Surgeons: Ketan Badani and Inderbir Gill

Moderators: Ithaar Derweesh, Peter Caputo and Erik Castle


Dr. Ketan K. Badani is the Vice Chair of Urology and Robotic Operations at Mount Sinai Health System in New York. Dr. Badani has performed nearly 4,000 robotic procedures in his career, placing him in the top 1% of urologists worldwide for kidney and prostate surgery. He is one of the preeminent practitioners in the world for robotic partial nephrectomy for complex kidney tumors.

Dr. Badani is the author of over 150 peer reviewed publications and has presented more than 400 abstracts at national and international meetings. He leads innovative clinical trials, feasibility and safety studies of new technology, and health related quality of life outcomes research. He has pioneered the field of robotic urologic surgery with several of the early, fundamental publications on robotic surgery for prostate, kidney and bladder cancer. Analysis of robotic techniques during surgery to improve patient outcome has been a paramount focus in my recent work and efforts to improve surgical and oncologic outcome. Specifically, Dr. Badani has developed the First Assistant Sparing Technique (F.A.S.T.) which is utilized during robotic partial nephrectomy which specifically involves intracorporeal placement of sutures and bulldog clamps prior to clamping and tumor. This technique is published in the Journal of Endourology and reduces reliance on the first assistant and has been shown to lead to a shorter operation and shorter ischemia time for patients undergoing nephron sparing surgery. Dr. Badani is also an editor and/or reviewer for numerous academic journals including Cancer, Journal of Urology, Urologic Oncology, Journal of Endourology, among others.

In addition to surgery, Dr. Badani leads innovative research projects in the field of kidney cancer. He currently studies the optimization of MRI imaging data to predict long-term outcomes after treatment. Dr. Badani is also studying the role of recent advanced technology such as virtual reality and 3D modelling to help better understand the specific anatomy of each patient and apply that to planning the surgery to optimize the outcome. Another area of research focus is a clinical trial to study a novel medication for advanced and metastatic kidney cancer.

 

Inderbir S. Gill, MD, is Distinguished Professor and Chairman, Catherine & Joseph Aresty Department of Urology and Executive Director, USC Institute of Urology at the Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. He holds the Shirley & Donald Skinner Chair in Urologic Cancer Surgery and is Associate Dean (Clinical Innovation). Previously, he was chairman & professor, department of urology at Cleveland Clinic, Cleveland, OH, where he was on faculty for 12 years (1997-2009).

During his 10 years in Los Angeles, USC Urology has grown in scientific stature, clinical volumes, financial productivity and philanthropic gifts. As a result, USC Urology has progressed in U.S.News & World Report national rankings from being outside the ‘Top 50’ in 2011 to #4 in 2019. In NIH rankings, USC Urology was #16 (2016).

Dr Gill has published ~800 scientific papers with ~36,000 citations. His H-index is 104. He has edited/co-edited 10 textbooks and has been on the editorial boards of 9 urologic journals. He is principal investigator of a funded R-01 grant from the NCI and co-PI on 3 other NIH grants. He has been invited for over 450 visiting professorships, invited lectures and live surgery demonstrations world-wide. He is elected to the prestigious American Association of Genito-Urinary Surgeons (2003) and the Clinical Society of AAGUS (2009).

He has received various honors - the Dr. B. C. Roy National Award for Eminent Medical Person awarded by the President of India (2005); St. Paul’s Medal by the British Urological Association (2006); honorary Fellow of the Royal College of Surgeons of England; President, 24th World Congress of Endourology & SWL (2006); USC Presidential Medallion (2013); listed in Thomson Reuters “The World’s Most Influential Scientific Minds” (2014); AUA Ramon Guiteras Lecturer (2015); and AUA Chair Global Initiatives (2015-2017).

Dr. Gill’s primary academic focus is advanced robotic urologic oncologic surgery and, more recently, focal targeted therapies for prostate cancer. His aggregate team has amongst the world’s largest overall robotic/laparoscopic experiences for urologic oncologic surgery with ~15,000 cases in the United States.

 

Ithaar Derweesh received his MD at the University of Chicago-Pritzker School of Medicine in 1995. He completed Urology Residency at Yale under the guidance of Dr. Robert Weiss, and then went on to become an American Foundation of Urological Disease Scholar in Urologic Cancer and Fellowship in Renal Transplantation and Renovascular Surgery at the Cleveland Clinic under the mentorship of the late Dr. Andrew Novick. In 2005, he joined the Department of Urology at the University of Tennessee Health Science Center Memphis as Assistant Professor and then Residency Program Director. In 2008, was recruited to the Division of Urology at the University of California San Diego by Dr. Christopher Kane, where he is now Professor of Urology and Radiology and serves as Program Director of the Urologic Oncology Fellowship.

Dr. Derweesh has a practice focusing on kidney cancer and upper urinary tract malignancies and neoplasms. He has authored more than 200 publications and currently serves as an Assistant Editor for the Journal of Urology, on the Editorial Board of Minerva Urologica e Nefrologica, and on the NCCN’s Renal Cell Carcinoma and Testicular Cancer Guideline Panels. He has served on the AUA Kidney Cancer Guidelines Panels for the Clinical T1 Renal Mass (2009), Follow-up of Localized Renal Neoplasm (2013), and Renal Mass and Localized Renal Cancer (2017) and has participated in the AUA Leadership Program (2014-2015) and the AUA-EAU Exchange Program (2016), and was designated as one of the AUA’s Choosing Wisely Champions (2017).

 

Dr. Caputo was born and raised in Salt Lake City Utah. He is a graduate of Westminster College and attended medical school at The Temple University Lewis Katz School of Medicine in Philadelphia. His residency training was completed at the University of Texas Health Science Center at Houston and MD Anderson Cancer Center, after which he moved to Cleveland, Ohio where he completed a fellowship in Laparoscopic and Advanced Robotic Surgery at the Cleveland Clinic.

Throughout his education, Dr. Caputo focused heavily on contributing to the growing field of robotic surgery, publishing over thirty research articles in peer-reviewed medical journals, authored four book chapters on urological surgery and has presented at national medical conferences.

Since his return to Salt Lake City he enjoys teaching future urologists as an adjunct professor at the University of Utah. Dr. Caputo treats patients for all aspects of urologic health but has particular interest in treating kidney, prostate and bladder cancer. He implements minimally invasive surgical techniques whenever possible in order to facilitate swift patient recovery

 

Dr. Erik Castle is a Professor of Urology at Tulane University School of Medicine, specializing in urologic oncology surgery and minimally invasive/robotic surgery. 

Dr. Castle's surgical expertise includes robot-assisted radical cystectomy, prostatectomy, retroperitoneal lymph node dissection, and partial nephrectomy. He pioneered robot-assisted radical cystecomy in 2005 and robot-assisted RPLND in 2008. Dr. Castle has demonstrated many of these procedures internationally and has published extensively across topics of urologic care and science. He serves on the Early Detection of Prostate Cancer Panel for the National Comprehensive Cancer Network (NCCN). 

He earned his medical degree from University of Texas, Southwestern Medical School. He completed Urology Residency at the University of Kansas Medical Center and followed with a Laparoscopic and Reconstructive Urologic Surgery fellowship at Mayo Clinic of Arizona.

Dr. Castle's research focus includes prostate, bladder, testicular, and kidney cancers. He has experience in clinical trials, health sciences research, outcomes research, and basic science research.


Webinar Transcript

Dr. Chandru Sundaram:

Hello, welcome to the Endourological Society and the Society of Urologic Robotic Surgeons webinars in robotic surgery. We have every two weeks exceptional faculty who leads the seminars on webinars on various robotic surgeries as it's listed here. So please join us, same time on Fridays through the end of the year, every two weeks. We also have other Endourological Society, Endourology webinars on other Fridays. I am delighted to introduce our extremely experienced faculty with two surgeons, Dr. Ketan Badani and Inderbir Gill who need no introduction. As well as three moderators.

Dr. Chandru Sundaram:

Dr. Ithaar Derweesh, Peter Caputo and Erik Castle. Dr. Badani is the Vice Chair of Urology and Director of Robotic Surgery at Mount Sinai System in New York city. Dr. Gill is the Chairman of the Institute of Urology at the University of Southern California. Dr. Derweesh is a Professor of Urology at the University of California in San Diego. Dr. Caputo is at Salt Lake city in Utah, and Erik Castle is at Tulane University in New Orleans. So, you will see that these webinars do give you CME credits.

Dr. Chandru Sundaram:

After the webinars, you will receive an email from Michele Paoli of the Endourological Society, and this will help you claim CME credits. The format of today's webinar will include two talks. The first by Dr. Ketan Badani on the technique of robotic radical nephrectomy. This will be followed by Dr. Gill with his technique in a variety of modifications for IVC thrombectomy. During the webinars, please feel free to be interactive on the chat function. The moderators will answer the chat functions online, and those that are essential, will also be discussed live.

Dr. Chandru Sundaram:

These webinars are also being recorded, so in case you missed some or all of the webinar, they will be available online in the Endourological Society website, as well as the SURS website. We are delighted to acknowledge intuitive surgical for the educational grant that makes this webinar possible. I'm also here to let you know that I'm here on behalf of Jihad Kaouk, the first president of SURS who has made these webinars possible. Unfortunately, he couldn't be with us today because of a family emergency.

Dr. Chandru Sundaram:

I won't keep this any further, and we'll hand it over to Dr. Ketan Badani, who will begin his first talk. Ketan.

Dr. Ketan Badani:

Okay. Thank you. Thank you, Dr. Sundaram and thank you to Endo Society, Dr. Kaouk for inviting me to speak. It's an honor to speak with the group we have here. Dr. Gill, who will follow as well as the moderators. Dr. Caputo, Castle and Derweesh. So, I think we're going to have a fun time. And our topic at hand is robotic radical nephrectomy today, and we'll have different levels of complexity as we go through this. But what I'm going to do is start off by talking about some fundamental concepts as to why I think there's value in doing nephrectomy via a robotic approach.

Dr. Ketan Badani:

Happy to hear your comments or your contradictions in the chat box. So please feel free to make comments. We've got excellent moderators here to address those comments as we go. So again hopefully you'll feel free to weigh in on some of these thoughts. So essentially, what I'm going to say fundamentally is that, a lot of what we do with robotic radical nephrectomy is 90% in parallel to partial nephrectomy. And so this is just to demonstrate that the positioning is exactly the same. And in this talk, I'm focusing on XI, but I could say the same for SI.

Dr. Ketan Badani:

But the positioning is the same in full flank and the port placement, again, same as what I would do for a partial. And so now we have this linear port placement along the lateral border of the rectus. You see one, two, three, four robot ports in the gray assistant port. And whether I'm doing an upper pull, lower pull, partial, a [inaudible 00:05:03] an IVC thrombectomy, a radical nephrectomy of any type, this doesn't change so much. The only thing that would change this is some adhesiolysis that may change it.

Dr. Ketan Badani:

But other than that, it really is the same. And so a lot of these parallels end up translating into faster operative time, efficiency and actually lower cost when you actually look at this from an outcome standpoint, compared to Lapar open. So linear port configuration, standardized. All right. So this is just a graphic showing that I'm not the only one who thinks this way. And I know we have a lot of like-minded robotic surgeons on this call or on this webinar, but our country, at least this is US data as a whole, you see that the fastest growth in radical nephrectomy by modality, is robotic in the dark blue line here.

Dr. Ketan Badani:

And this is from last year. This line has actually surpassed open in laparoscopic. And so, you all as a urologic community, also are seeing value in whatever ways you're seeing it because it is being adopted in a very rapid fashion. So why do it? And here's my thoughts, right? The similar setup and steps of dissection we talked about, which does lead OR teams feeling comfortable with robotics, the setup, the turnover, et cetera. There have been improvements in instrumentation for autonomy. One of the criticisms was, you couldn't staple yourself or do certain specific maneuvers yourself.

Dr. Ketan Badani:

Then we're not going to get into this, but I do think it improves the rate of partial nephrectomy, the more comfortable you get with robotic radical nephrectomy. Then there's data that we have in our own system showing cost of equivalence. Actually, it's less than laparoscopic surgery. When all of these things fall into play. So here's the first case, and this is a 13 centimeter renal mass. And the reason why I picked this one is, that a very aggressive partial nephrectomist, I know Dr. Derweesh is on the call and many of the others might say, "Hey do a partial on this."

Dr. Ketan Badani:

But this is an appropriate radical in my mind. But my point is that the approach is the same, right? We have the same setup, the same port placement, and essentially 90% of this operation is in parallel. And so what we're seeing is that the operative times, the OR staff satisfaction, the assistance role is really very good now when we do these things robotic, because everyone's in tune with it, right? What you're seeing is the ureter, the posterior structures, the hilar dissection.

Dr. Ketan Badani:

The retraction of the kidney, this is exactly what ... I couldn't tell you if this was a partial or a radical right now, based on what I'm doing, up until the time the patient walks in the room up until this step. So I really do think that the more of this you do, and the more familiar you get with robotic kidney surgery, the more challenging scenarios you're going to be able to tackle, including complex partial nephrectomy. Then this is the autonomy piece, right? So now you can use the surgeon-controlled stapler.

Dr. Ketan Badani:

I use it off the fourth arm because you get this nice angle to the artery from the side. It's very nice. You have full control over this. And so although many of us do have wonderful assistance that can do this easily, many don't, or many just would like to do it themselves. And so some of those issues are gone now with the advanced instrumentation. I know there are some talk about the cost of this stapler versus lap stapler, and to be honest with you, I think it's all over the map so I don't actually have any good data to suggest how much of a difference it would be.

Dr. Ketan Badani:

I've heard that this stapler is cheaper than the left stapler. I've heard the opposite. But nonetheless, I feel like it can't be that far off. And then of course the rest of the radical nephrectomy is going to be a little different than what we do for a partial, but this is easy stuff. And so, this is the value that increases efficiency experience with retroperitoneal operations. And ultimately it gives you a better outcome. So here's the next case. This is the example I'm using, because I want to show that there are a lot of times you're doing a radical nephrectomy, where you're just glad you have a robot there for you.

Dr. Ketan Badani:

And a lot of those instances where we have some difficulty where we come across aberrant anatomy, you just feel happy you have the robot because you can do certain maneuvers, you can suture, you can do things that you feel more comfortable doing in those scenarios. Here's one of those scenarios. So here's a patient that had an open right partial, and now has this three centimeter recurrent tumor. You can see here. So during this case, we're doing the hilar dissection, and it's really very scarred in.

Dr. Ketan Badani:

Sometimes it's hard to tell in a salvage surgery setting how much scarring there will be from open surgery, which tends to have more than prior Lapar robotic, but you see, this is just complete scar right there along the vena cava. And so as we're cutting through, looking for cava, making sure we don't actually go into that, as we're cutting through, this is one of those scenarios where I was just extremely happy I had a robot with me. And you'll see why because, these are challenging procedures many times.

Dr. Ketan Badani:

The kidney, Gerota's, everything's scarred to the psoas muscle in these settings. And as you're cutting through, there you go, right. There's the renal artery. And so now I can quickly grab it, compose myself. And I'm sure we all have our own approaches. I don't think this was a good idea, right? So I want to show this to say, if everything's in scar and you try to control the artery. A Hem-o-lok clip's not going to work. And by and large it'll make it worse as you see here. But again, the beauty of robotics is, when you don't have control over the situation, you can get control.

Dr. Ketan Badani:

So, here's a situation that is fairly extreme. You have a renal artery bleeding, having trouble getting control over it, but this is not caused for a conversion. We don't convert these cases anymore. We don't convert to lap, we don't convert to open. You just take control of the situation. I've seen worse cases than this in many situations, but this is a good example of just, we have control on the robot, I'm able to hold the artery. I can switch my right hand, put in a suture, and sow one handed, right?

Dr. Ketan Badani:

And although in Dr. Gill who's probably one of the most proficient laparoscopic surgeons can say that this can be done laparoscopically. I think the reproducibility of doing this and avoiding conversions, isn't the same as robotic. We just don't have to convert in this situation anymore. And you see, you have good control over the situation. And obviously we don't have time to go through a lot of these different examples. So I wanted to just pick one that was a little bit stuck, a little bit of ... "Oh my God" moment, but how it can be managed robotic.

Dr. Ketan Badani:

Here's the case I did last week. Another criticism was not having space to deal with large tumors. Here's a polycystic kidney symptomatic, and you can see how big these kidneys are on the coronal view. And we're able to do this purely robotic and really working in small spaces. And so I think that criticism is not true and I actually think it's much better because you have stable retraction, you can hold that kidney up with the fourth arm, and do these very large complex ... these cases, this was last week. This patient did great, went home the next day. And then the other piece of course is retroperitoneal lymph node dissection.

Dr. Ketan Badani:

One of the really nice things ... Ii think this video ... Oh, there we go. One of the really nice things is, whether it's a nephroureterectomy or whether it's a higher risk renal cell with some potential lymphadenopathy, the quality of the lymph node dissection is really nice when you do it robotic. Here's the left side, you see the anterior surface of the aorta. Now it depends how aggressive you want to be with this lymph node dissection. In this particular case, I'm just doing these paraaortic lymph nodes. But if you look at how challenging this could be in other settings, laparoscopically, and even retro, an open approach through a flank retro incision, is challenging.

Dr. Ketan Badani:

This exposure is not as easy. And the exposure in a robotic setting is very nice. You can get through this, it doesn't add much time to the procedure. And so we've been doing more and more retroperitoneal or at least paraaortic or paracaval lymphadenectomies in higher risk kidney cancer, without much consequence. And so you see you get these nice lymph node packets, and you could go all the way into aortocaval. You can get to the other side of the cava if you wanted to in the left flank position. But I think this is valuable because a lot of you out there who are doing radical nephrectomies, may feel like you want to do lymph node dissections and I'll tell you, doing it robotically is really very nice as you can see here.

Dr. Ketan Badani:

Just a quick video just showing the right side, same thing, paracaval. I did one this morning. Radical nephrectomy with a pretty extensive paracaval lymph node dissection, but just giving you an idea, this video is not playing, but just to give you an idea of what that looks like, you have nice straight on view of the vena cava, and even these lumbars, you can sow them, you can clip them yourselves, you have good control over the situation. Dr. Sundaram had made a point that it's important to show lymphadenectomy because, it's so facile with the robotic approach.

Dr. Ketan Badani:

I know there's controversy and I'm happy to hear it, about whether we should be doing these for high-risk kidney cancer, but I think that if you see some lymphadenopathy on the scan, or even if there's suspicion when you're doing it, doing the case itself, there is value to doing this. And so, here's some lumbars, we can nicely avoid them or you can sacrifice them and take them, and do a nice lymph node dissection. Go into aortocaval, et cetera. So, essentially my take home messages are that I believe and I know that many may agreement, many may disagree that complex radical nephrectomy is better performed robotic compared to lap or open.

Dr. Ketan Badani:

Some of those examples are doing a lymph node dissection, a nice thorough lymph node dissection, IVC thrombectomy, which we'll hear more about soon. Recurrent tumors after ablation, open partials, lab partials, robot partials, et cetera. In our data and obviously due to time constraints, I'm not sharing a lot of this, but I'm happy to if you want to reach out to me. We looked at our system, which is a seven hospital system in New York city, and compared to all surgeons doing open lap and robotic, and actually found due to the fact that the length of stay is shorter for robot, the operative time is shorter.

Dr. Ketan Badani:

For the reasons I outlined that it's actually cost equivalent and the data shows that it's a little less expensive than lap and open. Again, including hospital stay is part of that cost. And so the more facile you get with this, the cost argument disappears very quickly even for radical nephrectomy. Now, I don't mean to take away from the last bastion of laparoscopic surgery in urology, which is lap nephrectomy, but if there's obviously a benefit to doing something this way, then we should be talking about it. Then there's the demonstrated trend, more and more people are doing the radical nephrectomies robotic.

Dr. Ketan Badani:

I hope that that will translate to more complex surgery being done minimally invasive, from a radical standpoint, but then also increase the utility of partial nephrectomy ultimately because there's familiarity in comfort level with dealing with a little bit more of these complex situations with the kidney. With that again, I want to thank the Endo Society, Dr. Sundaram for inviting me to speak. I look forward to our discussion at the end of the seminar. With that, I'll hand it over to you. Thank you very much.

Dr. Chandru Sundaram:

Thank you very much, Dr. Badani. That was an excellent discussion. We have a second poll here. I'm going to read it out. Audience please participate in this poll. In an elective setting, when is a radical nephrectomy preferred or partial nephrectomy? And you can pick more than one on these, just to give us an idea of what the consensus is amongst the audience, about when they would do a partial versus a radical. We'll now move on to Dr. Gill. After both these talks, we will start with a discussion, but please keep the chat box busy, and we will keep answering your questions on the chat. Dr. Gill.

Dr. Inderbir Gill:

Thank you. Thank you Dr. Sundaram. Also thank you Dr. Jihad Kaouk and the Endourology Society for inviting me to participate in this excellent discussion with my distinguished colleagues. I'm going to give you some thoughts about robotic inferior vena cava surgery, specifically tumor thrombectomy for level 2, three and four thrombi. Okay. So we published this some time ago, bottom line, as you know, level zero is something that's only in the renal vein level. One is into the vena cava, less than two centimeters in size, level 2 is greater than two centimeters, but intrahepatic level 3 is intrahepatic, and level 4 is suprahepatic. Or into the chest.

Dr. Inderbir Gill:

So these are the various kinds of vascular controls that one needs for varying levels of trauma. One thing that is critical for vena cava thrombectomy surgery robotically, is complete and detailed and total knowledge about the anatomy. That is critical. I want to know where the right renal vein is entering the vena cava versus the left. I want to know if it's one centimeter up one centimeter down. I want to know where the lumbar veins are, et cetera. And so, a detailed CT scan with a 0.5, one centimeter cuts 0.5 or one centimeter cuts, and then sitting down with the radiologist, to really figure this out upfront.

Dr. Inderbir Gill:

Because during surgery, you're not going to have clarity on the anatomy that you have not yet dissected. And it is very nice to know the anatomy before you see the anatomy. This is an instance where, here's a level 3 thrombus going all the way up to the upper part of the liver here. So this is three B and this patient has a bland, a distal thrombus and showed up in the emergency room with a pulmonary embolus. And the treating physicians did not scan the belly and just felt it was ... they did a duplex Doppler of the legs, found a DVT in the leg and felt he needed IVC filter, so they put this through the inferior vena cava, they put it through the internal jugular, rammed it down the thrombus and malpositioned IVC filter you can see here.

Dr. Inderbir Gill:

So we did this case robotically. As I mentioned, it is critically important for me to know what is the diameter of the cava? What is the length of the thrombus? Is there any patent vena cava alongside the thrombus? What is the tumor thrombus width? Here is the right renal vein, here is the left renal vein. And you can see here, less than one centimeter difference between the entry point of the left renal vein and the entry point of the right renal vein. Why is this important? This is important because if these two veins were at the same level, then I have to do the infrarenal control over here, which means, then I have to control the right renal vein.

Dr. Inderbir Gill:

Which means then I have to control the right renal artery, which means, your right kidney is going to be in a ischemia, a warm ischemia. And which means that since the left kidney is going in this particular patient, now the solitary remaining right kidney is going to be an ischemia for 30, 40 minutes. Which is not a good thing. So just knowing this upfront that there is a one centimeter distance between the entry of the left renal vein to the right renal vein for example, I'm just giving you one example. One is able to place the tourniquet in an oblique fashion, thereby controlling the infrarenal cava, and yet leaving the right renal vein open, therefore the right renal artery open, therefore the right kidney perfused, which is a big plus for somebody who's going to be very shortly having a solitary kidney.

Dr. Inderbir Gill:

The four essentials of the technique that we have gravitated towards and developed and learnt as we went along, is IVC-first kidney-last. So first the vena cava ought to be controlled, and then we'll work on the kidney number one. Number two, midline-first lateral-last, in other words, given that the renal vein has a thrombus here, there are going to be collaterals, and collaterals are all concentrated around the renal hilum. So if you go dissecting the renal hilum right off the bat, these very thin-walled collaterals, they will tear just at mere retraction of the perihilar tissue.

Dr. Inderbir Gill:

You don't even have to touch the collateral, just retracting the ureter could lead to some oozing. And once the losing starts, it's downhill. However, in the midline, in the inter-aortocaval region, there are no collaterals. So you start there in the midline inter-aortocaval region, and then go elsewhere. Minimal-touch IVC approach, such that we are trying at least in our mind, theoretically, trying to tease the tissue away from the cava, rather than teasing the cava away from the tissue. And of course the excluded IVC segment has to be completely blooded, before we open it. All tributaries must be controlled.

Dr. Inderbir Gill:

Let me start off with the complication. This is in a patient with a left renal mass 3.7 centimeters, level I caval thrombus, and he had GFR of 17 at the get-go, creatine of 3.5. This gentleman flew in for this surgery. And so again, left-sided thrombus and we've already done the NGO infarction of the left kidney. So now we are dissecting here. This is all a trans plate on the approach, getting the duodenum. So for a left sided thrombus, the patient is placed in the right side of position, because first you want to control the vena cava, then you reposition the patient for the left nephrectomy. So this is right side up, and here is the vena cava being dissected.

Dr. Inderbir Gill:

We are putting the infrarenal tourniquet, Rummel tourniquet, all controlled intra abdominally. So this is the infrarenal tourniquet and we are now going around the thrombus bearing left renal vein, putting a tourniquet around that. Just getting that teed up. And I just mentioned, this is a level 2 thrombus so, you can see some short hepatics have been taken, and now we are going suprarenal, subhepatic and putting the tourniquet down there. And now, it's about a four centimeter or so thrombus. Now we are cinching down the tourniquets.

Dr. Inderbir Gill:

You cinch the infrarenal first, and the suprarenal and the contralateral renal vein. And then we transect the thrombus bearing renal vein after the suprarenal tourniquet has been cinched down, so as to disconnect the cava from the renal vein and thereby being able to rotate the vena cava circumferentially to ensure that all vena's tributaries are taking care of. Now you'll see, I'm cinching down these tourniquets tightly. And here it is, and I'll be making the vena cavotomy. I don't know if you noticed, but the tourniquet, we put it on the vena cava in one. It was not a double loop, it was a single loop [inaudible 00:26:18].

Dr. Inderbir Gill:

So here we are doing the vena cavotomy, and everything is under good control. We are at this point about ... here's the thrombus now coming out, you can see the white bits of the vena cava which is a nice thing, which is confidence inducing that the hemostasis is well-controlled and that the thrombus is out. Here's the thrombus. So at this point we are about an hour and a half into the operation, and only about 50 cc or 100 cc blood loss. Okay? And here it is, the thrombus is out, and things are going beautifully. Now we'll bring in the bag to put the thrombus in it. And boom. We're going to show you this a couple of times. It'll rerun by itself, just to show you ... here we are.

Dr. Inderbir Gill:

The thrombus is up in the air, vena cava ... We're not even touching it, and you see if you note carefully, the lower tourniquet, just pops. See that? The lower tourniquet just pops, and we are not even touching it. So, I'm just showing you two to three or four times. And this was obviously very dramatic and happened spontaneously without us doing anything to the tourniquet. We of course converted to open surgery immediately, and then got the control, and repaired the ... We convert it to open, and this is the way the Rummel tourniquet was constructed. And this is the Rummel tourniquet we found in the operative field.

Dr. Inderbir Gill:

This lowered loop has basically disrupted. You can see that. So, the reason this happened is, I believed in the infallibility of this vessel. Obviously it is not. And so since then we have gone to double looping, which does not therefore need to be cinched down as much as a single loop does. And this is just showing you the control that was obtained intraoperatively, and fortunately everything went well. And the other patient was discharged from the hospital after a couple of weeks hospital stay. But obviously this is dramatic stuff. At the end of the day, it is through our learning and through the complications that we share with each other that we learn from each other, on how to carefully keep moving this forward.

Dr. Inderbir Gill:

Here is another thing about patch cavoplasty. The question is often asked that, if one was to find intraoperative invasion of the vena cava, we are not double looping this. The point being made here is, how about if when you do the thrombectomy, you're inside the cava now, you find invasion of the caval wall, which can certainly happen and not always predicted by the preoperative CT. You can see here this area that is invading, which was confirmed pathologically. You can excise it, in this case appropriately sized pericardial, bovine pericardial patch that is perfectly sized to the amount of cava that you excised, and then cinching it down with number four or number five Gore-Tex stitch is what we are doing here.

Dr. Inderbir Gill:

And just putting it back together and doing this. This is a patch one could potentially replace, we've not had occasion to do that. Although we've used bigger patches. This is another thing I want to just quickly show intracaval balloon control. We're putting in Fogarty balloon past the thrombus carefully. So that's why I need to know if there is any space between the thrombus and the caval wall, right? And you can see the balloon over there. So the suprarenal infrahepatic control is completely by the balloon here, now has to be done very, very carefully, and we need to know the exact size of the diameter of the cava, so that we can know exactly how many ccs to put in the balloon.

Dr. Inderbir Gill:

And we need to know exactly the length of the thrombus so that we have to get the lower part of the balloon above the thrombus and all this has to be done in real time, but just showing you that that is possibly a way to control the suprarenal cava. Showing you finally a robotic level 4 tumor thrombectomy. And I think I just have a few minutes. So it's what? A 16 centimeter tumor thrombus length, 5.2 centimeters was in the atrium. And here is the thrombus, you can see going into the heart. So here we go, you can just see the various things. This is the thrombus in the atrium, touching the valve.

Dr. Inderbir Gill:

You can see the thrombus going through the cava, all the way up to the ... there's the thrombus in the vena cava. And this is just showing you the overall graphic of it. And we can really support positioning no different than usual, here's cardiopulmonary bypass is what we put the patient on. This is the robotic team and the cardiac team. This is the thrombus only the intraabdominal part. The cardiac part was taken by the cardiac team is not in this picture. And just show you a few things here regarding doing it in a methodical, careful way. Retracting the duodenum is very important and sometimes is a challenge.

Dr. Inderbir Gill:

Because it's in the way, so you have to pad the duodenum and be very, very careful. We've had duodenal injury in a couple of patients. It has to be guarded against, and then if it is there, it has to be fixed, which we were able to do in both cases without sequela. And this is just showing you that the dissection around the infrarenal IVC is being done. And then the left renal vein is on stretch here. Here are the retro caval lumbars, with the caval retracted up. You can nicely control these.

Dr. Inderbir Gill:

Again, I see that I first went in the inter-aortocaval region, where the collaterals are minimal, and by the way, we now do preoperative angio infarction in the majority of our cases. Certainly for all left-sided thrombi because we got to go right side up first, and we control the vein first so we got to have the artery done upfront, but also for larger tumors, to cut down on venous collaterals is a big deal. So we don't see any downside to this other than I guess the cost aspect. But it certainly gives more intraoperative confidence. Now we are dissecting the suprarenal IVC, and going posterior to it.

Dr. Inderbir Gill:

Here is the double fenestrated grasper going in an oblique fashion. See, it's below the right renal vein and above the left renal vein. So this was the oblique control that I was talking about, and be able to ... Below the right renal vein above the left renal vein, and thereby keeping the contralateral kidney perfused, and in good shape. And then we have to take the short hepatics, not an area which typically as urologists we work in, but again, one can get comfortable with anything as long as you'll really dedicated yourself.

Dr. Inderbir Gill:

So we take three, four, five short hepatics as needed. Here is the right adrenal vein, which has to be done carefully because remember the thing is coming across the cava. You see this clip applier coming across the cava, and the cava is full of thrombus. You don't want to be pressing on it. So this is not as easy as the usual right adrenal vein control, but obviously can be done. And now we are going with the double fenestrated grasper, posterior to the cava, and putting down this Rummel, this is a level 4 thrombus, so clearly this thrombus is going all the way to the heart.

Dr. Inderbir Gill:

So this Rummel is not cephalad to the thrombus, but just subhepatic, we've already got the Pringle. I don't know if you can see the Pringle over here. I guess I'll show you in a little different shot. So the reason we put the subhepatic tourniquet is because, once the cardiac part is finished, we want to be able to cinch down subhepatic, such that we can restart the heart, et cetera. And so this is now the IVC-first kidney-last, as I mentioned. The cardiac guys are already up there doing the heart under control. And there's some cardiac bypass. We are now transacting the tumor thrombus bearing the right renal vein.

Dr. Inderbir Gill:

The kidney is now being retracted laterally. So here cava. And we are cinching down the ... By the way it's not a good idea to be cinching this down with the scissors in my right hand. There should be a grasper, and that is very important to do which we have learned not to make [inaudible 00:35:56]. This is the Pringle right here. That is the Pringle that we did at the very start of the case. So that goes around the porta hepatis. And now with the cardiac forks, having the chest open through a sixth intercostal incision. Six intercostal incision, and we are now extracting the thrombus.

Dr. Inderbir Gill:

Many of these thrombi are fryable and often do not come out in a single piece. Even opened surgically. So, one has to be careful though to the extent possible, but at the end of the day, if you're saying, how about microscopic spillage? Well that happens during open surgery every single time. So, here we are getting the thrombus out. As I mentioned, the cardiac guys are up there controlling it from the heart perspective, and we are getting inside the intrahepatic cava now, getting the thrombus out. Now you can see the intrahepatic, cava very nicely. That's the hepatic vein confluence that you saw on the left side.

Dr. Inderbir Gill:

We put the thrombus right away inside. Then we are putting in this Fogarty balloon all the way into the heart, and then inflating it and pulling it down to confirm that indeed there is no residual thrombus. We did this twice, to make sure that that's good. And then finally, to do visual inspection, we did a cavoscopy with a cystoscope, not very efficient because they cava is open and therefore you don't have a good expansion, but certainly enough to have a quick view to make sure there's nothing staying behind. Now we are closing off the cava as the cardiac team is closing the heart, and being done simultaneously.

Dr. Inderbir Gill:

It was not easy to have enough space for the cardiac guys to do their thing as we are doing our thing in the abdomen. And this patient remember he is on cardiac bypass, 25,000 units of heparin intravenously. So I was petrified that we would have bleeding once the heparin kicked in, but mercifully the intraabdominal blood loss was just 300 ccs. Overall the patient required six units of blood because when somebody goes on bypass, some blood is involved in the tubing, et cetera, but intraabdominal was about 300 ccs. Hospital stay was six days. Operative time was 10 hours, cardiopulmonary bypass, two hours Pringle time, a half an hour.

Dr. Inderbir Gill:

This is the post-operative picture. And over here, I'm sorry, this is not a very good photograph, but this is the sixth intercostal incision to get into the chest. I'll stop there. Just to say that we are not saying this is how vena cava thrombus surgery ought to be done. What we are saying is that with careful, thoughtful, step-by-step progression and learning from our mistakes or learning along the way I should say, and in discussions with open surgical colleagues and other robotic colleagues, gradually carefully as a community, we can expand and can push the frontier forward step-By-Step in a careful, responsible, thoughtful manner. Thank you.

Dr. Chandru Sundaram:

Thank you very much, Dr. Gail, that was an exceptional demonstration of a high-class surgery. This reminds me of disclaimers you see on TV that says, for professionals only, don't try this at home. And this is very similar. On a more serious note, my question to you is, how many caval thrombectomies at USC are done robotically versus open.?

Dr. Inderbir Gill:

So, Dr. Sundaram, by now we've done about 45 or so caval thrombectomies, how many are done open versus robotic? I would say I really don't know the exact ratio. We looked at this over 12 years or so. I hope that number is correct. I am not 100% about 220 or so, maybe 12 years or 20 years. One or the other open thrombectomies were done. And our robotic experience has been in the past I would say, I don't know, four or five years, something like that. So, I just don't have a good idea. I would say, two is to one, three is to one open versus robotic.

Dr. Chandru Sundaram:

Thank you very much. Now we'll get opinions from our moderators. We'll start with Dr. Castle. Erik.

Dr. Erik Castle:

Yes, I'm here.

Dr. Chandru Sundaram:

So you have a lot of experience with robotic surgeries, any opinions on what we saw today? And the specific question to you is, what about lymphadenectomy in patients? When would you choose lymphadenectomy? How extensive would it be for a typical case with where you're doing a robotic radical nephrectomy?

Dr. Erik Castle:

Yeah. So, there's reasonable data retrospectively on lymphadenectomy for renal cell carcinoma. Let's forget robotic at the moment. Just, what is the role of RPLND and just removing lymph nodes for stage III or higher kidney cancer. In general, the conventional wisdom is, if you can remove it safely without adding any significant risk, there's probably some staging value, but there's been absolutely no survival data that's demonstrated any benefit whatsoever. That actually comes from large experiences open from Mayo Clinic in Rochester.

Dr. Erik Castle:

But I think the value of it, is maybe understated because we now are treating advanced renal cell carcinoma in a very different way moving forward. We are now seeing that the old era of TKIs is not the first-line therapy for advanced kidney cancer, both stage III and stage IV disease. I think the combinations of various checkpoint inhibitors can change all that. So, knowing if someone has positive lymph nodes pathologically that's confirmed in the operating room and potentially lowering all the tumor volume, if you can do that safely without any heroic maneuvers or large vessel injury, I still do it because I'm big into lymph nodes.

Dr. Erik Castle:

Do I think surgeons have to do it? No. Now, whether I do it robotically or not is ... no, I like using the robot for everything. And so I do see value in using the robot for doing a concomitant RPLND at the time of radical nephrectomy.

Dr. Chandru Sundaram:

Thank you, Dr. Derweesh a question to you. Is there a role for neoadjuvant systemic therapy in patients with advanced kidney cancer, especially with with caval thrombus?

Dr. Ithaar Derweesh:

I think that's a very intriguing area of investigation. Certainly there are from the data with the TKI inhibitors that various groups such as the Cleveland Clinic Group, as well as the MD Anderson Group have looked at, they do show some with the first-line agents, for example TKI. You can get some reduction in thrombus size, as well as in the primary tumor size. I would say that the more intriguing data is coming now in terms of case reports with the immune checkpoint inhibitors, seeing some really dramatic declines in the thrombus size, as well as primary tumor size.

Dr. Ithaar Derweesh:

I would say at this point, it's still investigational in terms of using it to facilitate surgery in that type of fashion, whether you're looking at it for a radical nephrectomy or for a partial nephrectomy in an imperative circumstance. I would say that what should be driving systemic therapy use prior to thrombectomy should be the overall disease burden and presence of metastatic disease. But I can say that anecdotally, looking at this prior to our caval thrombi, we've actually in a series of 13 of these patients, we've had two of these patients actually by the time that we went back to actually do the nephrectomy, there was no evidence of any tumor in the actual nephrectomy of thrombectomy specimen, and after a dramatic decline.

Dr. Ithaar Derweesh:

But I would say that we're not there at this point. We need more study and more data.

Dr. Chandru Sundaram:

Thank you.

Dr. Erik Castle:

Chandru if I can ... May I jump in real quick?

Dr. Chandru Sundaram:

Go ahead.

Dr. Erik Castle:

[crosstalk 00:44:39]. I think it's important to know that even adjutant trials that were TKI based, really did not show enormous benefit as TRAC had a little bit in it. So I think that most people the conventional wisdom is if you can take into the operating room successfully do it before systemic therapy that's probably the preferred approach. I think in the caval thrombus situation, you have to worry about bland thrombus developing below it. In fact, when patients or other physicians are reaching out to me about these patients, I recommend they get immediately started on anticoagulation if they're not having any gross hematuria to prevent a bland thrombus from developing before we can get the patient to the operating room.

Dr. Erik Castle:

So, I think we've got to wait on that data. Those immune checkpoint inhibitors are very exciting. But I don't think we generally use them unless we feel they're not operable and maybe you can make them an operable patient later.

Dr. Chandru Sundaram:

Thank you. Peter Dr. Caputo, we have seen two remarkable surgeons at work. Could you enlighten us on other techniques or tips or tricks that you may have or different instruments you use other than what we saw today with Dr. Gill and Dr. Badani?

Dr. Peter Caputo:

Now, I'd like to add that I really want to thank Inderbir Gill and Dr. Badani for showing us these videos. They demonstrated some great techniques. The points that I'd like to mention are that, we asked that some of the poll questions of, should these cases be done robotically, should it be done lap? Should it be done open? There was no nuance to those poll questions. And I think the important thing is that it's different for everyone and each case is different. Not every nephrectomy needs to be done robotically, and not every surgery needs to have one approach. It's important to choose what you indeed are comfortable with.

Dr. Peter Caputo:

So I think that's the take home is, incorporate these methods into your practices you can see fit and take home the tips and tricks you learned from these sessions, from these amazing surgeons like Dr. Gill and Badani and ... that's my take home message is that there's really no one size fits all for these surgeries.

Dr. Chandru Sundaram:

Thank you. Ketan I have a question for you Dr. Gill showed us putting patches to excise. So caval wall when there's an invasion, and there are some reports especially from China that talks about cavectomies very radical surgery when there is involvement of the walls of the cava. My question to you is, preoperatively, how would you assess these situations? Is there a way to do this? And is that an indication for cavectomy, caval wall reconstruction and other instances when you should say no, I cannot do it robotically despite the best of technical expertise that you have.

Dr. Ketan Badani:

Yeah. Good questions. I'll tell you that my practice on this is, if it's invading the wall of the cava, you can excise up to a third of the wall of the cava and not need to graft it. You can still close the cava and they do pretty well. But I think if you end up excising the circumference being more than a third of it, it starts to become problematic. So doing a patch, Dr. Gill showed bovine which is what we've used works very well. I have done one robotic and several open transections of the cava where you just take the cava.

Dr. Ketan Badani:

But in those situations, those patients have tremendous collateral venous circulation and you can see that preoperatively on the imaging. So the consequence of someone who's been obstructed for so long in the vena cava, taking the cava is of no consequence. There's no flow that goes through there anyways. So we've done that many times in that situation.

Dr. Chandru Sundaram:

Would there be a circumstance where when you would say we should do it open?

Dr. Ketan Badani:

I think, well, haven't done level 4s as Dr. Gill has done, and I have gone to 3, I've taken the hepatics, there are nice ways to do that, but I haven't gone beyond that. So, that's been my limit for the robotic approach. The only other time I've said, "Let's do it open." Is if there's so much mass, the tumor is so big and the thrombus is so big that there's not enough room to work, which doesn't happen that often, but I've had one case where the entire abdomen was just taken up with tumor and the cava was pushed past the midline and I just didn't feel comfortable doing that.

Dr. Chandru Sundaram:

Thank you. So, Dr. Gill I have a question for you. Any advice for someone who's starting off doing caval thrombectomy in the audience? What would your advice be?

Dr. Inderbir Gill:

Don't do it. That would be my advice. Because, you live and you learn. The room for error is zero. One must be very honest with oneself, and one should have enough of a robotic personal experience, but also have the team necessary from the cardiac anesthesiologist perspective, the cardiac surgeons, radiologists, ICU folks, they're your operating team, that this is a significant undertaking. If it goes well, it goes beautifully. If it doesn't, it can be a real showstopper. As regards your question about which ones would be indication ... but as you become more comfortable of course, step-by-step-by-step, keep advancing, following the principles.

Dr. Inderbir Gill:

I think one should be very leery, careful when the IVC diameter is beyond a certain diameter, five centimeters, six centimeters, et cetera. You can do more than that, but again, we are talking now really dicey stuff, and actually cavectomy, nothing is simple. So please don't misunderstand what I'm going to say, but cavectomy compared to caval thrombectomy is a far simpler operation. I shouldn't say far, it's a simpler operation. Again, preoperatively the renal vein diameter, the IVC diameter are predictors of caval invasion, but carefully sitting down with the radiologist can also give you a good idea about caval invasion.

Dr. Inderbir Gill:

But it's not a 100%. So we've seen intraoperatively folks that we felt in preoperatively are not invading the cava, to be having invasion and the vice versa too. But if the vena cava is nonfunctional, i.e it is obstructed, then there is fighting and endo GI infrarenally and then disconnecting the two kidneys, and taking it subhepatically, actually makes for a simpler operation. Of course, the right renal vein would have to be revascularized maybe it is going quarterly into the infrarenal vena cava. You have to figure out how to make that happen. But those are my thoughts that, this is not something that we need to be pushing beyond at centers where there is the requisite expertise, experience and the team.

Dr. Chandru Sundaram:

Very well said. I think this is a really, really advanced surgery and a team is so important, very well said. We had a fantastic webinar. We've got a few minutes, three minutes actually, to be precise left. Any comments from our moderators or from Dr. Badani before we end this webinar?

Dr. Ketan Badani:

Yeah-

Dr. Inderbir Gill:

I would jump in with one quick one. Ketan, beautiful video. Just for the audience, I wanted to say that as immunotherapy goes, gets more underway and we are doing more consolidative nephrectomies, et cetera, we are going to come across hilums that are plastered, like your video short. Okay. So, I guess my comment would be that in some of these circumstances, individual dissection of the renal artery and vein, is fraught with danger and potentially end block stapling, as long as you know that the ipsilateral great vessel exactly where it is, 100%, no confusion. We have the soarses, no confusion, and then, fighting an endo GI and block laterally away from the great vessel, under good excellent visualization, could actually speed it up.

Dr. Inderbir Gill:

And the concern about arteriovenous fistula, et cetera is a non-existent issue. I don't think that's an issue. You can switch it up later if you want, but I just wanted to throw that in for the audience really that don't feel compelled to dissect out the artery in the vein individually in these difficult hilums.

Dr. Ketan Badani:

Yeah. Thanks for making that point. I think one of the things that's interesting, one of the downsides is that when the tissue's really hard, the stapler can't quite close against it in those situations. The robotic stapler has a mechanism, an electronic mechanism to tell you if that's the case. So as I think the instruments get better, we may be able to circumvent that in that scenario. But I agree av fistula is not really a concern.

Dr. Chandru Sundaram:

Thank you all very much. We have come to the end of another hour of a fantastic technique and description by our faculty. Thank you all very much for joining us and we look forward to seeing you in the next couple of weeks for the next robotic webinar from the Society of Urologic Robotic Surgeons, as well as the Endourological Society. You will receive CME credits. You will receive a survey from Michele Paoli, please fill out the survey and you will get the CME certificate. Also, please join in the Endourological Society. If you are not already a member, there are multiple benefits of the society, including access to Journal of Endourology, Videourology and the Atlas of Urology.

Dr. Chandru Sundaram:

All this is available on our website. So until the next time we see you on the next webinar, goodbye and thank you all very much. We look forward to seeing you in Hamburg in 2021, bye bye.