adrenal and tumor, and I'm just cauterizing my way across it. I tried to get fancy and use FireFly. You don't need that here. But it was just to show that there was viability of the remnant adrenal that I didn't devascularize it with cautery. It's hanging by a thread. Use a clip just to prevent bleeding, and again that's often in the bag. I'll sometimes use this, too, for equivocal cases where it's a soft call as to whether to do it and if the tumor is just hanging there, we can do a partial adrenalectomy with the option to salvage it with a total if necessary.

Dr. Craig Rogers:

With that, I want to thank you for the opportunity to present I'll turn the time back over.

Dr. Chandru Sundaram:

Thank you very much, Dr. Rogers. That was a phenomenal illustration of your technique. What I'm going to do is, I've got a few points, there's lots of discussion on the chat box, and I'm just going to have all the moderators talk about that technique. First, based on the poll questions about laparoscopy versus open versus transperitoneal versus retroperitoneal. I'll just start with Dr. Abaza and then Dr. Dal Moro and then Dr. Autorino and then they can give us their views on this topic. Dr. Abaza?

Dr. Ronney Abaza:

Yeah. My routine for adrenalectomy is a transperitoneal robotic approach, but I've also done retroperitoneal. I suggest it, for those of you who are comfortable doing retroperitoneal partial nephrectomies, there are times when retroperitoneal adrenalectomy is really a beautiful surgery, and the time that I've done it and also for things pyeloplasty and whatnot is for patients who have had just tons and tons of previous abdominal surgery. If I want to avoid the peritoneum mesh and adhesions and whatever, I think that's a great approach. It's nice to be able to do both.

Dr. Ronney Abaza:

In terms of the question of laparoscopic versus robotic adrenalectomy, I think the major argument against robotic has always been cost, but for me, I do it robotically but I try to minimize the cost and I try to do it with just two instruments. I do a total of three ports, and I just use the robotic cautery scissor and the bipolar in my left hand. I don't use the fourth arm, I don't use any special energy devices or whatever just to keep the cost down. Then if I do use clips, I'll use the robotic Hem-O-Lok clip because that instrument has 99 lives. There are ways that you can keep the cost down, if that's a concern for you. If it's not really an issue, it's not a limiting factor, then I think robotic is just a beautiful way to do the operation, and I would do it anyway even if cost wasn't an issue, but that's my preference.

Dr. Chandru Sundaram:

No, I agree. If the robot is available, that's what I like to do. If the robot is not available and the patient wants to get it done soon, then I would go to laparoscopy with small. However, robotics certainly much better if it's a huge mass, it could be a cancer, a big field. There's no question that it makes a huge difference in those methods.

Dr. Fabrizio Dal Moro:

I completely agree with you. Personally I prefer the robotic approach, the transperitoneal robotic approach. The main reason is that I have a warning message that is represented by the [inaudible 00:40:29] bleeding is due to vascular anomalies. In my experience, I had a problem with a small right adrenal vein draining into the right renal vein, not the [inaudible 00:40:45]. It's important for me to have an adequate and extremely accurate control of the vessel and the dissection is better using a transperitoneal approach in my opinion and in my experience. In case of patients that underwent previous abdominal surgery, a retroperitoneal approach could be useful in order to avoid the impact of the adhesions in [peritoneal 00:41:16] adhesions.

Dr. Chandru Sundaram:

Thank you. Dr. Autorino, what are your views on the retroperitoneal versus transperitoneal, what is your approach, pros and cons? There are some who do retroperitoneal for all adrenalectomies.

Dr. Riccardo Autorino:

Right. My preference is, and that applies also for kidney surgery in general is for transperitoneal robotic approach. One of the reason being the familiarity with anatomical landmarks, larger working space, the fact especially, as Dr. Fabrizio was saying, if you're working on right side, levers there it might be a tough space to be in, and I think I want to be comfortable in case anything happens, and that's the plus of the robot compared to laparoscopy I believe.

Dr. Riccardo Autorino:

Also, regarding the trans versus retro, since this is a essentially an extirpative procedure. There is no reconstruction involved. I'm not sure even if there is an advantage of doing retro versus trans as it was shown, for example, for partial where most of the studies show you can have an advantage in terms of earlier discharge, earlier return of bowel function. I'm not sure if the data is there to support retro versus trans for adrenalectomies, but certainly in very difficult abdomen when a lot of scar tissue before, you should be able to offer that approach. But in my experience, that doesn't happen so often. Also, with transperitoneal we really nowadays do surgeries also in abdomen where a lot of scars. You still have able to get your space and do the surgery anyway yeah.

Dr. Chandru Sundaram:

Thank you. Dr. Rogers, there's been a lot of talk on the chat box about clips versus bipolar versus vessel sealer and so forth. I saw you using all those techniques. Why don't you comment on that? But before that, I would to just share with you that Dr. Rogers is the President-elect of SURS, and we are delighted that he has accepted to lead SURS during this crucial time. Look forward to lots of exciting stuff with the Society of Urologic Robotic Surgeons under the leadership of Dr. Rogers. Dr. Craig, go ahead.

Dr. Craig Rogers:

Thank you, Dr. Sundaram. By the way, I'm totally honored to be involved in SURS. Your question about clips and vessel sealers, it's evolved for me. It started more just out of paranoia that I always wanted to clip the arteries thinking that that's what could burn me afterwards if something went into spasm and bled afterwards. I really wasn't as worried about the veins. I would make pedicles and clip everything, and I have more confidence in the energy approaches now. I think the vessel sealer would be fine for any of this, and I think it will save a lot of time. Time is money. If you're looking to save cost, that might be a way to do it, just one instrument and motor through.

Dr. Chandru Sundaram:

Yeah. Absolutely. I think it's dealer's choice. It's a matter of cost, availability, and so forth. This poll results is absolutely equal here on what do you think is a must-have instrument during robotic adrenalectomy? Robotic clip applier, vessel sealer, fenestrated bipolar, and none specifically. I guess that's appropriate, right. It's a matter of what you want to do and what you're comfortable doing and based on the local conditions. That's fantastic.

Dr. Chandru Sundaram:

Let's move on from a little bit of technique to workup and indications and of forth. Dr. Abaza, what is your workup for an incidentaloma? A patient shows up with an incidentaloma, it's a very common thing, so what's your workout?

Dr. Ronney Abaza:

Yeah. I think some people will routinely involve an endocrinologist for the workup, but I don't routinely do that. If I do suspect a pheo, if you have an obvious pheo and you need blockage, then I'll usually involve the endocrinologist for that. But otherwise, usually I'll do the workup myself. If the patient comes in with any suspicious heterogeneity or anything like that, then I'll send them for an adrenal protocol CT, so that we can see the washout and make sure it's benign. You could alternatively do an MRI, and then we'll just do the routine lab work, the 24-hour urine, the serum studies to rule out pheo, aldosteronoma, Cushing's.

Dr. Ronney Abaza:

I think there's some difference of opinion in terms of what the best test to order are. But, obviously, it's just critical above and beyond everything else just to know whether or not you have a pheo. I think that's the number one thing that I'm trying to do in my workup is to find out is this a pheo or not.

Dr. Chandru Sundaram:

Dr. Dal Moro, what is your serum test protocol for an incidentaloma? Just give me three tests.

Dr. Fabrizio Dal Moro:

Three tests. It's crucial to have a biochemical evaluation of the incidentaloma, and then I think that it's important also to have an evaluation with a PET in order to evaluate the activity. But I have a question for Dr. Craig in order to talk about the partial adrenalectomy, because I'm very interesting on this technique, and personally I didn't perform it. But can you consider the use of the FarFly in order to better identify the margins of the adenoma in case of the partial adrenalectomy for an adenoma.

Dr. Craig Rogers:

I think so, and in that case, I cut it out. But that's exactly what I was using it for, because one of the risks in a partial adrenalectomy is if you're using too much cautery, you could devascularize the limb of the adrenal that you're taking it out from. I just wanted to confirm that I had viable adrenal, even though I completely mobilized it. The adrenal will survive. You can take the adrenal vein, completely mobilize it, it'll be hanging by a thread, and it will still function and survive.

Dr. Craig Rogers:

My perspective on the partial adrenalectomy came from my training at the National Cancer Institute in my fellowship where there were a lot of patients coming in with Von Hippel–Lindau disease. It was a routine thing. It was hereditary, they all needed partial adrenalectomies to try to spare the adrenal from the morbidity. It's a high morbidity to go on lifelong adrenal replacement. That's why you're trying to spare that patient with hereditary disease.

Dr. Chandru Sundaram:

I do the same thing. Partial adrenalectomies, I would do it primarily with bilateral pheochromocytomas. That's my most common indication for partial adrenalectomy. As far as the biochemical workup is concerned, I have a very standard workup: dexamethasone suppression test, serum metanephrines, aldosterone-renin, and electrolytes. That's it. Everyone gets the same thing. If it's abnormal or if you're suspicious, then we can talk about that for another hour about ambiguous cases, but that's a very standard, simple test, one blood draw, one tablet, and you're done. That's as far as that is concerned.

Dr. Chandru Sundaram:

Now Dr. Autorino, what's your size criteria for adenomas? When would you observe? When would you remove them? Assuming they are non-functional and look benign on a CAT scan.

Dr. Riccardo Autorino:

Yeah. I think it's also besides the cutoff itself, it's probably important to look at how it's progressing. I think in terms of size, if it's a growing mass, it could be concerning. Usually the four, five centimeter probably is a reasonable cutoff to use. But where you want to also exclude the possible cancer, that's based on imaging mostly. But I believe, about four centimeters is probably my cutoff and certainly if you have a patient coming in, we know previous imaging, and we don't know, I think it's reasonable to repeat imaging after six months and see how it is progressing, if it's progressing and go from there.

Dr. Chandru Sundaram:

Yeah. That seems reasonable. Even if you wait for six centimeters, if you remove all six centimeter adrenal masses that are not clearly malignant, about 25% are malignant. It's not a huge number, but certainly the growth kinetics, characterization on the CAT scan, and the size itself are all important. Dr. Rogers, what is your pre-op workup for pheochromocytomas, pre-op medical management?

Dr. Craig Rogers:

Blockade?

Dr. Chandru Sundaram:

Yeah.

Dr. Craig Rogers:

If serum catecholamines confirm it's a pheo, I'm usually doing blockade with Cardura doxazosin. I used to use phenoxybenzamine, which is an irreversible blockade, but you're going to get more rebound post-op. It'll be quicker. Your goal either way is to get them so they're symptomatic, that they're orthostatic. If they become orthostatic, you have successful blockade. With Cardura it takes longer to get them there. It may take three or four weeks. It's titrated. I could do it myself, but I work with the endocrinologists, more to involve them. That's where your referrals are coming from oftentimes. I want to have a partnership with them. I'll have them get involved in the titration and give their blessing as to when we're ready to go.

Dr. Chandru Sundaram:

Yeah, I agree entirely. I do the same thing exactly. It's more to keep rapport with the endocrinologists, because they get very excited about a pheochromocytoma, any of these matters, because most of the time they're taking care of diabetes and stuff like that. This is a good case for them though it may be fairly routine for us. Dr. Abaza, what about cancer? You deal with a lot of cancers. I know you're very experienced. He's one of the most experienced robotic surgeons in the country. Talk to us about adrenocortical carcinoma, the role of robotics in adrenocortical carcinoma.

Dr. Ronney Abaza:

Yeah. It's actually very controversial actually. If you look at the general surgical literature and, obviously, a lot of these adrenalectomies are done by general surgery, not by urologists, which I think is tragic. I think honestly urologists are better at it, but that's okay. But anyway, if you look at their literature, you'll find that actually most general surgeons don't believe that adrenocortical carcinoma should be done minimally invasively, whether laparoscopic or robotic. They think it should be an open operation.

Dr. Ronney Abaza:

Honestly, to some degree, I would agree with them. For me, if I suspect that it's an ACC, the most important factors that I'm looking for on my pre-operative imaging is whether there's a lot of stranding around it. If there's a lot of stranding and I suspect that it may be invading structures around it, then I wouldn't tackle that robotically. If it's a potential malignancy, but it's well circumscribed and I feel like I can get a nice margin around it, then I have tackled those robotically and have been successful.

Dr. Chandru Sundaram:

Yeah. A very good point. There was a comment on our chat box. What would you do if the patient had a positive margin after a partial adrenalectomy? Anyone on the panel would to take this?

Dr. Fabrizio Dal Moro:

Actually Dr. Craig is the master of it.

Dr. Chandru Sundaram:

No, again, I think it depends on what the pathology is and why you're doing a partial adrenalectomy. If it's a benign pheochromocytoma and the serum markers are negative, then you can observe it. I think it all depends on the individual case, because these are not common operations. These are done for specific indications. My next question, we have five minutes left over, is about adrenal venous sampling for primary hyperaldosteronism. Dr. Dal Moro, do you do it on all patients with the primary hyperaldosteronism? What is your criteria for doing adrenal venous sampling?

Dr. Fabrizio Dal Moro:

Not for all patients, because I'll follow the suggestion of our endocrinologist in order to have a complete evaluation. But, obviously, there are some problems in order to the intraoperative evaluation of these patients. It's important for me to stress the concept of a strong relationship with the anesthesiologist in order to have a safe surgery for this kind of patient, because there are some possible problems really dramatic during the surgery. Not only for the pheochromocytoma but for also the other forms of active adenomas, we can have some problems. It's important a multi-disciplinary approach also in the operative field.

Dr. Chandru Sundaram:

Dr. Autorino, what is your criteria, indications for ABS and what would you consider positive or lateralizing to one side or the other?

Dr. Riccardo Autorino:

Yeah. Also in my case, I will leave basically that decision mostly to the endocrinologist. I would say that is done when is needed. In the cases where there is not a clear situation, then you want to make sure you are putting the right surgical indication. Not all the cases, but certainly most of my workup would be in the end of the endocrinologist. I will not much interfere with that, to be honest.

Dr. Chandru Sundaram:

No, my default is to do it and have a good interventional radiologist, who I have a rapport with. The only time I would definitely not do it or probably not do it is patients who are young, who have got a clear-cut nodule on one side, who've got severe hypokalemia, who have a very high serum aldosterone level. We've got only two and a half minutes. I want all the moderators to chime in on anything that they would like to say before we close. Dr. Rogers.

Dr. Craig Rogers:

I just wanted to jump on the last thing about adrenal sampling. There are times where you'll see a nodule on one side and it lateralizes to the other side. The sampling always trumps what you see on the CT scan.

Dr. Chandru Sundaram:

Absolutely. That's why I do it on almost everybody. Yes.

Dr. Craig Rogers:

Yeah.

Dr. Chandru Sundaram:

Dr. Abaza, last minute comments. We've got two minutes.

Dr. Ronney Abaza:

Yeah. This was phenomenal. I really enjoyed this. I thank you for including me. I did want to comment one thing on the cases that you and Dr. Craig showed. Just to stress one factor that I thought was really important to share with everybody, and that is that when your initial dissection and you were reflecting the colon or reflecting the pancreas, the spleen, you respected the Gerota's and you didn't enter Gerota's right away, and that is so critical. I just wanted to stress that for everybody who's watching is that you don't want to enter Gerota's until after you've done all of the reflection and then you can go after the adrenal vein et cetera. I just wanted to stress that because your videos beautifully showed that in all cases, and I just wanted to make sure it was mentioned.

Dr. Chandru Sundaram:

Thank you, Dr. Ronney. It's fantastic having you around as always. Dr. Dal Moro, when would you use MIBG scan in pheochromocytoma? I want to be respectful of the people who put their questions on chat.

Dr. Fabrizio Dal Moro:

We will just observing the evaluation of the patients. But I'd also like, first of all, to congratulate all the surgeons for the wonderful video. Then to make a short comment, because the adrenal surgery is a specific field for the urologist more than for the general surgeon.

Dr. Chandru Sundaram:

Yeah. You don't need to convince us or anyone who's watching I'm sure. Dr. Autorino, one last question from the chat box. Lipid poor versus lipid rich mass, how would you differentiate it? We have 10 seconds.

Dr. Riccardo Autorino:

Yeah. I think in that, if CAT scan is not clear, MRI probably is a good way of studying the mass. Of course, that depends also on the experience of the radiologists you have and considering the size as well and other factors.

Dr. Chandru Sundaram:

Thanks. I would go with the washout as well. If it's not lipid rich, then go with the washout. It's greater than 60%, then it's probably lipid-poor adenoma; if not, it's something else. It really was an honor and a privilege to associate myself with this group here of fantastic surgeons and moderators. Thank you all very much. For the audience, thanks a lot for being here. I truly appreciate you being here and please log on to our website, be part of the Endourological Society as well as the Society of Urologic Robotic Surgeons. Thank you all very much.