Surgeons: Ashok Hemal and Michael Ferrandino

Moderators: Rafael Sanchez-Salas, Jason Lee and Sammy Elsamra


Dr. Rafael Sanchez-Salas, MD

Rafael Sanchez-Salas is a surgeon and clinician scientist with main interest in minimally invasive treatments in Urological Oncology. He is an established leader in the field of Focal Therapy for the treatment of Localized Prostate Cancer. Dr. Sanchez-Salas earned his Medical degree from the Universidad de los Andes in Mérida, Venezuela; He was Valedictorian of the Class of 1998. He completed his basic Surgical and Urological training at Universidad Central de Venezuela in 2005.

He was awarded with Scholarships from Confederation Americana de Urologia and The European Association of Urology to pursue fellowship training in urological oncology and minimally invasive urological surgery at Memorial Sloan Kettering Cancer Center in the US, Clinica Santa Maria in Chile and L’Institut Mutualiste Montsouris in France, where after his training he joined the Faculty in 2008. Dr. Sanchez-Salas has coined a sound international career as a talented surgical proctor and cancer researcher. His current research priorities include Focal Therapy for Prostate Cancer and its impact on prostatic microenviroment and outcomes. He Chaired the SIU-International Consultation on Urological Disease on Image guided therapy for Prostate and Renal Carcinomas in 2015.

In addition to his clinical, academic and research commitments, he has been responsible for fellowship training (Advanced laparoscopy and Robotics) at the Department of Urology of L’Institut Mutualiste Montsouris over the last 8 years. Dr Sanchez-Salas serves on Board of the Société International d’Urologie and the Robotic Urology Section of the European Association of Urology. He is a member of the Editorial Board for “European Urology Focus”, “The Journal of Endourology Part B, Videourology” and “Actas Españolas de Urologia”. He is a Reviewer for major Urological and Oncological journals. He has authored over 200 indexed scientific papers and is an internationally sought after speaker.

Dr. Jason Lee

Dr Jason Y Lee completed medical school at the University of Toronto, where he also completed 5 years of urology residency training. After successfully passing his Royal College certification examinations, Dr Lee completed a 2 year combined clinical and research fellowship in Minimally Invasive Urologic Surgery and Surgical Education at the University of California Irvine.

Dr Lee returned to join the University of Toronto Department of Surgery faculty in 2011 and completed a Master's Degree in Health Professions Education through the University of Illinois at Chicago in 2014.

Dr Lee's clinical practice focuses primarily on Robotic and Laparoscopic surgery for kidney cancer as well as Advanced Endourologic surgery for complex renal stone disease. He is also a part of the Kidney Transplantation Program at UHN.

His clinical research interests include evaluation of innovative surgical technologies and urologic imaging, outcomes research in robotic surgery and endourology. He also has a research program focusing on curriculum development, surgical skills assessment, and the use of simulation-based training in surgical education.

 

Webinar Transcript

Dr. Chandru Sundaram:

Greetings from the Endourological Society and the Society of Urologic Robotic Surgeons. My name is Chandru Sundaram. On behalf of Dr. Adrian Joyce, the Chair of the Office of Education of the Endo Society, I am delighted to welcome you to the Master Class in Robotics. Today's subject will be robotic nephroureterectomy. Please join us every two weeks, same time on Friday, for a robotics webinar until the end of the year. You will get CME credits and we have outstanding faculty, as noted in the slide.

Dr. Chandru Sundaram:

I am delighted to introduce Dr. Dr. Jihad Kaouk, the President of the Society of Urologic Robotic Surgeons. Jihad.

Dr. Jihad Kaouk:

Thank you, Dr. Sundaram. We are excited to present our session today that will focus on robotic nephroureterectomy. We have a world class faculty from all over the globe, and without taking too much time, I would like to introduce the two surgeons who will present their techniques. I will start with Dr. Ashok Hemal, who is a professor and Director of Robotic Surgery in Wake Forest Medical Center in North Carolina. And Dr. Michael Ferrandino, who is a surgical oncologist at Duke University Durham, North Carolina, also. So, we'd like to welcome our surgeons who will be moderated by Dr. Dr. Rafael Sanchez-Salas. Dr. Salas is a robotic surgeon and oncologist at Montsouris Hospital in Paris, France, and Dr. Jason Lee, who is a urologic robotic surgeon in Toronto, Canada, and Dr. Sammy Elsamra, who is a robotic urologic surgeon practicing in the Robert Wood Johnson University in New Jersey. We're very excited to spend the next hour. We will start with Dr. Michael Ferrandino first, focusing mostly on the nephrectomy part of the nephroureterectomy, followed by Dr. Hemal for the bladder cuff.

Dr. Jihad Kaouk:

A little bit about the format of today's session. This is a CME accredited session and we will be having live chat on the chat box. Please remember that the Q&A button is disabled, so for your questions, post them in the chat box that our moderators will be answering live as the surgeons are presenting, first 20 minutes for Dr. Ferrandino, then 20 minutes for Dr. Hemal, and then the last 20 minutes will be live discussion. During the session, we will have polls. Please join us on the polls to get your opinion about the current practice from what we're presenting. For the CME credit, please log into the Endourology Society. You will find a link that you can claim your CME credit from. The session will be recorded and will be on the Endourology Society Membership section of the website for you to watch these sessions. Please be a member of the Endo Society to get the full benefits of the society itself.

Dr. Jihad Kaouk:

Dr. Ferrandino, we will start with you.

Dr. Michael Ferrandino:

Well, first, thanks to the Society for Urologic Robotic Surgery as well as the Endo Society for having these events. It's great during these times to be able to work with my colleagues and it's an honor to be able to speak today. I'm going to be talking about the nephrectomy portion and the lymphadenectomy portion of the procedure. Dr. Hemal will follow with the ureter and the bladder cuff. I was also asked to speak about a bit of the preparation, the room setup, positioning, port placement, early beginning stuff of the procedure. I'm not going to spend too much time on the Si, as most of us nowadays have the Xi, but there are slides included which will have the Si set up and references to room setup and port placement for this in greater detail if you need to go back or would like to go back and review it. The Si though, in this picture, as you can see has two dock approach typically with an approach over the ipsilateral shoulder added to approach the upper portion of the procedure, and then a second dock or repositioning to access the lower portion of the abdomen. The Xi has a lot more flexibility and therefore can come over the ipsilateral side or the contralateral side, depending, and be rotated around thanks to its boom, and additionally you can see that the robot now typically only needs one dock to approach all quadrants.

Dr. Michael Ferrandino:

Positioning is fairly standard for a nephrectomy, nephroureterectomy. Patients are placed in a lateral decubitus position. The back is supported with some type of foal, gel roll, beanbag. I'm a beanbag user myself. The bed is flexed 20, 30 degrees to open up the ipsilateral side. All pressure points are padded. And then the arm is either supported at the side or out in front of the patient with either beanbags or the Krauss, and the patient is appropriately secured to the table. This gives access to the abdomen and the pelvis.

Dr. Michael Ferrandino:

The Si has a variety of port placements. On the left side of the screen, you'll see a two dock port placement, which is very popular. Additionally, my esteemed colleague, Dr. Hemal, published his technique for port placement, which I've demonstrated on the right side of the screen for you to review.

Dr. Michael Ferrandino:

This is another single dock port placement that again is available for you to review at a later time with the reference in the lower right hand of the screen.

Dr. Michael Ferrandino:

The Xi port placement, and the Xi is what many of us, most of us, are using these days, is a bit simpler, thankfully. This is now the preferred method that I have. On the left side of the screen, you'll see what was published by the group out of Miami in 2015, which is an oblique straight line from about two fingerbreadths below the costal margin, lateral to the rectus sheath, towards the midline. This will give you access to both the upper pole of the kidney, all the way down to the bladder and bladder cuff. But if you look on the right side of the screen, this is again my colleague, Dr. Hemal's, publication on his approach, which is more a straight line along the lateral border of the rectus.

Dr. Michael Ferrandino:

So, there obviously are a variety of ways this can be done and you just need to try one or the other. Again, I prefer the oblique angle and I find that it gives me really good access without having to reposition the patient, reposition the robot or even rotate the table.

Dr. Michael Ferrandino:

I was also tasked to speak about lymph node dissection. I'm doing it at this point because the videos I have are kind of all encompassing, so instead of going back and forth and dissecting everything out, I wanted to talk about lymph nodes and then we'll get right to the videos and spend the bulk of the time on that.

Dr. Michael Ferrandino:

Lymph nodes remained somewhat controversial as far as what the proper template should be, how extensive a dissection should be for upper tract urothelial carcinoma. This is a nice paper on the left by Surena Matin and John Sfakianos, which identified retrospectively a large cohort of patients who had undergone nephroureterectomy with lymph node dissection and identified where the lymph node positivity was noted. So you can see that for a right upper tract tumor, the hilar lymph nodes and the paracaval lymph nodes, as well as the interaortocaval lymph nodes, predominantly got about 85 to 90% of nodal disease. For the left side upper tract, it was the hilar lymph nodes combined with the paraaortic, were the predominant sites again getting up to 85, 90% of metastatic disease. This is confirmed by other studies as well. So, while we don't have very proscriptive templates, I think that's an area that we could do a large group research project in an effort to identify really what would be the best long-term outcomes. But there are a number of templates that extend from the hilum down to the iliac. Whether or not they encompass both the interaortocaval and the retrocaval depends upon your position on lymph node dissection. But I do think that a lot of these patients would benefit from an extensive lymph node dissection.

Dr. Michael Ferrandino:

We're going to get right to the surgery now and my moderators are welcome to weigh in when they have questions. We'll start demonstrating the standard mobilization of the bowel. Here we have our left hand putting gentle traction down and the right hand releasing the attachments of the bowel from the anterior surface of Gerota's fascia. You want to extend this dissection as medially as you can, as cephalad as you can and as distally as you can. Here, we can see Gerota's fascia being reflected off of the lateral aspect of the undersurface of the peritoneum, elevating the ligament so that we can get under the spleen and start to roll the spleen off of the superior aspect of the kidney. You do want to take care in this area not to enter the splenic hilum.

Dr. Michael Ferrandino:

We now come back down to the lower pole and you can see ... I left this in here to show that we don't edit everything out. There's a small peritoneal window and, as I like to tell my trainees, the most common place I ever encounter a peritoneal window and make a small peritoneotomy is on the left side on the medial aspect of the lower pole. Then once we've mobilized the bowel medially and we're able to start to get under the tail of the kidney, our next step is going to be to elevate the lower aspect of the kidney and then start to approach the area into the retroperitoneum. So you can see the left hand is gently holding up on the kidney. My assistant is holding down and suctioning, but in a moment they'll start elevating for us, so we can continue to work with two hands.

Dr. Michael Ferrandino:

I often will use two hands only for the upper portion. I try to minimize external clashing and improve mobility for my assistant by using as few arms as possible. If we find we need the third robotic hand for retraction, I will have that available to be docked. You'll definitely want that available during the case, particularly for the lower aspect.

Dr. Michael Ferrandino:

So, we have elevated the kidney. Now this elderly lady had had some positive adenopathy. I had tried to approach the hilum and get control of it over the adenopathy, but I found that there were a few too many branches, so we came back and decided to do an en bloc resection of most of the aortic lymphadenopathy. So here we identify the gonadal and get under the gonadal and lateralize it. You can see the aorta coming into play on the lower aspect of the dissection, right around here. So as we proceed cephalad along the aorta, we know we're going to encounter the left renal artery. We can see the left renal vein somewhat retracted medially and we continue to carefully lift the adenopathy as we progress increasingly cephalad towards better dissection of the hilum. Any of these larger lymphatics, we do like to take with clips. You'll see throughout portions of this video judicious use of clips in an attempt to minimize any lymphatic leak, chylous, ascites.

Dr. Michael Ferrandino:

We now have the renal artery coming into play, off of the aorta. And then you can see that we've identified a lumbar vein coming off the backside of the left renal vein, which we are going to take with clips in a standard fashion. I was always trained by my mentor, Dr. Dave [inaudible 00:15:00], to never load a clip applier on top of the vessel for the potential risk of the clip being ejected and cutting through the vein and I try to teach that now to all of my trainees. So now we've got the lymphatics and lumbars out of the way. We try to identify the renal artery and get control of it. That is a 30 mm Endo GIA stapler. We've really skeletonized both of these vessels very well beforehand so that when we approach these to do our hilar dissection, our nodal hilar dissection, we've not incorporated any of the additional tissue and we are therefore more readily able to dissect the hilar lymph nodes off of these structures without injuring the vessels that we've so carefully preserved.

Dr. Michael Ferrandino:

Once we've done that, we can now go back. I do like to take the gonadal vein so that we don't have to try snaking the kidney underneath the gonadal vein. So I'll take the gonadal vein and then we'll come in and identify the ureter. At this point, now that the hilum is controlled, I feel comfortable taking the ureter as well, or at least clipping the ureter, which you'll see in a second. There's our ureter and we'll clip it so that we'll minimize any risk of seeding of the lower tract.

Dr. Michael Ferrandino:

We'll now proceed along the lateral aspect of the kidney, freeing the kidney from its lateral attachments from the sidewall. This area is generally very easy managed bluntly with small bits of cautery. Once I've got most of the lateral aspect mobilized and freed up, I'll go ahead and then come at what's remaining at the superior aspect because we'll have a lot more mobility. You need to use judicious cautery in this area because you can have a significant number of vessels that run in the renal colic and splenocolic ligaments. I think you'll see in a minute we weren't using all the cautery that we probably should have and got into a small vessel there. So a lot of bipolar and monopolar cautery as we freed the upper pole attachments.

Dr. Michael Ferrandino:

Then we'll tuck the kidney down towards the pelvis and we'll go back onto our aorta and clean off the lymphatics, as possible. The preferred extent for this dissection for me is going to be everything along the lateral aspect and anterior aspect of the cava. I'd like to try to, and you will see at one point we do get down to the bifurcation where the left common iliac artery becomes visible. Care should be taken throughout this portion of the procedure to preserve any of the nerve structures, which is what's being identified here. We're just teasing all the lymphadenopathy out from behind them, again clipping where appropriate so that we have control of the vessels or control of the lymphatics, and continuing to cut and cauterize as appropriate.

Dr. Michael Ferrandino:

I see my buddy Sammy Elsamra mentioned that use of the robotic clip applier is appropriate. I do use that, not infrequently. Especially I find it for difficult to reach areas. But for areas like this, where I can put them on a nice stretch and have my assistant access it directly, it's a little more of a time saver to not have to change the instrument as much so we can keep working forward.

Dr. Michael Ferrandino:

You try to split and roll around the nerves and the arteries where possible. It means that we may have to take these out in multiple smaller packets, but again the goal is to really debulk the lymphatics and not necessarily do it all in one. I do try to maintain the lymphatic packet into as few bundles as possible. It'll minimizing losing any of the tissue. It will also allow for better retraction and mobilization as you continue to move forward.

Dr. Michael Ferrandino:

So, we've done the distal dissection and now we're working back up at the hilum and cleaning off any of the hilar vessels, hilar lymphatics that are remaining, taking great care not to injure the renal artery or the stump of the renal vein. If you continue to watch, what you'll see in a moment or two is that we'll have accessed the IMA and then I'll show a brief overview of the entire dissection template that we've done.

Dr. Michael Ferrandino:

(silence)

Dr. Michael Ferrandino:

Just for completeness sake, we've gone ahead and shown also a bit of a right-sided template. So what you see here now is a different patient. Obviously we had completed the nephrectomy portion on the right side. So you see the cava down now at the bottom of the screen and lumbar is coming off of the side of the cava as we continue to work our way alongside the cava and elevate the lymphatic packet, again being careful not to avulse any of the lumbars. If you need to because they're engaged, you can clip the lumbars to get better mobilization of the vena cava.

Dr. Michael Ferrandino:

One of the questions I saw just come up was whether or not we can do a cavotomy during these procedures. I've done them for small renal tumors, RCCs growing into the vena cava. I've also, with a robot, injured the vena cava on occasion when lymphatics or the tumor itself was directly engaged with that tissue. But thankfully it is relatively straightforward to be able to place either a Prolene or a Vicryl suture and close a bit of the vena cava.

Dr. Michael Ferrandino:

So we'll continue to work along the vena cava, clearing out anything that we can retrocavally. You can see my assistant is mobilizing the vena cava medially as we continue to work. And after we tease everything out that we can retrocavally, we'll continue to work down towards the pelvis, again freeing up the remaining paracaval tissue and then start to work here in the interaortocaval space and freeing up everything that reasonable to approach and safe to approach both in front of the vena cava and then between the vena cava and the aorta.

Dr. Michael Ferrandino:

Generally, there's a nice dissection plane between the lymphatics and the great vessels. It's really the very aggressive tumors that I find get kind of sticky and [inaudible 00:23:45] that are a little bit more challenging to dissect free.

Dr. Michael Ferrandino:

Once we've mobilized everything off of the vena cava, what you'll see is we'll go ahead and I like to use sealant, either, in this case Floseal and Surgicel to help for any of the minor bleeding around the great vessels, and also potentially seal off any lymphatics. If I'm worried about any larger lymphatic channels that may be in play, I'll try to click them directly or potentially use a surgical glue like Evicel or TISSEEL.

Dr. Michael Ferrandino:

With that, I have covered, I think, nephrectomy and lymphadenectomy. I'll turn it back over to our moderators and hosts.

Dr. Chandru Sundaram:

Thank you, Dr. Ferrandino, for an excellent overview for the nephrectomy part of the nephroureterectomy and we'll the mic to Dr. Ashok Hemal to focus on the bladder cuff management. Please note the polling points there. Please give your opinion back and Dr. Lee will be presenting the results. Thank you. Dr. Hemal.

Dr. Ashok Hemal:

First of all, I'd like to thank Professor Dr. Jihad Kaouk, President of the Society of Urologic Robotic Surgery, Dr. Dr. Chandru Sundaram, creator of the society and I'd also like to thank Mr. Joyce, the Director of the Office of Education and Peggy Pearle, who is the Secretary of Endo Society, for putting up this program.

Dr. Ashok Hemal:

I have been asked to talk about the management of distal ureteral and bladder cuff, always why. So, the first why we should distal a distal ureterectomy and bladder cuff excision. As you all know, based on the literature, almost 30 to 50% of patients can experience intravesical recurrence if they undergo radical nephroureterectomy. There are two proposed mechanisms for that. One is monoclonal therapy. Because of the tumor seeding, which happens during this procedure and these disrupted tumor cells can implant in the bladder.

Dr. Ashok Hemal:

The second is oligoclonal field change theory. As you know, the urothelium has an increased potential for developing malignant recurrence. So these are the two proposed theories for having a recurrence in the bladder. Now, our technique is basically these are the five major steps. As you saw previously by Dr. Ferrandino, the nephroureterectomy and lymph node dissection. In addition to that, we do an intravesical instillation of either mitomycin or gemcitabine. Our procedure single-docking technique without any intraoperative repositioning, based on the strategic port placement according to the patient. We also do practice concept of neoadjuvant and adjuvant chemotherapy in the appropriate patients.

Dr. Ashok Hemal:

This is by large the port position as shown by Mike. Basically, by and large, to remember easily, you can place all these ports in the linear fashion in the lateral border to the rectus muscle. Even the large patient with the morbidly obese patients, this guy had a 70 BMI and still with the same kind of configuration you can handle this case.

Dr. Ashok Hemal:

I'll show you this because I have been assigned to talk about the bladder cuff part. Basically, these are the standard steps, what we do for these kind of procedures. This is flank position. I do standard flank position you do for the kidney position. The only difference from the Si versus Xi, in the Si you can place the port to be more lateral and the fourth port more medially. I will go straight to the bladder cuff part. I'll not show the lymph node and radical nephrectomy, as that has been already shown nicely.

Dr. Ashok Hemal:

Okay, so, after having finished the lymph node dissection, then you move to the ureter and then you saw I have already placed the clip there, and the clips prevent the tumor seeding while you are manipulating the kidney. So that is very important and beneficial for preventing that downward seeding of the tumor while you are manipulating the kidney. Then you try to dissect towards the ureterovesical junction. So here you can appreciate that the ureter ... and this guy had tumor mostly in the pelvis. The other advantage of the Xi robot, you can move the camera from the cranial port to the other port and you can do the leak targeting towards the distal ureter part where you want to do it.

Dr. Ashok Hemal:

The Xi robot also has facility of using the integrated table motion. So even if you want to dock robot, you want to give a more [inaudible 00:29:06] or change the position right, left, you can do that while robot is docked. So these are the advantages of the Xi robot.

Dr. Ashok Hemal:

Now, here you can see this is the ureter here and that's the ureterovesical junction and here is the bladder cuff. There are ways of doing that. I placed the stay suture before dividing the bladder cuff, and the reason for that is because if I cut the bladder cuff first, sometimes it recedes back and it's very difficult to figure it out. So I'm holding the ureterovesical junction with the fore thumb from my left hand and here is the stay suture and I'm going to excise the bladder cuff. This is using monoclonal scissors with diathermy to excise the bladder cuff and you are doing under vision.

Dr. Ashok Hemal:

While you are doing this part, there is a little trick that you can put suction over the Foley catheter so there will be no spray out the urine in the bladder if it is there. Once you divide, you try to put immediately specimen into the bag, so that the raw surface does not touch to any part of the peritoneal cavity. So especially when there's tumor in the lower part, you should bag the specimen right away. Last is the closure of the bladder cuff, which you can do two layer bladder cuff closure. I'm using a barbed suture. This is a 3-0 barbed suture. And continuous suture being used from one to other end. So in the first layer we are taking mucosa and the detrusor muscle and in the second layer, again, we take a detrusor and seromuscular suture. So that's how we do a perfect cystorrhaphy and then you can fill the bladder from 200 to 300 cc just to make sure there is no leakage, and we try to do a [inaudible 00:30:53] this part.

Dr. Ashok Hemal:

Now, this is another small clip to demonstrate the same concept. Here you can see you put a clip. This is very important in my mind because, as I mentioned to you earlier, the monopolar recurrence happens because of the tumor seeding, which is one of the possibilities for developing recurrence in the bladder. By putting a clip as soon as possible in the ureter, that prevents the downward seeding of any stuff coming from the upper tract. And then you try to keep going down to doing the dissection near the ureterovesical junction. If you want, you can use ultrasonic device or you can use a vessel sealer for doing this part, or you can do a cold scissors and diathermy as I'm showing here. Again, taking our stay suture, I like doing that in the medial caudad in. As soon as you cut the bladder cuff, it recedes back. So, that is the advantage of putting in stay sutures.

Dr. Ashok Hemal:

Here you can appreciate that. We are going through the bladder cuff. At this time, when we do the bladder cuff, we attach the suction to the Foley catheter, so there is no split. In some of the cases nowadays we give mitomycin or gemcitabine before starting surgery, so the patient has in the bladder for almost 60 to 90 minutes and then before cutting the bladder cuff, we empty the bladder and, if you require, you can clean with a bit of distal saline. So that's done in other regions if there is any urine or something, you may show that it [inaudible 00:32:27] out nicely. Then, again, you're trying to close bladder in two layers. The reason for nice two layer closure, as I said, you can take advantage of giving mitomycin or intravesical chemotherapy in the perioperative period. That is another good endpoint to doing a nice bladder cuff and we are holding the bladder cuff with the forceps and making sure that I didn't touch any raw are in the pericolonic cavity.

Dr. Ashok Hemal:

Next, I'm trying to sew the ... Also, you can use indocyanine green. So these are some of the tips. It's not necessary to use in each and every case, but some of these tips you can use in difficult cases with very thick pelvic tissue or very obese patient. In those patients, you can give indocyanine green. Again, there is a difference In uptake. You can see more green in the bladder part, in comparison to the ureterovesical part. So that way you can define and divide using the indocyanine green.

Dr. Ashok Hemal:

The next tip, you can also use pneumocystoscopy. So, what happens when you need to do a simultaneous cystoscopy while you are especially doing a tumor at the ureterovesical junction and you want to make sure that you're cutting at the right place? In those cases, you don't want it splayed inside the peritoneal cavity. Then you can use that pneumocystoscopy and on the console you can see the same while you are cutting and which area you want to divide.

Dr. Ashok Hemal:

This is another example of the tumor involved the distal ureter and ureterovesical junction. Up here, you can see this is the picture and this is the retrograde pyelogram that's involving the distal ureterovesical junction. This is the clip. Here you can appreciate that this is the median umbilical ligament and we are going [inaudible 00:34:22]. Here you can appreciate the splenic artery, common iliac artery. We are dividing the distal ureter above the tumor part. Since we have already done retrograde pyelogram earlier, we are aware, and after dividing this proximal ureter, this is a division here and also this is part of the lymph nodes there. Here you can appreciate the ureter, lower part of the ureter, and this here is the bladder. In this case, we are planning to do complete excision of the distal part of the ureter and after dividing the ureter, we have taken the distal ureteral margin and we have already sent for the frozen section to make sure these margins are negative, and then we are excising the bladder cuff. Now here you see the open bladder cuff and now we are trying to make sure under vision we are going away from the tumor.

Dr. Ashok Hemal:

So this is the excision of the ureterovesical tumor and we are making sure it's a good 5 mm margin. We have taken multiple frozen sections from the bladder edges, which have been reported as negative. Then we start closing the bladder. So it's a kind of partial cystectomy with excision of the ureterovesical junction. When you are seeing the Foley catheter, I'm putting a mild suction on this so that way there will be no spray of urine in your field where you are operating. The advantage of AirSeal, that maintains your pressure. Because if you are using the regular insufflation and if you do suction through the Foley catheter, the pneumoperitoneum will collapse. So it is a good advantage of using AirSeal when you are doing this kind of stuff.

Dr. Ashok Hemal:

Once you close the bladder cuff, then in this case as you know, we are going to do a ureteroneocystostomy. We started closing from the posterior part and this is using a Gore-Tex suture we are trying to do a psoas hitch, because, as you saw, we excised quite a bit of bladder on the ipsilateral side. So that is necessary to do a psoas hitch for doing a ureteroneocystostomy. I use the Gore-Tex sutures. Gore-Tex sutures are nonabsorbable sutures, but you can use [inaudible 00:36:35] PDS suture or Vicryl suture as you like.

Dr. Ashok Hemal:

So, this is demonstration of the ureteroneocystostomy. Because given the current surgical situation, we are putting an interrupted suture and this is an 8 French 26 cm soft stent. After putting a couple of posterior sutures, easily once posterior [inaudible 00:36:59] is formed, then you can place this JJ stent. Here you can see those stay sutures and we have done a bilateral pelvic lymphadenectomy in this case and this is further closure of the ureteroneocystostomy.

Dr. Ashok Hemal:

This is a postop picture. You can see this is ureteroneocystostomy site and this is upper tract, you can see. So the question is why management of distal ureter and bladder cuff is important. Because the chance of intravesical recurrence is very high and still there is no consensus on which way to go, open, lap or robotic.

Dr. Ashok Hemal:

Now, when we look at the illustration of the open surgery, these are the standard ways of dealing with the distal ureter, either extravesically, transvesically and combined approach. In the past, I have published comparing retroperitoneal laparoscopic radial nephroureterectomy with open surgery for these cases, and in the world of minimally invasive surgery these were being used with the stapled technique or the ureteral unroofing technique, ureteral resection "pluck" technique. Also we have used LigaSures. All of these techniques have very well been described in the minimally invasive surgery literature. However, the biggest problem in these patients that undergo open radical nephroureterectomy, there are 54% chance of intravesical recurrence. Also, there is a possibility of 20% recurrence in the retroperitoneal area.

Dr. Ashok Hemal:

Patients who are undergoing open radical nephroureterectomy, if the stump is left behind, based on the literature, there is a possibly of 50% of patients may have a ureteral stump left behind. In those cases, there are 30 to 64% chance of intravesical recurrence.

Dr. Ashok Hemal:

What we've found, we have reviewed this paper we published this year. We reviewed 105 patients of robotic radical nephroureterectomy. In 6.6 patients, basically seven patients, we did not dissect the distal ureter or bladder cuff, the reason being local condition in three patients above 90 years of age, and there were circumstances that we did not try to do that. So if we left behind ... So, this is a very good example. In seven patients, we left behind the distal ureteral stump and the cuff, and in those patients, three patients died of metastatic disease and two patients developed local recurrence. So basically, if you leave behind ureteral stump or the bladder cuff, there is as chance that these people can develop intravesical recurrence.

Dr. Ashok Hemal:

Now, this is the device control trial when comparing open and laparoscopic procedures. What they've found is patients undergoing laparoscopic nephroureterectomy, they had a poorer oncologic outcome in comparison to the patients undergoing open surgery. This is a meta analysis of almost 42 studies where they have covered 7500 patients and what they found, when you compare oncologic equivalent of lap and open surgery, you cannot compare the lap with the open surgery where the bladder cuff is not excised, and it is a poorer outcome, especially for the high-risk upper tract urothelial cancer.

Dr. Ashok Hemal:

So what is the best approach? I think a open hand assisted pure ... you may want to consider doing a robotic-assisted nephroureterectomy with bladder cuff excision and lymph node dissection and intravesical insufflation of chemotherapeutic agent. Again, we've published the data in the European Focus and this is from the multicenters and a different author. This is from doctors of all groups, they have published way back in 2014. But most of the people they have done pure robotically doing a bladder cuff, two layer repair and lymph node dissection. So this is being used by all across the board nowadays.

Dr. Ashok Hemal:

The why intravesical for the chemotherapy, nowadays we give therapy just before starting [inaudible 00:41:02] patient is inside, we give intravesical therapy at that time. If you cannot give it at that time, you can give in the perioperative area. The reason for that is to prevent intravesical recurrence and timing you can see according to your case. Usually you can use mitomycin or gemcitabine as you like. We have also given neoadjuvant chemotherapy in a select group of cases, especially for the high risk disease. Adjuvant chemotherapy also you have seen this POUT report which has come in January of this year, where they found the advantage of giving adjuvant chemotherapy since certain patients you can give that.

Dr. Ashok Hemal:

We have also seen doing a nephroureterectomy for advanced disease and we have done for the T3 and T4 disease, however, the cancer specific survival and overall survival may not improve, but there is advantage of doing this procedure.

Dr. Ashok Hemal:

With this, I would like to thank Endourological Society and Society of Urologic Robotic Surgery for giving me this opportunity. I would also like to thank all the listeners. Thank you very much.

Dr. Chandru Sundaram:

Thank you so much, Dr. Hemal. As usual, it is a lot of education listening to your presentations. At this point, we will turn the mic to our esteemed moderators and we'd like to have the moderators answer some of the questions from the chat box and also pose their opinion or questions to the rest of the panel. So, to the moderators.

Dr. Jason Lee:

Maybe we'll start with one of the questions that came up in the chat that several of us answered, but there's probably a lot of discussion about the timing of when to clip the ureter. I know there was, even in the chat box, a lot of discussion. Some for early clipping, those against early clipping. Perhaps maybe we can start with the speakers and get their opinions, and then the moderators about your opinion on early versus later clipping of the ureter.

Dr. Ashok Hemal:

There are two ways of doing that. Early clipping can be done if the kidney is not hydronephrotic, there's not very huge tumor or this kidney is not producing a large amount of urine. In those cases, you can do an early clipping. But if patient has gross hydroureteronephrosis or hydronephrosis, in those cases you should clip. Once you clip the renal artery, thereafter immediately you clip the ureter. As long as the blood supply is going to the kidney, it's going to make the urine. So these are two tricks. For the non hydronephrotic kidney or mild hydronephrotic kidney, you can do early clipping right in the perineum below the tumor. Otherwise, you can do a delayed clipping once you control the renal artery.

Dr. Michael Ferrandino:

My preference is generally to not clip early. Perhaps even despite me doing this for 10, 13 years at this point, I don't have the experience of Dr. Hemal, so I don't always trust that the kidney is going to be able to make it in case there's some other problem, so I do want to clip after I get the arterial and venous supply.

Dr. Sammy Elsamra:

I'm in favor of clipping early. I think the likelihood of not going through with the nephroureterectomy is pretty low, but the points brought up are very valid points.

Dr. Jihad Kaouk:

Wonderful. Dr. Lee, do you want to tell us about the results from the first poll?

Dr. Jason Lee:

I'll post the results to everyone. Hopefully everyone can see them. The first question was about the thought that perhaps MIS radical nephro-U has worse oncologic outcomes. I know Dr. Hemal talked a little bit briefly about that. The majority of this audience feels there may not be detrimental oncologic outcomes with MIS, but there are a decent handful of people who are either unsure or think that there might be worse oncologic outcomes. Any roll for further discussion from the moderators or speakers?

Dr. Sammy Elsamra:

I think MIS is a little bit misleading because it's a big term. It could be laparoscopic, hand-assisted. I think Dr. Hemal pointed that out. I really think a robotic approach with an intracorporeal cuff is going to get you as good an outcome as an open surgery, particularly if you're following the same principles, not spilling, giving neoadjuvant chemotherapy when appropriate, using intravesical mitomycin or gemcitabine. So I think that makes it equivalent to open. Laparoscopic with suboptimal techniques is going to be inferior.

Dr. Ashok Hemal:

There is enough evidence in the literature. When we talk about laparoscopy, I published the data comparing [inaudible 00:45:56] laparoscopic radical nephroureterectomy and comparing with open nephroureterectomy. Since those times, dealing with the distal ureter and bladder cuff used to be a challenge, but the robotic has been a game changer. I can tell you, for the last 13, 14 years, we are using left and right, and that is very helpful for doing a same laparoscopic procedure, but in a more precise way and following all the oncological principles, which you do with the open surgery.

Dr. Rafael Sanchez-Salas:

I think it's very important to point out the oncological principles because even if we agree that the robot is really the way forward, definitely we need to have a surgeon behind the robot, and oncological principles are the key, even if you have to go back to open or lap.

Dr. Jason Lee:

I agree completely as well. I think the robot doesn't make a bad surgeon a good one all of a sudden, if they're violating oncologic principles. I think the technique matters. Some of my open only colleagues, when I have debates about this, there's some concern about the pneumoperitoneum sort of aerosolizing cancer cells and potentially causing more seeding and things like that. Theoretically, if you don't violate the urinary tract and clip the ureter, manage the bladder appropriately, that would be the same open or lap, so I think it's more technique and being fastidious on following the principles in robot lap.

Dr. Ashok Hemal:

If you review the literature, even the people who have undergone open nephroureterectomy, they have developed cutaneous metastasis. They have developed local recurrence. When you are doing robotically as demonstrated, you should not leave the raw specimen inside the body, make sure you are putting in the bag right away and follow all the oncologic principles that we demonstrated. In the literature, the report of the port side is recurrence is 1% to 1.5% for upper tract urothelial cancer.

Dr. Rafael Sanchez-Salas:

Dr. Lee, if you would talk about a no touch technique. Would you do a better job with a robot than we were doing before with the other techniques?

Dr. Jihad Kaouk:

Your point is a great way to get to the next topic about the lymph node dissection.

Dr. Jason Lee:

Yeah. So the next question was about doing lymph node dissections during radical nephroureterectomy. We asked how many people are routinely performing this and the extent of the lymphadenectomy. Approximately 40% of our attendees and maybe panelists who responded as well, do not routinely perform lymphadenectomy during radical nephro-U. 20% said that they always perform it, and then a large portion as well, I guess depending on the location of the tumor, will perform a regionalized lymphadenectomy. So perhaps maybe again we can go back to the speakers and ask them to comment, and then the moderators.

Dr. Michael Ferrandino:

I think, obviously ... I'll start. I think it depends somewhat on the reason you're going ahead with the nephroureterectomy. If you're looking at someone with low grade lower volume disease and a poorly functioning kidney, perhaps it's someone that's very reasonable to avoid it. Additionally, Dr. Hemal brought up the case of a couple elderly individuals where part of the role is getting them on and off the table, so that may be someone else who you want to avoid it in. But in folks who have visible, either directly or via imaging, adenopathy and can tolerate a little bit more prolonged surgery, especially if it's high grade disease, I think it's very important to perform a lymphadenectomy. Again, as I said during my talk, the extent of it is still not defined well enough that I think you're doing wrong if you're doing a regional versus a more extended template, but given the correct indications, I think you should be prepared to do a more extended template.

Dr. Ashok Hemal:

Jason, what you presented the data, is a very clear picture that is a true story that 40 to 50% of people don't perform the lymph node dissection. The biggest challenge with upper tract urothelial cancer is the biopsy report. When you do the biopsy, you just get a superficial part of the tumor. You never get to know if it's T1 or T2. So for thinking whether it's a T2 or T3 or relying on the cross sectional imaging, but not based on the pathology, it's very important to figure it out. If it is a high grade cancer, cytology is positive and cross sectional imaging is showing hydronephrosis or involvement of the peripelvic area, you may want to consider doing a lymph node dissection with two lymph node dissections. So basically, these are the couple of indications for doing a lymph node dissection. When you do lymph node dissection, definitely a template lymph node dissection is a good idea. Dr. Ferrandino has shown a brilliant lymph node dissection. I'm sure not many of us would do for every case that kind of dissection, but in limited cases you can do that.

Dr. Ashok Hemal:

At this point in time, based on the literature, what is the role of lymph node dissection for urothelial cancer, it is just the accurate staging you are going to get and also there can be a prediction of survival in some cases. But it does not improve the overall survival based on the literature at this point in time. But you can remove the maximum debulking of the lymph node and then you can give adjuvant chemotherapy. Based on the POUT trial which has been published in January, adjuvant therapy is good for the T2 and T3 disease.

Dr. Michael Ferrandino:

There was a question in the chat, and I think it's a very important one, about getting tissue diagnosis versus going off of imaging and cytology. I definitely have a strong preference to get tissue. It's a big surgery with a big recovery and significant comorbidities to the patient potentially, so I really want to know that I'm doing it for the right reasons. It's an exceedingly rare instance to proceed without tissue.

Dr. Sammy Elsamra:

[crosstalk 00:52:17]. I think it's also critical to note since it's high risk, the patient should be given the opportunity to get neoadjuvant chemotherapy and you won't know that without a tissue diagnosis.

Dr. Michael Ferrandino:

Correct.

Dr. Sammy Elsamra:

And you may lose the opportunity to give cisplatin-based chemotherapy if you lose a kidney and the GFR drops below 40 or 50, whatever your medical oncologist is comfortable giving cisplatin based therapy.

Dr. Ashok Hemal:

I totally agree for the [crosstalk 00:52:47] ... Sorry.

Dr. Rafael Sanchez-Salas:

Sorry. That being said, I agree with that, but if you have a gross lesion on the CT scan in a patient with hematuria, you can eventually consider to go ahead and perform the nephroureterectomy.

Dr. Ashok Hemal:

I totally agree.

Dr. Rafael Sanchez-Salas:

Because it changes completely the situation.

Dr. Ashok Hemal:

Rafael is a very, very good point. Most of us, when you come across these cases, they are not coming as a silent majority, these patients. They come with the hydronephrosis, flank pain, gross hematuria. So, that is the biggest challenge to giving them neoadjuvant chemotherapy. We are a proponent of giving neoadjuvant chemotherapy, but in our setting, only maybe 15 to 20% of patients are getting neoadjuvant chemotherapy. So we are not able to give it, because of the gross hematuria, flank pain. Unlike bladder cancer, like even patients who have hydronephrosis, you can put a PARP2 and you can give a neoadjuvant chemotherapy. But for the kidney upper tract urothelial cancer, you cannot do a PARP because there is a urothelial cancer there, so that's all the more reason most of the patients undergo nephroureterectomy first and then you can for adjuvant chemotherapy.

Dr. Jason Lee:

So, this poll was about the management of the distal ureter. There was already some discussion both in the talks and in the chat. The first question was about technique too manage the distal ureter. A large proportion of our respondees said that they perform a formal bladder cuff excision. Based on Dr. Hemal's talk, he'd be very happy with that. But there are a few people who also still perform other methods of managing the distal ureter. Just wanted to open it up to the moderates and the speakers to comment on their technique, on why and when.

Dr. Ashok Hemal:

I see there are three points. So one, they said cystoscopic resection technique. I would not encourage doing that. There are two reasons for that. Number one, you are going to use irrigation while you are doing that. So if there is involvement of the bladder cuff, due to the field changes, you are going to spill urothelial cancer in the peritoneal cavity. Similarly, you are trying to do it blindly, excising the bladder cuff. So there is a chance of more extravasation. So that is number one for that part. Plus technique is again operator dependent. It requires technically skilled. Those who have done, they know that. Again, it's out of favor, and only there are two people that have signed up.

Dr. Ashok Hemal:

Regarding the completely intracorporal, yeah, I do believe in doing completely intracorporeal minimally invasive technique, and that's how I do in the robotic. But in some cases, you cannot do. This is not hard and fast rule that you've got to finish intracorporeally. For me, most important, it is an oncologic operation. If you cannot completely do robotically, do kidney ureter part robotically, make a Gibson incision or the Pfannenstiel incision and take out the bladder cuff from there. But do follow the oncologic principles.

Dr. Michael Ferrandino:

I agree with dr. Hemal completely. This is a cancer operation. Do the right surgery for the patient. I will say through the years, prior to robotics and even early on with the Si, I've done the cystoscopic resection and then with the pluck. I've gone through all the machinations. But currently, thankfully, the equipment has advanced, as has my skillset, to the point where we typically can do it intracorporeally, completely robotically, but even before I was completely comfortable doing that, if I ever hesitated endoscopically, I was doing a Gibson incision to extract and get a small bladder cuff. You have to do the right thing.

Dr. Rafael Sanchez-Salas:

In which patients we could avoid to do the bladder cuff? Are there any situations in which, beyond the clear understanding of the oncological principles, we can eventually not to do this step?

Dr. Ashok Hemal:

The reason is, as I said, there are two proposed mechanisms. If you're going based on the [inaudible 00:57:05], the tumor seeding they can [inaudible 00:57:07] in that area, that is one possibility. And second, because the field changes. Based on the literature, if you look at the literature, when there is intravesical recurrence, that happens at the ipsilateral ureterovesical junction area. So that is the reason for doing a bladder cuff excision. Now, even if you don't want to do a bladder cuff, you have to do a ureterovesical junction. So think about that. Terminal ureter at least 1 cm, it transgressed through the detrusor muscle. So you are doing that, so you've got to do that.

Dr. Ashok Hemal:

Now, bladder cuff, we are not saying to excise the 5 cm bladder cuff, but just you're trying to make 5 mm or 1 cm margin around the ureterovesical junction.

Dr. Jason Lee:

All right. Maybe time for one more poll question to review, and that's mainly the management of the Foley catheter. With the robotic approach, you can really limit your dissection, your cystotomy. Even when taking a bladder cuff, you can really test that closure intraoperatively. So looking at that, there's a decent proportion who remove the Foley catheter fairly soon, it looks like, after surgery, like they would after a radical nephrectomy. There's still a large proportion that still formally do either a cystogram or wait a week, two weeks, etc. Then there's also discussion, and I think it was discussed in the chat as well, about the role of intravesical mitomycin or gemcitabine at the time of Foley removal or intraoperatively as discussed. Maybe perhaps folks could comment on their opinions on that or their management.

Dr. Ashok Hemal:

Jason, if you look at the randomized control trial which was published from the UK, in that first randomized control trial they would remove the catheter after one week or 10 days, do the cystogram, then given the mitomycin. In the other Japanese trial, they use to give it after 48 hours or so. Now with the robotic assistance, things have changed entirely. In our practice, we give patient in a side position. We give that because you are going to take about hour to 90 minutes apart for doing the kidney and lymph node part. By that time, you have already given the intravesical chemotherapy, whether you want to give mitomycin or gemcitabine, and then you clip the ureter and before cutting the bladder cuff, you can empty the bladder.

Dr. Ashok Hemal:

The other way is you do a really nice closure, you test the repair by giving intravesical watering stimulation on the table. If there's no leak, then you can give in the postop perioperative period. Now, as far as the timing is concerned, there is a lot of debate. There's no clear cut evidence to say you should give within 24 hours, within six hours, but it is always important, looking at, extrapolating from the bladder cancer data, you should try to give as early as possible. So this is one part.

Dr. Ashok Hemal:

Regarding if you have given intraoperatively, then you can take out catheter depending on how is your repair. You cannot make argument if you take out the catheter in two days or five days, but one has to see, according to individual patient. If you are operating on a 90-year-old patient, perhaps you want to leave a catheter for a week or 10 days, or if repair is a little bit [inaudible 01:00:18] or you're not very happy, you may want to leave a catheter in longer. But usually five days by and large I will say average, we take out the catheter. I do not do a cystogram routinely.

Dr. Jihad Kaouk:

I am afraid I have to end the discussion here, as we are running out of time. We can keep listening to all these tips and tricks from you all day without being bored. Fantastic session. One of our best attended sessions so far. Thank you, Dr. Hemal, Dr. Ferrandino, and our esteemed moderators. I would like to remind the attendees that this session is recorded and it will be posted on the Endourology website for those of you who missed part or all of it.

Dr. Jihad Kaouk:

Our next webinar will be on September 11, in two weeks from now, and that will be focused on robotic partial nephrectomy. On behalf of the Endourology Society and the SURS Society, we would like to thank you all for participating and attending this session. Thank you all.