Surgeons: Raj Pruthi and Amar Singh

Moderators: Monish Aron, Amr Farouk Fergany and Alvin Goh


Amar Singh, M.D., FACS

Associate Professor and Chairman
Department of Urology
University of Tennessee College of Medicine Chattanooga

Dr. Singh is currently the Associate Professor and Chairman of the Department of Urology at the University of Tennessee College of Medicine Chattanooga.  He attended Cornell University College of Engineering in Ithaca, NY and received his doctor of medicine from SUNY-Upstate University Hospital in Syracuse, NY.  Dr. Singh also completed a Urology Oncology Fellowship at the National Cancer Institute.  He is a fellow of the American College of Surgeons, a member of the American Urological Association, the Society of Urological Oncology, and the Society of Academic Urologists.  Dr. Singh is Chief of Minimally Invasive Surgery for the Erlanger Health System and specializes in robotic-assisted laparoscopic urological oncology surgeries including:  prostate, kidney, urothelial, testicular, penile, and adrenal tumors.      

Dr. Pruthi is professor and chair of the Department of Urology at the University of California at San Francisco. He previously served as chair of the Department of Urology at the University of North Carolina at Chapel Hill (UNC Chapel Hill), where he was on faculty for nineteen years.

Raj Pruthi, M.D.

Nationally, Dr. Pruthi serves in a number of professional and academic capacities:

He was a member of the ABU/AUA Examination Committee and serves as an examiner for the Certifying Exam for the ABU. He also on the Executive Committee for the Society of Academic urology and currently serves as the organization’s treasurer. He is also the Chair of the Advisory Council for Urology of the American College of Surgeons, and also serves on the Board of Governors for the College.

He served on the Guidelines Committee and helped to develop the American Urological Associations Guidelines on the Management of Non-muscle Invasive Bladder Cancer and also served on the Bladder Cancer Guidelines Committee of the International Consultation on Urological Diseases.

He is an elected member of the Urologic Research Society, the Society of Pelvic surgeons, the American Association of Genitourinary Surgeons, and the Clinical Society of Genitourinary Surgeons.

Dr. Pruthi is a graduate of Stanford University, where he double majored in economics and in biology and became interested in health economics. He received his MD degree from the Duke University School of Medicine. Following medical school, he completed his residency and post-graduate training at Stanford University. Most recently, he completed the executive MHA program at UNC.

Dr. Pruthi is a recognized expert in minimally-invasive, robotic surgery for prostate and bladder cancer. He incorporates nerve-sparing techniques to improve recovery and long-term quality of life. He is focused on optimizing a patient’s surgical journey and integration of patient-reported outcomes to improve his patients’ experiences and recovery. He and collaborators study the use of health-information technology to provide early feedback so as to address preventable complications and reduce readmissions. He is committed to compassionate, comprehensive, innovative, and patient-centered care that balances long-term survivorship with a high-level of functioning and an optimal quality of life.

In his role as chair, Dr. Pruthi has been tackling health economic issues to better understand the drivers of faculty productivity, compensation, and burnout. He has explored urologic workforce, projections, gender disparity issues, factors impacting career earnings, predictors of dissatisfaction and burnout, and understanding the impact of workflow initiatives, including the implementation of scribes. His work in these areas has been recognized nationally and has had an impact on the understanding of the practice of urology.

Alvin Goh, MD

Dr. Goh is a fellowship-trained urologist specializing in minimally invasive surgical treatments, including robotic, laparoscopic, and endourologic procedures, for general and complex urologic oncologic diseases.  He has particular expertise in bladder, prostate, and kidney cancer as well as adrenal masses, and urinary tract reconstruction. He is Director of Robotic Urologic Surgery Technology and Education at Memorial Sloan Kettering Cancer Center.

Dr. Goh received his medical degree from Northwestern University and completed his general surgery internship and urology residency at the Baylor College of Medicine.  He pursued sub-specialty fellowship training in advanced laparoscopy and robotic surgery at the University of Southern California.

Dr. Goh has helped to develop novel techniques for robotic bladder cancer surgery and intracorporeal urinary reconstruction, robotic kidney-sparing surgery, and single-site robotic and laparoscopic surgery.  He has won multiple awards for his scientific presentations and surgical videos at national and international meetings.  His research focuses on the application of new technology in the treatment of urologic diseases.

Monish Aron, MD

Dr. Monish Aron is an expert in robotic and laparoscopic surgery for malignant and benign conditions of the prostate, kidney, bladder, adrenal gland, and ureter. He trained in urology at some of the premier institutions in India, Australia, and the United States. Dr. Aron completed his fellowship training in advanced robotics and laparoscopy at the Cleveland Clinic, and was recruited to USC in 2009.

He has received numerous acclaimed awards including the GB Ong Medal from the Royal College of Surgeons of Edinburgh, as well as several awards for his scientific presentations and surgical videos at the American Urological Association Congress. Dr. Aron has published extensively (>200 publications) and serves as reviewer for 8 leading urologic journals, including editorial board appointments for 3 journals.

Dr. Aron has played a pioneering role in the development and refinement of robotic prostate and kidney surgery, single incision laparoscopic surgery, and robotic surgery for bladder cancer. Dr. Aron has been invited to speak at and demonstrate minimally invasive surgical techniques at numerous national and international institutions.

Amr Fergany MD PhD

Dr Amr Fergany is a retired staff urologist from the Glickman Urological and Kidney Foundation at the main campus of the Cleveland Clinic in Cleveland, USA.  He is a member of both sections of Urologic Oncology as well as Robotics and Minimally Invasive Surgery.  Dr Fergany joined the Cleveland Clinic as a research fellow in 1991, and has been an attending staff physician there since 2002. In 2020, Dr Fergany retired from the Cleveland Clinic to join Sebastian River Medical Center in Florida. 

Dr Fergany received his medical education in Cairo University in Egypt, where he completed his urologic residency and attained his postgraduate degrees as a member of the Urology Department of Cairo University.  After moving to the USA, Dr Fergany completed the residency training program as well as research and clinical fellowship training at the Cleveland Clinic before becoming a member of the professional staff.

Dr Fergany’s field of practice includes urologic oncology, namely prostate, kidney and bladder tumors.  Robotic and Laparoscopic surgery constitutes the majority of his practice.  Dr Fergany has numerous notable publications in his fields of interest, is a member of multiple urological organizations, and has received several awards including the Bruce Hubbard Stewart, Abdel Wahab Mooro, and Teacher of the Year awards.  Dr Fergany is also currently an honorary Professor of Urology at Cairo University, and an honorary Professor of Surgical Oncology at the Egyptian Cancer Institute.


 

Webinar Transcript

Dr Chandru Sundaram:

Hello and welcome to the Endourological Society webinars on robotic surgery. We have an hour of webinar today on robotic cystectomy with Doctors Pruthi and Amar Singh as the surgeons, and terrific moderators as well. I'm here to introduce to you the president of the Society of Urologic Robotic Surgeons, Dr. Jihad Kaouk. Every two weeks please join us same day, same time for very illustrative robotic surgery webinars. Jihad, take it away.

Dr. Jihad Kaouk:

Thank you so much Dr. Sundaram and thank you for the Endourology Society Office of Education with Dr. Adrienne Joyce and Dr. Ben Chew being on the call today. And special thanks Michelle Paoli the executive director of the Endourology Society for putting all these webinars every two weeks and as you hopefully will enjoy this next hour.

Dr. Jihad Kaouk:

In the next hour, we have a focus on Robotic Radical Cystectomy that with minimal discussion of the diversion in this particular session. We will have two distinguished surgeons presenting their techniques; Dr. Raj Pruthi, who is very well known in the robotics and cystectomy, and bladder cancer in specific who chairs the urology department in the University of California in San Francisco, UCSF, and he will start first focusing on the cystectomy in the female patient. Followed by that would be Dr. Amar Singh, who is the chair of urology in Chattanooga, Tennessee who is also very well known in robotic surgery and build a very busy practice down in Chattanooga from start. Dr. Singh will be focusing on the male robotic radical cystectomy.

Dr. Jihad Kaouk:

We have really a power house of moderators today who will share experience, answer your questions. Please direct your questions to the chat box. The chat box will be read by everyone and answered to everyone in the first 40 minutes and the last 30 minutes we will have the discussion live on the webinar.

Dr. Jihad Kaouk:

I would like to introduce the moderators that we have. Dr. Monesh Aron who is the vice chair at the USC and have a lot of work on robotic cystectomies. Dr. Amr Fergany who is a dear colleague of mine at the Cleveland clinic, just moved to Indian River, Florida and those of you who know Amr, Amr is very experienced in open laparoscopic and robotic cystectomy. And Dr. Alvin Goh, who is the head of robotics at Memorial Sloan Kettering in New York, also a thought leader in bladder cancer and robotic cystectomy.

Dr. Jihad Kaouk:

This is a CME session and in this you will earn one CME for every seminar you attend and there is a website link that will be sent to you by email. This is a webinar that is supported by an educational grant by Intuitive to the Endourology Society to run this bi-monthly seminar.

Dr. Jihad Kaouk:

Without further comments, I will give the podium to Dr. Raj Pruthi to start with his Robotic Radical Cystectomy in the female patient. Thank you so much Dr. Pruthi for joining today.

Dr. Raj Pruthi:

Thank you, Jihad and Chandru for organizing all this and I'm really honored to be presenting the video of Robotic Cystectomy with Dr. Singh, who is an expert in this. And our moderators are certainly... It's an honor to amongst people who're really leaders in this and I think all those who are watching really, hopefully, will enjoy and get a lot out of this session and I'll certainly make my stuff available, too, and share my email for those to be able to help after if there's anything I can do to get people started or help facilitate.

Dr. Raj Pruthi:

So I'm going to talk a little bit about robotic radical cystectomy in the female. What we'll do is I'll review the cystectomy robotic anterior pelvic exenteration and then at the end I'm going to talk a little bit about, and show a video on, the pelvic lymph node dissection and we can potentially have a little bit of a discussion regarding that.

Dr. Raj Pruthi:

So we know that cystectomy has a high level of morbidity and mortality, as shown here. I think this is certainly a challenge. Challenge for our patients, challenge for ourselves. But I think for us it represents an opportunity for quality improvement and I think one way we potentially can improve the morbidity is minimally-invasive surgery. We've seen these benefits with cholecystectomy, with nephrectomy and I think there is that potential with cystectomy as well.

Dr. Raj Pruthi:

Our collective experience with robotic cystectomy has emerged from our mature, now very mature, experience with robotic prostatectomy and, I believe, offers a nice alternative for our patients to an open cystectomy. That there's several benefits that we've seen consistently less pain, less blood loss, less fluid imbalances and bowel manipulation by doing the extirpative portion of this operation within the body, but we also have to be careful. I think we have over the last 10 or 15 years of experience. And I started doing this operation 2004 and five and I think it's probably been the most carefully studied prospectively with regards to things such as oncologic integrity, complications, costs and the learning curve.

Dr. Raj Pruthi:

My suggestion would be that robotic cystectomy should not be your first robotic case. I would recommend overcoming the robotic prostatectomy learning curve first. The numbers are there with prostatectomy. You get familiar with the robotic pelvic anatomy and then with that, I would consider starting with a male patient before a female patient because you'll be very familiar with, that, again robotic male pelvic anatomy to transition over to cystectomy. Remember that there is less room for error with cystectomy than with prostatectomy. Margins matter in cystectomy and can be lethal so really be careful of that. And expect longer case times than open.

Dr. Raj Pruthi:

I want to transition and these are the instruments that I use. There certainly is flexibility like with any procedure. Scissors, bipolar. I use this thing shown here in the bottom right, a bowel grasper. It doesn't have a lot of closing pressure on it so can manipulate the bowel. I typically will use a zero degree lens and then maybe a 30 down for the lymph node dissection. The suture, 3-0 silk pre-tied to the crotch of the Hem-o-lok clips to clip it and identify the ureters. I'll use a Vicryl SH to tag the bowel and a CT-2 for vaginal closure. Lastly, we use Hem-o-lok clips. I often like the use of the laparoscopic EndoGIA for the bladder pedicles or the prostate pedicles in the male. And then the ligature also can be very helpful if you don't use a stapler.

Dr. Raj Pruthi:

We no longer prep patients steep Trendelenberg position as in most cases limit the intraoperative fluids. And the placement of the ports, this is the robotic ports, I typically had my assistant on the left side. I think if you do an intracorporeal diversion this is almost essential, but I think for cystectomy it could be mirrored the other way. And these are the assistant ports, but I'm going to show you I've gotten rid of that 12 port, moved it over. So I use a 15 port laterally and a 12 port on top. This can be used for the stapler, and the 15 port is for the removal of the specimen. So it looks like this.

Dr. Raj Pruthi:

Surgical steps. Now I'm going to take you through the surgical steps by video and then I'll show you a combined video with everything together. I used to use, and I'll show you this, this Zuni retractor, this uterine manipulator. I don't think you really need that, I think a sponge stick is all you really need. One thing that I used to do, and I know some people like this, is start with a peri-urethral incision and maybe saline injection to develop the vesicovaginal plane. And maybe even do a little bit of that dissection, almost like a sling, before. I no longer do this. I actually think you can get very, very distal robotically and this isn't an issue, but this is a trick that you can try to help develop that plane. I'll take you through this with the videos, the ovarian pedicles and then transection of the ureter.

Dr. Raj Pruthi:

So here what I'm showing you is the IP ligament and the ovarian pedicles. So were incising the peritoneum to pediclize it and then you want to cauterize this bi-polar, and cauterize this well. Even, sometimes, I'll put a Hem-o-lok clip on this because this is something that might retract up and bleed. And then there's, on the right side here, and we're pulling the peritoneum back and as you can see, the ureter will often stick to the underside of the peritoneum. So, that's where you often can find it. And we'll carry this down distally. Remember kind of the water runs under the bridge and you're going to have the uterine vessels coming over the top of you as you get closer, so be careful.

Dr. Raj Pruthi:

And so we've done this on each side and now incising the peritoneum between the vagina and the bladder, and I'll show you more of that shortly. Laterally, you want to incise the peritoneum on each side, lateral to the medial umbilical folds, because you want the medial umbilical folds to keep the bladder suspended so you can work behind. And then often you can take this down to the endopelvic fascia. In a neobladder, I'll preserve the endopelvic fascia because I think some of the continence mechanisms lay beyond it. But in a non-neobladder, I'll incise it and you can go all the way with your stapler, and then you see your pedicles on each side. I use a stapler. Often a single fire is all you need and as I mentioned, avoid stapling beyond the endopelvic.

Dr. Raj Pruthi:

So, here you can see we're incising the peritoneum and developing the lateral space. You can see the bone there. And then we've developed our space underneath and lateral and then I'll come in with a stapler. Again, you can use a ligature with this but I enjoy the stapler, I think it's quick, it's easy, it protects anything below, it'll staple below. And in here, you can see we've stapled now on the left side and we're going to go a little bit further. This is transitioning now a little bit into the hysterectomy and I'll often do a transcervical hysterectomy. So I won't go above. The reason I go transcervical is actually at the advice of one of my gynecological oncology colleagues, is we're not doing this for cancer. It makes a smaller os to close, and number two, it maximizes the vaginal length for the patient.

Dr. Raj Pruthi:

Then we're going to go anterior, develop the prevesical space and the lateral tissues. So here we're going anterior now. Again, you want to save this for last because you need it suspended. And here, this is for a neobladder and you have to be careful. You see we haven't gone past the endopelvic fascia, again to preserve the continence mechanisms. What you want to do here is transect in a neobladder right at the level of the bladder neck. If you go too high, the patients will actually have retention. If you go too low, they'll be incontinent. And there's studies that show going right at that level is ideal. Now we'll Hem-o-lok that and then we're now freeing up some last bit of attachments to the bladder. And, again, I'll show you this again shortly in a completed video. And there, you see our urethra there, or the anastomosis if we need to. Then we'll bag the specimen, irrigate and then pre-place any anastomotic stitches in a neobladder.

Dr. Raj Pruthi:

A couple comments I want to make, with female patients, be careful to avoid bladder entry. The bladder is very thin in the female and even the instruments, scissors and so forth, can inadvertently tear the bladder. In most cases I will do a vaginal sparing unless there's evidence on imaging or on bimanual exam or at the time of surgery. I will err on the vaginal side, vaginal entries can be repaired. I mentioned already, transcervical hysterectomy to maximize the vaginal length. We already talked about the case not going past the endopelvic. If you want to you certainly can take an en bloc resection of the vaginal wall. And then, I'll close the vagina with a sturdy 0 Vicryl suture, and you can also do a perivaginal fixation to avoid prolapse, as well, with prolene.

Dr. Raj Pruthi:

Now here's going to be what we just talked about with a condensed video. So this is with a Zuni retractor. You can see it can manipulate the uterus and be helpful as far as retracting side-to-side. Here we have it pulled over. I don't think you need to use this but it can be helpful. So here, now, I'm scoring the peritoneum and, again, pediclizing the IP ligament on each side. Again, I would cauterize this well and maybe even Hem-o-lok clip this. Just because this is going to disappear out of view for the rest of the case and you don't want it to be oozing above you. And then we're going to work our way down. Now, again, we're going to pick up the peritoneum medially and then find the ureter, see that attached underneath the peritoneum there. When the gynecologist injure the ureter it's usually at the IP ligament, ovarian pedicle or at the uterine vessels here.

Dr. Raj Pruthi:

So we're going to take this down, we've clipped it and then we'll do the same thing on the other side, which not shown in the video. And now we're kind of connecting the dots from the right to the left side. And in a patient who's had a hysterectomy, it's actually this plane between the vagina and the bladder can be scarred initially. So just be wary of that. In somebody who’s had a hysterectomy it actually easier. It's a virgin plane. And then there we've dissected laterally, so we have posteriorly and the stapler... I think when you're doing neobladder, when you go posterior to the bladder you need to be careful not to dissect too far. You can get there in a hurry and because you don't want to undermine the bladder neck with your dissection. Because I think there's a lot of support for continence that lies there. So, here again, we're stapling on each side. And then we have the bladder really suspended up there.

Dr. Raj Pruthi:

Now I think this is going to show our hysterectomy. Again, the vessel come kind of up and down here, you can see how they are for the uterine vessels. So I'm going to come kind of lateral to medial for that and really cauterize that well and use a lot of heat. Again, I will tend to do this transcervical to maximize the uterine length and to minimize the size of the os that needs to be closed. And you can see we're going through the muscular cervix there. And then we have a freed up specimen. I think some people are uncomfortable with doing this first, it's really probably the easiest part of the case, is the hysterectomy part. If you're uncomfortable you can include your robotic gynecologist into the procedure the first time you do it but it's pretty straight forward. And now we're coming anteriorly like we showed before. And then we just showed this, we'll come through the bladder neck. So I'm going to take you next then to touch on the lymph node dissection.

Dr. Raj Pruthi:

These are landmarks that we all know and aware of. Laterally, posterior, the boney pelvis and proximally.

Dr. Raj Pruthi:

I'm going to start with a discussion of these steps. The obturator dissection, we really want to identify the artery and the vein and then develop the medial border of the vein and work your way back. Always be careful, I'll emphasize this, I tend to do this than the Iliac dissection. I'll show you all of this. As you dissect back here be careful of the ureter. I tend to do this at the end of a case. And then the periaortic dissection, the Xi is helpful for this.

Dr. Raj Pruthi:

So, here we've identified the artery and the vein right over here and actually you can see the nerve here. Sometimes you can't. What I'm doing here is, I apologize it a little bit grainy here, but I'm developing the medial border of the vein first. And then I'm going to take this distally and as I go above I can see the boney pelvis there and I know I can come through that because the nerve is not going to come above the pelvic brim. So I can come through everything above the bone here which I'm doing and I'm clipping. I don't use a lot of clips on the lymph node dissection, maybe for the big pedicles distal and proximal I will. But we tend to be intraperitoneal. So now, here, once we do that we can see the nerve below quite easily there. And then for the obturator packet we'll just come through that and cauterize and that'll be our obturator packet.

Dr. Raj Pruthi:

Now I think we're showing here on the other side and again I want to emphasize that I do this at the end of the case, after the cystectomy. And by then, patients are run pretty dry in the case. They've been in the steep Trendelenberg position and the vein can be very decompressed. So you just have to be very careful about that you think might be perineum or a little slip of tissue, is not vein. So just be very cautious of that. I'm more concerned about the vein than I am the artery. So we'll take this distally. Little bit of heat there to stop little bit of that bleeding. And then there I can see my nerve below. Again, this isn't like an RPLND. You don't need to skeletonize the obturator vessels or nerve, you just need to take your node dissection there where it is. We're just going to finish up here shortly and then we'll take that back. And there is our node packet.

Dr. Raj Pruthi:

Now when you come above, I want to find my vein. There's my vein. You can see how thin that vein is, right? I mean, that is the vein right there in front of us here. You can see how thin that was. Again, be very careful that, again, you don't think it's just a little slip of peritoneum. So what I'll try to do is get the tissue over the artery and the vein out lateral to the nerve. And then I'll amputate it distally and then I'll bring it back proximally as far as we need to go. You'll see, we'll come over the common iliacs here shortly.

Dr. Raj Pruthi:

I think there's increasing evidence in studies now that maybe an extended node dissection may not provide any long term cure rate. I think there's the SWOG trial that's also upcoming results, I think in 2022. The European trial did show, I think it's the LEA trial, that there wasn't a benefit in that. But here, I'm kind of going the other way. I typically will come back but artery and vein and I'm just taking everything down distally with that and then we've taken that. But typically I'll take that proximally back as far as I want to or need to.

Dr. Raj Pruthi:

Here we are bringing that back and you can see the common iliac right above it here, and we'll keep taking that back. I think you can do this at the beginning of the case. I've done this occasionally at the beginning where I'm concerned about a node, and maybe I would want to stop if I found the node to be [inaudible 00:21:24] maybe by imaging. But typically I'll do it at the end, that way I know my ureter's out of the way. I'm going to zoom ahead a little bit and just show you a little bit of the periaortic dissection that we're doing here. You can see the IMA and we're coming across that over the vena cava in a different case. It'll really be an uncommon case that I do this extended of a node dissection but it certainly you can do it and I think, again as I mentioned before, I think the Xi really helps with this.

Dr. Raj Pruthi:

And I'll be curious to hear what Dr. Singh thinks about that and about the concepts of node dissections or even the moderators of what we need to be doing in this day and age.

Dr. Raj Pruthi:

So we got that freed up there and I'll usually take my node dissection to the level up by the common iliacs. We're free there. Should be able to pull that through and then... Okay, I'm going to move on then. In the extraction we'll use... I'll send left and right separately, decrease the pneumo to check for bleeding.

Dr. Raj Pruthi:

And just in finishing up, I want to make a couple of comments. I think we're seeing increased worldwide experience of robotic cystectomy and we're getting medium term oncologic assessment. There's been the RAZOR trial which is a large multi-institutional trial. It shows two and three year benefits and, I think, intracorporeal diversion.

Dr. Raj Pruthi:

As I leave you here, I just want to touch a few recommendations. Set specific times, maybe limit your first case to three or four hours and then convert to open. Maybe start with your cystectomy robotically and then do your lymph node and diversion open. Measure your own outcomes. I would use internal and external benchmarks; what did you do before, what did you do after? Be honest in assessing your successes and failures. I really think watching videos, your own and others, is very, very valuable and at the end of the day this is an unforgiving disease so don't compromise any oncologic principles.

Dr. Raj Pruthi:

This is my email. I would encourage anybody to feel free to reach out to me or email me personally and I'd be happy to help and answer any questions for you. Thank you very much. Thank you.

Dr. Jihad Kaouk:

Very well said. Thank you so much for this outstanding presentation. Dr. Pruthi. And we'll go next to Dr. Amar Singh from Chattanooga. Dr. Singh?

Dr. Amar Singh:

Thank you for the opportunity to society to allowing me to present male cystectomy. The key objective is, I'm going to try to make it so people who are comfortable doing prostate can, I think, replicate male cystectomy very easily and that will [inaudible 00:24:37] outlining some key steps Followed by positioning and talk a little bit about instrumentation and some important anatomical considerations.

Dr. Amar Singh:

So one of the key points is that radical cystectomy is a multi-quadrant surgery and therefore I think trocar placements and how we manage it needs to be considered. So similar to prostrates except for cystectomy I found that if you put the trochar and shift it cranially, it helps for bowel manipulation. If you have to take a decent down. If you want to do intracorporeal diversions, it allows you for that and it also allows you tunnel and deal with larger prostates in obese patients.

Dr. Amar Singh:

The technique I use usually just a simple five trocar technique. This is the same trocars I place for prostate. Except in this case we make it little bit more cranial. Just for reference, this is pubic symphysis here, that's the cranial area. Ostomy's been marked and when I place the trocar we shift it about a couple inches from the umbilicus based on the obesity and body habits of the patients. Assistant gets a AirSeal 12 millimeter and essentially is a four arm prostate technique with not whole lot of modification.

Dr. Amar Singh:

So the operation are broken down into several steps from initially with inspection of abdomen and enterolysis, identification of ureters and ureteric division, followed by lateral space development, pedicles, nerve sparing, posterior dissection, and then space of Retzius and DVC management, followed by urethral division, and lymph node dissection. Now there's another webinar Dr. Kaouk mention on intracorporeal urinary diversions. However, I will share with you if you want to do extracorporeal, what are some of the tricks to make it very efficient in this operation.

Dr. Amar Singh:

So this here placed into a prior hernia surgery and enterolysis, I think, is a key portion because more time you spend here it sets us up for better success. As far as the instrumentation is concerned, I tend to do, if I'm not going to do nerve sparing, the entire removal part just using vessel sealer and scissors. I love vessel sealer because I can use it as another instrument that helps you divide. You can divide things internally as well as you can take pedicles. I used to use ligature before but I pretty much now switch to this for the enterolysis, pedicles and including lymph node dissection. In this case you can see there's a lot of bowel stuck here from prior mesh and taking this down helps us move forward better.

Dr. Amar Singh:

The next step is identification of ureters. I will usually begin on left side or right side depending on where ever more adhesions had to be taken down. You gently open the peritoneum and most of the times, when in doubt go cranial. And further up you go you can usually see it starts right in your face. And then essentially I think that this part we tried to do as internally as possible because I do think that long-term ureteric strictures are a terrible complication to deal with. even if you use thermal energy on some of the collaterals, you try to go as lateral as possible. And then with the blunt dissection we kind of keep going forward. Some of the key landmarks you can see obliterated umbilical artery, that helps you find the ureter sometimes. And once you dissected, then we will clip it and send the intraoperative frozen section at this point so pathologist can work while you still moving forward.

Dr. Amar Singh:

Once the one side is done you can, in a similar fashion, go over to the other side. The thing I find very helpful is, on the right side most of the times with the fourth arm you can pull the sigmoid laterally and then again open up the peritoneum here. And then move forward.

Dr. Amar Singh:

Now, in terms of the next step is the lateral space of Retzius development. This part is very familiar to all surgeons who do robotic prostate and here you can swim down to the endo-pelvic fascia. If you want to do a retrograde nerve release for later nerve sparing, you can do that. And then with lateral traction the pedicles are very easily identify and can be divided. And then posteriorly this, again, is very familiar at this angle to folks who do prostatectomy because this is where the vas and seminal vesicles will come into play. You could do some of this dissection and I agree with folks who say, "Leave the ureter for later if you have to, to divide," because it is a key landmark.

Dr. Amar Singh:

So going back to it, this is the lateral space development. You can swim down and expose the endopelvic fascia and then you could consider doing retrograde release of the nerves. And then subsequently, once the pedicles are defined you can take that with vessel sealer easily. Here is the ureter, here is the posterior peritoneum. We can open that at this angle and usually here you can take staples to do this, you can open it sharply, it's totally up to the surgeon preference. When I'm doing nerve sparing I try to go in thermally with staples otherwise vessel sealer works great. Same thing on the contralateral side. We can open that space up and then again, folks who do prostates this arena is quite familiar. Again, here, peritoneum is being open. Vas deference for anatomical references there. We can divide that and then subsequently the pedicles are going to come in view and it can be divided. At this point the both lateral planes has been opened up and then next we go to the pedicles of the prostates and nerve sparing.

Dr. Amar Singh:

Again, here using fourth arm you can lift up laterally, define pedicles. You can take it with thermal technique or if you're interested in nerve sparing, you could do this similar to what we do for prostates with clip and thermally. Again, for reference, here is the prostate coming up. That's the earlier where we had done some of the nerve release. That's the pedicle coming over here and you can get good traction and countertraction on it. And then assistant can apply clips and can be divided very easily for mobilization of the lateral aspect of the prostate. And this part, it becomes quite easy to do especially if you're not worried about nerve sparing because you can develop that plane and fire one load of stapler and that will help you mobilize pretty much this entire pedicle or the prostate.

Dr. Amar Singh:

On the right side in this case, again here the pedicle is highlighted. And occasionally if you see a discrete bleeder, if you want to touch it thermally you can. Otherwise, I try to go through this pretty cold to release this all the way towards essentially the entire posterior aspect of the prostate all the way to the urethra.

Dr. Amar Singh:

Posteriorly, if there's anything left this is very similar to what folks who do posterior prose for prostatectomy. You can open this plane up and separate the rectum in the midline completely from the seminal vesicles. This is in a vascular plane, for the most part. There's some small bleeders you may encounter. If you're encountering heavy bleeding in this area that means you are probably too close to the rectum. So most of times you can get the areolar fat plan here that will help you separate this out and mobilize the entire bladder.

Dr. Amar Singh:

Once this is done the only thing you have left is just the anterior attachments. And this is pretty routine for anyone who has seen or done any kind of robotic prostatectomy. And at this point the case essentially becomes easy in terms of the extirpative part of this case, which is mobilize the space of Retzius. And this part you can fly through for the most part and then get to the DVC. DVC management for neobladders, I usually do like to cut them thermally and then suture the DVC if I can. I do recommend folks to take two minutes and put a stitch in it because I think it helps you see the urethra better. And it will help you maintain urethral length, especially if you're considering doing a neobladder.

Dr. Amar Singh:

The second part is that in most of the bladder cancer there is a higher rates of prostate cancer. So I think having it thermal and doing a good apical dissection here is important from oncological perspective should you have an incidental high risk or prostate cancer. And nerve release here at the apex. Again, you can be careful and take that down sharply without much difficulty. Sometimes if you're not worried about neobladder, you can even take the DVC thermally with the vessel sealer or some folks have described firing a stapler.

Dr. Amar Singh:

Now in terms of urethra. This part I think is crucial for all beginners who are doing radical cystectomy because you don't want to cut the urethras just blunt because of tumor spillage. In bladder cancer there is seeding that's been described, so I generally will mobilize the urethra completely and a 15 millimeter Hem-o-lok clip apply usually works really well. You can seal the urethra after pulling the foley back and then take it sharply. Now, again, if you are doing neobladder with a fairly dry field, the urethra can be peeled back further to gain urethral length to help you with continence. And after this step the entire bladder is essentially free and is bag.

Dr. Amar Singh:

Now, Dr. Pruthi talked about lymph node dissection. I'll mention a little bit. So I tend to start my lymph node dissection from cranial to caudal. I find that if I can open up the peritoneum and keep moving it further cranially, it allows me to see the aortic bifurcation easily. And then once we get to this point, then using split and roll technique and using vessel sealer you can slide that right on top of the artery and take any of the lymphatics pretty easily by using the split and roll technique.

Dr. Amar Singh:

Some of the things I've learned over years is that, especially in majority of our bladder cancer patients, they tend to be vasculopaths and in that scenario for some reason they have extremely tortuous artery and vein both. And to reiterate what Dr. Pruthi said, the veins can be flat and can be hard to see. so again even in this case you can see the course of the artery is quite tortuous and if you think it's a straight line, before you know you're going to end up in the blood vessel and can lead to some less than favorable outcomes.

Dr. Amar Singh:

And then we carry this dissection caudally, any collaterals you can take down the smaller ones with monopolar. The larger one you can sealer it with vessel sealer. Here you can see the split and once the right side is done, then I will move over to the left side, mobilize the colon to hold the sigmoid colon over to the right side and then basically clean out the other gutter. So this I think is a very important and extremely tedious portion of the operation and it can be full of pitfalls. However, I think folks who have experience doing prostates, again, the obturator node dissection is fairly easy and I think if you open up the peritoneum you can follow the artery as a good landmark and get a good lymph node dissection done.

Dr. Amar Singh:

And lastly, setting up for urinary diversion. So early on when I started, you could set up the urinary diversion very easily so you don't have to make a big incision. So I tunnel the ureter robotically and if you've done it good enough, no dissection that plane is fairly wide open. And then we tag each ureter with a separate color suture. Also, look at the bowel and I'll put a short and a long silk as a reference point. So then my obturator is tagged and bowel is tagged and at this point robot is undocked, the specimen has already been extracted. And then I'll show you in the next slide what we do.

Dr. Amar Singh:

So, through that small extraction incision you can pull both ureters and the bowel up. So you have a tag right there and the entire diversion can be done through your extraction incision, and it's extremely efficient and doesn't take a whole lot of time. So this is what it essentially ends up looking like. And again, this was one of the trocar sites where the ostomy was marked before extraction incision and one of the other trocar sites we use for drain. So I found this technique over more than 10 years to be extremely helpful. Now we using the exact same technique when we do the robotic cystectomy with the new single port or SP system. Average operative times consistently, and that's from incision to conduit or dressing, is about four hours. And overall we have had fairly good outcomes with this approach.

Dr. Amar Singh:

So again, I want to thank my residents who helped me do this. Dr. Tonzi helped me put some of these shots together. And our small department here in Chattanooga. And thank you for the opportunity.

Dr. Jihad Kaouk:

Thank you so much Dr. Singh for your presentation. Lot of tips and tricks. We appreciate that and I see the chat box really busy. And I think now we can get to the most exciting part of the discussion. And that would be the last 15 or 20 minutes until the top of the hour. So I will give the mic to the moderators to run the show for the rest 20 minutes and direct questions to the surgeon speakers or to the attendees from the questions they've had.

Dr. Goh:

Yeah, to Dr. Singh and Dr. Pruthi, excellent presentations. Very informative. I think really great tips there on how to get started with these operations. First question to Dr. Pruthi there is, there was a lot of conversation in the chat about female organ sparing. And so a couple questions regarding that. First of all, how do you select the patients that you're going to do that in and do you use any imaging modalities for that? And so, maybe I'll just start with that and then we can follow up with some of the other discussion that took place around that.

Dr. Raj Pruthi:

Yeah, thanks Dr. Goh and I think that's a great question. I think classically we've done this sort of maximally extirpative operation and the data has shown us that we don't really need to do that. I have a kind of engaged conversation with my patients. I think it began with vaginal sparing and I think the data was pretty clear that if you have negative imaging, and negative bimanual exam, and at the game time decision the planes develop, that it's a very safe thing to do. I think there's also data showing that having concomitant disease and the uterus or the tubes or ovaries is really minuscule when you have negative imaging.

Dr. Raj Pruthi:

So I think certainly for low and intermediate risk patients I think it's very, very feasible. And I think it's worth having a conversation with the patient of what they would like to do. Some of them have said to me, "No, go ahead and take it out. I don't want to deal with this anymore." Or some have said, "No, I'd like to leave it in." I think there's an increased movement in women sparing their uterus, too, and not just going to hysterectomies broadly. And I think comments were made about prolapse and preventing prolapse. I think there are benefits to that, maybe less is more in that case.

Dr. Goh:

You know, as a quick follow up to that. With the emerging data on the use of MRI with regard to identifying muscle invasion, it's very good at that it appears. Are you using MRI routinely in patients who are undergoing cystectomy? And here at MSK we tend to use pelvic MRIs very commonly. We have G radiologists who're dedicated to this. But have you used it and have you found it helpful in that selection?

Dr. Raj Pruthi:

Well, I'll just speak for me. I'm curious to hear what others think, too. We don't routinely use that and I'm aware of the literature showing the possibilities of that, of vesicle MRI and scoring systems for that, like the VI-RADS, I think VI-RADS. So I'm curious to hear of what's going to come down the pipe with that.

Dr. Jihad Kaouk:

Right. Dr. Aron, would you like to take it from here?

Dr. Monesh Aron:

So, excellent talk, Raj and great talk, Amar. Thank you so much for the wonderful demonstration. So about the female organ sparing, when I do an orthotopic neobladder in women, I've had experience in the past where I've had fistulas when I've gotten into the vagina. So I only do an orthotopic neobladder when I spare the vagina and I always put an omentum there whenever I do a neobladder. So, do you Alvin or Raj, do you guys do an orthotopic neobladder when you've done a adhere exam and taken the vaginal wall?

Dr. Raj Pruthi:

No, I agree with you a hundred percent. I think I would do everything possible. You know, typically a patient who's a candidate for a neobladder, who's highly functioning and so forth is a good candidate for vaginal sparing as well. So I think they go hand in hand and I agree with you, I worry about a fistula, which can be a very difficult thing to handle.

Dr. Goh:

Yeah, I mean I would agree. We routinely try to avoid any entry into the vagina if we're doing a neobladder. There's an increased risk of fistula. If you do need to take some of the vagina, usually go laterally so off the midline, make your incision a little bit away and then close it that way. But a critical point was in the discussion is, you just mentioned as well, was using the omentum as a flap. So, that's essential to bring down. And then there's, with regard to support, if you are going to take the uterus at the time for whatever reason, in a patient you are considering a neobladder, then usually you make your cuff kind of horizontally. So, again, away proximally or even cervical sparing, or super cervical as you mentioned, if you're going to do a neobladder. And then we will usually do a sacrocolpopexy at the time. We have some pretty good date in patients open and robotic using mesh, actually prolene mesh, in patients for sacrocolpopexy. You put that underneath the omentum and that helps with the continence, they're emptying afterwards.

Dr. Monesh Aron:

Any experience with ureteral sacral ligaments suspension?

Dr. Goh:

Yeah we did that at the beginning and it's limited in the experience but it doesn't seem to be durable. Is kind of-

Dr. Monesh Aron:

I always worry about hitting the pudendal nerve when I'm doing that.

Dr. Goh:

Yeah.

Dr. Monesh Aron:

So I personally use a biologic mesh when I do a sacrocolpopexy and I do that even when I'm doing a conduit because sometimes if there is a prolapse after a female cystectomy it can be notoriously difficult to manage because there is hardly any support.

Dr. Goh:

Right, agreed.

Dr. Jihad Kaouk:

All right, wonderful. Great tips, actually I'm going to start write these down myself. Dr. Fergany are you on? If you can [crosstalk 00:46:13].

Dr. Amr Fergany:

Yes, I'm here and I'd like to thank both our presenters for the great videos. Question from the audience which is an old fashioned question but I think it is quite important as well. Does either of you have any indications for an open cystectomy in their practice anymore?

Dr. Raj Pruthi:

I'll go ahead and take that one... start with it and then I'll let Dr. Singh talk. I don't think there's one right approach for every patient. I don't think that every patient should get a robotic cystectomy or an open cystectomy. I do probably 10 to 20 percent of my cases open, and they're typically patients that are they're older, they're sicker, maybe with cardiopulmonary issues that wouldn't tolerate the pneumoperitoneum, the steep Trendelenberg position. But yeah, I've done 85 year old patients robotically, I've done 65 year old patients open. So those tend to be my criteria. I think just judgment. In my hands, I can do the open a little bit faster and get a patient on and off the table. And I've always had that, so I think that would be my criteria. And Dr. Singh, curious to hear what you think about that, too.

Dr. Amar Singh:

So I tend to do, I would say about 50 percent of my bladder still open. So my criteria oncologically, if they have what I think is a bulky T4 disease they get an open operation. Number two, if they want Indiana pouch or continent cutaneous diversion I do them open. And the third is, anyone who's 80 or older or is bad risk, I was started doing these under a spinal. When I can get them off the table in under two, two and a half hours. And they are walking out of the hospital pretty quick. So, so far we have almost 30 40 patients who are out done them under spinal anesthetic and that has been a huge win for us here. Otherwise I think if it's a straightforward bladder, I think robotic approach is ideal form.

Dr. Jihad Kaouk:

So I had a question along the same lines. So we know from the robotic prostatectomy that the obese patients or patients who are on blood thinners that risk more bleeding or difficulty exposure, robotic may be better than the open. So how does this translate to the cystectomy? The very heavy patient, would that be a plus to go robotically or you will still select open?

Dr. Amar Singh:

Jihad, in my experience I love robotic approach on them because one of the most common complication of cystectomy is wound related complications. So that minimizes that big time. The second is, I think in terms of exposure and not having to deal with larger incisions and just bleeding, I think robotic definitely gives you an advantage. The third is, I'm going to use [Dr. Menescot 00:48:01]. He always said that when we look at these robotics we always look at surgical complications, surgical outcomes. When I think in morbidly obese high risk patients, I think the medical complications are less in terms of pneumonia I can ambulate them better, clots, so on and so forth. So, subjectively I think it's better approach.

Dr. Jihad Kaouk:

I see. So Dr. Fergany, you've done so many of these open before I came into urology even, and now you do them all robotic. So what's your comparison on that one?

Dr. Amr Fergany:

I think I agree with both our presenters, that there are patients that benefit from each approach. I think the obese patient is definitely easier to deal with robotically. I think an older, thinner patient can be done open quite quickly. I will add something that may be a little counterintuitive, but I have found that patients who have had radiation to their pelvis are actually easier dealt with robotically than they are open. So that would be my first preference for these patients. But there certainly is a role for doing an open cystectomy, with the benefit of being shorter and getting a sicker patient off the operating table faster.

Dr. Jihad Kaouk:

We didn't talk about the diversion too much, but intracorporeal versus extracorporeal, will that impact your robotic-open approach? [crosstalk 00:51:21]

Dr. Amr Fergany:

I don't think so. I think the biggest benefit of the robotic approach is the decreased blood loss which belongs more with the cystectomy part. And I think that the patient can get that benefit whether you do with the diversion open or robotic. So, as you know, I do mostly extracorporeal diversions and I think that doing the cystectomy robotically is still a huge gain for the patient.

Dr. Raj Pruthi:

[crosstalk 00:51:52]

Dr. Jihad Kaouk:

I wonder our surgeons and the moderator, do you prefer intra- or extracorporeal as the most common? Dr. Pruthi?

Dr. Raj Pruthi:

You know, I think that's a good and a tricky question as far as we started doing some intracorporal diversions a long time ago and I think for conduits there is a benefit to that. But I don't think anybody's still been able to show that there's a clear benefit to what Dr. Fergany says. I think the real benefits in cystectomy patients is the extirpated portion of it. So I think I would love to see better data on that, but I think probably for things like ureteroenteric strictures is a real potential benefit of that. We saw little bit less narcotic use but it was a little bit less. The biggest benefit was open to robotic extirpative and there was just a little bit of a benefit to that. So I think it's more of a TBD type of thing. I think time will tell but potentially, yes. Dr. Aron has done quite a number. I'd be curious to hear his experience.

Dr. Monesh Aron:

So first of all, I echo what Amr said, that the cystectomy part is just the visualization is so much better doing it robotically than it is open surgically where you're under the pubic bone, especially in a big bulky tumor. So I think there is no question in my mind that if you are skilled robotically, the cystectomy should be done robotically. We even do T3 and T4s robotically. I mean, T4s are challenging either way because it's going into the pelvic sidewall. Of course those guys will get a lot of chemotherapy before they even come to the operating room. Those are challenging either way, but I think the cystectomy, the way to go is robotic. For diversion, doing a conduit is actually a joy doing it robotically. It is so easy, so quick. I would not consider doing that extracorporeally at all, unless somebody's had lot of bowel surgery and everything is matted together.

Dr. Monesh Aron:

Neobladders take longer, there is a lot of suturing involved and like with anything, we get better with time. I used to take seven, eight hours to do an orthotopic neobladder and now I'm down to six hours including, sometimes, between five and six hours. So it keeps getting better the more you do. But certainly if you're doing a cystectomy with conduit I would definitely recommend doing it robotically, the whole thing. Neobladders, you shouldn't be taking 12 hours doing it, if you can bring your time down to less than six hours, I think it's worth it.

Dr. Jihad Kaouk:

Yeah, even for the cystectomy part over time, I see much faster and efficient to do it robotically.

Dr. Monesh Aron:

Yup.

Dr. Jihad Kaouk:

So I hear you when worrying about frail, older patient that you want to go very quick. But even that have the potential to be an hour cystectomy before going to the lymph nodes. So the robotics, once you get used to the planes, I think is very effective. And this vessel sealer nowadays made you less dependent on your assistant because the staplers are kind of expensive to use the robotic staplers. So most of us depend on the assistant, while your vessel sealer, you cut with it. Sometimes I use it to cut and dissect without the cautery, as a dissecting tool and it's very efficient and articulates too.

Dr. Amar Singh:

I was going to say that, to echo your point, I think ever since switching to vessel sealer, I would say at least 30 percent or 20 percent time improvement and we even looked at the finances in terms of cost saving and I think it helps in terms of minimizing instrument.

Dr. Jihad Kaouk:

Yeah, good point. Dr. Fergany?

Dr. Amr Fergany:

I would just add about the intra versus extracorporeal discussion that I think this discussion should not affect the choice of diversion that we use for patients. I think Indiana pouches remain a very, very good option for diversion, particularly in woman. I find them very acceptable for women. And I think that we should not choose the approach before we choose the diversion. So, a patient who will want an Indiana pouch should still get an extracorporeal diversion, obviously.

Dr. Raj Pruthi:

[crosstalk 00:56:12]

Dr. Goh:

Yeah, I would just add to that, I completely agree and we've shown the feasibility in doing intracorporeal Indiana pouches or right colon pouches. It's very, actually, straightforward to do once you know how to handle bowel and know how to suture. And I think it's actually nicer to do that intracorporeally because you don't have to make an incision into the xiphoid. You can mobilize all the way up to the hepatic flexure and beyond easily intracorporeally, especially the Xi system. So yeah, no reason to change your approach based on diversion type and we've shown that you can really do the full range of all diversion intracorporeally as well as extra, so.

Dr. Raj Pruthi:

But, I was going to make a comment. Somebody asked a question regarding whether length of stay is affected by type of diversion and I haven't seen that in my experience. I think the ERAS has really made all the difference between length of stay. We actually don't even have much of a difference in length of stay in open versus robotic because of ERAS. So I think that is the real game changer. Nobody's doing that, you ought to think about switching to that. I think there's a lot less morbidity for the patient.

Dr. Monesh Aron:

That has been our experience, as well. Our open cystectomy patients and robotics cystectomy patients have the same length of stay and similar complication rates with the same pathway. So its pathway driven rather than approach driven.

Dr. Jihad Kaouk:

We still have few more minutes. Maybe we can touch on the lymph node dissection a little bit here, since it's an important topic. Template, tips and tricks, Dr. Aron?

Dr. Monesh Aron:

Historically have been going up to the IMA but not always. We do it for T2s and T3s. But sometimes for, say recommend CIS or high grade T1s, which for the cystectomy we will stop at the aortic bifurcation. Like Raj, I don't use too many clips during the lymph node dissection. I just find that they get in the way and sometimes if the assistant is applying the clip, they can clip the wrong structure. So I just cut through it with my scissor. I use the vessel sealer a lot but I also use Cadiere forceps during the cystectomy part of the operation because I've to use those, also, for the bowel diversion. So I think Amar elegantly showed that you could use the vessel sealer in your left hand. I haven't done that but maybe I could get rid of one of my Cardieres and use a vessel sealer in the left hand. So thank you Dr. Amar for showing me that.

Dr. Goh:

Dr. Aron, do you like to start your cystectomy with the nodes first and then do the cystectomy or vise versa?

Dr. Monesh Aron:

No, I just do the cystectomy first. But as I mention I separate the obturator fascia from the bladder pedicles because I've had a bad complication in the past. So I do the cystectomy first, get it out of the way, and then I do my lymph nodes. When the bladder is gone, the pelvis is wide open and I can see better my entire anatomy and dissect all the way from the general femoral nerve down to the pelvic floor.

Dr. Jihad Kaouk:

[crosstalk 00:59:20]

Dr. Goh:

Yeah, I would echo your comments about the vessel sealer. I use that usually in the fourth arm. It's great for handling pedicles while you're doing the bladder and then when you come to the lymph nodes, if you come across larger perforating vessels or even those very proximal large lymphatic channels, especially over the pericaval periaortic space, it's very helpful for that.

Dr. Monesh Aron:

[crosstalk 00:59:40]

Dr. Goh:

But I usually use a lot of cautery for most of the dissection.

Dr. Monesh Aron:

Does it seal lymphatics, the vessel sealer?

Dr. Goh:

Yeah, I mean I found that it's useful for sealing, yes.

Dr. Monesh Aron:

Okay.

Dr. Jihad Kaouk:

You know, I've not seen a increase in lymphoceles after we shifted almost completely in that part, for the vessel sealer. Dr. Pruthi, what's your opinion on the lymph node dissection?

Dr. Raj Pruthi:

Yeah. I do what Dr. Aron said. I like it out of the way to do the lymph node dissection. I think what we're going to see in the next few years is, again, if you look at the results of the LEA trial out of Germany, there was not a difference between extended and standard. And standard just being common iliac. I think there'll be a SWOG trial. So I think we've always, in the last decade, 20 years, been pushed to do very extended lymph node dissections, I think without really the data to carry that. And the LEA trial, what it did show was no benefit, but it did show no increased complications. But I agree with Dr Aron. I've heard issues of emboli to the feet and so forth, and it takes longer. So I think this is an important question that needs better evidence, that we're starting to get, that maybe a standard dissection is adequate.

Dr. Monesh Aron:

So we did a retrospective comparison between USA and Urs Studer's program in Bern a few years ago, when we had a fellow from Studer's program, and there was no difference in oncological outcomes between what Struder did, which is up to the ureter, and what was done historically at USA, going up to the IMA. But, again, the SWOG data automated and hopefully will shed more light on that.

Dr. Goh:

But I think a key point to add to that is, though, including the common iliac. So those would be your N3 disease. If you're just doing a limited, as in the bifurcation of the iliacs, than you're going to miss potentially significant disease. The other point about the LEA trial was it remember what it was structured to prove; a 15 percent difference. Now if you look at all the curves, though, recurrence free, cancer specific, and overall, extended was always on top, actually, on all the surgeons. Although, it didn't meet statistical significance. So I think there's a lot of nuance in that, in trying to describe, "Well what are the best patients that are suited for that and what should the extent be?" So, probably not just a very limited pelvic but something in between. It doesn't have to be super extended but probably including the common iliacs.

Dr. Raj Pruthi:

And I think you touched on something, Dr. Goh. It's probably going to be stage specific, right? Because T1 and less have less than a five percent node involvement. Your T3 is going to be higher, so we probably need a much more rather than one size fits all stage specific approach.

Dr. Jihad Kaouk:

Wonderful. We still have less than two minutes and maybe we can quickly comment on the urethrectomy as part of the cystectomy, male and female. Dr. Fergany? You're muted.

Dr. Amr Fergany:

Yes, just give me one second to unmute. It's very uncommon to, unless the patient has gross disease in the urethra, it is very uncommon to do a urethrectomy on block with the cystectomy. Most of these patients are patients who end up somehow having recurrence and have the urethra done separately as a separate session. So in most cases the decision, I'm sure like everybody else in our panel, whether you do a neobladder will depend on the frozen section at the time of surgery. But I think the enthusiasm for doing a urethral cystectomy, because of disease affecting the prostate or preoperative biopsies of disease involving the prostatic stroma, I think that enthusiasm has long gone. In my experience it's very uncommon to do a combined cystectomy urethrectomy.

Dr. Jihad Kaouk:

Thank you so much. I'm afraid we run out of time and we exceeded by almost 10 minutes our session. So the discussion was really very enlightening and exciting. Thank you so much for our surgeon presenters and moderators for making such a really educational session today. This is recorded and it will be included on the endourology website for people who didn't have a chance to watch it or in a different time zone. Don't forget to log into to claim your CME credit. They add up. This one is one CME. And please join us in two weeks with another webinar that will be focused on nephroureterectomy. We have an exciting panel being built for you. So again, thank you for the endourology society spearheaded here really by Dr. Sundaram have made so much effort on that and Michelle Paoli for putting everything together. Thank you all attendees, faculty. This is a poster reminder for the 2021 world congress of endourology and technology in Hamburg next September. Thank you all and thank you so much.