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QUAING J. LI: --question from the experts. Now I would like to introduce our members, all members. I'm assistant professor in Roswell Park, and I did my residency in Georgia and a fellowship at Memorial Sloan Kettering. I started there two years ago.
My main focus is bladder cancer and kidney cancer. Next is Dr. Bernie Bochner. He's the [INAUDIBLE] ranked chair in surgery at Morris Sloan Kettering Cancer Center.
He's a PI of the first randomized control trial comparing robotic versus open cystectomy. The result was published the New England Journal of Medicine. And he taught me how to do the open cystectomy and neobladder. He'll give us a talk regarding what robotic surgeons should learn from the open surgeries.
Dr. Peter Wiklund-- he's on the way. He's the director of bladder cancer program at Mount Sinai. He's also a world-renowned surgeon pioneer in robotic cystectomy. Prior to joining Mount Sinai, he built a cystectomy program at Karolinska Institutet in Sweden.
Dr. James Peabody-- he's vice chair in [INAUDIBLE] Detroit. He has interest in teaching robotic techniques and serves as a director of robotic program and urology residency program. Dr. Karim Chamie is associate professor of urology at UCLA.
His primary research interests are health service research and clinical trials in bladder cancer. Clinical interests focus on robotics as urinary diversion. He will give us a talk regarding post-op care and follow-up after cystectomy.
Dr. Edward Messing-- he's ex-chair of the University of Rochester. He's an internationally renowned expert on all aspects of urological oncology. And recently, he's a PI of a large phase III clinical trial of immediate gemcitabine after TRBT. He will give us an update of the field of intravesical chemotherapy.
Dr. Kamal Pohar-- he's a urological oncologist and associate professor at Ohio State University. He's on the panel of NCCA guideline of bladder cancer. He we'll give us a talk updates of immunotherapy in bladder cancer.
Dr. Saby George-- he's associate-- professor and a medical oncologist at Roswell Park. He has dozens of clinical trials. The result of his clinical trials led to the FDA approval of multiple novel drugs for bladder cancer and kidney cancer. He published a lot of papers in the New England Journal of Medicine, Lancet, et cetera.
Dr. Khurshid Guru-- he's a director of applied technology laboratory of advanced surgery. It's a charity here at Roswell. He's director of robotic surgery. He has performed over 600 robotic cystectomies, and all the uterine diversion are intracorporeal recently. He's in the OR right now to get the patient ready.
So the first case will be a male cystectomy and neobladder. This is a 49-year-old male. BMI is 27, otherwise healthy except uncontrolled hypertension. And no surgical history-- no allergy. And last year, he started to have a gross hematuria. And TURBT at outside hospital demonstrated high grade urothelial carcinoma invading to lamina propria and muscles not involved.
For some reason, care was delayed. He developed a recurrent gross heamturia in December. The CT scan demonstrated right moderate hydronephrosis. And creatinine at that time is 1.6.
He underwent TURBT. Demonstrated pathology revealed high [INAUDIBLE] risk of carcinoma was extensive nephrosis and focal squamous differentiation. Muscles present but inactive. He had a right nephrostomy tube and followed by the antigrade stent placement.
When he came here for a second opinion, we ordered the PET CT scan repeat stage working up. It showed there is a one centimeter, 1.2 centimeter meter, right inguinal nodes with some [INAUDIBLE] uptake. So at that time, the patient was discussed, and the patient was started on chemotherapy.
And he was started-- split dose of gemcitabine and cisplatin. He had good response. His creatinine normalized, and the stent was removed. Then he was switched to dose [INAUDIBLE] VAC. He finished that in March.
He tolerated the chemotherapy very well. There was minimal drainage of the nephrostomy tube. That was subsequently removed.
The repeat PET CT scan recently showed that the right inguinal node was no longer hypermetabolic. He also underwent MRI for the pelvis, which revealed decreased size of the nodes, which is only like subcentimeter. And we went ahead and biopsied that node. It was negative for metastasis.
The patient was discussed in the multidisciplinary conference. A patient was discussed options of continued-- go ahead for the consolidation surgery versus immunotherapy versus observation. He decided he wanted to have a cystectomy and neobladder.
So the plan for today is a robotic assisted cystectomy by lateral extended lymph node dissection and the W neobladder urinary diversion. For our live viewers, if you have any questions, please click the button, then ask question, or on the Twitter. For those that are in the room, please raise a hand. Hannah will approach you with a microphone.
So as this point, we're going to hand it over to our panel members. And let's go to the OR.
KHURSHID GURU: Good morning, Quaing.
QUAING J. LI: Good morning, Khurshid. How are you doing?
KHURSHID GURU: Good.
QUAING J. LI: Give us--
KHURSHID GURU: I hope everybody's here, and wonderful to see you all our friends here. Welcome. I'm sorry I wasn't there this morning, but [INAUDIBLE] see everybody in the afternoon.
I haven't-- I just have put the ports in and did a little bit of lysis here for bowel. That's basically all I did. And I wanted to wait until time we started.
So all this [INAUDIBLE] young guy. We're going to kind of try to see if we can do a neobladder What I'm going to do to start with is the spaces for the cystectomy. And--
SPEAKER 3: Can we get the [INAUDIBLE].
JAMES O. PEABODY: Hey, Khurshid. This is Jim Peabody. We're not seeing the internal view yet. So if you do-- if you're doing--
KHURSHID GURU: [INAUDIBLE] you don't have yet?
QUAING J. LI: We don't have operative view here. So--
SPEAKER 3: [INAUDIBLE] think that's good.
KHURSHID GURU: Can I get a [INAUDIBLE] while we wait? So Dr. Peabody, we're just getting ready to get you guys in. Just waiting for the live feed. So it should be a second while we clean the camera.
SPEAKER 3: OK, [INAUDIBLE].
JAMES O. PEABODY: Could anything particular about this patient you want to tell us about it beyond what--
KHURSHID GURU: Quaing said so. Well, basically young, healthy guy-- we discussed the different options with him. But additionally, he's Quaing's patient.
And the option that he was really interested in, the neobladder. So he kind of came back to us and wanted to do a neobladder. And also, the whole option of kind of getting treatment before he got the new [INAUDIBLE] therapy [INAUDIBLE] pretty well.
No other issues. What we are hoping for is to have a regular cystectomy. Hopefully, all looks good. And at the end of the day, lymph node dissection with [INAUDIBLE] neobladder. That's kind of the plan going in. Do you have image?
JAMES O. PEABODY: Yeah, we do.
SPEAKER 3: Yeah, we do.
KHURSHID GURU: OK, so let me just give you an idea. So this is kind of the view of the pelvis. I have the 4 [INAUDIBLE] holding the colon away. I did a little bit of lysis of adhesions here. And you can see-- can everybody see that?
JAMES O. PEABODY: Yeah.
SPEAKER 3: Yes.
QUAING J. LI: Yes.
KHURSHID GURU: OK. So what I'm starting with is the [INAUDIBLE] space on the right side and kind of defined that first-- the [INAUDIBLE] space, identify the ureter. I do this [INAUDIBLE]
JAMES O. PEABODY: We just--
KHURSHID GURU: --some spaces.
QUAING J. LI: We lost the view.
JAMES O. PEABODY: We lost the image, Khurshid.
[INTERPOSING VOICES]
QUAING J. LI: We lost the view from the OR.
KHURSHID GURU: Yeah, hang on a second. I think they're working on the view. So for everybody [INAUDIBLE], kind of our primary goal obviously would also to do a-- we had a lot of requests for live demo globally. So we kind of live telecasting this all over. So kind of-- a lot of people invested outside to kind of do an intercorporeal and see robotic cystectomy. So--
QUAING J. LI: We have it.
KHURSHID GURU: --the primary focus. So it's kind of a nice thing to have a panel which is very distinguished and kind of work with them to go through different things, different parts, especially a lot of my colleagues who have kind of almost now done both, the robo as well as--
SPEAKER 3: [INAUDIBLE].
KHURSHID GURU: --open. So it's kind of nice to blend the two worlds because at the end of the day, kind of, it's all about technique and all about principles of surgery more than anything else. So I'm just going to wait for a second to get you the image.
JAMES O. PEABODY: OK, we're up.
PETER WIKLUND: We're back again.
QUAING J. LI: We're back, yep.
KHURSHID GURU: You good?
JAMES O. PEABODY: Oh, now we're not.
QUAING J. LI: Lost again.
JAMES O. PEABODY: Now we lost-- oh there it is.
SPEAKER 3: [INAUDIBLE]
JAMES O. PEABODY: OK, we're back.
KHURSHID GURU: All right. So we can see I think [INAUDIBLE] kind of a vertical [INAUDIBLE]. A lot of people would dissect the [INAUDIBLE]. We have to move all this [INAUDIBLE] fascia and all that tissue intact on it. This gives you the best chance to [INAUDIBLE].
QUAING J. LI: Can you change your microphone? [INAUDIBLE]
KHURSHID GURU: [INAUDIBLE] kind of made available for reimplant. So it's really critical to kind of leave this tissue intact and manipulate the ureter the least you can.
SPEAKER 3: [INAUDIBLE]
KHURSHID GURU: You have an image there?
JAMES O. PEABODY: Yeah, we do. We got the image.
SPEAKER 3: [INAUDIBLE]
KHURSHID GURU: [INAUDIBLE] always a good idea.
SPEAKER 3: [INAUDIBLE] leave this. Yeah.
KHURSHID GURU: Something else?
SPEAKER 3: [INAUDIBLE] cases.
KHURSHID GURU: Dominant vessel.
SPEAKER 3: [INAUDIBLE] took him too long [INAUDIBLE] bladder [INAUDIBLE], which was this right [INAUDIBLE].
KHURSHID GURU: So we use the hook a lot. I also use the scissor. You'll see use of both instruments.
I Also kind of am a big proponent now of-- I'm kind of a big proponent of using just the least amount of instruments. And for this case, I kind of wanted to try both. So you can see we're trying to leave majority of the tissue around the ureter.
And [INAUDIBLE] for all of our colleagues who do [INAUDIBLE] open also and have done both, they'll all testify that these are exactly the principles that they kind of want you to follow when you're doing robotics, and you want to leave the maximum tissue on the ureters. You want to manipulate the ureters the least.
SPEAKER 3: [INAUDIBLE] yeah, exactly. If they can't see [INAUDIBLE].
KHURSHID GURU: So you can see where they have defined the periureteric space with the goal that--
SPEAKER 3: [INAUDIBLE] tissue is [INAUDIBLE].
KHURSHID GURU: We leave a lot of tissue intact. And--
SPEAKER 3: [INAUDIBLE]
KHURSHID GURU: --well, that's kind of the periureteretic space. That's kind of the first space we usually develop. And then we at this stage kind of [INAUDIBLE] through the lateral pelvic space.
Now I know a lot of people [INAUDIBLE] did the lymph node dissection first. But I kind of thought that this was an easier way when I was training at Ford. The [INAUDIBLE] Dr. Peabody that I felt like it was easier for everybody to learn this way because dissection kind of haven't been a lot of open-- you didn't [INAUDIBLE] lymph node. Now I don't know if this Panel--
SPEAKER 3: [INAUDIBLE] first guys--
KHURSHID GURU: How many people do lymph node dissection first?
SPEAKER 3: [INAUDIBLE]
JAMES O. PEABODY: Yeah. I-- hey, Khurshid. We lost your feed a little bit, but I definitely learned to use-- to do the lymph node dissection first. I think I've done the lymph node dissection before the cystectomy because the lymph node dissection is the most painful part of the operation. And when I start the operation, it's when I've got the most energy. It seems almost anticlimactic to do the lymph node after you've gotten the bladder out, but--
KHURSHID GURU: Yeah. Yeah, it's kind of two schools. I've kind of seen both sides. Tim Wilson did that for a little bit, and Tim kind of-- and I think Bernie-- I don't know what Bernie does or [INAUDIBLE] Kamala or Dr. Messing. I don't know what kind of [INAUDIBLE] approach is-- I know [INAUDIBLE] is now doing cystectomy [INAUDIBLE].
[INTERPOSING VOICES]
QUAING J. LI: Yeah, Messing's on the way. Doc Wiklund is on the way as well. They're not here yet.
SPEAKER 4: Can I ask a question?
KHURSHID GURU: Sure.
SPEAKER 4: Of course, [INAUDIBLE] the [INAUDIBLE].
KHURSHID GURU: Whoa, Dr. [INAUDIBLE]. Welcome.
SPEAKER 4: Morning, yeah. I have a question from you. This patient has had dense [INAUDIBLE] isn't it?
KHURSHID GURU: Yes.
SPEAKER 4: We know about chemotherapy, that they cause a lot of fibrosis, especially with the advanced disease. Have you operated any patient who has received pre-op Immunotherapy?
KHURSHID GURU: No, we haven't, but we do a lot of [INAUDIBLE] like-- at about chemotherapy, we're about 40%. I think Bernie has done a lot of patients, I think. He is in the crowd, and he probably might talk about his experience with-- he might have done some patients with previous immunotherapy. I haven't, but always [INAUDIBLE] chemotherapy is like-- neoadjuvant chemotherapy is more 60%. But I tell you, It all depends on some are really sticky, some are not.
BERNARD BOCHNER: Khurshid, good morning. Bernie Bochner here. So our experience with the IO agents in patients prior to surgery is growing.
KHURSHID GURU: Mm-hm.
BERNARD BOCHNER: And we're beginning to run into the same issues that are lung cancer and melanoma, cancer surgeon, [INAUDIBLE] surgical colleagues are experiencing or have already experienced. So what we find is that you can definitely see a significant inflammatory reaction around some of these tumors. I've seen now a couple of cases of local pseudo progression as well--
KHURSHID GURU: Yeah.
BERNARD BOCHNER: --so patients that had received pembrolizumab prior to surgery.
QUAING J. LI: Yeah, yeah. That's known from--
BERNARD BOCHNER: Yeah, and it's very interesting. I did two cases within a 10 day span both having received pre-op pembro. Very similar masses to start with.
KHURSHID GURU: Uh-huh?
BERNARD BOCHNER: One mass completely resolved, was a P0, very large mass that had progressed radiographically and the second identical features but was all tumor.
QUAING J. LI: Oh.
BERNARD BOCHNER: And it was it was impossible to tell the difference radiographically. So we've got some work to do to figure out exactly who we should be operating on following this. But both cases were actually quite challenging-- for different reasons but were actually quite challenging. So--
KHURSHID GURU: So Bernie, do you think that kind of it's also going to be like a new challenge to operate on these patients because we have more of inflammation and more of kind of the reaction that you see in neoadjuvant chemotherapy?
BERNARD BOCHNER: I think what is likely to happen is that as we get into a subset of patients that are maybe not responding to chemo or don't have this-- don't meet the same radiographic criteria that we would use for response, right? Typically, somebody with advanced disease or adenopathy, we're looking radiographically for a very significant response to be able to proceed with surgery. We kind of have to redefine that now in this era of immunotherapy where we may not see the same radiographic signs.
And as I mentioned, on some patients, you'll see progression radiographically, but that still may correspond to a response in the bladder. So it's a bit of an unknown for bladder. As we mentioned, it's already been recognized for lung and other tumor types. But I think we're actually probably going to be operating on more advanced disease in the field of IO. The number of patients that we'll be seen coming to consolidative surgery probably will actually increase.
KHURSHID GURU: Yes. What about Kamal or Karim? What is their experience?
KAMAL POHAR: Hey. It's Kamal Pohar. Sorry-- Kamal Pohar. Good morning.
KHURSHID GURU: Welcome, Kamal. Have you done a few of these cases, like Bernie, or you also have kind of anecdotals?
SPEAKER 1: No, very few. But you know, there is a phase two cooperative group trial using IO with cisplatin-based chemotherapy. So we're participating in that trial.
So I've had experience on a couple of patients. But-- so my overall experience has limited it, and I share the same comment just from a subjective standpoint that I also felt that the degree of potential inflammatory response fibrosis, especially around the lymph node dissection, seemed to be more than the average. But I don't have a lot of experience in the area.
KHURSHID GURU: [INAUDIBLE]
KARIM CHAMIE: Hey, Khurshid. This is Karim. Yeah, I haven't done any cystectomies post-immunotherapy yet, but I think we're all going to get our hands-- we're all going to get exposed to it at some point based on the number of trials that are using immunotherapy for patients with BCG unresponsive cancers.
We currently have a study open with Noah Hahn from Johns Hopkins that's using immunotherapy combined with an additional agent. But I'm not so concerned about the fibrosis. I'm more concerned about the long term medical complications from immunotherapy. I think for a long time, we've been given checkpoint inhibitors to patients who have failed chemotherapy, and it's a second line or third line setting.
These patients have-- prognosis is poor, and their life expectancy is minimal. Nowadays, we're giving it to earlier stage disease. And we're going to, at some point, run into a wall where we don't know whether somebody is experiencing complications from immunotherapy or whether it's their autoimmune disease. So I think as urologists, we've got to be careful with what we do these patients. So--
KHURSHID GURU: Absolutely. So going back to the case, I just want to sure. And you guys are welcome to give your experiences. This is kind of how we have developed this tech.
So we use the perureteric space. That's kind of the first step that Fellows do when they come here for training. And then we go to the lateral pelvic space where technically, your boundary should be the [INAUDIBLE] pelvic fascia, the pelvic side wall, almost up to kind of the base of the pedicle.
And if you join the two together, you kind of almost identified your pedicle right there. And what I did is I did the right side, and I'm kind of almost heading towards this side to kind of make sure that I could do that this patient. As Quaing said before, he had neoadjuvant. And he had hydro on the left side and kind of had a stent also.
But then the hydro disappeared, and the stent was taken out. And he obviously has a little bit of inflammation around here. So I'm trying to kind of make sure that I stay a little bit away. And that's one of the things I think we could talk about is that the whole sensation feel of-- and this has been a debate for a long time-- that with the robot, you don't have that feel that you could kind of feel-- touch tissue and feel it and all that.
But we kind of have-- lens cleaning-- we kind of have a changed gears in a way, kind of more for visual imagery and visual memory comes into play. And also, what I've done over the years is-- if look at all the intuitive videos of people doing cystectomies, there's a lot of people who used to cut the ureter right away. And I don't do that because I leave it intact.
And one of the reasons is that you kind of want to have a landmark. If you don't have the field [INAUDIBLE] you would go. Because often sometimes, your field is blurry, and you can't tell. You're kind of looking at not knowing how far you want to go, especially if you've already cut the ureter. Leaving the ureter intact kind of almost is a nice little tool to kind of use for that.
So I have done that. Here you can see going t almost going through the vas here, trying to make sure that the post neoadjuvant chemotherapy, this is not kind of stuck. So it's the vas here I'm trying to work through here.
A little bit slower here because I want to make sure that there's not a lot of that reaction. And we see this in, like Dr. [INAUDIBLE] said, we see this impatience sometimes post chemo and especially if they have had fibrosis or they have had [INAUDIBLE] side tumor, and you kind of want to make sure that your, number one, staying away from the tumor, number two, you kind of-- even though there was nothing extra [INAUDIBLE] here, it was just the hydro. But obviously, that kind of worries you that you have some diseases you might not be able to pick up.
We can see here I'm trying to kind of make ground here to get to the point. Now let me ask the panel. Nurse caring-- everybody give their kind of opinions about nurse caring, what they do, and when do they do, what's the indication.
BERNARD BOCHNER: So Khurshid, Bernie Bochner here. So nerve preservation is absolutely something I think that we should be practicing on patients who are appropriately selected. Who's the best candidate?
Obviously, there are going to be patients with reasonable potency coming into surgery. But the disease status is critical here and invasive tumors. Remember now-- if we restage T1 disease, most of the time, we're pretty accurate in assessing whether there's deeper invasion or not.
They tend to be very good candidates for bilateral nerve preservation, obviously, the refractory CIS patients. As far as muscle invasive disease, I think we have to be very selective with invasive patients. If they receive pre op chemo and you see a significant reduction in the size of the tumor, it's up higher along the bladder itself away from the neurovascular pedicles.
It's reasonable at that point to consider doing bilateral nerve preservation. I would strongly recommend doing that on the same side as a T3 tumor or higher. And then at that point, you have to really think about what your personal results are with unilateral nerve preservation.
Many older patients, if you're going to spare a single nerve, you know, even in the hands of some of the best, the potency rates, the spontaneous potency rates, will drop significantly. And then you've got to sort of work through the risk benefits for doing a unilateral nerve preservation. But I think in the right patient, it absolutely can be done and is something that we should offer to patients.
KHURSHID GURU: Yes, exactly right. What about others in the group?
JAMES O. PEABODY: Bernie, do you think that sparing the nerves helps with continence with the neobladder?
BERNARD BOCHNER: It's a great question. There was some early information that came out of the group from Burns, suggesting that perhaps sparing the nerves led to a quicker return of continence in the neobladder population. And it was a little hard to tell-- it was a relatively small series-- whether we were just doing a better job at preserving the apex because we were doing the nerve preserving or whether nerve preservation actually made a difference. I actually think that it may.
But the nerve preservation tends to be done in the younger group, more potent group, tends to be done in the earlier stage group. We spend a lot of time at the apex being careful with the nerves. That helps to dissect out the sphincter complex. So I think it's difficult to sort out all the different variables because it tends to be the more favorable group that are getting the nerve preservation to begin with. So it may just all sort of come together in the same patient, I think. But I do think, again, it's certainly reasonable and should be offered to the correct patient.
KHURSHID GURU: What about others in the group? Sabir or-- you know, is Dr. Messing here already?
KARIM CHAMIE: He's not here yet.
KHURSHID GURU: Oh, OK. So what do you think? Yeah, I thought-- I kind of had [INAUDIBLE] before talking to Bernie about this, these were his thoughts, what about the Kamal and Sabir and Karim? What are your thoughts? And Peabody, I know you kind of like you do the same thing what Bernie said.
BERNARD BOCHNER: So you know, if I'm doing a neobladder, I always tend to try to do a nerve sparing. And I think I think I do it for a number of reasons. I think it keeps me honest, and I think there's less iatrogenic injuries when you're doing a nerve sparing.
Not that I've had any rectal injuries, but I've heard of people who kind of march through aggressively not nerve sparing, and I think sometimes you get into trouble. And so I try to teach the residents and the fellows to kind of keep their kind of anatomical landmarks. But I do it, and I don't know what it does to continence.
But I've kind of been a little disappointed with potency. You know, I could tell you that I do a very aggressive nerve sparing. And for the first few months, they're--
[INTERPOSING VOICES]
QUAING J. LI: Uh huh.
BERNARD BOCHNER: --they're getting erections, and then they regain their continence, and their pouch gets bigger. And then all these guys tend to then have problems with erectile dysfunction. And I don't whether it's me, whether it's the neobladder. Maybe I'm not putting them on Cialis and citrulline, like we're doing all of our prostates. Maybe I'm doing something wrong. But I definitely notice that I've been underwhelmed by the successes of a nerve sparing on a neobladder patient.
KHURSHID GURU: I mean, you have had good results. But again I think in the end, it's kind of what you guys say. It's picking the right patient.
And like Bernie said, I think the key goal here is oncologic principal. And I think we all agree to that.
Nobody should kind of compromise that because the recurrence is going to be a nightmare. And you kind of try to pick the right patient, but I think age and also-- you know, the average age of a-- at least in our institution, average age of a cystectomy patient is 70.
This is like unusual patient for us to have young patients. And we have a older patient population [INAUDIBLE]. So we kind of get a lot of those.
BERNARD BOCHNER: So Khurshid, if you could just go back to your apical dissection there, because I think that this is one of the real critical parts to this procedure, which is the part that you--
KHURSHID GURU: This is what you're talking about post--
BERNARD BOCHNER: Yes.
KHURSHID GURU: --the apex?
BERNARD BOCHNER: Yes. You made this look so easy. But if you could just sort of run through how you're retracting anteriorly and what plane you're looking for because I think this is where a lot of people tend to get a little lost. They can get into trouble out here.
KHURSHID GURU: Very good point. And I'm going to get a lens clean wash, and I'm going to talk about it. And one of the things, I think it's very important, is are you intrafascial, are you extrafascial, and do you go through that [INAUDIBLE] layer and get in deeper?
Now a lot of people will try to do a nerve spare and preserve everything. But then Bernie, very key point what you said is they never reserve this area. And that whole-- kind of that hammock which holds all of this together is underneath this. Because I'm almost kind of, you can see, almost intrafascial to the prostate.
And because there's no [INAUDIBLE] involvement, so I'm OK with kind of being a little closer to the prostate and leaving all of this intact. Now if you wash that down and clean it, a lot of times, you'll see this area, and you'll see yellow perirectal fat through this because somebody has gone through the thing. Now what I do is in my principles, the key is obviously stay away from the bladder.
So if you see, I didn't touch anywhere here. I made my incision [INAUDIBLE] more [INAUDIBLE] I directly went to the vas and the seminal vesicles. Then once you lift these, you kind of try to slowly peel this kind of this layer. And I think that's the, Bernie, you're talking about.
This layer has to be [INAUDIBLE] gently and pushed but not all the way down and just enough for you to kind of retrieve things here. So kind of then, what you're talking about is that as you read reach here-- we all know anatomically the [INAUDIBLE] layer [INAUDIBLE] And you kind of almost have, as you reach the apex, there's no [INAUDIBLE] fascia anymore. So one layer kind of almost fuses near the apex. So once you get to the point where you just see the apex, that means you kind of stop. That's what I can burn.
BERNARD BOCHNER: Yeah, I think those are the perfect points to make. And you can see that if you're dealing with larger tumors, particularly posterior tumors or tumors involving the prostate, that this type of dissection needs to be carried deeper right through [INAUDIBLE] right onto that anterior rectal wall fat in order to minimize those posterior lateral margins being involved.
KHURSHID GURU: So that's kind of key, the [INAUDIBLE] dissection and where do you do them. And I think that's what we all kind of feel that that's the most important. And if you see, I didn't carry the dissection out further at this point because I wanted to wait until I released posteriorly and I saw this area so that I could make sure that I'm not getting in the tumor.
And I saw the area, and if this area looked rough, I would literally have not dissected this and [INAUDIBLE] here. And that's kind of why I need this intact, because this almost kind of becomes my guide of the perivesical tissue which kind of, how far should I go and where I should dissect. Can I get a grip?
QUAING J. LI: So at this point, do you plan to do a nerve sparing, or you still have to wait?
KHURSHID GURU: Yeah, I'm kind of going to try because I see the tissue. And does everybody agree? And I would like to take everybody's opinion.
The tissue looks pretty nice. I don't think there's any [INAUDIBLE] areas. And the tumor [INAUDIBLE] like Bernie was pointing out. Kind of you have [INAUDIBLE].
SPEAKER 3: [INAUDIBLE]
KHURSHID GURU: Hello? Yep.
BERNARD BOCHNER: These are all gold clips you're using here, Khurshid, or are these purple clips?
KHURSHID GURU: These are [INAUDIBLE] purple, right? Large [INAUDIBLE].
SPEAKER 3: [INAUDIBLE]
QUAING J. LI: Do panel members-- can you share how is your typical technique doing nerve sparing, either open or robotically? Do you go from the above to below or from below to the above? Or how do you identify those key structures that need to be avoided?
JAMES O. PEABODY: I try to release the pedicle here to get it started and then work down.
[INTERPOSING VOICES]
JAMES O. PEABODY: See where the seminal vesicles are and try to stay just anterior to those--
KHURSHID GURU: --go a little higher.
JAMES O. PEABODY: Minimize the use of cautery there. These clips more. Until you get into plane, and then you work it sort of like a prostate.
KHURSHID GURU: No, no, don't pick it upwards. Lower, lower, lower. Yeah, close.
OK. So before I [INAUDIBLE] this, I want-- it's a great opportunity for me to learn also and everybody who kind of I feel that you've done this in the field, and it's great to have all of you here. So what I do is I kind of try to take the bladder and pedicle-- I think that I'm almost in sync with Dr. Peabody, what he said. Get this whole bladder pedicle taken care of first without manipulating what is below and underneath.
And if you see, kind of use the least amount of work below underneath and file this to the [INAUDIBLE]. And you see this, why I kind I of always say that we don't have to cut the ureter. Once you clip the ureter and cut the ureter, you kind of almost lose orientation on this a little bit. And I still do it despite doing so many cases because like Bernie said,
It's kind of very critical that if you have tumor margins positive doing all that. So you fire the stable. Fire that, [INAUDIBLE]. Now remember, this is not a wide dissection case. So we're going kind of little higher. And I almost reach--
QUAING J. LI: You said above the seminal vesicles.
KHURSHID GURU: Pardon me?
QUAING J. LI: This is-- the stapler is above the seminal vesicles. Try to avoid those--
KHURSHID GURU: I haven't gone lower than that yet. So there's a little-- did you use the vascular stapler, [INAUDIBLE]? OK.
OK, so I'm going to take a scissor, please. So I want to stay-- and you know, I'd love to hear comments about this if I should change direction. It's kind of a learning process for all of us.
But the way I do this is so I kind of think this, obviously. And then I kind of am below, like Quiang said, this is seminal vesicle here. I'm going to go in here and try to find a plane getting in here and leaving all the bladder [INAUDIBLE] up.
And like Bernie said, this is kind of a case where we will want to kind of make sure that there are select cases. This is not for every case.
This is a select case. He's young. He has-- kind of sexual function is good.
The disease is not posteriorly. The disease is not-- OK, so hold on. Let me just [INAUDIBLE] better. Now how many people do frozen sections of the ureter regularly?
KAMAL POHAR: It's come up over. I don't too frozen sections regularly. It's very uncommon that I would do a frozen section. If grossly the ureter looks normal, I don't send a frozen.
KHURSHID GURU: Is there anytime you send, Kamal, or you just kind of basically, based on the operative field, you decide that it looks good, or no?
KAMAL POHAR: Yeah, no. I certainly wouldn't send a person section unless something grossly gets my attention in the operating room that I think a margin would be important because finding carcinoma in situ at to margin on frozen I don't think has direct relevance to the patient in terms of the pure implication of developing cancer at the ureteroenteric anastomosis.
KHURSHID GURU: Very good point. OK, can I have a Maryland on the left side and also a hydro dissection needle?
BERNARD BOCHNER: So I would agree with Kamal that in general, it's probably not beneficial for most patients to have frozens and chasing those frozen margins of the ureters. What I tend to do just routinely is resect at least the lower third of the ureter and remove that. And there's been other groups that have shown by aggressively removing lower parts of the ureter and making the anastomosis to the bowel up higher, you have an incredibly low risk of a positive margin.
I think that if you had a patient with diffuse carcinoma in situ, recurrent carcinoma in situ, maybe that's the patient you would want to consider doing a frozen on. But the reality is a positive margin is a reflection of the field defect of that urethelium within that upper tract. It does not necessarily mean that it's just one specific region of the ureter that's at risk.
KHURSHID GURU: Yeah, got it. So yeah, that's almost the same thing we do. We kind of decide to select before. We do a lot of these and kind of stopped doing that now. So as you saw, what I did was I kind of used this needle to just inject some saline.
BERNARD BOCHNER: Can you talk about that needle a little bit, Khurshid?
KHURSHID GURU: Yeah, sure. So this is a needle. We kind of took this trick from the thorasic guys. They use it-- another clip.
It's a long needle with a little small pointed end. Now when I started doing this-- and I think this was Dr. Peabody, with you and another resident, we tried to do the hydro dissection for prostates. And I do this often for my prostates. The problem with the regular needle was that you couldn't generate the pressure to dissect or hydro dissect with a regular needle.
So what would happen is that at the end or the tip of the needle, the pressure was very low. So what-- clip. So what would happen is that you wouldn't be able to dissect well. The beauty of this needle is this, and you'll see this come back again on the other side, is that it's a very rigid, hard needle. It basically generates very good pressure [INAUDIBLE].
QUAING J. LI: Are you dissecting the tip of the seminal vesicle?
KHURSHID GURU: Yeah. So I kind of tried to dissect this from here. And one of the things I do is a kind of-- the panel nicely alluded to is that you want to stay away from where the bladder issue and try to avoid it. Now obviously--
QUAING J. LI: You know, some surgeons, when they do the nerve sparing, they open the interpelvic fascia first, identify the neurovascular bundle, and peal that off anteriorly. And the way you're doing that, you started posteriorly, then kind of found the capsule and followed anteriorly. What's the comment-- what's--
KHURSHID GURU: So--
QUAING J. LI: [INAUDIBLE] doing this?
KAMAL POHAR: Yeah, why don't you hear from the panel, then I'll tell you what I do for prostates and also these?
BERNARD BOCHNER: I think you can do it either way. I typically do it the way that you're doing it now, Khurshid-- start from posterior and work forward.
KHURSHID GURU: Yeah, yea.
QUAING J. LI: [INAUDIBLE]
BERNARD BOCHNER: I think from the-- most of the open approaches have worked in a retrograde fashion. Open the endopelvic fascia and then work back from the apex. But as we're gaining experience with doing this robotically as well, we tend to do these more in an antigrade fashion.
KHURSHID GURU: Yeah.
[INTERPOSING VOICES]
KHURSHID GURU: It's kind of both.
JAMES O. PEABODY: I tend to do it this way. I tend not to drop the bladder and try to do the nerve sparing because then you've got that big, heavy bladder flopping in your way. I think the way Khurshid's doing it is quite nice where you're doing it posteriorly first. And then once you drop the bladder, you'll be able to do the finishing touches. But starting off posteriorly and then working your way anteriorly later, it's just easier.
QUAING J. LI: And Dr. Pohar, how--
KAMAL POHAR: Yeah, I agree with that. I pretty much do all of my cystectomies open. And I think doing most of them by opening the endopelvic fascia and releasing the neurovascular bundle at the apex of the prostate but I think being flexible for the points that are made and starting to do more of them from an antegrade approach as opposed to the classic open approach, I think myself, I'm evolving as well. But I think I'm flexible in operating and I kind of adjust to what the circumstances in a given patient.
QUAING J. LI: Yeah, I think it's nice that he shows that posteriorly, he dissected close to the prostate capsule. And then peel off--
KHURSHID GURU: [INAUDIBLE] here [INAUDIBLE]. This is-- so Quaing, the point you made is very critical. I don't open the endopelvic fascia at all. I don't open it for prostates also.
And I don't kind of get closer, and I kind of-- you can almost see, just for the sake of everything else, we can kind of look at this. So I'm trying to look for the edge of the prostate here. And I almost kind of have married the two techniques-- the open and the thing.
So kind of, you almost want to play safe, and you kind of try to find a way to go lateral a little bit, dissect a little. I mean, the most important thing is [INAUDIBLE] from the bladder. Can you see there's this vessel kind of?
QUAING J. LI: There is some surgeons that start doing like seminal vesicles sparing cystectomy, try to save that nerve close to the tip of the seminal vesicle. Any comments on that? Any reason to make the efforts to save the seminal vesicle to preserve the [INAUDIBLE] function? Dr. Wiklund's here.
PETER WIKLUND: Yes, so many years ago, when I did a lot of open cystectomies, I very often spared the seminal vesicles to have a better nerve sparing approach. with the robot, I don't do that typically. I would do very similar to this.
And I normally would actually open the other pelvic fascia because I think you see the lateral part of the prostate, and it's easier for me to take down the [INAUDIBLE] coming like antegrade and lateral and sort of pushed the bumble of the prostates. The good thing with bladder cancer is that you can go very close to the prostate. Doesn't even matter if you're sort of interfascial or not because you're not so afraid of [INAUDIBLE], of course, on the prostate.
And even in Stockholm, where I work most of the time, we have 48%, I think, prostate cancer incidental. But we have very, very few of them are clinically significant prostate cancers. So you can actually go close to the prostate and really do a nice nerve spear.
QUAING J. LI: And other comments from the panelists?
KHURSHID GURU: [INAUDIBLE] you know, you're going to want to make sure that you are away from everything here. So I kind of don't use a lot of cautery here. Entirely it's OK if it bleeds a little. Peter, welcome.
PETER WIKLUND: Thank you. It's nice to be back.
KHURSHID GURU: Yeah. I haven't seen you since you moved to New York. The closer you come in, the harder it is to find you, eh?
PETER WIKLUND: Yeah, yeah, yeah. But it took only 1 and 1/2 hours to come here this time. So--
KAMAL POHAR: Yeah, I know. [INAUDIBLE].
QUAING J. LI: So we have a question from Twitter for the panels and Dr. Guru. What factors into your decision whether to do a neobladder or ileal conduit?
KHURSHID GURU: Can you [INAUDIBLE]? You can start with the panel, and I can answer later on. I can hear.
QUAING J. LI: Yeah, let's start with Dr. Wiklund.
PETER WIKLUND: So I mean, this is a lot of patience. I don't have a lot of contraindications for a neobladder, basically. I do think this is a patient's preference and that the most important thing is to explain the difference in quality of life to having a neobladder and to having a conduit.
I don't think that there is a lot of difference in outcome surgery. The post-operative course and some of the complication rates are basically the same. But there are differences in quality of life afterwards. So that's what I sort of discuss most of the time with patients. And I mean, very seldom, I don't--
KAMAL POHAR:
[INTERPOSING VOICES]
PETER WIKLUND: Neobladder in patients that had radiotherapy before. But otherwise, I don't have a lot of contraindications.
QUAING J. LI: Dr. Peabody, you have any comments?
JAMES O. PEABODY: I would agree. It's largely driven by patient preference and a thorough preoperative discussion and trying to see what they're willing to deal with. There is a little more maintenance involved in a neobladder I think. Some people are less up for doing that.
KHURSHID GURU: The small one, yep. Thank you, Dawn.
QUAING J. LI: Dr. Chamie, any-- how do you--
KARIM CHAMIE: Yeah, you know, it's obviously patient preference, age, co-morbidities, and risk of disease. I think someone's got pretty advanced disease, and they're likely to require more treatments down the line. I'd be a little more hesitant to give them a neobladder, but not to say I don't. I just incorporate all those factors when I counsel the patient.
QUAING J. LI: Dr. Pohar, what's your neo practice?
KAMAL POHAR: I think all the comments, you know, I agree with. But I think there are certainly, you have to be cognizant of social issues, hand coordination for the potential that they may need to catheterize. I think you do need to be aware of some physical limitations, potential social emotional--
KHURSHID GURU: [INAUDIBLE] go a little lower. Yeah, yeah.
KAMAL POHAR: --limitations. I think that's important to ascertain at a clinic visit and including the family. And metabolically, I think renal function-- I know the panel really felt that it really-- everybody's a candidate for a neobladder, but I think you do need to be somewhat cautious about the patient's GFR going into surgery and the appropriateness of a neobladder, whether what that cutoff is for the GFR, whether that's 40 or, 50 what that translates into a serum creatinine. And so I think there does have to be some diligence of looking into those factors. But otherwise, I agree with most of the comments.
QUAING J. LI: Dr. Messing just arrived. Welcome, Dr. Messing.
EDWARD MESSING: Thank you.
QUAING J. LI: So let me rephrase that question. Let's say pretty much have the patient preference for [INAUDIBLE] of neobladder [INAUDIBLE]. Do you have any contraindications?
Say, this is a patient. I'm not doing the new bladder. And what's your selection criteria? Say, for the patient, I don't offer you neobladder because of this. What is your criteria for contraindication?
PETER WIKLUND: So I would say that previous radiotherapy to the pelvis would be a contraindications for me to do a neobladder. If they have a severe kidney dysfunction, I would also-- don't recommend the neobladder. I don't think that-- I mean, if you look at the follow up from kidney function after neobladders and conduits, it seems to be exactly the same. So I don't think it's a big difference. But anyhow, if they are in severe kidney failure, I would not offer a neobladder.
JAMES PEABODY: So selection or I guess contraindications primarily would be tumor-related factors, right? Involvement-- extensive involvement of a prosthetic urethra or overt involvement of the penile urethra is obviously a direct-- an absolute contraindication for doing a neobladder. I think age is a relative contraindication.
I have lost my enthusiasm for doing neobladders in the 80-year-old population-- not so much that the daytime control doesn't eventually come back, but the time to regaining that daytime control can be quite prolonged. And the nighttime control rates are just not great in that population. You know, having somebody volitionally void and just teaching them to become a time voider is probably about the easiest thing that you can get somebody to do.
It becomes somewhat problematic as the population ages and becomes forgetful. Takes more prompting, but you know, again, in general, I think that there's a wide range of people that are going to be reasonable for this. Severe radiation in the pelvis is going to lead to a higher incontinence rate, no question. Patients that have had prior radical prostatectomy-- quite variable how the apex sets up, but many of those patients are actually reasonable candidates as well.
KHURSHID GURU: [INAUDIBLE] here.
BERNARD BOCHNER: But sometimes, that's a game time decision depending upon how much scarring there is at the vesicle urethral connection. So you know, I still feel that the majority of-- many patients are going to be best served with a conduit as well. It really does just-- it's on a patient to patient basis. But I think after 35 years of experience with orthotopic reconstructions, we now know that there is a wide-- big group of patients that we see that are going to be reasonable candidates for orthotopic reconstruction.
QUAING J. LI: Dr. Guru, can you update us where you are as far as the nerve sparing?
KHURSHID GURU: So I just want to show-- OK. So here, I kind of stayed above-- I tried to preserve this vessel here. And I kind of almost did what Bernie was saying earlier, that they do a lot of antegrade. So I kind of went back and found the edge of the prostate here you see and peeled off all of that.
And that's why I don't feel that you need to open the endopelvic fascia higher up near the urethra. The reason is because I think it really helps with the continence and everything else, and these vessels you see-- kind of-- that's what I do in the prostate.
I don't open the endopelvic fascia here. So we're almost-- yeah, let me just cauterize this area [INAUDIBLE] prostate. OK. I'll do a little wash for everybody.
So kind of it's very important, and kind of this is another clip. The biggest challenge is kind of going underneath the bladder, making sure that you don't go higher, and finding that kind of-- that groove between the two and then dissecting it off. And this, I think, happened in [INAUDIBLE]
And probably Dr. Peabody could testify to this. But when Dr. [INAUDIBLE] took the robot 15 years right there, this is kind of how they were looking at the veil of Aphrodite. I need a lens clean.
JAMES O. PEABODY: Yeah, that's the story of how he first started to do it.
KAMAL POHAR: So--
QUAING J. LI: Messing, do you have any--
PETER WIKLUND: I just wanted to mention that the neobladders, patients-- less in men, certainly, but definitely in women, they have to be willing to do intermittent catheters. They have to be willing to do intermittent catheterization.
KHURSHID GURU: Yes.
PETER WIKLUND: They have to know about it in advance and be able to do it. And I've had people refuse just because we tell them it's a possibility. And they don't want it just for that reason.
KHURSHID GURU: I think that's a very, very good point, especially in our region here. Majority of the people who we offer a neobladder [INAUDIBLE] kind of the reason not to get it is this.
QUAING J. LI: And Dr. Peter--
KHURSHID GURU: [INAUDIBLE] how catheterization is a big issue.
QUAING J. LI: [INAUDIBLE] can I ask and enlist Dr. Peter Wiklund also to make a comment on offering neobladder in patient with diabetes? These are the patients who can get infection, and they get infection in the neobladder. How do you tackle that?
KAMAL POHAR: I've not found that diabetics or having diabetes necessarily sets them up for any worse infection, whether it's from the neobladder or the conduit. They're prone to infections either way. And the reality is is that a man who's emptying the neobladder well, which is the vast majority of men that we're going to do this on, as Dr. Messing just said, the catheterization rates are actually quite low in men in general. Most of that urine is actually probably more sterile than the urine that's coming out of a conduit and refluxing back up. So I would not see diabetes as a contraindication for doing the neobladder.
QUAING J. LI: Anybody-- any other comment on [INAUDIBLE] you deal with the infection like any infection of the bladder, or--
BERNARD BOCHNER: Yeah, I don't have a different view either. I think [INAUDIBLE] really doesn't have an impact--
QUAING J. LI: Because our experience are very different. In India, we have had a lot of problem in the patients who has a diabetic. And they've gone on antibiotic for a long time.
And recently, I'm thinking to not to offer it. But I want to take an opinion from experienced people. So [INAUDIBLE].
KHURSHID GURU: [INAUDIBLE]
BERNARD BOCHNER: I think the--
KHURSHID GURU: [INAUDIBLE] angle that, yeah?
BERNARD BOCHNER: You know, really making sure that the population you're looking at is adequately emptying. That they're being religious about their timed voiding and emptying would probably be something to really look at in that population.
KHURSHID GURU: Opened again.
BERNARD BOCHNER: Soon as people get too relaxed with respect to that, and they start walking around with [INAUDIBLE] residuals, that's when they're going to set themselves up for these recurring infections. And they're hard to clear if they're not emptying the bladder.
QUAING J. LI: So Bernie, in your center, how many-- what is the percentage of patients [INAUDIBLE] bladder rather than conduit?
BERNARD BOCHNER: So it's actually practice-specific, as it probably is across the country. But even with our own institution, we have a fairly big staff. So when we look at all patients undergoing radical cystectomy, just over half of the patients are receiving continent versions.
But from practice to practice, they can vary from 70% to 80% receiving continent reconstructions down to below 50% or around 50%. There's no question there's a population that will best benefit from a conduit-- the elderly group of patients, patients with more advanced disease. And so again, as you've heard from the panelists, I think it's on a patient to patient selection.
QUAING J. LI: Kamal?
KAMAL POHAR: Same.
BERNARD BOCHNER: You know, my personal rate of [INAUDIBLE] is about 40%, you know, being in the Midwest of the United States. You know, it's more of an elderly co-morbid population with significant obesity. But I think that's reflective of maybe the United States in general inside very selected centers plan with a lot of-- other factors that influence that. And I think overall, 30% of patients in the United States in higher volume centers are getting continent diversions today. And these are in high volume centers with a fair bit of experience. I think that's reflective of what's happening in the country.
QUAING J. LI: Since we're doing a nerve sparing, there is a question from Twitter. Can we preserve the prostate completely during cystectomy? When can you do do?
KHURSHID GURU: [INAUDIBLE] moment.
PETER WIKLUND: Well, you can definitely do that. And it is also very helpful for the functional outcome in the sense that you have better nerve sparing if you don't touch the prostate. The problem is that you might have oncological issues, of course.
Even if I did-- when I did open cystectomy, a series of like 40 patients with prostate sparing, and it worked well. Functional outcome is excellent. But you leave a lot of prostate cancer in, and you have some patients where you have urethelic cancer going into the prostatic urethra.
So you're always having this sort of oncological discussion. And then with age, you'll also probably have more issues with emptying your neobladder if you-- but the confidence would be very good, of course. I don't know if anybody answers something else.
BERNARD BOCHNER: That's rare. I agree with Peter 100%. That then-- just to add to that is that we really don't have--
KHURSHID GURU: [INAUDIBLE]
BERNARD BOCHNER: --big series with long term follow-up and leaving the prosthetic urethra and ductal system in place in people who have developed bladder cancer. And we know from non-muscle invasive disease that long term, 10% of patients will develop extra vesicle involvement of the urethelium. Whether it's the urethra, the ductal system within the prostate, or the upper tract, that's another 10%.
So there are risks involved. And to date, I think good nerve sparing and setting up the apex for a neobladder, the results are very favorable right now. And given the absence of information long term on what happens when we leave the prostate in, it's still got to be considered almost experimental at this point. It's not standard of care.
QUAING J. LI: I agree. That's a balance between the risks and benefits. Risks is higher, much higher than the benefits probably.
JAMES O. PEABODY: So Kurshid, I noticed on this side, you didn't use the hydro dissection approach.
KHURSHID GURU: Yes. I wanted to show both style. I honestly use a lot of hydro dissection. So let me just show what the other way I've done this.
And the other room has been and still is bloodier because I kind of hate using too much cautery, especially in these nerve sparings. So if you can find the plane-- and I wasn't going too close here because of the hydro previously before. So I wanted to kind of leave a little more tissue.
So didn't want to kind of dissect it to the point that I went too close to the bladder. So I'm kind of trying to avoid that and just leave the [INAUDIBLE] here and see if I could do that, [INAUDIBLE] that. That's why I didn't use hydro dissection here.
JAMES O. PEABODY: Khurshid, when you did the hydro dissection on the other side, you did it just at the base. Do you sometimes redose it down?
KHURSHID GURU: [INAUDIBLE] back and sometimes also take-- hold on one second, Dawn. Sometimes I kind of go back at the prostate level and do a second there if I have to. Let's put a clip here though. It's probably [INAUDIBLE] leading to [INAUDIBLE].
BERNARD BOCHNER: Jim, what's your experience with using hydro dissection? Is it something that you currently use or not or--
JAMES O. PEABODY: I don't currently use it. We did a project, Khurshid and I, a while back. I did it for a while and then sort of got away from doing it. I haven't, to be honest with you, thought about it until I'm just seeing it again here. So--
KHURSHID GURU: So yeah, it's kind of-- it's also, Bernie, the problem with it is that if you are in the wrong plane, you kind of mess it up.
BERNARD BOCHNER: Interesting to do it with sort of ultrasound guidance to see what you're really pushing away and where the fluid's going exactly.
KHURSHID GURU: You can see here almost-- there's an apex where you almost see that fat.
QUAING J. LI: Can you tell us-- how do you plan to approach the apex? How do you identify the bundles in apex, and how do you avoid those-- injure his apex, which is easy to injure?
KHURSHID GURU: So what you see is as you get anterior, your [INAUDIBLE] finishes. And you have the prostate now. And you kind of dissect it to the point where you almost see the apex here. And we're going to clean the lens, and you probably can see a little better.
You can see here. I'm coming along here on the two sides and trying to almost be intrafascial prostate-like situation. We're very close to the prostate.
Finally, kind of make sure that-- I don't mind moving a little bit of prostate tissue if I have to, which I kind of obviously avoid, to spare the nerves. I'm going to get closer and closer and kind of go slower and slower. Clean lens, please
JAMES O. PEABODY: Khurshid, do you notice that-- I don't know if you had the SI system before. I think you've got the XI now. Do you notice there's a lot more camera cleans with the XI because the smaller camera? You're closer up.
KHURSHID GURU: It's kind of one of the most annoying things about this system is that the lens is very small, and the clean rate is very high, especially when you are in a situation where you operate closed. I don't know what-- probably we should hear from everybody what their-- oh wow. Can I get a clip for this? Keep on ignoring it, thinking it's going to go away, and doesn't-- no. Let me see if I can part with this. Hang on.
JAMES O. PEABODY: Yeah, what I've started to do is I've actually started to zoom out. And so if you put it, I think, at 4x, your resolution goes down a little bit. But at least you get less splatter.
KHURSHID GURU: They recommended it to me, and I tried it for a little bit. And I didn't like the resolution going down, you know? If we clip here?
QUAING J. LI: Can the panel members show us your experience--
KHURSHID GURU: Yeah, yeah, yeah, yeah. Yeah.
QUAING J. LI: --and tips about apical dissection as far as save the nerve and continence? And what's are key factors at the apical dissection?
PETER WIKLUND: I think that for me, the key factor is to spare as much of the urethra as possible. So I'd like to have a long urethra. That's my main issue.
The other issue is, of course, not to destroy the neurovascular bundle if you want to do a neuro sparing. We did not see, in our series, a big difference for continence sparing. We did nerve sparing and non-nerve sparing.
But there's a lot of open data to suggest that you should do nerve sparing because it's better for the continence. I don't know exactly why we didn't see it but, I think that I'll try to spare as much of the vascular bundle as possible. But for me, the length of the urethra is the most critical issue.
BERNARD BOCHNER: Yeah, then in the supporting structures, the [INAUDIBLE] prosthetic ligaments, the degree you can not dissect so much laterally and keep that tissue intact I think is helpful too. That's what I try to do, anyway.
QUAING J. LI: I see comments. Other members.
JAMES O. PEABODY: You know, the [INAUDIBLE] fascia certainly in a male can be opened safely without disrupting continence. It's the anterior dissection that you need to be quite careful with. It's totally different in the female. In the female, that endopelvic fascia should not be disrupted because the anterior branch is coming off of the pudendal nerve, which are really supplying that [INAUDIBLE] sphincter. So I think it's approached differently between men and women with respect to continence on how you're going to deal with the endopelvic fascia itself.
KHURSHID GURU: [INAUDIBLE]
PETER WIKLUND: Yeah, I agree totally that women are very different from men in continence respects, and I think we don't really understand very well how the continence mechanism in females work. I only do neobladders in females if I can spare-- if I do organ sparing cystectomy because I think otherwise, for me, the functional outcome is not as good as in male. But when you can spare all the surrounding structures and you just do cystectomies, which means that most females are not really suitable for neobladders--
KHURSHID GURU: [INAUDIBLE]
PETER WIKLUND: --I think that's my experience.
BERNARD BOCHNER: And that speaks to this the whole issue of the potential importance of nerve sparing in females. And it's likely that that tissue preservation, particularly on the lateral vaginal wall, are preserving these neurovascular structures that are supplying the sphincter or the proximal portion of the urethra. So it becomes-- it remains innervated.
One of the concepts that I'm beginning to think is responsible for a lot of the issues related to inability to empty in women is related to a denervated proximal segment of that urethra that just collapsed and is actually serving as an obstruction because these women are wide open. They generate a good pelvic pressure. They don't prolapse posteriorly.
But yet, they can't empty. But Peter's 100% right. By sparing those nerves, you're coming at the 11:00 and 1 o'clock position along the vaginal wall when you do your resection, and you can only do that in the earliest stage tumors that are away from the apex of the bladder in women. So it's probably a relatively small number that are going to be able to do the tissue sparing. And we have to live with the higher intermittent catheterization rates for now until we sort this out.
QUAING J. LI: Now is dropping the bladder approach anteriorly-- and I hate to ask these questions. You know, open approach versus robotic approach-- he finished anteriorly. For the open, typically, you start anteriorly, identify the key structures. Do you feel any difference robotic versus open, have better vision or handling of the tissue around the apex? Or it's a surgeon's--
BERNARD BOCHNER: My experience with-- if you were to drop this down early robotically, you're going to have a bladder just sitting right in your view. It's going to be difficult to retract back. I don't think that from the experts here that have started this procedure, this makes total sense to wait as opposed to the open, where you would do this early. But I think you can achieve the same goals. It's just the sequence has to be changed based on the approach here.
QUAING J. LI: Approach.
PETER WIKLUND: Yeah. I think one of the things which I think is important when you do robotic surgery is that you actually go all the way out to the abdominal wall because if you just start cutting into the fats, you can actually leave some of the perivascular fats. And I don't think that's something you do in open surgeon, and you should avoid that. And I think that when I see a lot of the old videos where there was mostly prostate cancer surgeons doing cystectomies, they actually just went through all this fat and [INAUDIBLE].
KHURSHID GURU: You [INAUDIBLE] 20? And can I get a scissor?
PETER WIKLUND: Sort of extravesical fat in the patient still, which I don't think is oncologically safe to do.
BERNARD BOCHNER: Yeah, I agree with Peter. I think, you know, dropping the bladder is not as trivial as it is for doing a prostatectomy. I think you've got to be a little more radical with the anterior dissection. I tend to tell the residents and the fellows that you kind of want to see the fascia as your anterior landmark when you're doing this.
QUAING J. LI: Khurshid, can you tell us a little more about your interior approach right now as far as the [INAUDIBLE]?
KHURSHID GURU: Quaing, so what I'm doing here is that I had already pushed this away. And the key is not coming directly under 12 o'clock position. Key is coming laterally and finding where you're [INAUDIBLE].
And you can see I'm almost in the sinus right here about. I'm going to kind of just peel this away, go back to the other side. [INAUDIBLE] kind of-- so get the point where the fat here. So I'm going to try to remove the fat so that you can see better.
Again, I'm kind of trying to get into the DVC here. Leaving a lot of this tissue, we will go higher up. [INAUDIBLE] kind of followed the apex of the prostate more. And I'll show you this more prominently here.
So you can see here this is kind of coming in. And the DVC kind of stretches here. So I'm going to now-- going to cut it forward right here. And then the moment I'm through the DVC-- how many people cut the DVC cord?
BERNARD BOCHNER: Yeah, I do. I cut the DVC just like you do. One of the important things I tell my assistant is never to suction-- yeah, never to section while you're doing this. I think Dawn is doing a beautiful job just gently irrigating. I tell the assistant-- I take the motor off from the suction irrigator, so it's more of a drip rather than, you know--
KHURSHID GURU: Yeah.
BERNARD BOCHNER: --squirt.
QUAING J. LI: And how many of you will control the DVC before you cut? Or just like he does?
JAMES O. PEABODY: I always cut it before I control it.
KHURSHID GURU: What is the pressure now? Can you ask him what is the name of--
JAMES O. PEABODY: He turned it up to 20, I think.
SPEAKER 3: 20.
QUAING J. LI: Since we're getting close to the urethra, there is a question from Twitter.
KHURSHID GURU: Yeah.
QUAING J. LI: Do you always do frozen section for the neobladder? And what do you do if it's CIS, inactive, or gross cancer or inconclusive?
KHURSHID GURU: Well, obviously, then you kind of [INAUDIBLE].
QUAING J. LI: And this patient had cystoscopy recently. There was no gross tumor. Yep.
KHURSHID GURU: John was generous to offer his patient.
PETER WIKLUND: So I think it depends a little bit on how well-trained the pathologist are to look at frozen section. But I always use the frozen section. Even if I have a prostate biopsy beforehand, I do a frozen section.
If I get an equivocal answer, I will actually continue to do the neobladder. But if they say that I see cancer-- I mean, like CIS or high grade cancer-- then I will abort the neobladder at this stage.
QUAING J. LI: What about focal CIS?
PETER WIKLUND: Well, I don't know what focal CIS is. It's either CIS and that is [INAUDIBLE]
QUAING J. LI: CIS.
PETER WIKLUND: And then I would not do a neobladder, but--
BERNARD BOCHNER: Yeah, any involvement is basically telling you the risk of that urethelium. It's the same as receiving a frozen section of the ureter. It tells you that that entire system is likely at risk.
All of our recurrent state is based upon patients who have undergone screening of that distal urethra margin. In general, they're patients who have a negative margin at the time of surgery. And we know that the urethral recurrence risk in that setting is low. It's about 5% to 6%. And men with a cystoscopically negative urethra and negative frozen section, we do not have large series of patients with positive margins in which neobladders are done.
And they're urethra recurrence risks. We don't know what that is because it's basically always been a contraindication for doing the neobladder. So focal CIS, extensive CIS-- now the question is, you'll get some atypia readings. And you know, that's when you might want to scrub out and grab your GU pathologist and look at it yourself with them. But if it's not called cancer, then I think you can move forward safely.
JAMES O. PEABODY: So Bernie, if there was cancer, obviously, you'd do a conduit. But how extensive would you do a urethrectomy? I was talking to [INAUDIBLE], and he would do a complete urethrectomy, a total urethrectomy, in a case like this.
BERNARD BOCHNER: So in the setting of a positive frozen, what I'll do is whatever their backup plan is-- and you can talk about [INAUDIBLE] cutaneous reservoirs or a conduit, whatever they decide they want. But as far as dealing with the urethra, what I'll do is I'll telescope in as much of the pelvic and membranous urethra as possible and core out at least the membranous portion and divide it at that point.
JAMES O. PEABODY: Yeah.
BERNARD BOCHNER: I will then survey the penile urethra. As long as cystoscopically, that distal urethra was negative, I'll wait. And we know that in general, the majority of those patients are not going to recur in the urethra.
And if they do, using urethra washes, you'll pick them up at a very early stage and could do the completion urethrectomy. This is a long procedure as it is. And so waiting, surveying the urethra, is typically what I'll end up doing. But I'll make that subsequent urethrectomy a lot easier by removing the membranous portion.
JAMES O. PEABODY: Got it.
KHURSHID GURU: So both the ureters were negative because you have previous [INAUDIBLE] and he's young and all that and has a hydro on the left side. [INAUDIBLE] send it. They just came back negative. So--
QUAING J. LI: You know, we know the patients with prostatic stromal invasion have increased risk of urethra recurrence. When do you do the concurrent urethrectomy? And if the patient's interest in neobladder, he has a prostatic stromal invasion but negative frozen section, would you still do it or not do it?
BERNARD BOCHNER: So the long term data, probably the best series comes out of the USC data. Demonstrates that patients even with stromally invasive disease of the prosthetic urethra-- obviously, this wasn't picked up prior to their cystectomy. They had a negative margin at the time of surgery, which led to the neobladder. Less than 20% of those patients recurred long term in the urethra-- less than 20%.
And so that's the number that I'll quote patients if you had high risk disease. So these again, these are patients who are screened cystoscopically negative urethra. But they were found at the time of cystectomy to have invasive disease within the prostate.
That's different from a patient who's got overt involvement of the prosthetic stroma that you had picked up by lateral [INAUDIBLE] biopsies prior to surgery. I think in those patients, they're probably best served with a cutaneous diversion of some sort. But yeah, we know that if it is found that probably no more than one in five actually end up developing.
And you can think about this. Stromally invasive disease has at least a 40% to 50% node positive rate. Their distant metastatic risk is so high, they're likely to die distantly before they develop a urethelial recurrence, which is probably why we're seeing such smaller rates-- competing risks.
KHURSHID GURU: So here, you can see I kind of-- you can spend a minute talking about this apex. So let's get our lens clean so that we can look at it. And give me a scissor on the right side, please, and a regular grasper on the left.
Thank you. So I saw the DVC before I cut the ureter because of the retraction. And also, the problem is then it retracts, and your nerves are on the side. You kind of always try to go lateral and cut your nerves.
So I kind of leave the ureter intact. And only time I go lateral is if I see a sinus which is kind of almost way lateral, which I kind of have to take. Otherwise, we just [INAUDIBLE] on time.
And you can see here this is what we got here. So you can see I stayed away from the apex. This is the DVC sinuses.
So you can see here on the side. And I kind of avoid getting into the lateral sides. [INAUDIBLE] I kind of pump laterally and then go up and then go higher up like this and lose everything so that all of this is kind of intact. And you can see this is the urethra.
So we're going to send a frozen section while we do the lymph nodes. So I might kind of dissect this a little bit more and make sure that-- kind of have the maximum ureter length. Any comments? Anything people would do different?
JAMES O. PEABODY: No, it looks good. Now you put a clip on that urethra. You take the catheter out and put the clip in, or how do you do it?
KHURSHID GURU: Yeah, you know, the only time we have not put clips is if it's a neobladder, they lose length. Because we already have a-- the Foley catheter's draining now. That's a very good point. So let's go across the panel. How many would put a clip and how many won't put a clip?
JAMES O. PEABODY: Yeah, I always put a gold-- I take the catheter out. I put a gold clip. I hug that prostate right at its neck. I always have that fear of spillage.
KHURSHID GURU: Mm-hm, good. What about others? Peter?
BERNARD BOCHNER: Yeah, you almost try to clip the prostate itself and get the urethra in it as high up as you can to do that.
PETER WIKLUND: So I don't clip the urethra because I want to spare the whole length of the urethra. So I do exactly as I do it in open. So I would go in, almost into the prostate, open the urethra, but don't deflate the catheter.
Pull the catheter out. Put two clips on the catheter so that the balloon stays inflated and never-- because whatever you do, you have to open the urethra at some point here. And whether you should pull down the catheter from the tumor up in the bladder and then open the urethra or whether you should do like what most of us do, I think, and open-- open the urethra and pull out the catheter and having the balloon still inflated.
KHURSHID GURU: Others?
JAMES O. PEABODY: Well, you know, since I do them open, I think-- certainly I don't put a clip there. You can divide the urethra under direct vision there. But you have the opportunity.
You can pack that side of the field [INAUDIBLE] by putting [INAUDIBLE] tech or a lab pad. You know, you have the opportunity to protect that potential for spill. So [INAUDIBLE].
BERNARD BOCHNER: So working together with Alvin Go at our center in doing these, what we've changed here is rather than putting a clip there-- because I agree with Peter that it can alter the anatomy or the shape of that urethra as you're dividing it a little bit. What we've done is we've put a little box stitch into the apex of the prostate so that as the catheter is pulled back and we've delineated exactly where we want to cut across, we tie down on that suture so the prosthetic apex is closed. And this has to do with my fear perhaps, not others here, of any opening in the system and any spillage that may occur at the apex there.
I've even gotten him to place a little ray tech underneath the urethra here as we're doing this maneuver so that as this is divided, the ray tech and the specimen go right into the bag. And if there's a drop or two that's come out of the bladder, it's all removed immediately. Because this is the only break in [INAUDIBLE].
And so if we're worried about spill, perhaps those-- and they're very quick maneuvers that they could be incorporated. Now whether that's going to change any of the risks that some of us have seen with some recurrences, you know, to be determined or not. Others haven't seen it.
I know Peter has not reported. He's had very good results without seeing issues. So--
QUAING J. LI: Dr. Guru actually did a wash study looking at the wash from the fluids. [INAUDIBLE] can detect the cancer cells by next generation sequencing recently. So Dr. Guru, I wanted to briefly mention that the paper you just recently published?
KHURSHID GURU: Yeah, basically--
QUAING J. LI: --that the wash--
KHURSHID GURU: --we tried to kind of identify it. It was also a lot of tumor stage of-- what stage the disease was. And we found that kind of sequencing and the recurrence depended on kind of the extra [INAUDIBLE]. Well, [INAUDIBLE] like this so that they can shave-- and I hold it up.
And they can share the [INAUDIBLE] off the clip [INAUDIBLE] so that above the clip side is the [INAUDIBLE] side. So I send it like that. And then I hold it [INAUDIBLE] and put it in the back.
PETER WIKLUND: [INAUDIBLE] so Khurshid, why did you cut the urethra like that? Now you open it. I think that that's maybe-- I would not like to cut it like that because now, you put your clip first. And then you take--
KHURSHID GURU: I do it only for the neobladder so that I save the-- I basically clipped it, and I sent a little-- I got a little bit above to make sure that, one, the spillage doesn't happen right there, and that whole thing I'm holding, when I cut it across, there's no spillage. And you cannot send the clip directly. And I put this in the bag right there. And kind of-- I feel like putting-- I have done the putting the sponge and all that kind of-- it's a little tedious intracorporeally, you know?
SPEAKER 3: [INAUDIBLE]
KHURSHID GURU: OK, let's get this. Yes, so talking about the paper-- let me just get this bleeder here [INAUDIBLE] on. This is kind of bothering me, this vessel, this vessel. Why don't we get a clip? Small clip.
PETER WIKLUND: So maybe I--
KHURSHID GURU: Go ahead, Peter.
PETER WIKLUND: So instead of sending a clip, I would rather put the suture there because I don't want to have a clip so close to the anastomosis. Because, you know, if you come in after like two years and look at these clips, you see there's lots of fibrosis.
KHURSHID GURU: [INAUDIBLE] you're right. Agreed. It's just-- it's far away about the-- but you're right. It can migrate very clearly into there. So let's get a wrap.
Day 1 (part 1 of 3) of the Masterclass on Bladder Cancer at the Roswell Park Comprehensive Cancer Center featuring a robot-assisted radical cystoprostatectomy with bilateral lymph node dissection, possible bilateral nerve sparing, and neobladder ICUD. This includes a panel discussion with Peter Wiklund, MD, Mount Sinai Health System; James Peabody, MD, Henry Ford Health System; Karim Chamie, MD, University of California; and Bernard Bochner, MD, Memorial Sloan Kettering.
Related Presenters
Chair, Department of Urology
Director, Robotic Surgery
Director, Applied Technology Laboratory for Advanced Surgery (ATLAS)
Robert P. Huben Endowed Professor of Oncology
Professor of Oncology
Khurshid A. Guru, MD, was appointed Director of Robotic Surgery at Roswell Park Comprehensive Cancer Center in October 2005. Dr. Guru completed his residency training in Urologic Surgery (2005) and a Robotic Surgery Fellowship (2004) at ...
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