Surgeons: Chandru Sundaram and Francesco Porpiglia

Moderators: Arieh Shalhav and Jihad Kaouk


 

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. 


Dr. Arieh Lieb Shalhav received his B.Sc. and M.D. degrees from the Hebrew University of Jerusalem.  In 1995, he completed a urology residency at the Sheba Medical Center, Sackler School of Medicine of Tel Aviv University. In 1998 he completed a 2 year fellowship in laparoscopy/endourology at Washington University in St. Louis with Ralph Clayman. He remained as faculty at Washington University for one year. In 1999 he accepted a position as Director of Laparoscopic Urologic Surgery and Assistant Professor of Urology at Indiana University School of Medicine, Indianapolis, where he developed one of the most active laparoscopic donor nephrectomy programs in the country.

In 2002, he joined the faculty at the University of Chicago Medical Center as the Director of Laparoscopic Urologic Surgery. At the University of Chicago he established one of the nation’s largest laparoscopic and robotic urologic surgery programs and fellowships of the Endourological Society and Society of Uro Oncology. He authored multiple manuscripts, has been faculty on multiple conferences and run 5 major courses on robotic surgery at the University of Chicago.  In 2007 Dr. Shalhav was named The Fritz and Mary Lee Duda Family endowed Professor and Chief of Urology at the University of Chicago. In September 2010, Dr. Shalhav was the President and host of the 28th World Congress of Endourology Meeting in Chicago. At the University of Chicago, he founded and built one of the nation’s most preeminent multispecialty robotic surgery program. He has received awards for his teaching, research and clinical work from multiple Societies. Dr. Shalhav has a vast experience in robotic and laparoscopic management of urologic disease. His major academic contributions focused on refining laparoscopic and robotic donor and partial nephrectomy, as well as robotic radical prostatectomy technique and clinical pathways.

His current clinical and academic work is focused on management and outcomes of localized kidney and prostate cancer, his administrative interest is building a cross specialty institutional robotic surgery program.

Jihad Kaouk, MD FACS, FRCS (Glasgow) is an American Board certified Urologist and the Director of the Center for Advanced Robotic and Image Guided Surgery at the Cleveland Clinic Glickman Urological and Kidney Institute. He also serves as a Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, the Vice Chair of Enterprise Surgical Operations and the chair holder for the Zegarac-Pollock Endowed Chair in laparoscopic and robotic surgery. Dr Kaouk is immediate past President of the Society of Urologic Robotic Surgeons (SURS) and Editor-in-Chief of Urology Video Journal (UVJ).

In Innovations, he has performed several first ever done surgical procedures, including the first Robotic single port surgery through the belly button in 2008, the first completely transvaginal kidney removal in 2009, and the first robotic perineal prostatectomy in 2014 Dr. Kaouk holds 2 USA patents for medical devices used mainly during partial nephrectomy and in robotic surgery.

Since 2005, Dr. Kaouk has served on committees at the national and local levels. From 2005-2008, he belonged to the American Urological Association’s Urologic Diagnostic and Therapeutic Imaging Task Force, and from 2006-2010 he was on the Guidelines for the Management of small Renal Masses committee. Currently Dr. Kaouk chairs the AUA “Laparoscopic, Robotic and New Technology” committee.

Dr. Kaouk have lectured in over 145 scientific meetings, chaired 26 urologic meeting and performed live surgery in 18 medical centers worldwide. He authored over 520 peer reviewed scientific publication, 46 book chapters and hundreds of scientific abstracts and surgical movies. Dr Kaouk received 32 honors and awards including “Cleveland Clinic Innovator Award” twice, “Teacher of the Year” award, and several best surgical movie awards.

Presently, Dr Kaouk holds membership with the American Urological Association, the Endourological Society, Society of Urologic Oncology, Society of Robotic Surgery, and the Lebanese Order of Physicians. He is a fellow of the American College of Surgeons. Recently, Dr. Kaouk received an Honorary Fellowship of The Royal College of Surgeons (Glasgow).

 

Webinar Transcript

Dr. Chandru Sundurum:

On behalf of Doctors Joyce and Dr. Matlaga from the Office of Education of the Society, it is my pleasure to invite you all to a bi-weekly webinar on robotic surgery. Same time, every Friday for the rest of this year, once in two weeks. This webinar will also get you CME privileges and credits, so please watch out for those and ensure that you [inaudible 00:00:35] for that opportunity. We have fantastic faculty and moderators to help us along during this webinar.

Dr. Chandru Sundurum:

I am delighted to introduce to you, our past President of the Society of Urologic Robotic Surgeons, Dr. Jihad Kaouk, who has put in a lot of work to set up these webinars. He will introduce the speakers and moderators. Jihad.

Dr. Jihad Kaouk:

Thank you so much, Dr. Sundaram. Indeed, this is a very special session, today, in our series on robotic surgery, presented by the endourology society and sirs. Today, the focus will be on robotic partial nephrectomy and we have two world leaders in robotic partial nephrectomy. We have Dr. Chandra Sundaram, who you just heard from and he is from Indiana University. He is the fellowship program director there and the vice chair.

Dr. Jihad Kaouk:

Also, we have Dr. Francesco Porpilgia, who is a full professor in Turin and actually runs one of the premiere meetings in Turin, every year, in January, about the latest technologies and the meeting is called [inaudible 00:01:59]TUMP. This session will be moderated by Dr. Arieh Shalhav, who is the Chief of Urology at University of Chicago. Also, a world leader and a pioneer of laparoscopy to start even before robotics and partial nephrectomy and I will join him in the moderation of this session.

Dr. Jihad Kaouk:

A few things about the session today, we have divided the one hour into three 20 minute blocks. The first 20 minutes we will have Dr. Chandra Sundaram will be presenting the latest techniques on the partial nephrectomy, followed by 20 minutes by Dr. Francesco Porpiglia, where he will present some intraoperative navigational systems that will help increase the precision of the surgery. During this 40 minutes, we will have a live chat where all of you attending this session can write to chat. Please note that the questions go on chat, not on the Q & A button and we'll be answering you in real time via the chat itself.

Dr. Jihad Kaouk:

The last 20 minutes of this session, we will focus on a live discussion by the moderators and we will have some of the questions answered live by the surgeons.

Dr. Jihad Kaouk:

A reminder that this is a CME accredited session so you can log in as Michelle Cauley instructed us in the emails on the link below. We will move on with the first speaker. Dr. Sundaram, the mic is yours.

Dr. Chandru Sundurum:

Thanks, Jihad. During the next 15 or 20 minutes, I'm going to share with you certain technical aspects of a standard robotic partial nephrectomy. This is based on my experience, about two decades with robotic renal surgery.

Dr. Chandru Sundurum:

So, this is a 67 year old man who is found to have a three centimeter right renal mass with an adjacent renal cyst, and I will review some of the images for you before we get to the video. You can see the mass out here and adjacent to that is a cyst. So, the plan would be to remove the cyst and the mass and block. It does [inaudible 00:04:32] the collecting system and that is a [inaudible 00:04:36] view of the mass as well as the cyst that you just saw.

Dr. Chandru Sundurum:

So, this is the full placement. The patient's head is on the right, the foot is on the left, and typically, views of three robotic arms: a camera arm, an assistant arm (this is for the retraction of the liver), and you have one other five millimeter trocar for the assistant. You will notice that in many robotic partial nephrectomies, they use two trocar for the assistant and the others for the robotic system.

Dr. Chandru Sundurum:

This video is played in 2x speed, so I'm not as fast as you would think I am. For us to go through all the steps. You will see the liver on your right, up here, and we go straight to the liver to mobilize the liver and get to the inferior vena cava. That allows us to get access to the hilum in a much quicker fashion and is quite predictable.

Dr. Chandru Sundurum:

You can see the duodenum on the lower part of the screen and within a few minutes, you get to the hilum. Once the duodenum is mobilized, the inferior vena cava can be visualized. This is the inferior vena cava and you can see the beginning of the [inaudible 00:06:25] vein here. The renal vein is up there.

Dr. Chandru Sundurum:

Once you get below the hilum, you can observe lateral traction and use the fourth arm. The video is a little choppy, but I'm hoping it settles down in the next few minutes. So, the key is to get below the hilum and [inaudible 00:06:57] source muscle as you can see there at that arrow. Once you develop that plane, use the fourth arm to observe lateral traction on the kidney. Once that is done, you can see the renal artery there, that shows up. Now, the renal artery is now being isolated with a vessel loop. A Hem-o-lok clip is placed on that to isolate the artery.

Dr. Chandru Sundurum:

That is the tumor that is exposed. Once the hilum is done, get to the tumor. You can see the cyst as well as the tumor being visualized there. The question here is, is this simple cyst adjacent to the tumor or is it part of a cystic mass? Is part of it being cystic and the other being solid? In any event, the decision was made to take this out in one mass.

Dr. Chandru Sundurum:

It's important here to visualize the renal parenchyma 360 degrees around the tumor or entirely around the tumor. Once that is done, ultrasound is done very meticulously. That is not shown in this video. So, it's important for every case to do a very thorough ultrasound using a drop in probe to mark out the margins. Once that is done, the sutures are introduced and so are the bulldog clamps. Using the appropriate bulldog clamps is good. In this case, we use a SCANLAN's bulldog clamps, but there are various other bulldog clamps that can also be used efficaciously.

Dr. Chandru Sundurum:

It's important to know that the closing pressure of the bulldog clamps are good and it has not decayed over time because that can cause problems. So, I typically use two bulldog clamps on the artery. The vein does not need to be, typically, clamped, but in case of a large mass, especially on the right side, clamping the vein as well would be good. In this case, the vein is being clamped.

Dr. Chandru Sundurum:

Once you get good vascular control, the mass has been exposed. It's important to expose the mass, like I said, all around the tumor, and what I do is deepen the margins, create the margins right around the tumor before going deep. This allows some of the venous bleeding to take place so as we get deeper, the field is dry. In the right hand, I'm using a bipolar forceps. On the left hand is the scissors. On the left hand is the bipolar forceps. The right hand is the scissors. Blunt and sharp, the section is used with clear visualization of the margins.

Dr. Chandru Sundurum:

If you do have a positive margin at this point, you can re-correct your margins and achieve a negative margin. So there, when you see a blood vessel, there are some who would use clips, little clips. I tend not to use clips, but just mark it with a bipolar diathermy and carry on. So, the margin continues. The resection continues. And you can see the assistant's suction is important during this time to ensure a bloodless field is [inaudible 00:11:43].

Dr. Chandru Sundurum:

By going circumferentially, initially, you can join those cut margins as you complete the resection. The goal is to get a negative margin. It does not need to be a very large margin. In fact, enucleation in some cases would also be acceptable. That completes the resection and the next is the renography. So, the question is do you do a single layer renography or a two layer renography? Typically, we do a two layer renography. You see the vessels being coagulated there and marked, and this is to also mark them so that when I do the renography, I can individually pay more attention to those areas where the blood vessels were.

Dr. Chandru Sundurum:

So, the first layer renography is being done with a barbed absorbable suture. I think any suture you're used to is fine, whether it's Vicryl or Monocryl, it's perfectly acceptable. It's important not to go very deep here because you may compromise deep blood vessels. That completes the first layer of renography. You do a sliding clip renography there. I tend to pull up on both sutures, but using a STRATAFIX suture you could do that, even on the other side.

Dr. Chandru Sundurum:

This is the running second layer of renography. Here, we're using a [inaudible 00:13:42] barbed absorbable suture, a STRATFIX is being used in this case, and after each stitch, I use a sliding clip technique to compress the renal parenchyma and to bring the margins together. There are multiple ways of doing this. You could do a horizontal mattress. This is what I tend to do and this seems to work, but again, there are lots of methods to do this. So, that completes the second layer of renography. You could do an [inaudible 00:14:21] early on clamping before you do the second layer. That is certainly acceptable. That completes the second layer of renography and brings the margins together.

Dr. Chandru Sundurum:

I do not, typically, use bolsters. In fact, I almost never use bolsters and use the Floseal or any sealant only if I do a single layer renography or a non-renography technique. Otherwise, you do not need any sealant or glue.

Dr. Chandru Sundurum:

The clamps are released in this case and then you ensure that there is no bleeding, and that completes the partial nephrectomy. You tighten it up a little bit more. You can use a [inaudible 00:15:22] clip or what we tend to use now to save on cost is to use two clips at the end, rather than add a [inaudible 00:15:31] clip as well, but that is certainly acceptable too. So, tighten up all the sutures, make sure there's no bleeding, and add another clip.

Dr. Chandru Sundurum:

So, negative margins and a bloodless field are probably the most crucial parts of an operation during this partial nephrectomy, apart from having a [inaudible 00:16:00] time that's less than 20 or 25 minutes. This is certainly ... It shouldn't take too long, but it's not a race for every minute in most cases with normal renal function. If renal function is compromised or you have a solid kidney or multiple masses, you can techniques like enucleation or non-clamp technique.

Dr. Chandru Sundurum:

It's important at this point to have a good assistant for this operation since every part of this operation is important. There's lots of little technical details, but not every partial nephrectomy is the same. The [inaudible 00:16:57] fascia is being sutured overlying the defect to retro[inaudible 00:17:03] the kidney once again. And that completes this standard partial nephrectomy.

Dr. Chandru Sundurum:

I chose this case primarily because this is what most people do majority of the time and this is a technique that has been useful for me for many, many years.

Dr. Chandru Sundurum:

So, that was a pathology. I'm just going to go through this interrupted closure. I've got another three minutes or so and I'll be done. So, you could use an interrupted closure, for sure, and some people do use that, and this is just a depiction of an interrupted closure. In this case, o-Vicryl is being used. The advantage of this is you can tighten them up individually at the end of the procedure, but is a little bit more difficult then when you do a running second layer renography.

Dr. Chandru Sundurum:

So, you'll lay all these four or five o-Vicryl sutures and then you tighten them up, and you can see here that they're all sequentially tightened. You can unclamp and you can tighten even more, and if it continues to bleed, you can actually use these sutures to put in another couple of sutures as well. There's lots of wiggle room when you use an interrupted technique. When you're starting off, I think, doing an interrupted second layer renography is certainly an option.

Dr. Chandru Sundurum:

I'm going to go to the next slide. This is a T1b tumor, solitary kidney. The reason I want to show this to you is sometimes you're not able to do a two layer renography. In this case, it was a solitary kidney, two layer renography doesn't compromise some renal volume post-operatively. So, in this case, we elected not to do a two layer renography. This was a large mass that was removed and you just do a single layer renography. Nothing wrong with that. You can unclamp and in this case, we do use a Floseal and a bolster just to make sure that there's no further oozing there, and that's certainly an option.

Dr. Chandru Sundurum:

Just to give you an idea of what this is all about. We just looked at 300, 298 ... The last 298 cases that we did. It takes about, for skin to skin in our hands, less than four hours warm ischemia time. Conversion in two cases. Mean hospital stay a little over two days. Overall complication, this is including every complication, minor complications included, like [inaudible 00:20:33] and anything at all, is about 13%. We had one leak that was managed conservatively because we had a drain. We typically use drains in about, maybe, 30% of the time. Most of the times, we don't. So, this is our outcomes data and that concludes my presentation and I look forward to Dr. Francesco Porpiglia's presentation on advanced techniques on imaging during robotic partial nephrectomy. Thank you for this opportunity.

Dr. Jihad Kaouk:

Thank you, Dr. Sundaram, for this wonderful presentation. This is a very nice demonstration of the robotic partial nephrectomy technique. We do have one poll question. We're going to, through the hour, have three polls that may help us in direction our discussion in the last 20 minutes. At this point, please answer the polls and let's listen to Professor Porpiglia. Very excited to hear from you.

Dr. Francesco Porpiglia:

Thank you, Jihad. I'm very honored to take part of this very important [inaudible 00:21:40] and my presentation today will be focused about the possibility to use the 3-D augmented reality, and obviously, as you know, I have good experience about the possibility to use a 3-D reconstruction and the 3-D reconstruction, in my opinion, is very important because it can give us the possibility to play in the operation. At the same time, we're going to transfer if you want, the images [inaudible 00:21:57] inside the robot. [inaudible 00:21:57]. To do the operation and the guidance with the 3-D modeling.

Dr. Francesco Porpiglia:

So, now, we're going to start with the video and show the [inaudible 00:22:30] case. The case is of one young lady with a tumor that [inaudible 00:22:37] and located in the posterior face of the kidney. Okay, and in this posterior face over the kidneys, you can see the completely centered tumor, as you can see. This can be defined as a complex tumor and this CT scan is made with a 1mm slices, and this shot, thanks to the CT scan, we can do the 3-D reconstruction.

Dr. Francesco Porpiglia:

The 3-D reconstruction is this one. [inaudible 00:23:13] kidney and thanks to one of the [inaudible 00:23:18], we can visualize very well the tumor and the structures. The tumor structures that are inside the kidney, in the center part of the kidney, and the [inaudible 00:23:29] as you can see, we can also evaluate the possibility what [inaudible 00:23:35] and the one that we clamp [inaudible 00:23:37]. A single branch over the artery like this. The posterior branch of the artery and [inaudible 00:23:44], as you can see, it is possible to visualize the degree of ischemia that we have in concern.

Dr. Francesco Porpiglia:

In this case, we established that 40% of the amount of parenchyma is involved in ischemia time. So, at this point, we can simulate, also, other type of other clamping like this. Certainly, the single branch can be simulated. In terms of the involvement, of the amount of parenchyma, that [inaudible 00:24:17] evolve in the ischemia. [inaudible 00:24:21] it's very important to establish the type of ischemia that we'd like during the operation.

Dr. Francesco Porpiglia:

At this point, they can [inaudible 00:24:32], like in this case, they're going to do the clamping of the posterior branch. For the main artery, I think [inaudible 00:24:43] this on the ischemia and certain at this point, that they can establish that this is good to do this because they're going to [inaudible 00:24:52] vasculature the distribution up to the branch. At the same time, inside of the parenchyma are giving me possibility to perform [inaudible 00:25:04] clamping with respecting in this case, the big amount of the parenchyma.

Dr. Francesco Porpiglia:

Moreover, as you can see and you can study also the relationship between the tumor [inaudible 00:25:19] system. As you can see, the upper parts are debilitated. The debilitation could be correlated with relationship to the tumor and the [inaudible 00:25:31]. So, at this point, I think that we need to remove the upper [inaudible 00:25:36] in order to become two to be more radical in our operation.

Dr. Francesco Porpiglia:

Certain after I schedule this operation, I start with the operation and at the same time, this is the final view. [inaudible 00:25:54] start with the incision of the perineum and the [inaudible 00:25:56]. As you can see, I can visualize very well the kidney and the [inaudible 00:26:09] from the fat and other [inaudible 00:26:12], and after [inaudible 00:26:13]. At this point, I try to dissect the [inaudible 00:26:20] and the single branch of the artery.

Dr. Francesco Porpiglia:

This is my kind of view that I have. As you can see, this is the ureter and the vein, and now, as I try to dissect the main artery and [inaudible 00:26:36] I, obviously, going to dissect and I loop around the main artery, and I suspend around the loop. It's important to dissect this [inaudible 00:26:52]. If I want, I can dissect the single branch, but it's important that I dissect the first artery branch. [inaudible 00:27:01] capillary because you can not have a [inaudible 00:27:03] on two clamps on the capillary artery.

Dr. Francesco Porpiglia:

Certainly, in any case, also [inaudible 00:27:07] two clamp on the capillary plane, the capillary artery can in all cases, you can isolate it. In any case, [inaudible 00:27:17] because in case of bleeding, obviously, it's better to be safe. [inaudible 00:27:17]

Dr. Francesco Porpiglia:

When a tumor is a center tumor, I think that this is very useful to dissect, to suspend, also, the vein in order to have good control on the vein. Now, they're going to perform the operation in a safe manner.

Dr. Francesco Porpiglia:

This is the [inaudible 00:27:18]. This is the dissection that I did. This is where we [inaudible 00:27:18] the artery and I will clamp during the operation. So, at this point, they're going to take the two and tie it off. [inaudible 00:27:58] They're screening two parts. The upper part and the lower part. The lower part, they can superimpose the images like this one so I can visualize the [inaudible 00:28:08]. At this point, where the tumor is located because, as you know, the tumor is in the posterior part of the kidney. So, I imagine that the tumor will be posteriorly and certain there is a [inaudible 00:28:21] artery and there is also the relationship with the [inaudible 00:28:24] cortex.

Dr. Francesco Porpiglia:

I continue with this superimposed imaging [inaudible 00:28:31] where the tumor is located, but as you know, the tumor is posteriorly. So, at this point, I can rotate the kidney and, thanks to this rotation and with the manual guidance, I can individualize the tumor and under this visualization I can perform the incision along the surface of the kidney with this seesaw.

Dr. Francesco Porpiglia:

Certain under the vision, under the superimposed imaging, without using the ultrasound, I mark the surface of kidney and certain, at this point, I can start with the [inaudible 00:29:17] incision of parenchyma.

Dr. Francesco Porpiglia:

So, at this point, with the incision, I can clamp [inaudible 00:29:25]. [inaudible 00:29:27] capillary, I can inject the [inaudible 00:29:31]. I see [inaudible 00:29:33] at this point, I can show you exactly what happened. So, when the posterior face of the kidney is completely black because vascularization is blocked and has been established the posterior part of the upper [inaudible 00:29:51] is going to continue to be vascularized.

Dr. Francesco Porpiglia:

In order to show that this is the correct area for the incision, again, I tried to do the superimposed imaging and as you can see, this is the area of the tumor where the incision was going to be made and certain, at this point, again, I am sure that this is the area for the incision and certain I can start my incision, and we can start with the enucleation of the tumor.

Dr. Francesco Porpiglia:

The enucleation has started in a traditional manner and certain I perform it on the big tumor, on a deep tumor. A center tumor is, obviously, going to be [inaudible 00:30:39] a enucleation and not a partial nephrectomy because I try to respect on certain [inaudible 00:30:51] of the tumor and [inaudible 00:30:52] and what I follow and I know how to do a perfect enucleation of the tumor with a surgical certainty.

Dr. Francesco Porpiglia:

This is enucleation that we do, that we perform in a traditional manner, but at this point, I wanted to focus my attention on the possibility to control it step by step with a single vessel. The [inaudible 00:31:25], they go inside the tumor. So, as you can see, in the center part of the kidney, very close, they're going to the [inaudible 00:31:34] and certain that I can clip on the feeding artery, and step by step, I try to clip onto the singular feeding artery and this, in my opinion, is very useful because in this way, I can control the bleeding. I can prevent the bleeding and certain I can do the suture that I do. The level of the [inaudible 00:32:03] will be safe because the single [inaudible 00:32:07] on the feeding artery is very blocked, very closed during the [inaudible 00:32:12].

Dr. Francesco Porpiglia:

Certain as I do, as you can imagine, the control of bleeding [inaudible 00:32:18] and during the [inaudible 00:32:20] recession at the same time. This is a very important point. As you can see, I use a special clip. They are an absorbable. They are Hem-o-lok and the Hem-o-lok will give me the possibility to prevent and the possibility to work on the [inaudible 00:32:33] corbitus at the level in the upper [inaudible 00:32:39] cortex. So that I can prevent in this way complications and the scars. Enucleation will follow it along the, sort of, face of the tumor step by step and I can control, as I said before, the single feeding artery.

Dr. Francesco Porpiglia:

Now, we fit a tube in the feeding artery under a tight clip and this is what I do. So, as I can you see, [inaudible 00:33:20] inside, the parenchyma, this is the fat of the [inaudible 00:33:25]. This is another feeding artery. [inaudible 00:33:33] and I can control this feeding artery [inaudible 00:33:36] with the enucleation. If you want like this, but if the artery is a little big, so I prefer it like this they're going to do, put the clip.

Dr. Francesco Porpiglia:

So, at this point, after [inaudible 00:33:55] and the control the feeding artery and, obviously, I schedule it before and I try to find the [inaudible 00:34:03] cortex, the upper [inaudible 00:34:04] cortex, and certain this is the [inaudible 00:34:09] cortex, that this is very close to the tumor [inaudible 00:34:15], I perform incision on the [inaudible 00:34:17] cortex, and I will remove the [inaudible 00:34:19] cortex and something I tried to do one partial nephrectomy or if you want, a enucleation with an anatomical monitor with the complete respect of the upper ureter [inaudible 00:34:33] because you're going to cause a motion of the tumor, I need to control it, and also the [inaudible 00:34:43] cortex, I tried to remove the [inaudible 00:34:43] cortex.

Dr. Francesco Porpiglia:

So, when the upper [inaudible 00:34:47] of the kidney has been removed, this has been necessary and it has been useful because, as you can see, the tumor in both parts of the upper boat. At this point, I can [inaudible 00:34:59] again, the kidney, and I scheduled it before the operation, I removed completely the [inaudible 00:35:09] cortex, the upper cortex because I, obviously, cannot use [inaudible 00:35:15] because removal [inaudible 00:35:17] parenchyma, the [inaudible 00:35:17] cortex, and I tried to dissect it to isolate the infundibulum of the cortex. In order to respect the anatomy, I tried to close the [inaudible 00:35:36] in the cortex, the infundibulum. So, this is the anatomy that we [inaudible 00:35:45] here.

Dr. Francesco Porpiglia:

This certain anatomy was well clipped before the operation and is continually clipped during the operation. [inaudible 00:36:01] Finally, we meet. [inaudible 00:36:02] With the CT scan, we can treat the reconstruction. At this point, I perform the complete [inaudible 00:36:13] of the cortex and now when the operation is finished, I try to do the reconstruction of the parenchyma. The reconstruction will be done with two layers. First, I'm going to suture [inaudible 00:36:26] monofilament and this suture will be a double suture because I use a two suture because the rescission is a typical rescission, and I need to do a reconstruction of the parenchyma because [inaudible 00:36:26]. The suture I want that are in margin are completely closed to prevent and to have good control to prevent the space from bleeding and possibility to [inaudible 00:36:39].

Dr. Francesco Porpiglia:

Again, each suture, each stitch is with the Hem-o-lok and, again, I use the Hem-o-lok in order to prevent, as I said before, risk of [inaudible 00:37:24] inside the parenchyma. Again, this is the second suture. It's, again, the finality [inaudible 00:37:35] to have a good reconstruction and to give it a possibility of having a perfect cortical suture that I will do with one [inaudible 00:37:48] in monofilament.

Dr. Francesco Porpiglia:

It is not necessary to perform a deeper suture because I think the feeding artery that I controlled before can reduce the risk of bleeding and so, it's a little bit [inaudible 00:38:07] in order to prevent damage of the [inaudible 00:38:15] and intravascular artery. The cortical suture secured with a Hem-o-lok with this running suture, a traditional, standard suture that I do. Obviously, this is not new, but this is like I've shown before, Dr. Chandru Sundurum, this is a standard manner on this kind of suture. So, there's nothing new about this second step of technique.

Dr. Francesco Porpiglia:

So, as you can see, control of the suture, of the parenchyma in the margin, the parenchyma and artery are very close and this is very important to have a very sealing suture in order to prevent bleeding and what I can do, systematically, [inaudible 00:39:18]. So, after the operation is finished and if I want, if I use the Floseal and so, again, I check with the heat [inaudible 00:39:18]. Possibility to see and, again, the vascularization they can complete it and respect it.

Dr. Francesco Porpiglia:

So, at this point, so what has happened in the posterior face. The tumor is removed and suture is okay, and so the operation is finished. Thank you so much for your attention.

Dr. Jihad Kaouk:

Thank you so much, Professor Porpilgia. This is very exciting and maybe the way to go in the future with all the intraoperative navigation. This is the second poll question if you would like to take a second to answer it and we will go to the third segment of our session today that will be the moderated discussion. Dr. Arieh Lieb Shalhav and myself will be joining the attendees and posting questions for the surgeons.

Dr. Jihad Kaouk:

First, I would like to add just the point of clamping the hilum and that, I will share the answers with the first poll. From the attendees, 22% said they clamp both artery and vein, and 68% clamp only the artery, and 18% do selective clamping. I think in the chat box, we add just the clamp of the artery and vein, and so on. So, let's focus on the selective clamping.

Dr. Jihad Kaouk:

Dr. Arieh Lieb Shalhav , what's your opinion about the selective clamping during these partials?

Dr. Arieh Lieb Shalhav :

Usually, don't do selective clamping. I do clip arteries as we go during the excision, and the reason I see them so well is because the blood is not there and the field is beautiful, and you can actually, as you go, identify them and clip them. That really reduces the likelihood of bleeding in the future. So, in general, I almost never do selective clamping. It's either artery only or the whole hilum.

Dr. Jihad Kaouk:

Dr. Chandru Sundurum?

Dr. Chandru Sundurum:

I agree with Dr. Arieh Lieb Shalhav . A few years ago, there was a lot of emphasis on selective clamping and super selective clamping, and zero ischemia and stuff like that, and I don't think that made a big difference for 95% of the cases when you're dealing with really bad renal function. The only place I think selective clamping may have a role is if you have a completely bifurcated renal arterial system. Two renal arteries, one going to the lower pole. The lower pole renal mass and a patient with a solid kidney. Maybe that'd be a great idea to do that, but not required in most majority of patients.

Dr. Jihad Kaouk:

Dr. Francesco Porpiglia?

Dr. Francesco Porpiglia:

So, in my experience, usually I employ the selective clamping. 40% from my experience, you can do partial nephrectomy. Obviously, [inaudible 00:42:36] to dissect and also, the main artery and to have good control of the main artery in case of bleeding, but I think selective clamping can be done only if you have [inaudible 00:42:50] anatomy. If you [inaudible 00:42:52] very well, like in the kidney before doing the selective clamping, and I think that I understand a lot of selective clamping when I introduce it to my daily practice, especially for the [inaudible 00:43:06] lesion. For a complex lesion, a [inaudible 00:43:09] reconstruction.

Dr. Francesco Porpiglia:

Thanks to the reconstruction, I extend the invitation for selective clamping. I understand that it does not have advantages in many cases, but I think that it's useful for us to extend the invitation because in the next future, perhaps, many old patients, so patients with the [inaudible 00:43:25], they need to unplug during the operation with selective clamping, and this could be in the next future as a demanding technique. It will become a necessity to use this type of technique.

Dr. Jihad Kaouk:

Thank you so much, Dr. Francesco Porpiglia. I agree. Selective clamping may have a good role for central tumors that may look, sometimes, so difficult and find them sitting in the hilum between vessels and one big vessel going to feed the mass. So, that takes us to the next topic that we had a lot of questions in the chat box on and that is the intraoperative navigation system that you showed Dr. Francesco Porpiglia. So, can you please tell us how do you synchronize the images to overlap them accurately and is this done automatically or manually?

Dr. Francesco Porpiglia:

Now, this is a very interesting question. Obviously, nowadays, we have [inaudible 00:44:41] automatically superimpose imaging. What we are doing is [inaudible 00:44:42] automatic superimposed imaging when we do a radical prostatectomy, but for partial nephrectomy, it's not possible. So, it's very crucial to collaborate with an assistant. Usually, there is a second assistant that can follow me during the operation because he has the software, a computer, and is closer to the console. He will follow me with the images, with the superimposed imaging, and it is very important that you have a good collaboration with them, because if he can't follow me during the operation and, sometimes, I stop and he superimposes the imaging so he can follow me during the different steps of the operation.

Dr. Francesco Porpiglia:

So, with that, I can say the superimposing is manual, but the assistant following me with the special joystick, not a standard joystick, with a special joystick that will give him the possibility to move easily and to move quickly. [inaudible 00:45:53] and this is a very important collaboration, a very important step. If you do not have a good assistant, your assistant does not have enough experience with this technology, it's not possible to utilize this technology. So, it's very crucial to collaborate with a good assistant that is experienced, that's on time. It's also essential to be assisted by an engineer because in my operating room, there is also a bioengineer that contributed to create this type of system and contributed to assist during the operation in order to have good navigation in all steps of the operation.

Dr. Francesco Porpiglia:

As you can imagine, it's very difficult to have a good navigation of when the tumor is posteriorly because when we [inaudible 00:46:47], synchronizing between the images is not easy and this is the reason why we need to synchronize with an assistant.

Dr. Francesco Porpiglia:

In the next future, it's going to be the opposite. We're going to employ it automatically. We started [inaudible 00:47:05]. I show last year during the meeting. [inaudible 00:47:10] We can inject the green and the [inaudible 00:47:14] can give the possibility of having an automatic [inaudible 00:47:17] in position and I think we are improving this technology that we will test in next future.

Dr. Arieh Lieb Shalhav :

I want to salute Dr. Francesco Porpiglia for his pioneering this because I think in the future, we all will be able to easily do it and know where the tumor is and where the vessels are compared to the tumor, relative to the tumor. Right now, I really think the ultrasound is what you need to be a master of in order to do a really good complex case.

Dr. Arieh Lieb Shalhav :

So, you know, this is the future, but I want to emphasis the ultrasound [inaudible 00:47:57] where the patient didn't go with a lot, but I think it's one of the major points to allow you to do a very complex case to know how to use the drop in ultrasound during the case.

Dr. Jihad Kaouk:

Yes, we're going to move from the intraoperative imaging to some oncological questions that also came up. Dr. Chandru Sundurum, what's your opinion about partial nephrectomy for the t2 tumors or the t3a tumors? Are we, sometimes, during more partial nephrectomies than we need?

Dr. Chandru Sundurum:

I agree, entirely. Patient selection is so important. Review of the pre-operative images, looking at the patient as a whole, looking at the renal function pre-operatively. All of this is important. It also depends on the aggressiveness of the tumor. So, I think all of this has to be taken into consideration before you decide to do a radical or a partial.

Dr. Chandru Sundurum:

You're right. On one hand, you're doing too many radicals for small renal masses. On the other hand, we may be pushing the envelope, maybe, a little too far. So, I think it's good to have a nice medium that would get the best cancer control and the best renal preservation.

Dr. Chandru Sundurum:

So, I agree with you on why, oncologically, most studies would say it's comparable whether you do partials or radicals. I think in [inaudible 00:49:25] cases have to be determined based on all these factors I just mentioned.

Dr. Jihad Kaouk:

Yup, I totally agree. Dr. Arieh Lieb Shalhav , what's your opinion about frozen section during partial nephrectomy?

Dr. Arieh Lieb Shalhav :

I never do frozen sections during partial nephrectomies. I think if you have a very dry field, you know exactly when you went into the tumor. Very, very rarely will it be that the tissue of the kidney looks just like the tumor. So, if that happens and I feel that I am going a little into the tumor, I pull back, restart a new plane, and just take it right there and then with a new plane, which will include what I need to include. So, I think it's a very low efficacy procedure to send a frozen during it. There's no way a frozen section will come back before you finish your warm ischemia time even in the best institution in the world. So, just trust yourself. Do a good job and rarely, very, very rarely, you'll be surprised.

Dr. Jihad Kaouk:

Dr. Chandru Sundurum, you had a question?

Dr. Chandru Sundurum:

Just one point, I think a frozen section, I agree with what Dr. Arieh Lieb Shalhav said, but I think it's important to remove the tumor, [inaudible 00:50:42], section yourself, especially when you're starting off. That allows you to know exactly what sort of margin you've got, whether there's too much or too little, and you'll be able to refine your technique for the future.

Dr. Jihad Kaouk:

Actually, that's one reason when we excise the tumor, we do not use [inaudible 00:50:58], so we cut cold, because the quality of the tissue is preserved and with the magnification of the robot, the vast majority of the time, you can immediately tell if the tissue looks normal where you're cutting or, at least, auspicious. So, Dr. Francesco Porpiglia, what about if the margins came back positive in the final pathology? Would you go back for a radical?

Dr. Francesco Porpiglia:

Usually, in my experience, my positive margin are about 2%, so when it's very close on the percentage. Obviously, the can speak from the same experience, I think that we can find those in the literature and usually when we have positive margins, we follow the patients, and in my experience, there have only been a few cases we have a recurrence. I remember from my experience only one case. A recurrence after three years and in this case, we needed to perform a radical nephrectomy.

Dr. Francesco Porpiglia:

So, usually a positive margin is not correlated with the [inaudible 00:52:05] the recurrence, and this is very important because the follow-up, in my experience, can be done in the same amount that we schedule for patients in which we have in the negative margin.

Dr. Arieh Lieb Shalhav :

One point here is the, you know, the final pathology is very important. If you find a sarcomatoid tumor in the end with a positive margin, no doubt you need to go in and get the rest of the kidney out in a second operation. No issue. But if it's a [inaudible 00:52:37] grade one, two, three, I don't even see one. Four, I'm starting to feel a little uncomfortable, but there's so many features. Necrosis in the tumor. Sarcomatoid change and so forth, that you should be much more aggressive when you get towards the range of a very aggressive tumor when you do that.

Dr. Jihad Kaouk:

All right, wonderful. So, the last poll that was posted is about management of a bilateral kidney tumor and while I do not have the results for that yet, let me ask the panel here. So, for bilateral tumors, what are your thoughts? Would you do a stage partial? Would you go for both at the same time? Would you start with the more difficult or the easier one? Dr. Chandru Sundurum?

Dr. Chandru Sundurum:

I would tend to do a stage partial. In the old days, we would always say you do the smaller mass first, I tend to do the more aggressive, biologically aggressive, mass first, and then the smaller mass can always be observed or you could treat with other modalities. Also, when you have bilateral masses, I tend to be more likely to biopsy the mass pre-operatively.

Dr. Jihad Kaouk:

Dr. Arieh Lieb Shalhav , would you biopsy routinely? Small renal masses?

Dr. Arieh Lieb Shalhav :

So, in the last couple years, I started doing biopsies way more than I did before, and I'm trying to correlate it with my gut feeling of how the tumor looks. So, we have a nephrometry score to see how complex the partial nephrectomy is, but we don't have a score that, eyeballing the tumor, you could say it's more aggressive or not. So, size is one thing, but also, an infiltrated and tumors that suck tissues toward them, and the border of where the tumor ends is vague, always gives me pause. And when it's in the fat, in a sinus fat, it looks very vague also, I tend to be very suspicious that this is high grade.

Dr. Arieh Lieb Shalhav :

When we have small tumors, I'm feeling very comfortable to biopsy today, which I didn't do before, those tumors that look even 4cm. That look very, very defined. Biopsy, it's a low grade. We keep following it if the patient, obviously, has high risk and there's a good reason for a biopsy.

Dr. Jihad Kaouk:

Thank you so much. Indeed, very nice discussion going on here. Dr. Francesco Porpiglia, what about multiple tumors in a kidney? Do you find your system particularly useful when planning excision when you have more than one tumor in a kidney?

Dr. Francesco Porpiglia:

Yes. When there's multiple tumors, obviously, this technology is very useful because as you can imagine, solitary clamping can be very useful, especially when you start with enucleation, with the first enucleation, because we can start with solitary clamping, for example. You could start treating or performing a partial nephrectomy with the simple cases. So, in these cases, we can do solitary clamping or all no clamping. This is very important to have this information because of the planing of the operation, and usually when they perform a rescission for multiple lesions, I start with the simple lesion and after that, I clamp. Go to the artery and then I'll clamp, solitarily, and I continue with the rescission of the second complex tumor.

Dr. Francesco Porpiglia:

This is my strategy and, obviously, they're going to reduce the ischemia time and I think the planing during the operation [inaudible 00:56:36] is very, very important.

Dr. Jihad Kaouk:

Good enough. We are coming to the conclusion of the one hour. I would like to ask if there any comments by the panel that you would like to present before we close?

Dr. Arieh Lieb Shalhav :

I just want to thank, again, Dr. Francesco Porpiglia for pushing the envelope. I feel like I'm operating in the stone age compared to what he does in his cases, but that work will lead us to where we need to be at the end, you know, to do better on our cases.

Dr. Jihad Kaouk:

Yeah.

Dr. Chandru Sundurum:

I just want to thank Dr. Arieh Lieb Shalhav nd Dr. Francesco Porpiglia for joining us, but Dr. Kaouk for putting all this together. This is a phenomenal experience and a series.

Dr. Jihad Kaouk:

Thank you all for this very exciting discussion and I learned from every one of you a lot here. I would like to mention before we adjourn that in two weeks, we have another session that will focus on robotic radical nephrectomy, and [inaudible 00:57:37] thrown back to me, and we have two amazing surgeons on the panel. We have Dr. [inaudible 00:57:44] Inderbir Gill, who has amazing experience with a thrombectomies and he will share that with all of us, along with Dr. Ketan Badani from New York about the robotic partial nephrectomies. So, please join us in two weeks on a Friday, noon, for the one hour lunch time.

Dr. Jihad Kaouk:

Thank you all. Dr. Francesco Porpiglia, we wish we can do this session out from Turin, Italy today, but today, it's on the webinar.