Surgeons: John Sfakianos and Alvin Goh

Moderators: Andrew Wagner and Prokar Das Gupta


 

Dr. John Sfakianos is an Assistant Professor at the Icahn School of Medicine at Mount Sinai. He completed his MD from the School of Medicine and Biosciences at Buffalo and completed his internship and residency at the State University of New York at Downstate Medical Center. He then went on to fellowship in Urologic Oncology, which was completed at Memorial Sloan-Kettering Cancer Center. His clinical and research focus is on understanding and treating patients with urothelial carcinoma.  He has lead the efforts in improving robotic cystectomy techniques, more specifically my performing this surgery without the use of opioids, Non-opioid Protocol (NOP). 

He is also a federally funded, DOD and NIH grants, translational researcher working with both human tissue and murine models to help understand and identify novel targets in treating urothelial carcinoma. Dr. Sfakianos is the author of over 100 articles in peer reviewed publications and several book chapter on urothelial carcinoma. 

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.

 

Dr. Wagner is director of Minimally Invasive Urologic Surgery at Beth Israel Deaconess Medical Center in Boston, Massachusetts.  He specializes in minimally invasive surgery for patients with cancer of the prostate, kidney, bladder and testes.  His research interests include active surveillance for prostate and kidney cancer, evaluating health related quality of life following urologic cancer surgery, and developing novel minimally invasive surgical techniques.  In 2009 he developed the Endourological Society fellowship at BIDMC in Laparoscopy and Robotics.  He has also served as the director of the New England Urologic Robotic Training Course. 

Prokar Dasgupta is Professor and Chair at Guy's Hospital, King's College London, UK. His main research interests are in the immunology of the prostate and advanced robotic tools to deliver cytotopic therapy. He is credited with over 500 publications and was awarded the Golden Telescope for significant and lasting contribution to urology. He is the current Hunterian President and Editor-in-Chief of the BJUI.

 

Webinar Transcript

Dr. Chandru Sundaram:

Welcome to this robotics webinar, sponsored by the Endourological Society and the Society of Urologic Robotic Surgeons. Please join us every two weeks until the end of the year, with outstanding webinars focusing on technique, as well as with great faculty, with tips and tricks and moderation and discussion, which is interactive. You will receive CME credits for these webinars. And these webinars are possible with the support of Intuitive Surgical, which we acknowledge.

Dr. Chandru Sundaram:

As you can see, these webinars are every two weeks. Please make a note, same day, same time on Fridays every two weeks, and we will look forward to seeing you then. It is my privilege to introduce to you Dr. Jihad Koch, the first president of the Society of Urologic Robotic Surgeons, who will introduce outstanding speakers we have today. Jihad.

Dr. Jihad Kaouk:

Thank you, Dr. Sundaram. We have a very exciting session prepared for you today on urinary diversion ileal conduit and neobladder. And for that, we have two very well-known surgeons in the field with vast experience. Dr. Alvin Goh from Memorial Sloan Kettering and Dr. John Sfakianos from Mount Sinai. And on the moderation side, we have Dr. Prokar Das Gupta. Professor Das Gupta is from King's College, London and Guy's Hospital. And Dr. Andrew Wagner from Dana-Farber in Boston. Obviously a [inaudible 00:01:53] group that we all look forward to learning from them today.

Dr. Jihad Kaouk:

We are going to start with just a few points about the format of the session today. We have a one hour, divided into 20 minutes each. The first 20 minutes will be a presentation by Dr. John of Candace about the ileal conduit, followed by Dr. Alvin Goh for another 20 minutes, focusing on the intra corporeal neobladder. We will reserve the last 20 minutes for a moderation and round table discussion on the topic. Meanwhile, throughout the hour, please ask questions and put your comments on the chat box, not the Q&A, but the chat box button on the Zoom platform, so that we can interact with you while the presentations are going.

Dr. Jihad Kaouk:

Without any more delay, I would like to ask Dr. John Sfakianos to start with his presentation. Thank you.

Dr. John Sfakianos:

Thank you very much and this is very much a humbling honor for me to present a video in our tips and tricks on the intra corporeal ileal conduit from Memorial Sloan Kettering. This is obviously a collection with Peter Wicklund having taught me much of everything. So, for this presentation I'm going to try to really focus on the tips of the [inaudible 00:03:27] and how to make the ileal conduit seamless. And then for the second part of this video, I'm going to actually show some interesting concepts using the single port as we have mostly now converted to doing our conduits with the single port at Mount Sinai.

Dr. John Sfakianos:

So the most important part I think is the port configuration. Everybody does this a little different. And then this is the port configuration that we use here at Mount Sinai. Just about three centimeters above the umbilicus here, we use a 12 port, either a Hasson technique or just a regular verus needle and place to port ... for us it doesn't matter because we do a significant amount of research here, and so once the bladder and the lymph nodes are completed, we'll replace this with a mini gel point to allow us to extract the specimen before we go to the diversion.

Dr. John Sfakianos:

We then place the two robotic ports roughly at the level of the umbilicus, about eight centimeters away from the umbilicus. And then we use two assistant ports, both being 12 ports, and this is important as well because the angulation can sometimes significantly vary and we need those. Then on the left, we placed a 15 port with [inaudible 00:04:53] lesion of a robotic port during the robotic procedure. And then this will be used for the stapling. We use five instruments pretty much for the entire procedure. Here you see on the right side, a bowel grasper on the left side a Cadiere.

Dr. John Sfakianos:

And we basically every single time look for the appendix in the ileocecal valve. Once we have that orientation in place, it allows us to then identify a good segment. We try to be a minimum 15 centimeters from the ileocecal valve, but further away sometimes is okay. The stapling is done all laparoscopically. And like I said, through our 15 port by our assistant, this is extremely important. So the placement of this port, I think is the biggest "tip or trick" I can give because you can see you want it to be straight in line with where you do your diversion.

Dr. John Sfakianos:

Then you can see here, it is pretty much in line allowing us to staple with ease, without too manipulation of the bowel. Another important thing is the actual instruments. So you can see our bowel grasper on the right, which does not have a significant amount of tensile strength. And so it allows us to actually grab the bowel itself and manipulate it. Well the Cadiere has a little bit more strength to it, and you want to just try to minimize manipulating the actual bowel similar to what was just done there with the Cadiere but use the bowel grasper to more significant use.

Dr. John Sfakianos:

We try to use exactly the same technique as you would to do this open or laparoscopic. Basically a side-to-side anastomosis, using the small little incision at the distal end of the bowel. And then again, we use the same stapling device, the same port to use a stapler. We try to make a 100 centimeter staple anastomosis. So to do that, we do use a 61st and this is what that is. Important to make sure that everything is lined up appropriately and you don't have the mesentery inside the staple line. So, you should take your time and make sure you're able to rotate and look at the other side of this bowel anastomosis, and you can see here that the mesentery is both away.

Dr. John Sfakianos:

So once we do that, we then replace with a 45 centimeter load in the same location and same area. And that allows us now to make a double staple line roughly about a 100 cm in length. This is important, not because there's really any data to support, the longer your anastomosis the better. But actually for when we do this part of the procedure, which is seal off the bowel anastomosis again with a similar stapling device that allows you to actually be fairly liberal in terms of how much you can take when you seal, allowing you not to minimize what you have below.

Dr. John Sfakianos:

We like to take this with one stapling load, but in some cases you may have to use a second. In the single port version of this video, I will have some different parts to show the differences, but if you can't fill it all into a 60 load, you can obviously take another load. And you can see here a nice anastomosis with good sealing. We use a Wallace technique for our ureters. Several important things for the ureters. You obviously do not want to manipulate the actual ureteral mucosa or ureter at all. As you can see there, we were holding the subcutaneous tissue of the ureter, the periurethral tissue.

Dr. John Sfakianos:

And then the posterior wall of the Wallace plate is what we do first. Here, we actually use a five OPDs and an RB needle, while that curvature allows you to bring that back wall and that back plate together without having to put too much tension, without too much manipulation. We back load that stitch back into the ureter, that allows the knot of that tie that we just did to be outside of the ureters, and then we just run it straight up and making a posterior plate.

Dr. John Sfakianos:

The other thing that we try to do here, which was already done and I'll show you again in the single port video is we do have a clip with a small Vicryl suture at the end of there, that allows us to hold up the ureters and manipulate the ureters. So this way the anastomosis is actually more careful. For our STEM placement, we actually remove the entire proximal staple line, and then use one of our instruments to go through. The key here is to try to get the angles accordingly. If you can get good angles, so you can see how this is almost a straight shot with our left instrument, then you should be able to very easily manipulate that instrument through to the other end and grab the stents.

Dr. John Sfakianos:

The stents do come in from our 12 port and our system feeds those in. Once they're in, we then place the wire through and then down our ureters. One interesting point to point out here is you can see that on our conduit, you have all these red blotches. That's because initially the needle driver was used to try to manipulate the bowel. And then if you saw on that video, it was unchanged over to the bowel grasper which is more gentle. Sometimes it's just best to take the extra 30 seconds and put in the right instruments to allow for less trauma to the tissues that you're dealing with.

Dr. John Sfakianos:

But once we get the uterus in, the nice thing about this is once both uterus are in, you can actually hold the ureters ... I'm sorry, once both stents and you can hold the stents at the area of the ureters, and then the assistant can actually pull the stents, which then allows you to line up as you can see here, the ureteralanastomosis and the bowel anastomosis. And once that is in the proper position, you actually can then do the anastomosis. The anastomosis, we use a 3-0 STRATAFIX, a double arm suture. The most critical part of this anastomosis is what you see here is to always go underneath the actual ureteralstents.

Dr. John Sfakianos:

This is just the way that we do it. But you always want to go under the stents and this way you are in the proper orientation, and then you cannot grasp the stents or lock the stents. Again, always under, and you can start with the left side or the right side. Here you can see that this video is actually showing us going on both sides. So start in the middle, and then you go left right, left right. The other video I'll show you is traditionally the way that we are doing it now more often, which if for our conduit is starting at the left ureter, and then moving over to the right ureter.

Dr. John Sfakianos:

I would say from learning, this is probably in my opinion, the one that's the most confusing, and everybody really has to come up with their own methodology and what is the least confusing for them, and then use that approach consistently throughout, and that will allow you to feel more confident and to have the better results. Once replaced, the posterior plate of this anastomosis, you can that it's a fairly straight and easy suturing, because everything is lined up nicely. Once the anastomosis actually gets to the area where the posterior plate ends, you can then cut the remainder of the ureter and then complete your anastomosis.

Dr. John Sfakianos:

And this again is now showing the other ureter, which you can see once that posterior plate is nice and completed, really is just all lined up nicely. Now, you can do this in a lot of different ways. I think that this is, as you can see, the tension that the fourth arm is putting on the ureters, because you have those sutures allows you to suture with good ability, because you have the attention and the needle goes through very nicely. And also it allows you to line up everything nicely.

Dr. John Sfakianos:

So, some folks I've seen won't put this tension, which is fine. But it does in my opinion this technique allows you, as you can see very seamless suturing, because you have the tension and things are not moving around. And you have everything lined up appropriately, which is the most important part I think when you're doing this anastomosis. We use six French ureteral stents for hours and these are single Js. And you'll see in a second what we end up doing because they go through the 12 port, we cut them, bring them into the patients, into the abdominal cavity, and then we place another port at the area of the pre marked site.

Dr. John Sfakianos:

We come in with a laparoscopic babcock or some laparoscopic instrument that allows us to then pull it out. And that is basically what we use and the technique we use for the ileal conduit [inaudible 00:15:24] diversion. Like I said previously, we are now moving over to doing all these, we're trying to do all of these single port to see if there is actually a difference between the single port versus doing this multiport. As I spoke, or as I mentioned before, in this case, we'll always put a gel point mini and as you can see this on the screen now, at some point of our procedure, because we do like to remove our specimens prior to starting or an anastomosis.

Dr. John Sfakianos:

So, for the single port, we actually start this from the beginning. And you can see the most important thing that we've learned from doing a single port is the importance of air docking. So you can dock the single port outside of the abdominal cavity inside your gel point, giving you that extra room. And then from there, we only place a 15 port on the left side similar to what we did before, that allows for the stapling to be performed. The other important thing like I mentioned before is really making sure that this 15 port has the appropriate angle and I think that does come with a little bit of trial and error and remembering where your port is placed is important for the next case, when you're doing it.

Dr. John Sfakianos:

And the gel point here is placed at the pre-marked ileal conduit. As you can see here now, we are doing the single port. The air docking allows that elbow of the single port to have significant room. So you're not clashing and you have the freedom just like an [inaudible 00:17:04] to do the dissection. This is our ureteral dissection. As you can see here, there is I guess different theories about the appropriate ureteral dissection. Should you leave a lot of tissue on? Should you not leave a lot of tissue on? We are on the side of less tissue, but just enough, if that is such a thing.

Dr. John Sfakianos:

And what I mean by that is that there are lymph nodes in this area, and we do believe in aggressive lymph node dissection. So, some of this fat that you leave here, may actually end up having a significant [inaudible 00:17:41] outcome. But you can see the blood vessels are right on the ureters. And so as long as you leave that periurethral fascia on I think you're in a good position. And again, using that stitch on the Hem-o-lok allows you to manipulate the ureters and allows you to actually without putting any tension on them or having to manipulate the actual tissue itself.

Dr. John Sfakianos:

We make our space underneath our large bowel or sigmoid, staple it, and then you clip those sutures together and use our fourth arm for tension and manipulation. Similarly as you can see here, the big differences here you don't have that bowel grasper, you only have two Cadieres for the single port. And so you do not want to grab the bowel. You want to be very, very cautious, grab the mesenteric border with both instruments, because these instruments do have a lot more strength and actually can damage and injure the bowel. Similarly to the Xi you can see here really if you're watching these videos, you couldn't tell if this is SI single port or maybe outside.

Dr. John Sfakianos:

But Xi or a single port from the standpoint that the same technique is performed, slightly different instruments, but you can easily do the procedure, a single port, or multiport with the Xi. We only use one needle driver for both the Xi and the single port, because your other instrument is usually good enough to allow for the proper suturing, that does help with some of the finances, not a tremendous amount, but the hospitals are always cautious in that can reduce some costs if you're using one less instrument.

Dr. John Sfakianos:

Similarly the stents were placed, and as you can see here, in this version, and this is pretty much how we do it all now, we start at the right ureter, pretty much mid ureter, work our way over to the left ureter, and that is a mid to posterior plate, which then lines up the bowel and ureter very nicely. We'll try to take as much of the ureter off as possible for oncological purposes. And then that allows you to complete the bowel ureteral anastomosis. Once again, the stents are cut and you can see the tips there on the right, and are brought into the abdominal cavity, with the [inaudible 00:20:32] and this is my favorite part of all these videos is with the single port you can just pull using your instrument, the bowel right out of your mini gel point, which is also our pre-marked conduit site.

Dr. John Sfakianos:

And then you can do your actual anastomosis. Just quickly, with our data, this is 83 patients that we've done this with. We can see that our internal results in terms of urine leak which is about 3%, stricture rate about 4.8%. And this is with a median of about 20 weeks with our longest being at about 60 weeks. So, I'm still slightly a little immature data to say truly, but we now over a year have been using the single port and we feel that the data is pretty much comparable with the multiport. And I think that's all I have.

Dr. Jihad Kaouk:

Thank you so much, Dr. Sfakianos. This is excellent presentation, and congratulations on the addition of the single port approach to your wonderful multi arm approach that you presented. We have a poll question that's been listed here. We will have more discussion about it later, in the moderated part. At this point, we will move to the second surgeon speaker, Dr. Alvin Goh. And after that, we'll get back to you, Dr. Sfakianos.

Dr. John Sfakianos:

Thank you.

Dr. Jihad Kaouk:

Thank you. Dr. Goh.

Dr. Alvin Goh:

All right, good afternoon everyone. And thank you for the opportunity to speak to you this afternoon. Thank you to Dr. Kaouk and Dr. Sundaram. Sundaram for the opportunity and the organizing committee from the Endo society. So today I'm going to be talking to you about robotic intracorporeal neobladder. So we'll focus on the continent urinary diversion. We'll go through some tips and tricks and ways to try to optimize the operation. So, intracorporeal urinary diversion is increasing in popularity and its utilization. You can see that figure on the right hand side, that's from the International Robotic Cystectomy Consortium.

Dr. Alvin Goh:

The Brown line that is rising is the rate of intracorporeal ileal conduits. You can see there's been a rapid rise, the mid 2000s, 2010s through '15, and even more presently, there've been descriptions of intracorporeal urinary diversions of all sorts, the full range, conduits, neobladders, continent cutaneous, et cetera. And today in the discussion we'll be talking about neobladders. There has been a slow tick up of intracorporeal continent diversions, but I think we still have some work to do in that area.

Dr. Alvin Goh:

The good news is, as you march through the learning curve for doing these diversions, is that many of the skills that you will pick up, are transferrable and can build on one another. For example, handling the bowels, doing a bowel anastomosis, whether that's an ileo-ileal, or ileo-colonic reconstruction, and then an anastomosis. So many of these skills you already have. And once you start with a conduit, it's very easy to scale up to the more complex urinary diversions. I'm going to go through some of the principles of the neobladder technique that we use.

Dr. Alvin Goh:

When we developed this procedure, we really wanted to uphold the principles of the open procedure. We translated basically an ileal neobladder that we did open to a robotic approach. We wanted to standardize techniques so this could be reproducible. So we maintain those same dimensions. We did a sown reconstruction as opposed to a stapled one, and a cross folded configuration, much in kin to a Studer, to preserve a globular pouch configuration. We do Bricker for our ureteral ileal anastomosis, and then I'll show you, we do the urethral ileal anastomosis midway through the reconstruction.

Dr. Alvin Goh:

And there's some thoughts about why we do it that way. I know there've been discussions about different forms, different pouches that have been presented over the years. This is really a translation of a Studer neobladder. There have been [inaudible 00:24:55] pouches that have been performed as well as other modified J and U pouches. And I think really the onus on us as minimally invasive surgeons really is to establish these alternative pouches and their functionality in terms of proving that they work well.

Dr. Alvin Goh:

So we started of course with what's been standardized, and this is the technique that we had done. So with regard to bowel dimensions, we're really talking about a 44 centimeter pouch with about a 10 to 15 centimeter efferent limb. And that's what you see in the figure on the left-hand side. The right hand pictorial is the same dimensions, but in the relation to the pelvic view. So this is the view that you'll see within the one you see on the robot and in the video, just so you have your orientation. So we're going to have two limbs of 22 centimeters, that'll make up the pouch.

Dr. Alvin Goh:

And then we'll have an efferent limb. Now there's this 11 centimeter mark that you'll hear me refer to, which is right here. This is the prospective site in which we will perform the urethral anastomosis. So we identified this mark early, and that is where all the references are for the formation of the neobladder. Here are a few more figures just because it can be a little bit confusing the way things are turning and the orientation. So this is, once you detubularize the first figure on the left. Detubularize and you form your first fold, that is the posterior plate.

Dr. Alvin Goh:

And the pelvis is of course at the top of the screen. And then the next is when we start to perform the urethral anastomosis. So we'll rotate that palate 90 degrees counter clockwise, and this yellow box is to marking that 11 centimeter mark, that's where the anastomosis is going to go. We'll fold that one more time perpendicularly this way. And then that'll complete the [inaudible 00:26:53] fold and then you'll have your neobladder. So let's get into the video. Here are the steps that I'll go through, and I just listened there for your information, but we'll walk through them one by one.

Dr. Alvin Goh:

There we go. So we're in steep ... We test the Trendelenburg, we are in 28 degrees of Trendelenburg for the cystectomy, and then you'll see later we come out of that Trendelenburg for the diversion, especially when we're doing a neobladder. So here's the access. Let me see. And here's at the port placement. So you got your 12 milliliter port superior medially and then a 12 millimeter laterally. That's where we'll do our stapling through this lateral 12 port. And then we have an air seal port at the top. All right. So those are that support set up.

Dr. Alvin Goh:

Now, once we're ready for the diversion, after the cystectomy is done, we'll come out of that Trendelenburg. So as I mentioned before, that's one of the things you can do to help bring that neobladder down. We come down to about 13 to 15 degrees, and that decreases that gravity pull and that will assist with helping bring the neobladder down. Okay. So we identify the ileal-cecal valve, what we're using here for bowel manipulation is tip up graspers. These look like bowel graspers, they're a little bit wider, so you can distribute the pressure. We're measuring about 15 to 20 centimeters away from the ileal-cecal valve.

Dr. Alvin Goh:

This is an 11 centimeter stitch I'm using, that's my ruler. And then we'll identify the dependent limb of bowel that will reach down toward the pelvis. So this is where we're going to find our prospective site for the anastomosis. And based on this reference point, all the other measurements that we made. So, we're using here a STRATAFIX suture, this we'll use later, you'll see to bring the pouch down. And then now I'm using my 11 centimeter measuring stick. So I'm going to measure 11 centimeters distally, and then we'll perform the division of the bowel here using a 16 millimeter bowel load stapler.

Dr. Alvin Goh:

So in this case, it's a Covidien stapler that's going to be your purple load. At the [inaudible 00:29:29] will be a blue load. This will come in from that lateral port. You can see in the diagram there, and you want to make sure it's perpendicular to the bowel, as well as the mesentery. This is very similar to what you saw before with Dr. Sfakianos' picture or video. We'll extend this cut into the mesentery with another tan load stapler. You can do with a tan load, or you can do it with a vessel sealer, but important to deepen that division a bit by convention we're using blue stitches, blues suture for bowel.

Dr. Alvin Goh:

And then everything that is white will remain on the diversion. So this helps with maintaining orientation here. All right. So this next 11 centimeter limb gets us to a 22 centimeter mark. We're going to measure about a 22 centimeter limb. So this is at your 33 centimeter mark, to keep track of where we are. That's that. And then now we'll measure that final 11 centimeters to give us the full 44 centimeters. So now 22 and 22 that gives you 44. And then we'll measure out another 10 to 15 centimeters for the efferent limb or the pouch. You can use a Penrose here or umbilical tape also works quite nicely.

Dr. Alvin Goh:

Here we'll perform our proximal division, again with the 60 millimeter stapler. Now, here we're going to do a discard segment. So, we discard about another five centimeters of bowel approximately, and this does a couple things. The first thing it does is it separates your bowel anastomosis from your diversion. So, you can get new bladder bowel fistulas. And this is in an effort to reduce that from happening by pulling that anastomosis away from the diversion. The second thing it does is, it may provide a little bit more mobility because you've got a little bit more mesentery to play with.

Dr. Alvin Goh:

Now we'll do a standard side-to-side bowel anastomosis. You saw this again, stapling comes from the left to lateral port for the side-to-side portion, and this'll be two fars of 60 millimeters. This buys you a little bit extra buffer for the anastomosis. And you'll be able to get a nice clean donut when you do the transverse closure. One thing that can happen if you do only one fire is, that makes you want to chip toward the end, in order not to narrow the anastomosis. So in this way, you have plenty of buffer and you can trim off any areas that may not be well perfused.

Dr. Alvin Goh:

So in this way I think it buys you a little bit extra space and a little more leeway for that anastomosis. So, for the transverse closure that comes from the upper that's a peer port, that's really the best location for that. Now we're going to move on to the detubularization. I'm just trimming off the staple line on the end of the efferent limb, and then closing this with a STRATAFIX Monocryl suture. And then now we'll move to the detubularization. Using a 24-French chest tube here to help assist with this detubularization, you're trying to do it along the anti-mesenteric side, and perhaps a by slightly toward the mesentery.

Dr. Alvin Goh:

So we're opening up that first 22 centimeters. We're rounding the corner here, and then we'll open up a second half of it. So this is starting from the efferent limb side, and then moving our way down. Now we have 44 centimeters of detubularized bowel, and then we'll start ... I usually mark this. This is at 33 centimeter mark. That's going to be the what we call ... referred to as the back corner of the [inaudible 00:33:29]. I'll show you a little later when that becomes important. So now we're fully detubularized. We're going to start the posterior plate.

Dr. Alvin Goh:

The posterior plate, it's easiest to set this up with some stay sutures. So this is a 2-0 Vicryl suture. These stay sutures can be grasped from your assistant and held toward the head, which provides you a little bit of counter tension. Just helps to line up this back wall. Posterior wall is going to be put together with a barbed suture. Again, this is 2-0 MONOCRYL STRATAFIX. Barbed suture helps to maintain that tissue at position. It's quite useful. We only do one layer, closure here, and the leak rates are very low with this form of suture. So now that the posterior wall is finished, this is where we'll do the anastomosis.

Dr. Alvin Goh:

So, I think it's useful to do this at this stage. So remember I said that there was a 33 centimeter mark? So this is that back corner. So what I'm doing is I'm just starting that back corner, just a few stitches there, because once you rotate this pouch to that back corner you can tell underneath it's hard to see. So now we're rotating the pouch 90 degrees, counter-clockwise, I'm going to bring this down to the urethra for the anastomosis. And this is helpful here, because if you folded up the entire pouch first and then try to bring it down to the urethra, it's very difficult to do. Namely because it's just hard to manipulate the pouch at that point.

Dr. Alvin Goh:

So, there are some techniques where you do the anastomosis first. In this one we do it in the middle, and you'll see why in just a moment. Once we do this anastomosis, we're using here 3-0 monofilament MONOCRYL suture, double armed. And we're using just that 11 centimeter mark to do this. So I previously used that suture to just bring it down like a Rocco suture and that fixes the neobladder in place. And now we can do the formal anastomosis. And that's what I'm doing here with this MONOCRYL suture. So we'll fold this around the urethra.

Dr. Alvin Goh:

This is the same technique as we used for prostate anastomosis. And you see as we roll around the urethra, the pouch rolls around, and then will come up to the 12 o'clock position. Now we're going place our catheter. This is the final catheter. This is the 22 French gauge catheter, which has a very large islet on it. And this allows for a very liable irrigation. So complete the anastomosis here. And what this does is it sets up a new line of tension, which is perpendicular to our first line. And it sets up a very nice cross fold. So, when you're doing a neobladder and you're aiming for a cross folded neobladder, this helps facilitate that.

Dr. Alvin Goh:

So that's why we do the anastomosis at this stage. You'll see, as this comes together, the two edges of the neobladder, the anterior closure want to re oppose each other, and that's exactly what your cross fold is attempting to accomplish. So, we'll start to close this anteriorly, and then we'll walk our way back to do the U stitch. So this is the actual crossfold. So this is from the zero mark, all the way to our 22 centimeter mark. So you see that white suture to the side we marked previously? So now we know we're at dead center right in the middle, and that we're evenly dividing up each of our segments.

Dr. Alvin Goh:

So we've got a front quarter to do and then a back quarter. So we'll put these. Again, do a few stay sutures just to line up the anterior closure. So you get it nice and even. I find it helpful to do this. If you ran it from the urethra all the way up, you can do that, but sometimes you might be a little bit off, and you might get a little dog ear. But lining it up along the way with a few stay sutures, really optimize it. I think the suturing too, you can get a nice line of tension, and then it's just whipping it close. So for those of you who do Studer neobladders, this should be familiar, this configuration.

Dr. Alvin Goh:

I think many of these different types of diversions are effective. It's just a matter of going with what you're comfortable with, and perhaps what your experiences open, in terms of how you know how to configure the bowel, but also manage those patients afterwards. So this is that back quarter I was referring to, and now we're closing the efferent limb and incorporating them into the suture line here, and now our pouch is completely closed. So, we usually test the pouch at this point for water tightness, and now we'll move on to the urethral anastomosis. So we brought the ureters underneath the mesentery here.

Dr. Alvin Goh:

We brought them up, there's a left ureter. We're going to measure this. So a few tips about ureteral handling. We leave a lot of tissue around the ureter, maintain that vasculature, we do no manipulation directly onto the ureter or periureteral tissue, use that discard segment as for manipulation, where opening it up and spatulating. And then usually we'll use ICG to help verify perfusion. We've looked and seen how many times that it actually makes a difference. And about 12, 12 to 14% of the time, we've noticed that a visually well perfused segment may not be that profused under ICG.

Dr. Alvin Goh:

So we've had to revise where we're going to do the transection. The other thing to do is to trim off any redundancy of the uterus, they have a nice straight shot to the anastomotic site. You can see we usually trim off about four to six centimeters of ureter here, because it's just redundant. So here we're doing the left side, we're doing 4-0 Vicryl here, place our corner stitch, or a pickle stitch. And this is a PS-2 needle, a little bit different. This is what we use in the open setting as well. It moves nicely through the tissue, and this is what we're used to, and it works well.

Dr. Alvin Goh:

It's very reliable. 4-0 Vicryl suture here, run the back half. Then once that's done, we use this as a six French 6.0X26 centimeter double J stent passing through, do that percutaneously using a two millimeter mini port, and then we'll place this into the efferent limb, and then complete the anastomosis here. There was some question about whether doing a brick or a Wallace. I think it's dealer's choice. I think both can be very reliable with very low stricture rates. I think the techniques you want to use to minimize the strictures that we talked about before, maintain good profusion, no crushing or direct manipulation of the ureter and have a direct path for it without redundancy.

Dr. Alvin Goh:

Like having two separate anastomosis mainly because you're going to have to follow these patients long term, if there's upper tract disease that develops, you can manage that separately rather than them being combined. And then if you have a stricture in the future, it's easier to replant one and potentially you may have to do two if you have a Bricker but I think both are reliable and really depend on your experience and what you're most comfortable with. So there's the other half of the anastomosis again. And then placed at the stent.

Dr. Alvin Goh:

The stencil come out around between the second and third week when we take out the catheter, we'll usually scope at that time. And then it's very easy the stent to usually have migrated within to the pouch is very simple to remove the stents at that time. When we do Indiana pouches, we usually will externalize those stents, but for stutters or neobladders, the internal stents have worked reliably. Drano usually stay while they're in-house. Our average length of stay is about four days. And we'll usually test that drain prior to removal and it gets removed before they leave the hospital.

Dr. Alvin Goh:

All right. So that wraps up my presentation. Thank you very much for the opportunity and your attention.

Dr. Jihad Kaouk:

Thank you so much. Dr. Goh. As usual, fantastic presentation. I've seen segments of your presentation many times before each time I keep learning from itself. Thanks for presenting today. So we have 20 minutes left and we'd like to turn the mic to our esteemed moderators. And please remember that we had the results from the poll questions if you would like to discuss that. So Dr. Das Gupta, would you like to start with some comments?

Dr. Prokar Das Gupta:

Indeed. I think very, very impressive and a good evening from London, if I may say so. The poll questions are very, very interesting. 53% of the audience, still do extra corporeal, but 46% think that the recovery of intracorporeal is quicker. So, it is possible that some different segments of the 162 people who are online, actually answered those questions. So I think there is some doubt about whether you really benefit from intracorporeal. I think we do. The evidence of course is still awaited from the IROP trial which is the one randomized trial head to head off intracorporeal versus extracorporeal. So I thought that was very, very impressive and the polls are very enlightening.

Dr. Prokar Das Gupta:

So those are my initial comments and we will take a few more comments from the two speakers. So a third poll has come up. So let's see. What do you think? Do you think complications such as ureteric stricture are less after intracorporeal conduit on neobladder? So please vote now.

Dr. Andrew Wagner:

I think while people are voting, I wanted to pose a question for John. I don't do single port surgery, not yet. So I don't have tremendous experience with that. I noticed that you pulled your conduit through the single port gel point. Is that incision in the peritoneum and fascial longer in your opinion than you normally would do for your stoma? And if it is, are you concerned at all with Parastomal hernias or is it about the same as you normally would do anyways?

Dr. John Sfakianos:

It is usually about the same as we do always. Sometimes we do have to make it a little bigger, especially because we want to extract a specimen from that side as well. It is definitely useful in females because we just extract from the vaginal opening. In males, it really depends on their prostate and so forth. We will close the fascia and make it a size that we feel happy with. In the males so far we haven't really seen any say differences in what I think in hernias, but I do think it's way too early and I'm not quite sure about that yet.

Dr. Jihad Kaouk:

If I can make a comment for the question of Dr. Wagner. I do single port cystectomies and astonishingly enough we started from our early series of SP with cystectomy application and very similar to what Dr. Sfakianos' approach, the only difference is that we, for the ileal conduits, we put the port at the conduit site and use it for the stapler and the assistant. And when we compare time, better operative parameters, all the parameters, you cannot see a difference between both and that was early in the series. So really it is just a matter of what instrument you're using for the cystectomy ileal conduit, if you're using an extra port at the conduit site.

Dr. Andrew Wagner:

So, if you don't mind, I'll just be a little provocative as someone who doesn't use single port. So I don't have any experience with it. What do you think you're gaining by doing that as opposed to multiport surgery?

Dr. John Sfakianos:

There's, I think two things mostly. So we actually do what we call non-opioid protocol that we've published on before, right? So we try to use no narcotics at all for induction during anesthesia, and even for post-op. We use a quadratus lumborum block with our anesthesiologist during or prior to the beginning of surgery. But I have to say that in some cases, patients still require some doses of narcotics when we do the traditional multiport surgery. With the single port, we can actually see a huge difference in just that alone, because there's really minimal to no pain with our non-opioid.

Dr. John Sfakianos:

They're actually mobile and moving much easier. And again, this is a bit anecdotal and we collect all this data. We just don't have enough cases to see, but I do feel like they mobilize much easier and much better with less pain, and then at least less complaints. I think that's definitely the biggest thing that we see.

Dr. Andrew Wagner:

Okay. Great.

Dr. Jihad Kaouk:

Yeah, we published our early eight cases or so in urology in 2019, and still the numbers are small to show a difference, but to answer Dr. Wagner, what we aim at proving is maybe duplicate what we found for the prostatectomies. For our cases that are extraperitoneal single port prostates, we found that the vast majority will go home the same day without any narcotics at all. And we're trying to duplicate that, but one observation that I found very interesting related to them, how they design of the single port [inaudible 00:48:00]. You cannot spread your instruments, you cannot retract far away from your origin canula. So what happen, you manipulate the bowel less.

Dr. Jihad Kaouk:

So from the very early small series that we studied, we found that alias or the return to bowel function was very fast. Like by the next day, the patient was really having good bowel sounds and so on. Does this mean anything or just a wishful thinking? We need more numbers.

Dr. John Sfakianos:

The importance of all that is that also you don't have to ... I mean again, I don't know why I'm on this financial key but don't doing this, you don't actually have to add any new opioid receptors, blockers, at least. So each one of those doses is a significant amount of money. And we actually don't use them at all and we haven't used them in our multiport or our single port, but you definitely can see the comfort level of our single port patients a lot more. But one thing I do have to complain about is the instrumentation of the single port isn't quite there yet, not having a bowel grasper tip up or something like that where you actually can more freely manipulate the bowel.

Dr. Alvin Goh:

I'll just comment a little bit about Parastomal hernia. So, there was a recent randomized trial that was published in European Urology about this placement of Parastomal mesh to [inaudible 00:49:21]. We've looked at our own experience and you can see clinically obvious Parastomal hernia is 25% up to 40%. If you look at radiologic Parastomal hernia, so it can be a significant issue. We have a randomized trial right now looking at the installation of Parastomal hernia mesh to prevent a hernia formation. We have level one evidence now that it works. I would encourage folks to look into that, if you're doing systemic ileal conduits regularly, because that is something that can be done.

Dr. Alvin Goh:

To the single port users, it may actually be something that's helpful or can prevent the development of Parastomal hernias if you're having to make a larger incision. It can be done both in the open setting, as well as the robotic setting. So something to consider.

Dr. Prokar Das Gupta:

So a few questions from the audience and then a question to Jihad. So Andrew and I have been looking at the chat box, so, the stapler John is a fascicular or a bowel stapler?

Dr. John Sfakianos:

We actually use a vascular stapler.

Dr. Prokar Das Gupta:

But Alvin, you said you use a bowel stapler. So, any comments on which is better, which is less damaging to the bowel and blood vessels?

Dr. Alvin Goh:

Yeah. It's a 3.5 I think millimeter stapler, that's your standard bowel stapler. That allows for profusion through the soft tissue segments. It's similar to what's used by all our GI surgeon. So, this is what you would call the purple load, so to speak. And the idea is you don't want to induce any ischemia into your nastimonic sites.

Dr. Prokar Das Gupta:

[crosstalk 00:51:06].

Dr. John Sfakianos:

There's actually not really that big of a difference between the two different, the staple loads. They're both, just laid down the staples, it's just actually the tension strength. And because there isn't really a cutting off of major blood supplies. I don't think that there's huge difference between the two. The only big difference would be the reinforcement. There are the staple loads that reinforce and those may be something that we've used in the past if we just see that the bowel isn't extremely healthy or pre-radiated patients, they just gives that extra level.

Dr. Alvin Goh:

Along those lines for folks who are starting out with bowel manipulation in anastomosis, ICG is a good adjunct for that. You saw a little bit of that. It's not necessary to use every time, but it can also help identify blood vessels upfront, but also verify your perfusion afterwards. Our colorectal surgeons are using that commonly for a colon anastomosis, and it's something that we've incorporated into our bowel anastomosis assessment, just to look at a profusion, also look at your diversion segment at the end. There's a little bit more reassurance, but also more information for those who are starting out or haven't been as familiar with these techniques.

Dr. Prokar Das Gupta:

So, let me ask you, this question came about ICG, should that become standard of care because Monish Aron's paper from Keck shows zero left ureteric anastomosis. Zero. 50 patients, but zero stricture rate. So, is that a game changer and do you use it routinely? Alvin.

Dr. Alvin Goh:

Well, it's like never say never right? Zero is probably not zero, but with follow-up and time, you'll see some of these strictures crop up. [inaudible 00:52:56] paper looking at the SEER database, looking at stricture formation, early experience with robotic surgery showed a significantly higher rate of strictures. And that probably has to relate to technique, familiarity, manipulation, all these things that we've learned cumulatively over time, have improved. And I think what you have to do is look at your own numbers. You have to look at your experience.

Dr. Alvin Goh:

If you get very low stricture rates under 5%, I think that's a very reliable target and one that would match probably the best open case scenario. Then you may not need ICG, but in those cases, they're post radiated patient. The very thin ureter, the ones that you might be worried about, ICG can give you some more information now. I think what we do need and I'll throw it out there. We need a multicenter trial where we can compare that, where there are enough folks doing robotic cystectomy these days, and more doing intracorporeal diversion. Let's do a randomized study where we study the effect of ICG.

Dr. Alvin Goh:

I think what you see across the board, there's just a lot of heterogeneity in stricture rates and reporting of it. So it's hard to say what you're going to improve on from where you start. But I think it's worth investigating further.

Dr. John Sfakianos:

I could play devil's advocate with that, because we don't use IC green for our ureters. And really the reason we don't is because we actually just try to take as much length as we possibly can, making the tension free anastomosis with our bowel. And then we think that that has some oncological principle obviously, depending on what your pathology and your bladder is. And so the role for IC green for us wouldn't make any difference, because we're going to go back as far as we can, to make what we feel is a good anastomosis.

Dr. John Sfakianos:

So if we see that there's poor profusion there, you really can't go any further back. So you're really limited with the choice of what to do.

Dr. Prokar Das Gupta:

Jihad. What about the ultimate single port cystectomy through the peritoneum which you and I discussed at the AUA a couple of years ago. Have you given up, or are you still persisting?

Dr. Jihad Kaouk:

I was hoping you would not bring this up.

Dr. Prokar Das Gupta:

Sorry.

Dr. Jihad Kaouk:

No. So, this is a lab exercise to see in the lab setting how far can we go from the peritoneum? And yes, you can do a lot of things through the abdomen, using the perennial approach. I think the next step in this machine would be instead of a rigid canula, have a flexible canula to make it more applicable to anywhere inside the belly. But again there will be questions posed like the question I got from Dr. Wagner is why. The why is very important. So, the why depends on what stage of an innovation is. The why it can be just curiosity. The why can be exploration, and then the why becomes clear for a few of the things that you try. So we're working on the why's now on this.

Dr. Andrew Wagner:

There was some questions about stents that are practical but very helpful questions. I think when we were first starting our program here, we use double J stents for about the first 30 patients. And we had several patients come back with fungemia. We were leaving those in for two weeks. We switch to more traditional single J externalized stents, both for neobladders and conduits, but I'm interested to hear you guys' opinions on that. We're definitely an externalized stent place. But for the neobladder Alvin, you're using double J's. Have you had any problems with that or you're happy with that approach?

Dr. Alvin Goh:

Yeah, it's worked well. I think the issues we've run into is when we have to leave the catheters for prolonged periods of time. So it's more than that two to three weeks, you can get that issue with the fungemia or the issue with the infections. The other situation I would use in externalized stent is if you have some issues perhaps with the anastomosis say it's a post radiated patient or someone in which you just wouldn't want the neobladder itself maybe the urethral anastomosis to be dryer, or try to have less fluid come in, then we'll use externalized stents in those situations.

Dr. Alvin Goh:

But, patients don't really like it that much, if it can have everything internal, it's favorable. For the conduits, we're actually looking ... Our group published on no stents actually versus stents and showed lower 30 day complication rates. I think the answer to that still needs to be defined and played out. But we're looking to try to study that prospectively and in a more randomized fashion, whether we use stents or not. And we'll probably start with conduits.

Dr. Andrew Wagner:

Very good multi-site study as well, no stentsless versus stented.

Dr. Jihad Kaouk:

But do you have difficulty when you want to go back and remove the stents and some tips like having a suture to keep it outside accessible if it goes to the chimney?

Dr. Alvin Goh:

Yeah, I think you can certainly leave the tail of the string on there, leave a short tail that you can actually grasp later. Have not had a problem. Most of the time, I usually use a long stent. It's like a 28 or a 26 or 28. It will migrate its way down the efferent limb. Haven't had a problem yet having to go in or take someone back to the OR to fish it out. But so far it's been reliable. The only thing I would just say is, be careful with your limb. If you make your efferent limb super long, then it might run into trouble with that.

Dr. Jihad Kaouk:

Yep. That's why I've had that once or twice and I've obviously trained at Memorial and we used to do all the wet neobladders but we've converted over to dry neobladders just because of that exact reason. End of one was enough, but then when it was end of two and end of three, we said, "Okay, really enough."

Dr. Prokar Das Gupta:

Jihad, looks like it's time to wrap up the session. So any final words of wisdom from you please?

Dr. Jihad Kaouk:

I want to thank the surgeons and the moderators on this session. This have been a very interactive session. We really appreciate all the pearls and wisdom thoughts that were discussed today. Thank you so much for your time, especially across the Atlantic with the time difference. But thank you, have a wonderful weekend. Thanks for our attendees and see you in two weeks. Thank you all.