QIANG LI: Masterclass on Bladder Cancer-- this is a two-day course featuring live surgery performed by Dr. Guru. Dr. Guru has performed over 600 robotic cystectomies and urinary diversion. But most recently, all the urinary diversions has been done intracorporeal.

My name is Qiang Li. I'm one of the junior attendings here. During the live surgery, we also have panel members discussing the tips and tricks of robotics hysterectomy and ileal conduit.

Please allow me to introduce the panel members. Dr. Bochner is a Sir Murray Brennan Chair in surgery at Memorial Sloan Kettering Cancer Center. He's also the PI of the first randomized trial comparing open cystectomy versus robotic cystectomy. And yesterday, he gave us wonderful lectures regarding what robotic surgeons should learn from open surgeons.

Second is Dr. Peter Wiklund. He's a professor of urology at Mount Sinai. He's also the director of the BladderCancer Program at Mount Sinai. He's also one of the world-renowned surgeons who pioneered the robotic cystectomies.

Dr. Peabody, he's a professor at Henry Ford in Detroit. He has particular interest in teaching robotic surgeries. He's a director of robotic program and director of the residency program at Henry Ford.

Dr. Chamie is an associate professor at UCLA. His research interest is the health service research in bladder cancer and clinical trials in bladder cancer. His clinical interests are focused on robotic cystectomy and urinary diversion.

Dr. Messing is the ex-chair at University of Rochester. He's a world-renowned urological oncologist in all aspects. And yesterday, he gave us a lecture regarding the intravesical gemcitabine treatment after the TURBT. The work was just recently published in JAMA.

And Dr. Pohar is an associate professor at Ohio State University. He's on the panel of the NCCN Guidelines. He runs a bunch of clinical trials for bladder cancer.

Dr. George is an associate professor of oncology here at Roswell. He runs dozens of clinical trials. He led a few trials that led to the FDA approval of multiple recent immunotherapies.

And Dr. Guru is a director of the Applied Technology Laboratory for Advanced Surgery. He's the chair of Department of Urology at Roswell Park. He will perform a robotic cystectomy ileal conduit today. Yesterday, he did a robotic cystectomy and neobladder. So please allow me to also welcome the online viewers.

So today, the case is a 72-year-old female. BMI is 27. Past medical history of asthma, some allergy. Surgical history is a hip replacement, appendectomy. She also have a few allergies.

And she presented last year with gross hematuria. She was found to have a bulky tumor. And TURBT was performed December, 2018.

Pathology revealed high-grade T1 cancer. Muscle was not present at that time. She had a palpable mass and a bulky disease. A CT scan showed the bladder wall thickening and extravesical extension. And she was deemed clinical T3 disease.

She came here to Dr. Guru for a second opinion regarding the further treatment. She was presented in multidisciplinary conference. She was offered to repeat the TURBT to confirm this is a muscle-invasive disease versus a front cystectomy versus neoadjuvant chemotherapy and cystectomy.

The patient opted to have neoadjuvant chemotherapy due to the clinical T3 disease. So today, Dr. Guru is going to perform robotic-assisted anterior exenteration and bilateral extended lymph node dissection with ileal conduit urinary diversion. So Dr. Guru, can you hear us?

KHURSHID GURU: Yeah, hi. How are you doing, Qiang?

QIANG LI: Good, good. So we'll head over to you and the panel members.

KHURSHID GURU: So we have-- this is a female examination, entry examination. So we had patient in previous surgery, so we had to [INAUDIBLE] of regions to get the ports in. So the ports are in. We're just talking to the robot.

QIANG LI: Khurshid, can you share your experience of the patients with prior surgery, multiple surgeries, and what's our tips and tricks to drop the port to make sure there is no visceral injury, et cetera?

KHURSHID GURU: Yeah, so obviously, the first key port is the camera port. And then from that, you want to make sure that your first entry-- because the majority of the time, we use needle. So our entry is usually kind of blinded.

Unless we feel that we need to do a Hasson, we try to enter with a Veress. But if you feel that the patient has multiple surgeries, and we feel that the abdomen is kind of tough to get in, so we use a Hasson. But most commonly, we use a Veress needle.

And we also have seen that the majority of the patients [INAUDIBLE] are usually who have had multiple previous surgeries. And these multiple previous surgeries are what define how hard it's going to be to get into the belly.

And especially if it's multifactorial. What we term here as a complex surgical field, we basically are looking at complex multiple surgeries with reconstruction and radiation on top of that. That kind of makes it always difficult.

So you can see here, this is a regular, run-of-the-mill [INAUDIBLE] where we have entry. So that makes it very helpful, because you have entry and your ports can go in easily.

One of the key things we have done-- and which I'm sure a lot of people in the audience and also a lot of people who do these cases-- you can change between different cameras to kind of get access. And sometimes, you might end up using a zero. Sometimes you might end up using 30 up.

So we entered the belly. Usually, we do all of the cystectomy cases with a zero, but here, we entered using a 30 up. And you also might want to sometimes even use 30 down to get in.

So the key is to find a way to get into the belly with all your ports-- or at least three ports-- the camera and the two robotic arms-- to enter in there without difficulty. And if you get in, and you can do that, you kind of have vision and access to do this.

I am therefore using a cold scissor for lysis. It's kind of what I've always been trained in, and that's kind of what I've always done. And a lot of people, I'm sure, do the same thing. So those are kind of my key things.

But if I could get in the ports, my visualization is better. So what I would do is I'd basically just do lysis until I get into-- [INAUDIBLE] the robot. And after that, I use my robot to kind of go in.

So it's kind of nice, and the vision is better. Now, if the lysis are bad, we all know that you can kind of have the risk of getting into bile or getting some kind of-- you've got to be prepared to handle it. You've got to be prepared to do what is right for the patient.

QIANG LI: OK, just in case for online viewers who were not in the course yesterday, can you describe how many instruments are you using, how do you set up those?

KHURSHID GURU: So there are six instruments. So I have the right arm, which is a scissor. And this could be a thermal scissor or a cold scissor. I always do my lsyis with a cold scissor.

Even if-- I see them, and they're easy to do, it's how I was trained. And on the left hand, it's usually the grasper or the [INAUDIBLE] is kind of with Cobra Grasper. And then I change depending on what I need to.

So it's kind of-- and also, obviously, an assistant who basically helps me out. It's kind of become the standard probe placement now globally for similar to any pelvic surgery. And it's kind of evolved from prostate.

The only difference, technically, is that you go higher, and you add things if you have to do urinary diversion. And the type of diversion, you kind of add things what you need to add to your list.

QIANG LI: Panel members, please feel free to ask him any questions or comments. So you mentioned that the important is to put the camera port, because sometimes the most difficult part is to put the camera port.

Do you have any tricks? Do you put the camera port in the virgin area? Do you use a [INAUDIBLE] needle to--

KHURSHID GURU: Sometimes really you are kind of complicated. You could kind of almost put the [INAUDIBLE] somewhere else and fill the belly. And then take it from there.

But the majority of the time, your rule is kind of almost to go into an area which is less. And I've found that especially for pelvic surgery, you don't-- it might be true for maybe kidney that you have to go somewhere. For pelvic surgery, you find a lot of space higher up in the abdomen to kind of go in, you know?

So it's all dependent on what kind you're looking for. So here you can see that I don't just do a little bit of lysis. I kind of made lysis enough that it's safe, which means, like, I know my periaortic space is going to be around that area, and the most important thing is my assistant is going to be going in with the instrument laparoscopically, in and out, when I asked him to help me, and they're kind of coordinating, so I want to make sure that their feeling is OK that we don't have a injury to any which we don't see, and as we know, all of these injuries can happen if you are in-- you can't see what you did, and you've got to try to help out, get past the instrument then for--

JAMES PEABODY: Could you-- this is Jim Peabody. Do you also sort of think about how you're going to be setting up your ileal conduit later and make sure that you have enough lysis that you can easily access the distal ileum?

KHURSHID GURU: Yeah, absolutely, and that's why I kind of release that area there, and you can see here, this kind of-- the small bowel is, like, stuck here, but I'm going to release all of it because you've got to have enough bowel to work. And I like to do this in the beginning because once I operate, and the field becomes a little bit more dirtier, and you kind of almost don't see things very well. You can see them. It's not that you can't, but I like to do them when it's really, really clean, and I can avoid any injury or, you know, any bowel in the way, so it's kind of that's how we have done it.

And I like the cold scissor a lot. Even if you have-- I mean, it's not always that you'll never-- to do these kind of surgeries, and people who do this, and especially the panel, you kind of got to be ready to deal with this.

JAMES PEABODY: It's a sharper scissor, too, so it's easier to cut.

KHURSHID GURU: Yes, exactly right. So we can see here, slowly trying to kind of clear the area so that we can see nicely what we need to see. Not a whole lot going on here. A lot of it was on this side, so I try to find-- so this is my ileocecal valve kind of thing. This is what we did the lysis on. And this is kind of-- I just kind of do it like an informal round, and say, OK, what I've got it going here, and how much of this lysis is needed. And this is here, you can see the omentum here-- it kind of starts.

JAMES PEABODY: You're releasing that in case you maybe need it later--

KHURSHID GURU: Yeah, I'm--

JAMES PEABODY: --at the end of the procedure?

KHURSHID GURU: --[INAUDIBLE] need it later, so I can just kind of having access to my bowel here, just to make sure that when I make the conduit, I don't have to worry about it. And so you can see here, so I'm kind of happy about this, that I have easy access to the bowel here, so it's good.

BERNARD BOCHNER: Khurshid, Bernie Bochner here. I think that, especially with some more advanced-stage tumors, and when you're working on some of the more dangerous histologies, I don't know if you know, if there's a plasmacytoid component, that evaluation that you just did in the small bowel serosa, I think, is critically important because occasionally you're going to end up finding some very small studding of disease that is present along those serosal surfaces that you may not otherwise pick up unless--

WILL: You see here--

BERNARD BOCHNER: --you look for them.

SPEAKER: --Yeah.

KHURSHID GURU: Can I have the results?

BERNARD BOCHNER: It can be very smart.

KHURSHID GURU: Yeah. No, I think that's a very, very important point. I mean, you never know, even though-- a thermal scissor?

ANDREA: I need the pick.

KHURSHID GURU: Or just give me the hook meanwhile. And here, I'm kind of trying to use something thermal because the omentum, and I kind of want to make sure that doesn't bleed on me all the time, so while I'm operating. So I'm kind of opening the pelvic area of all of this. They still don't have a thermal scissor, so I decided to go with the hook.

ANDREA: Done. I don't need that.

WILL: I'm trying to get behind it.

ROBOTIC ALERT: Too close. Too close.

JOHN LI: So you have done a lot of lysising with [INAUDIBLE] for other surgeries in the past. So I was just wondering, how do you handle the injury, doing lysis of adhesions, the serosal tear, the full layer, the cautery. Typically, what's--

KHURSHID GURU: Well, you know--

JOHN LI: --the principle?

KHURSHID GURU: --that's why I kind of do a light cautery because even if I have a-- my hook is off. So even if I kind of-- that's why-- if you see I didn't use this for-- when I was closer to the area where I was-- now, the only reason I'm using it here is because it's a really vascular area, and even if I cut it cold and it bleeds, it's kind of-- will always ooze and make my field look dirty, so I'll kind of use it for this area.

Clearly, John, with visualization, and if you kind of feel that you're going to do this, and you never get in the bowel anywhere and have a serosal tear or [INAUDIBLE] this, I mean, you shouldn't be doing these cases because it is part of the whole thing, that you will-- going to end up with that, so you just have to be prepared to do all of that and to be ready for that.

So you can see here that kind of nicely the bowel-- one of my tests is that, if that [INAUDIBLE], that the bowel should nicely fall back. That's my test for if, well, a lysis has gone well, and we have released everything, so you can kind of have the field open for yourself, especially if you have had previous surgery, and you kind of--

JOHN LI: Can you briefly tell us what you're doing and would try to achieve at this--

KHURSHID GURU: So as you know, I always do this technique of spaces, so this is my first step in the periaortic space, which basically is that I release that ovarian pedicle. And one of the reasons is because it kind of gets out of my way, and then I don't have to worry about it. Let's get a clip. I want a medial-- hang on a second-- you know, medial-- well, a little shorter than I am. OK, a double and single for--

JOHN LI: And, Khurshid, last year, you published a paper demonstrating 14% of the female cystectomy, you have the gynecology organ involvement. So when do you preserve some gynecology organ, and that, do you-- how often you do that?

KHURSHID GURU: Well, as you know, it's kind of, you're now seeing this very small number of patients who get that, and it's depending on the disease. Obviously, the first thing is the disease. Obviously, this patient is not even a candidate for that. The age of the patient, the requirement of why they're doing that-- the indications are very, very low of us preserving that. And so you can see here, again, once you open that, that kind of nicely opens your periaortic space.

JOHN LI: Just interested to know what panel members think, then, regarding the gynecology organ preserving. How do you select those patients for the cystectomy without taking out the ovaries, the uterus?

KHURSHID GURU: I would think of that as probably less than 1%, I mean, but would be very interesting to learn from other members.

BERNARD BOCHNER: So, look, you know, fertility preservation is going to be a very small percentage of patients, but in a young woman who's still interested in preserving her fertility, and with very early-stage disease, you could potentially consider organ preservation in that setting. In women who have not yet reached menopause, it's reasonable to consider sparing one or both of the ovaries.

But the routine preservation of the uterus and tubes, I think, is contraindicated in the majority of people. You're going to do a much more thorough job, especially in a patient like this, with potentially T3 disease, by removing those organs.

JAMES PEABODY: Yes.

PETER WIKLUND: Yes. Exactly, so I would agree in general, but I think that if there is somebody who wants to have a neobladder, a female neobladder, I'd try to spare it, or do an organ-sparing because I want to spare the whole pelvic floor basically without having any opening into the vagina. And so I will not extract a specimen through the vagina in patients like that, but it is a minority of female cystectomy that will have neobladders, and they are younger. And they cannot even-- or they cannot have a very extensive tumor.

KHURSHID GURU: So you can see here-- I just want to show something. Even though the ligament was here, but I kind of went as wide as this far. And this is kind of where it doesn't come from robotics, but comes from the original principles of surgery for these cases, that you kind of want to make sure, especially if you are concerned about pathology, and you're concerned about margins, you kind of have to make sure that you are far away.

JOHN LI: For those of you joining us live just now, we encourage you to ask questions either through Twitter or through the live broadcast. By pressing-- there's a button, ask a question. Click that button-- you will be able to ask questions, and our experts, panel members-- you know, you don't get a lot of opportunity to ask questions.

KHURSHID GURU: So the key here, as kind of what Peter and Bernie mentioned, and Dr. Peabody was saying, it's just important that you kind of go wide when you have to really go. This is not one of those-- like, this is a totally different case than what we saw yesterday, which was more of a little bit of nerve preservation.

Here, the goal is to be as wide. And you can see here, now we have the periaortic-- can I have a lens clean? So you can see here, this is the periaortic space. We found the ureter here, and you kind of-- you see I have not dissected this a lot yet. The goal here is to kind of make sure-- and you can see, this is what we talk about, like, leaving all that tissue intact on top of the ureter.

And then, you kind of go wide in here and try to see if you can find a-- I mean, if you look at it, I'm all the way above the bone. The bone goes here. I'm trying to release all of this tissue and stay wided until I reach-- there you go. So you can see here, kind of tried to do as wide as I could go here. I don't think I could go wider than that. And then here, gently peel that fiber off, and this is the side now. I just try to clean it up a little bit till I get to see the side wall. And you can see here--

JOHN LI: It's because you're getting close to the pelvic floor. I know we're doing-- you're doing an ileal conduit today.

KHURSHID GURU: Yes.

JOHN LI: Can you show us, like, the female anatomy that-- you know, what would you do if this is a female neobladder? Just show us anatomy-- what would you do differently? And we may have panel members to comment on the anatomy-- how do they do their neobladder, and what are important structures for the nerve, for the [INAUDIBLE], so the bladder neck, et cetera?

KHURSHID GURU: Yes, well, it's all-- let me just open this other side, then I have a-- obviously, this is not going to degrade demo case for that-- watch there, hmm?

JOHN LI: I have a question for the panelists. So your practice in the female patients, how many percentage you're doing conduit versus a neobladder? And how do you select those in general?

BERNARD BOCHNER: I think the main issue with the female neobladder is that you really have to make sure that the bladder neck-urethral junction is not involved with tumor. Those are the patients that are likely to end up having disease at the margin, or a very large posterior-wall-invasive tumor, one that may be involving the anterior vaginal wall are probably not the optimal candidates for a neobladder.

But that would probably leave at least 75% of women from a cancer perspective that would be eligible. They have to be willing to do intermittent catheterization because, unfortunately, we still have a relatively high rate of women who just are not able to empty adequately on their own and are going to have to IC. And I usually quote about a one in five chance that that's going to end up happening.

It still leaves a large percentage of women who are going to be eligible. Doing a neobladder in a woman, I think, is actually easier because of the wide pelvis. And as long as you can mobilize the omentum to be able to put as a barrier between your vaginal closure, then I think it leaves many women who are eligible. They tend to otherwise to do very well from a continence standpoint. And then, as far as cutaneous diversions, whether it's continent or incontinent is really patient choice. If there's no--

KHURSHID GURU: Do a little bit down there.

BERNARD BOCHNER: --if there's bowel availability, there's really no other contraindication. That's fine. So it will vary from practice to practice, and what you've been trained on, and what you're comfortable doing, but from a contraindications standpoint, many women are going to be eligible for continent reconstruction.

JOHN LI: Dr. Wiklund, and how's your practice doing robotics as technique?

PETER WIKLUND: So I would say it's the same, basically. I think that-- so I want to leave--

KHURSHID GURU: Lower, lower, lower, lower.

PETER WIKLUND: --the pelvic floor--

KHURSHID GURU: --there.

PETER WIKLUND: --as intact as possible, so for me, the most contraindication has to do with the tumor biology, rather than the other issues. But they also should be continent beforehand because there is-- at this age, there is a lot of patient that have-- female patient that are already incontinent already, before surgery, and so that I don't like to do a neobladder if they are incontinent. But I also think that it's actually an easier operation to do, so then it is easier to get the bowel to--

KHURSHID GURU: Out of my way--

PETER WIKLUND: --come down to the--

KHURSHID GURU: --till I'm ready.

PETER WIKLUND: --urethra. The pelvis is wider, so it's for-- to actually do the surgery, it's easier.

KHURSHID GURU: OK, hold it.

WILL: Hold on.

JOHN LI: Dr. Pohar, what's in your practice?

KAMAL POHAR: Yeah.

WILL: Flip it up.

ANDREA: [INAUDIBLE]

KAMAL POHAR: Yeah, I certainly agree with Dr. Bochner and Dr. Wiklund. And I think that clearly the number of women who get continent diversions in general clearly is lower for the reasons that have been outlined, or just their desire to not have a continent diversion, and to potentially have to catheterize.

JOHN LI: Dr. Peabody, you have any comments on this?

JAMES PEABODY: Nothing really additional. What percent of women wind up with a continent-- or with a neobladder, do you think, given the fact that 2/3 of them or so may be candidates for it? In your practices, what percent of women actually select the neobladder then?

So, you know, the numbers at most centers is going to be relatively small simply because of the 4 to 1 ratio of men to women, so you've already eliminated 80% of it, right? And within that, 20% of the overall bladder cancer population, the females themselves, I would say, again, it's very practice-variable. I would say probably somewhere in the range of 50% of women, I'm going to be able to do that type of reconstruction.

Now, some of that could be practice-referral-based. People are going to seek out either centers or surgeons that maybe have an interest or a preference for doing that. But I think, if you look nationwide, the continent diversion rates, as Kamal just mentioned, it's quite low. You know, nationally, we're still sitting at probably only 20% continent reconstructions, and it's certainly no better in the female population.

JOHN LI: Dr. Wiklund, you mentioned you will preserve the--

KHURSHID GURU: Will, can you hold on--

JOHN LI: --organs--

KHURSHID GURU: --to it?

JOHN LI: --for neobladder. Do you preserve everything, including the round ligament, everything, or just the vagina wall-- the vagina, uterus?

PETER WIKLUND: [INAUDIBLE]

JOHN LI: My question is that you mentioned, for the neobladder, you would do organ-preserving. Do you preserve everything, including the round--

[INTERPOSING VOICES]

JOHN LI: --ligament, everything, or--

PETER WIKLUND: Well, I try to spare as much as possible, basically, so I've tried to do a cystectomy which is closer to the bladder. That's why the tumor biology becomes very important because I tend to go closer to the better than what I deal with it normally.

JOHN LI: The round ligament, you do that as a-- preserve that as like a suspension mechanism as well?

PETER WIKLUND: No, I think that there is not a lot of evidence to suggest that it really matters for anything, but I do think that I want to preserve the anatomy as much as possible, so I'll deal with it-- and spare it, sort of every part that I can spare, but I don't know that there is any sort of significance, importance, of just sparing the ligaments. I think that there are-- in normal, if you just talk to a gynecologist, they would say that there, it's very difficult to show that this actually changes the outcome or the risk of poor functional outcome just because you spare the ligaments.

KHURSHID GURU: [INAUDIBLE] asking for it.

WILL: Just there-- just this part with the [INAUDIBLE] scissor.

JOHN LI: Khurshid, can you show us where you are?

KHURSHID GURU: Yeah.

JOHN LI: And are you doing a--

KHURSHID GURU: It's just--

JOHN LI: --lateral?

KHURSHID GURU: -- this, what I am doing right now is, I'm dissecting this periaortical space on--

WILL: You have-- it's going to be close here. Go this way--

KHURSHID GURU: The left side.

WILL: --with it?

KHURSHID GURU: And--

WILL: I'll just-- let's just grab it. But it's stuck against the--

KHURSHID GURU: Will, maybe you've got to grasp it here for a second.

WILL: I'm going to treat it like--

KHURSHID GURU: I'll just show these spaces.

BERNARD BOCHNER: Yeah. [LAUGHS]

JAMES PEABODY: Fancy.

[LAUGHTER]

BERNARD BOCHNER: That usually gets their attention.

JAMES PEABODY: Yeah, it's the practical way of being.

KHURSHID GURU: A wash.

WILL: Yeah.

KHURSHID GURU: I don't--

BERNARD BOCHNER: I like to get the--

KHURSHID GURU: --see a lot of tissue on top of the ureter to get.

ROBOTIC ALERT: Wrong entry.

WILL: Just get in here. Just [INAUDIBLE].

KHURSHID GURU: We're getting a little bit restless here. Do it.

WILL: Try right there in [INAUDIBLE].

BERNARD BOCHNER: I think this is an interesting point to, or time to make an observation that, in many patients that have undergone prior pelvic surgery, whether it's a gynecologic procedure or a colorectal procedure, that many times you'll actually see the external iliac vein pulled into that fibrosis.

KHURSHID GURU: Yeah, this one here.

BERNARD BOCHNER: The tissues can be-- so the normal distance, it's like looking into your side-view mirror, where you got that little sign saying, things may be closer than they appear.

JAMES PEABODY: Yeah.

BERNARD BOCHNER: Just keep that in mind because--

WILL: Which one?

BERNARD BOCHNER: --that vessel many times is adherent, as it is here, to the ureter, and you can be fooled, and before you know it, meaning before you have the area exposed, you can get into some nasty venous bleeding if you're not watching that closely.

KARIM CHAMIE: Exactly, that's right.

PETER WIKLUND: It's the same thing with an [INAUDIBLE] nerve, actually. It's that, sometimes, if you have a lot of inflammation, the nerve can be also swollen, curved into that inflammation, so it's, like, retracted into the inflammatory area, so it can have an also strange course in some patients.

WILL: Don't strip that there.

KHURSHID GURU: It's kind of a desmoplastic reaction, when it sucks everything in, like you said, and it's not like the other side. You know, you just open the thing, and it's just sitting there. You can see that's kind of for here. Hold that ureter-- yep. One of the other problems on these, especially these post a previous surgery and exent-- female exenterations is that those small vessels which you're kind of never worried about will really bleed because of all those plexus and all those interconnections between vessels here. And the small bleeders can turn out to be nasty. So you kind of have to be very careful.

And the worst part is just that, if you haven't done all your dissection, you end up with a field which is dirty, and then it's really hard to kind of keep your track of that field. So if it's not clean, you know, you just can't tell because you kind of don't have any other sense of touch, or anything other than just a sense of view. When that's not clean, you kind of-- wash there, please? Thank you.

OK, so that goes there. That good, Will? OK. So just to get a lens clean, and then we'll take a look at where we are. What time was consult?

ROBOTIC ALERT: 3 on the clock.

Pardon me?

WILL: 8:13.

KHURSHID GURU: 8:13, OK.

WILL: Yes.

KHURSHID GURU: So here is the view. So you kind of have this. You have the periaortical space right here. Now, nicely, you see the vessel go across here at the pedicle. Then you kind of go here. We went lateral. We see nothing other than the parallel side wall, so we kind of-- we went wide. Same thing on this side, and the same thing for the periaortic tissue here.

Now, I only say this, that I personally feel the manipulation is pretty low on these tumors, and if you see that we haven't manipulated the main tumor a lot. I feel that's kind of an advantage honestly for robotics to give you that opportunity to do that. Now, bulky tumors will range from just being simply a little bulky versus kind of pretty hardened-- so you can see I have this.

Now we're going to put the-- you going to push that vital stick in? So you can see here nicely the anatomy, and then the cervix kind of delineating there-- right there. So what I'm going to do now is I'm going to take the ureters and clip the ureters.

And I'm going to stay a little higher because I'm worried about that margin, like Bernie and-- you know, the whole group of my friends, they were saying that, you know, this is a bad disease, so you've got to be careful. So we're going to clip higher [INAUDIBLE]. That's-- little lower, little lower-- first one, yeah, there. And then, so we kind of don't want to go all the way deep there.

JOHN LI: Khurshid, can you comment on what's the main difference between of male cystectomy versus a female cystectomy? What are-- anything, like, you need to pay specific attention in female?

KHURSHID GURU: Well, I think you kind of have to remember that the bleeding, even though you've-- in a lot of male anatomy, you kind of feel that the smaller bleeding can be ignored. You kind of put a little pressure to stop it. Here, it won't do that, and it's going to annoy you, and it's going to all add up, and then-- so you have to be very careful. Can I get a scissor, please?

JOHN LI: From the panel members, any, in your experience, you know, for the folks who just started doing this--

PETER WIKLUND: So I think that the female bladder-- and most patients are female, then the male bladder, it sits more lateral, so it comes out on the side. So I actually think that something-- in the beginning, specifically, it's-- but it's fill the bladder a little bit when you're doing the cystectomy, so you see the contour of the bladder easier.

There is a risk, otherwise, that you actually cut into the corner on the side, on the female bladder. But, otherwise, in general, I will say that the female cystectomy is actually easier to do than the male cystectomy. But we are more used to the anatomy of the male pelvis. [LAUGHS]

JOHN LI: Dr. Bochner, is that true of open surgery?

WILL: Doctor, it has a stent here.

BERNARD BOCHNER: I think that it's-- some of the key things that I'll look for is early control of those infundibulopelvic ligaments because they do tend to bleed with almost any manipulation, so getting those out of the way early. Obviously, the perivaginal venous plexus is quite impressive, and regardless of the age of the patient. And that can lead to a lot of significant bleeding, so we tend to use a lot of thermal instrumentation when we do those dissections.

And that's particularly important when you're doing the-- anterior vaginal wall-preserving surgery, that that tends to be more of a virtual plane, and it does tend to bleed a bit as well. So those probably are the sites, I think, where you're going to see differences in bleeding.

ANDREA: Yeah.

WILL: [INAUDIBLE]

KHURSHID GURU: So then you're [INAUDIBLE]. [INAUDIBLE] for both, please?

JOHN LI: Or to get into the vagina soon?

KHURSHID GURU: So I kind of do the pedicles first to control, and I think--

BERNARD BOCHNER: So there's a trait.

KHURSHID GURU: --Dr. Bochner's absolutely right, that, the end of the day, those perivascular bleedings-- here, hold that-- you need a medium. They're kind of the bad bleeding, is so annoying, that if you don't pay attention to it, it'll fill your field in a second. Let's get the first vascular staple, please. Yep, lift it up, please? Yep.

WILL: So do--

KHURSHID GURU: Will you spread this?

WILL: --to here? Yeah, that's right.

KHURSHID GURU: All right, what's that? The spirals?

WILL: Vagina first, and then sending-- free it out to the pedicles, while it really gets--

JOHN LI: So, Dr. Wiklund, what instruments are you using for the pedicles?

PETER WIKLUND: So I would typically use the LigaSure to do this part, not--

JOHN LI: By assistant?

PETER WIKLUND: Yes, exactly. Well, you can do it by the robotal, but I usually just do it-- or the assistant is doing this part.

KHURSHID GURU: Wash. OK.

WILL: So watch in here.

KHURSHID GURU: So the reason I cut both of these pedicle sides is especially if the tumor is a little bulky. So what it helps me with is mobilization of both sides, and I could kind of almost pull it out of the pelvis easily. And, obviously, think Peter had a very good point that, you got to be very careful with that anterior nerve. Sometimes it's kind of almost plastered to the side. Fire it. So you see now, kind of you-- let me push there. That's good. Little more? No? That's good. Stay there.

JOHN LI: Are you using AirSeal? Is there any leak--

KHURSHID GURU: In fact--

JOHN LI: --if you--

KHURSHID GURU: --for the female cystectomy is the only time I use AirSeal. What about the panel?

PETER WIKLUND: Well, I mean, the AirSeal is very helpful for female cystectomies because-- but, I mean, normally, you can actually pack the vagina with a sponge stick or something, so you can do it anyhow, but the AirSeal is helpful.

KHURSHID GURU: Yes.

JOHN LI: So now we're getting close to the lateral vaginal wall. Dr. Bochner, you mentioned that for the female, the nerve-sparing, those are the nerves to the lateral wall-- came up with any comments on what we're seeing, where it's relatively located?

BERNARD BOCHNER: So the autonomic plexus that's described will run along the lateral aspects of the rectum--

WILL: We ought to wrap it up.

BERNARD BOCHNER: --proximally here, and then up along the vaginal wall, and variably, but you can think of it running along sort of the 9 and 3 o'clock positions of the lateral walls of the vagina, which means you need to stay quite anteriorly in order to be able to preserve those. And, obviously, that's going to require a lot of attention to patient selection--

KHURSHID GURU: OK. Can we clear off the lens--

BERNARD BOCHNER: --and the extent of tumor.

KHURSHID GURU: --please? Can you give me a 30-up?

ANDREA: We have [INAUDIBLE].

WILL: I'm sure.

KHURSHID GURU: Any comments from the panel? Would they do anything different? Should I change anything, or kind of some tricks?

PETER WIKLUND: Yes, I normally go a little bit more lateral to push the bladder medially so I see the vagina a little bit clearer when I go around the corner here, but, otherwise, I'll do-- it's pretty much, see, I open the vagina a little bit earlier, so that's my first step I do. So I open the vagina, and then I come from the lateral side in towards the vagina.

KHURSHID GURU: OK.

PETER WIKLUND: But--

KHURSHID GURU: Yeah, go ahead.

PETER WIKLUND: --but, otherwise, very similar. I don't use the staplers here because I would use the LigaSure, but, otherwise, it would be very similar. But, I mean, this is the area where you have to take a lot of care. Then if you want to do the nerve-sparing part of the vagina--

KHURSHID GURU: [INAUDIBLE]

PETER WIKLUND: --because otherwise you would go in-- come through lateral, and then you'll destroy the nerve at this level.

KHURSHID GURU: Yes, absolutely. Any other thoughts from other members? So this is [INAUDIBLE]. I deliberately grabbed the skin and pulled it back for a second. So I just want to kind of take a look here, but if there was anything else going through here before I cut through this wall, so I can kind of see.

So I kind of always-- if this is a bulky tumor, I'll preferably know before I get there because a lot of times, if they're bulky, you can't see. And I don't want to push too hard up and down and manipulate it, so what I do is I just change the length to, like, a 30, and then you can almost get a very nice view all the way in there. And it gives you an opportunity. Let's take it back to zero.

BERNARD BOCHNER: So I can tell you, that is a unique view to robotic surgery. [LAUGHS]

JOHN LI: And this is what Kamal was--

BERNARD BOCHNER: You would not see that with--

JOHN LI: --talking about yesterday.

BERNARD BOCHNER: --open surgery. [LAUGHS]

KAMAL POHAR: Getting down there.

KHURSHID GURU: This is what we were talking about yesterday. You know, that whole angle, you kind of get focused in the small area, which is probably a few millimeters, and then you end up magnifying it seven times. And it could be really helpful, but it could also disorient a lot.

BERNARD BOCHNER: I do think that maneuver that you just did is-- taking full advantage of that is terrific, especially in a patient that you're worried about with a posterior invasive tumor. Normally, open, you have a finger in there, and you're going to feel for any abnormalities, but here you actually get to see as well.

KHURSHID GURU: Let's get a clip here.

BERNARD BOCHNER: See?

KHURSHID GURU: I think my lens is not clean, but I would like-- so one of the things I wanted to say about what Peter was saying, the reason I open this later, Peter, is because these vessels worry me all the time because they bleed a lot. So I kind of control the pedicle like that first, and then go for this. Can I get a lens clean so everybody can see better?

Yeah. No, I agree. I mean, this is very critical, especially if then these tumors are bulky. I mean, I agree that that bulkiness of the tumor kind of pulls you-- close everything down. And you kind of have to look underneath because you don't-- you have that limitation of field. So the best way is change lenses and go for something you can see in and out through using a camera.

JOHN LI: So Dr. Chamie, do you have any comments? How do you approach the lateral vaginal wall? Do you go clean a little bit laterally first, or do you just go like he's doing?

KARIM CHAMIE: Yeah. No, I do exactly as Khurshid's doing. I end up finding-- I end up making a-- you know, I end up getting into the vagina, identifying my landmarks, and then being able to hug it a little more later. But I need to know where I'm going. I need that GPS system, and it kind of leads me into it.

JOHN LI: And what kind of instruments are you using for the pedicle and the lateral vaginal wall?

KARIM CHAMIE: So if it's a non-nerve-sparing, if I'm just doing a complete urethrectomy and bulky tumor, I would just use a LigaSure, but if I'm-- you know, if it's an organ or sparing operation, then I would use clips and cuts.

KHURSHID GURU: The other lens, please.

JOHN LI: And do you guys remove the entire urethra for every cases for the ileal conduit? Is that a routine, or--

PETER WIKLUND: JL, well, for me, it's the routine to try to take the whole urethra, yes.

BERNARD BOCHNER: Yeah, I agree. It should routinely be completely removed if you're not going to be using it for a reconstruction.

KHURSHID GURU: My screen is again messed up, Will. You are just showering me there. Can you just take it a little easy? Just kidding. I know-- I know you're pointing at it, and then I'm just joking with you.

WILL: Gotcha.

KHURSHID GURU: What's that?

ANDREA: Just put it on the side? I think, so just ask me right now.

KHURSHID GURU: What's that? OK. All right.

ANDREA: For you.

JOHN LI: So we have a question from the live viewers from the Twitter. Dr. Wiklund may have already mentioned this. The question is that, can you remove the bladder--

WILL: This good?

JOHN LI: --through the port, not from the vagina? For the organ-sparing, does that help the complications? You mentioned that, but it--

PETER WIKLUND: Yes, I don't want to open the vagina if I do a neobladder, so I would exactly do like that, so I will-- that was more like a male cystectomy, where the-- I'll take the specimen out at the end of the surgery through one of the port sites, but normally the camera midline port.

JOHN LI: Dr. Chamie, is that what your practice for a female--

KARIM CHAMIE: Actually, I do actually make a small opening at the apex, at the cuff-- start at the cuff, the most superior aspect, and not necessarily anteriorly, and have been able to remove the specimen that way because the bladder is less bulky when it's by itself, right? I mean, it's--

JOHN LI: So Dr.Bochner, I actually yesterday looked at my operative records when I was a fellow, I did a female neobladder with you when I was fellow. You remove the uterus, and then you mobilize the mesentery in the pedicle all the way, and you put a mesh first, [INAUDIBLE] came into the sacral colpopexy. Can you comment, and on why you do that, when do you do that, any benefits?

BERNARD BOCHNER: Well, the thought behind doing a formal sacral colpopexy--

WILL: [INAUDIBLE]

BERNARD BOCHNER: --goes back to the presumption that some of the retention in women with neobladders is related to a posterior prolapse of the neobladder, forming an acute angle at the neobladder-urethral junction. And to try and sort of rebuild some of that posterior support, a strip of mesh to support that cuff formally to the sacrum, which is usually exposed from your node dissection, is usually done. It's very quick. It's just a small segment of mesh.

KHURSHID GURU: Can I get a [INAUDIBLE] up?

BERNARD BOCHNER: But, again, this is usually in a woman with a vaginal-preserving surgery that you're doing a neobladder on, so that's the thought behind it. Now, this has been sort of a routine thing that many of us have been using in the open field to try and lower that rate. I do think it helps, and so I've continued to do that as one of the measures to try and decrease posterior prolapse.

PETER WIKLUND: You have concern about infection of the mesh?

BERNARD BOCHNER: I think any time you put--

KHURSHID GURU: [INAUDIBLE]

BERNARD BOCHNER: --any--

KHURSHID GURU: --19.

BERNARD BOCHNER: --foreign body in, there's always that concern. We simply haven't seen problems with it. I've not had to remove any of those segments previously. And it's not a degradable mesh. It's a permanent mesh segment. Now, what I do is I make sure that the sigmoid mesentery covers that area, so there's no exposed mesh. And that way, you have no contact with it at the bowel because, obviously, any time you have intra-abdominal mesh, you've got to be worried about erosion. So this way, it's completely--