SPEAKER 1: So, I think maybe if there's a pure uriterocele cancer going which is at T4, for it's less likely that you will be successful of doing a more extensive resection of the tumor.

KARIM CHANIE: Yeah, Chung. I mean, it's really an individual decision when you're doing those types of cases. What's involved, which venous structures are involved, can you control them while you're doing the resection, or would it be a relatively uncontrolled resection which would put the patient in danger?

Cell type is important. If you're dealing with a plasmacytoid and you have that woody, plastering disease out to the side walls, that's unresectible. Because of the nature of that tumor type, it's unresectible.

So, hopefully a good EUA beforehand and good imaging. Updated imaging-- nothing less than four to six weeks old before you operate-- will hopefully avoid a lot of those circumstances. But sometimes you're fooled and you just have to make a decision. Can you get it? Can you get it out? Can you do it safely? What other options do you have for the patient?

And sometimes with new information, you just have to readjust what it is that you're doing. And so backing out sometimes and coming up with a better plan sometimes is the right thing to do.

SPEAKER 3: All right, gentlemen. [INAUDIBLE]

I think I'm done with the node dissection. I'm going to just cross the left ureter. Any other suggestions?

KARIM CHANIE: I mean, it looks beautiful.

SPEAKER 3: Yeah, one side. Let's see if we can see this side. A lot of redundant [INAUDIBLE].

KARIM CHANIE: Yeah, so Chung, exactly what Dr. Bochner said.

SPEAKER 3: That was a clean little branch. Kind of everybody felt I was like overly cautious, but that's good. Here, let me get that ureter across. So, at least one of the reasons is probably is because the stent, this ureter doesn't want to sit.

SPEAKER 4: Is the stent still there?

SPEAKER 3: Yeah, the top part is there and it's clipped but--

KARIM CHANIE: So, yeah, I agree. You know, I've been burned maybe once or twice where I've had patients would adenocarcinoma, prior radiation therapy growing into the bone. Try to go heroic and try to resect everything. And then two weeks later, the tumor grows and eats right through your bowel anastomosis and now they got an enterocutaneous fistula.

And it's one of those things where once you remember a patient like that coming into your clinic, you end up becoming a little more gun shy about being all cowboy. So I agree completely with what he says. You go in there, if you can't completely resect it, as long as you haven't burnt any of your bridges, you haven't taken the ureter or anything like that, you can always come back at a later time and present the case to tumor board, give the patient chemoimmunotherapy, and reassess later. There's no harm, no foul.

As I get older, it's not that I'm a better surgeon, I've just become wiser and good judgment. Yeah.

SPEAKER 3: No, I'll pull the lab through here because the nodes will get stuck to it, Will. Hold on.

SPEAKER 5: [INAUDIBLE]

KARIM CHANIE: Again, I think the mindset is that when you're doing a radical cystectomy, it's for curative intent. And it should almost be outlawed to include palliative cystectomy in the same sentence. There's just so few times that you should be doing that for this type of disease.

Perks in that setting, in general, are enough to palliate a patient because their life span is going to be so short, in general, with that type of extensive disease.

So what you end up doing many times is they don't make it out of the hospital before the recurrence occurs, and that's of no benefit.

SPEAKER 1: The only ileal cystectomy I can remember which did fine was one with interactive hematuria in a 48-year-old gentleman and failed radiation, failed embolization, and he had to use [INAUDIBLE]

KARIM CHANIE: But that's different, right?

SPEAKER 1: Yeah.

KARIM CHANIE You're doing that because--

SPEAKER 1: Life-saving.

KARIM CHANIE: --of bleeding. That set's different. So voiding issues, obstruction, those can be alleviated usually with proximal diversion. It's a horrible-- I don't want to get into it.

[CHUCKLES]

SPEAKER 4: Yeah, I agree. There's so many factors, co-morbidities, cancer biology. I think you have to do a lot to kind of appreciate, get some sense of biology. Is that true? The more you do, the less aggressive? Over the career.

KARIM CHANIE: I'm not necessarily sure I would say that. I'm sure that all of us at times, when it's appropriate, are very aggressive. I think that you become better selecting the patients that are most likely to benefit from that treatment. That's really what it comes down to.

So, it's not as though, I think, any of us shy away just from doing a big surgery. When it makes sense and it's going to help the patient, I'm sure all of us are going to be in on that. It's probably just we're better at selecting the right patients, I think.

SPEAKER 4: That's right.

SPEAKER 5: Is there any chance that [INAUDIBLE] to an adjacent structure?

KARIM CHANIE: Absolutely. The question was, will imaging sometimes overestimate the involvement of adjacent structures?

And the answer is absolutely yes. It's sometimes difficult to-- especially in a pre-treated field, to be able to see planes. Tumors may just be a budding and not invading things.

Many times, on a good, sedated patient-- an exam under sedation-- you'll be able to tell the difference because you'll have a mobile mass. There'll be some ability to it.

If it's truly growing into sides--

SPEAKER 3: Good. Last one down the side.

KARIM CHANIE: --it'll be fixed. You should be able to tell. That's the real advantage of the EUA.

SPEAKER 6: Do you guys always have MRI of the pelvis for the local advanced disease, or only for planning?

KARIM CHANIE: If you really have a local-- if you think it's a local advanced disease, I think MRI is helpful for the planning the surgery. But normally, I think CT is as good to see a lymph node metastasis. But if you have issues when you plan what you want to do, I think MRI is much better.

SPEAKER 3: This is nice, Khurshid. You know, when I do this part, I do a lot more mobilization of the vagina, but it's nice to see you do it without needing to do so much.

SPEAKER 4: Yeah, you just kind of try to avoid doing a lot, because you also don't want to--

SPEAKER 3: And it looks like you're locking your stitches every once in a while.

SPEAKER 4: Yeah. You honestly don't need to do the lock.

SPEAKER 1: Is that the bigger needle?

SPEAKER 4: What needle size is this?

SPEAKER 3: I think that's, like, the CT needle.

[INAUDIBLE]

SPEAKER 4: CT1, VS21. Thank you, Andrea.

SPEAKER 3: Yeah. What I do a little bit different here is that I double needle it, and I go in the apex and I run one one way, and then the other one the other way.

SPEAKER 1: Do you do two rounds?

SPEAKER 3: No.

SPEAKER 1: Just one and a half?

SPEAKER 3: Just one, I just--

SPEAKER 4: [INAUDIBLE] he runs the other side, too.

SPEAKER 3: Yeah. So I just interlock the two sutures together and I just run one from each side.

SPEAKER 4: Yeah.

[INAUDIBLE]

You know that you lost this.

SPEAKER 3: [INAUDIBLE] joke and you want me to tell [INAUDIBLE]? Not terribly convenient for [INAUDIBLE]. These things always [INAUDIBLE].

SPEAKER 4: Chung?

SPEAKER 1: Yes, sir?

SPEAKER 4: So the yesterday's session, the [INAUDIBLE] session, we kind of discussed a lot of That, So I don't think we need to do that. I think the pathology sessions is probably the key, and if we can take a few of the cases and maybe merge as the two--

SPEAKER 1: Yep.

SPEAKER 4: --so that kind of makes it easy for people to get their board changed, get a little break. But they're going to be all busy at the U anyway.

SPEAKER 1: They want to see the conduit part, or they--

SPEAKER 4: Oh, no. I'm just saying after that.

SPEAKER 1: Yeah. Yeah.

SPEAKER 4: I hope we've made good time this time.

SPEAKER 3: And it depends whether she had spinach the day before. [LAUGHS]

SPEAKER 4: [INAUDIBLE] always in the middle.

SPEAKER 1: You have plenty of time. I think we'll finish before that. Would you guys do anything differently to close a vagina?

SPEAKER 4: I like the clamshell closure more than the-- I like the kind of-- the narrow vaginal cavity is kind of harder to take care of than this. The only thing, you might end up needing [INAUDIBLE] dilated a little bit, but these are nicer, I think.

[INAUDIBLE]

SPEAKER 1: So for those of you watching us online, we encourage you to ask questions either through Twitter or the live broadcast by pressing the Ask a Question button.

[INAUDIBLE]

Do you guys tie knots for that, Velop, or not at all?

SPEAKER 3: No. I just put a LAPRA-TY. I just put a LAPRA-TY, and I'm done.

SPEAKER 2: And what do you use for your neobladder and anastomosis?

SPEAKER 1: Same thing. I use different-- I use a 3.0 V-lock with the SH needle, the V-20. And I don't use the CT needle, the one that Khurshid used yesterday. And I just use V-lock-- I use LAPRA-TYs instead of tying.

[INTERPOSING VOICES]

On the serosal side. So I always make sure I dunk my needle so it's always on the serosal side.

SPEAKER 3: Tying knots. Same thing. Put a clip on it.

PETER WIKLUND: No. Don't put the clip. Actually, just go back in the other direction through one loop.

SPEAKER 3: [INAUDIBLE]

PETER WIKLUND: I [INAUDIBLE] you speed up for anastomosis. Plus, I think it's a little bit brutal, actually. But not very scientific based on my experience.

SPEAKER 2: So what's your robotic-cystectomy status in Japan? How many percentage of those cystectomies are done robotically?

SPEAKER 4: When I was in hospital, almost all cystectomies was done on the robotic system. So far, my university has only 30 cases. But he's more. His university is more. Now many hospitals began to start the robotic cystectomy like that.

SPEAKER 2: And what's the difference just compared to what Dr. Guru did? What's different?

SPEAKER 4: They're mostly the same way. But so far, we-- you know, in a comparaison. In comparaison, it's mostly conduit. So we are now trying to start in the corporeal neobladder now in the current situation.

SPEAKER 2: And how about neoadjuvant chemotherapy? Now how often's that used?

SPEAKER 4: We do. [INAUDIBLE] mostly we do. Three quarter [INAUDIBLE].

KHURSHID GURU: Can I get [INAUDIBLE] my right hand? Probably that stent. It kind of buckles back. No, it's not. OK, hang on. All right, this is zero, right?

SPEAKER 3: [INAUDIBLE]

PETER WIKLUND: [INAUDIBLE] if you want to release the [INAUDIBLE] at this point.

SPEAKER 3: You know what I'll do is I'll [INAUDIBLE] turn the ileum. It's about 15 to 20 centimeters from the [INAUDIBLE] valve. And [INAUDIBLE].

SPEAKER 1: So Chung, one of the things I do here is while I'm doing the bowel work, I just put a little suture, like a 2.0 VICRYL suture. I connect two ureters and hook it up to the sidewall so I don't have to put a little Hem-o-lok on it just to keep it out of the way, and I don't have to go looking for it later. I'd like to see what Khurshid does.

KHURSHID GURU: All right, so we'll see. They'll just sit. OK. Agreed? Ileocecal valve?

SPEAKER 2: Yeah.

SPEAKER 3: It's hard to see him because it's all [INAUDIBLE]. But if you [INAUDIBLE]

KHURSHID GURU: OK, Will. Go for it.

SPEAKER 2: He's using Keith needle to kind of put it up. How do you guys do that? Dr. Wiklund, how do you do it?

PETER WIKLUND: So I don't use the Keith needle for this. Khurshid likes to staple from above, I think, so he comes from the right side, with the stapler down, whereas we would staple from the left sides. And you basically don't need to lift it up like this. But this is more like a preference of the surgeon-- how you want to manipulate your intestine, I think.

You, Karem, so how do you?

SPEAKER 1: So what I do is I staple the bowel anastomosis, I put everything back together. And then what I do I put a silk stitch on the sidewall to kind of keep the conduit in place and oriented. But I don't do the Keith needle. It's the same thing.

SPEAKER 2: Your anastomosis is from the left side, right?

SPEAKER 1: Yeah, my anastomosis is on the left side. Although I have to tell you that Khurshid banged right through that anastomosis as in about five minutes yesterday, which is a lot slicker than I could going through the left side.

It's always a little more burdensome to do it. And the reason why I do it is because I want to avoid an extra port. But watching him do it so slick yesterday, I'm kind of jealous.

SPEAKER 2: He's going to make a window here.

SPEAKER 1: Yeah. [INAUDIBLE]

SPEAKER 2: And Dr. Bochner, you mentioned the groove between the terminal ileum and ileocolic.

BERNARD BOCHNER: Yeah. So if he-- Khurshid if you pull back just a tiny bit, right there, so you see two folds.

KHURSHID GURU: Yes. This fold and this fold?

BERNARD BOCHNER: Right. So the distal fold where your hook is on--

KHURSHID GURU: This one?

BERNARD BOCHNER: Yep-- is the little ileocolic artery. And where your graspers are pointing is the terminal SMA branch. And you see the fold of the mesentery in-between-- right there. That's your empty space. That's your free shot. If you go distal along that spot, you run into the-- go distal-- right there-- is your arcade that supplies the two. That's connecting the two vessels. So if you made that incision below--

KHURSHID GURU: [INAUDIBLE]

BERNARD BOCHNER: Yeah. You could go straight up towards where you have your bowel secured. You could ligature, so you make an opening below that arcade. And that would provide that freedom now to be able to-- especially with the neobladder if you're trying to get [INAUDIBLE].

KHURSHID GURU: Great point. I mean, this is really important.

[INTERPOSING VOICES]

SPEAKER 3: Yeah. That [INAUDIBLE] started doing that early on, and so.

SPEAKER 5: You just flipped it up, right?

BERNARD BOCHNER: Yeah. You just pull it 15 centimeters.

SPEAKER 2: It's not [INAUDIBLE].

KHURSHID GURU: It would not work?

BERNARD BOCHNER: You see it [INAUDIBLE] right there.

[INTERPOSING VOICES]

KHURSHID GURU: No, that's not it.

[INTERPOSING VOICES]

Now, when I [INAUDIBLE], a lot of people will think that it-- this is when I say when they were [INAUDIBLE]. You would take that hot scissor. You just run through this.

BERNARD BOCHNER: Right out to the edge of the bowel. Conduit-- this is probably [INAUDIBLE].

KARIM CHANIE: Now, is there a reason why you're doing it this way for conduit and you did it in a different way yesterday for the neobladder?

KHURSHID GURU: To be honest, because here, I kind of use a lot more. And this is something I learned when I was a fellow. They used to do this, open with the hot scissor and just open it up because I don't need a lot of that-- bile opened up the window. Release the puppet.

SPEAKER 3: Release the puppet-- you don't get to say that every day. Release the Kracken.

SPEAKER 2: So he doesn't measure the length. Do you guys measure or not at all-- just eyeball it?

KARIM CHANIE: Well, I do. I have a Penrose drain that I cut to about 12 centimeters. And that Penrose drain is my landmark. I use the same one for my neobladders because 12 centimeters are my limbs.

And so here, I usually go about two Penrose drains proximal to the ileocecal valve. And then for my conduit length, I base it on their obesity. And if they're obese, then I make it about 20 centimeters or 24 centimeters if need be if they're very obese.

But if they're thinner, I leave it about 1 and 1/2 Penrose drains, which is about 18 centimeters because one of the things that you have to remember is that when you do these all intracorporeally, as far as conduits, the natural tendency is for someone to come in after you're all done to just put a Babcock and pull it up. But you have to remember you've got to take the pneumo down. It can definitely evulse it. And so I tend to make it a little bit longer to give me a little bit room, but the pneumo down is the trick.

KHURSHID GURU: Yeah. So the most important in your [INAUDIBLE] is this base. This base had to be wide. If it's not wide, you really messed up. [INAUDIBLE]

You pulled this too hard. That's OK. This is the stoma side anyway. OK.

SPEAKER 2: So Dr. Wiklund, how do you measure the length?

PETER WIKLUND: So I measure the length with the stapler. I know the length of the stapler, and I use that as measurement. I use 15 to 20 centimeters. I think this would be a little bit longer than I would use.

I think it's very important, as Chris is pointing out that the base of the mesentery has to be wide enough because you have to be careful when you staple so that you don't staple-- so that you angle the staple lines towards each other because then the base may be very narrow, and the circulation may not be so good.

I will also staple more superficial. So I only staple maybe like 3 centimeters into the mesentery, which means that I have less issues with circulation in the sense that don't go really deep into. You cannot damage any sort of serious vessels.

KARIM CHANIE: One of the other things is I've noticed that there is a little more kicking on the bowel in anastomosis on a conduit, especially on an obese patient, than you'd get from a neobladder. And so this is usually the time in which I would do what we were talking about yesterday, where you throw away 3 or 4 centimeters of the proximal bowel and anastomosis to kind of get that bowel and anastomosis away from your conduit.

SPEAKER 2: And how do you adjust the length for the obese patient with a very thick abdominal wall, not necessarily the whole body, but mainly the thickness of this much fat? And you have to preserve the supply to the tip of the conduit.

KHURSHID GURU: I use the [INAUDIBLE].

SPEAKER 2: Because if you pull the whole mesentery, it's going to be too bulky. Is there anything, like tricks to do that?

KHURSHID GURU: Use the [INAUDIBLE].

KARIM CHANIE: You almost kind of have to triangulate a little bit. You can't have it as a big-- it can't be a rectangle. So you got to have to almost come at a tip. And if you have to throw away excess mucosa, you do that. Otherwise, there's Turnbull stomas or other things you can do.

KHURSHID GURU: Scissors.

KARIM CHANIE: Yeah. I mean I would routinely do it Turnbull. I'd find the most mobile segment of the bowel. That, to me, is the key. You find that part of the medicine tree that will make its way out. And a lot of times, it's not the end which is tethered. So that's where the Turnbull's end up tending to really be nice because you can really identify where that most mobile segment is.

And then a really obese patient, you're going to check that beforehand and see. The length of the conduit will be longer. And despite that, especially as you get into these patients with BMIs above 40, it is a struggle to be able to get any protruding stone in these folks. And it's difficult.

We've done 50, 60-pound panniculectomies at the time of trying to get these stomas to go in. But it's a real challenge and in the obese patient, which is why, whenever possible, the internal reconstructions on an obese patient is by far the least morbid way to go.

SPEAKER 2: Could you tell us, how are you going to do this ureteroileal anastomosis? And what are the techniques you try to improve recently, since that paper came out?

KHURSHID GURU: What's that?

SPEAKER 2: I said, can you tell us your new techniques for the ureteroileal anastomosis?

KHURSHID GURU: [INAUDIBLE]. Other thing is if you saw the old videos, we used to make a little hole with the hook. And it was a very narrow opening. And I don't think that was good.

And then the second thing was retroperitonization was-- [INAUDIBLE]-- was not, honestly, a good idea. We were not doing it. I want to get the stent out because it's kind of holding this. [INAUDIBLE]

SPEAKER 2: So when I started and tried to select those segments, I use Buckner's exact technique. I just do one side deep, and the other side, discard the segments. So I don't worry about the blood supply, whether it's narrow because one is straight down. The other [INAUDIBLE] that.

So I have less concerns about the base. That's exactly just to pry that open technique to that. I think you're doing the same thing. Yeah.

PETER WIKLUND: So I try to avoid having stents in patients because now, you have possibly a breach where you can have a leakage of cancer cells. But instead, this stent has been in the bladder, where you have tumor cells. And it's open up into the upper tract. And you open the whole thing, so I think that this is oncologically not optimal to do it like this. So I prefer to have all my patients within a nephrostomy tube rather than to have stents.

SPEAKER 1: Have you guys looked at-- I mean, but that's a serious question. And I don't think anybody's done as many robotic cystectomies as Peter and Khurshid. But it'd be nice to look at patients who did develop carcinomatosis of the abdomen. And you get a negative surgical margin-- is it possible that it may be coming from patients having stents in place, opening up the urinary system and potential contamination?

KHURSHID GURU: My question to that is, what are you doing open if you have a stent? Do you take it out?

PETER WIKLUND: No, you should not have a stent in open cystectomies either. It's just that we are maybe more cautious now in robot because the discussion is ongoing, whether we are doing something which is not so good as far as tumor spread is concerned. But I think the same principle should be for open surgery.

KARIM CHANIE: Yeah. in the randomized study, I can tell you that the patients that ended up with peritoneal carcinomatosis or disease at the stoma site, an unusual abdominal pattern of spread, none of them actually had stents pre-op.

KHURSHID GURU: None of them had stents?

KARIM CHANIE: No. No.

KHURSHID GURU: OK, so that kind of proves--

KARIM CHANIE: But I think Peter's point is absolutely valid in that-- consequences may be different depending upon whether open or robotic for this type, when urine may leak. And I think your suggestion is excellent, particularly for these types of patients awaiting stents potentially could be very important. I think that's a very important point.

KHURSHID GURU: So not putting stents and just leaving nephrostomies?

KARIM CHANIE: I think so because of the potential. You know, what we need to do is get multiple big series, where we see no problems. And then we can begin to readjust. But I think that, at least theoretically, we think we know, whether it's transacting nodes or potentially having some sort of opening in the system. This is part of the plan that we need as a community to figure out how to avoid those-- avoid it completely. And I think that eliminating stents is an excellent idea.

KHURSHID GURU: Yeah. Honestly, we haven't done it. And I didn't know, Peter, you were doing that. We don't do that. Maybe we should do that too.

PETER WIKLUND: Yeah. This is something that I discuss every time I see a stent in a cyctectomy case. And I think that you should take the stents off, and you should add nephrostomy tubes.

KHURSHID GURU: [INAUDIBLE] open also?

PETER WIKLUND: Well, I think that's basic principles. You want to have a closed system, basically, where tumor cells are now--

KHURSHID GURU: What do you do when you have no stents, and you had an anastomosing and there's urine?

PETER WIKLUND: Well, if you don't have a stent, you normally don't have a reflux from the bladder up into the uteters. But now, you have a reflux. You have an open-reflux system, basically so that as soon as you increase the pressure in the bladder, you will have the possibility of urine or tumor cells going back the other way.

SPEAKER 2: So typically, what I do is that for the patients--

KHURSHID GURU: We should check this. This is a good idea. But yeah, go ahead, Chung.

SPEAKER 2: Typically, what I do for the patients who came in with a uteral stent placed by [INAUDIBLE] urologist. So what I typically do is that I put a nephrostomy tube, then do cysto and remove the stent, and leave the nephrostomy tube in until the conduit, the surgery's done. And I clamp that nephrostomy tube right after surgery, so they have urine going through there.

KHURSHID GURU: I'll be honest with you. We don't have a lot of-- well, the disease we do is very aggressive. We don't have a lot of carcinomatosis and things in our [INAUDIBLE].

PETER WIKLUND: No, but the issue is that this is such a rare event, so you should try to do everything to prevent it, basically.

KHURSHID GURU: Yeah. No, I agree. I get it. That's why I'm saying that we should do it. But what I want to see is maybe look at this.

KARIM CHANIE: Hey Khurshid, I noticed you're doing a Wallace. Is there a reason why you didn't just use the staple line to do the Wallace in anastomosis?

KHURSHID GURU: I like to keep it higher because of blood supply. I almost like to go a little bit more higher up because I feel it's more fresher.

SPEAKER 2: So you always remove the staple line for the Wallace?

PETER WIKLUND: So I would leave the distal staple, yes. And we have not seen any stone formation.

KHURSHID GURU: No. That's not [INAUDIBLE] done years with this. And I know a lot of-- I think Karim's point was more of like, it's more convenient. You just take the staple line up and hook it up.

KARIM CHANIE: Yeah. And it also gives you a little bit more length on the Rosebud. So if you get your ureters further down, there under less tension. And so that's why I also do it.

PETER WIKLUND: But when I do it, Wallace plate in a conduit. I would remove the stapler. It's not because I think it's dangerous to have them there. I think it's easier to stick the Wallace plate on the end of the intestines. But when I do a neobladder, I would leave the same staple line because then-- a distal staple line would be still there in the neobladder. And I haven't seen stone formation from that.

KHURSHID GURU: Oh, you leave the distal-- wow.

PETER WIKLUND: Yeah. When you staple your neobladder, there would be two-step-- one proximal, which is the shim which then you resect. But then the distal staple line actually sits in then neobladder.

But I think that if it's just one short staple line, that doesn't seem to be a problem. But if I did a few neobladders in the beginning where I stapled the neobladder. And there is a series from Italy, from Rome, also where they staple neobladders. And I'm brought up in Sweden doing a lot of [INAUDIBLE] works. So I know that if you have a lot of staples, you will have stone formation, so you should avoid that. But I think that maybe a few staples don't create an issue.

KHURSHID GURU: The [INAUDIBLE] guys never allowed you to leave a staple line.

PETER WIKLUND: But they also did [INAUDIBLE] at some points.

KHURSHID GURU: Oh, yeah. They work with him. They're scared of staples all the time. Yeah. I think it's for that reason-- and maybe I'm the last generation to grow up with a Kock pouch exposure as well. And I'd do anything to avoid staples in any urinary reservoir. But it's largely because of that experience.

[INTERPOSING VOICES]

PETER WIKLUND: So I would do [INAUDIBLE] see the patient the first time. And I see that there's a stem.

KARIM CHANIE" Yeah. I noticed that early in my experience, I was so frightened of stones at the staple line that I would not only cut the staples out, then I would do this Parker-Kerr like closure just because of this fear that your afferent limb's going to leak, and I mean that adds a lot of time to the operation. If you don't have to cut a staple line, that easily shaves 10, 15 minutes of unnecessary sewing.

KHURSHID GURU: I'm scared of those staple stones, man. Here, take this. OK, you can give it to me. I just want to [INAUDIBLE] that clip. Can I have a scissor?

So I have a question for the panel. I always want to asked this question-- especially, a lot of people that have done both robo and open. And I always feel this question is important to be answered when people have done both. So if I did this open, and I was doing a ureter when I was a resident, a lot of times, people feel that, oh, you know what-- maybe you're manipulating the ureter too much, or you're holding the ureter too much.

I [INAUDIBLE] it's somewhat magnified that you kind of are-- and this is more from my learning and getting better-- you don't have any choice but to hold some part of it, where you can-- and if you took a-- I did this for a lymph-node dissection, where you take an open [INAUDIBLE] lymph-node dissection. This is way back when we had that controversy.

And I compared it to my lymph-node dissection. Then we did similar steps, and we matched the videos. And we almost learned the same thing that Bernie was saying yesterday about, what [INAUDIBLE]-- what you see in magnification is different. Down toward the robotics, kind of get a mathematical equation of reducing the size and matching this. You basically are almost manipulating tissue or holding tissue.

Similar, we are less because you kind of have that edge, but you can never do this with open. But you could hold the edge of the ureter, for example. I want to take everybody's input on that one because it's kind of a learning point. I always want to-- [INAUDIBLE]. For example, here, how would you suction him?

PETER WIKLUND: So normally, what I do is I have a clip with the suture in my ureter still there, lifting the ureter up, which means that you very often don't need to touch the ureter because the ureter's attached to the grasp, or the, clip or the structure on the clip is attached to the grasper, so you can actually do this. And that's also why I like the RB-1 needle here, which is very sharp. It's not the cutting needle, but it's very, very sharp. It's just easier to push it through.

Most of the ureters now. We're not actually touching it. But now, you see you don't have any support of your upper part of the ureter here. I have better support, I think, because I pulled the ureter up a little bit.

KHURSHID GURU: That's why I asked the question. I wanted to learn what people do differently.

KARIM CHANIE: Yeah. So exactly. So when I bring that left ureter underneath to the right, and I secure those two ureters together to the side wall-- I put a helomolog clip-- and when I cut it at the sidewall, that clip and suture-- they're perfectly aligned as far as the length. And then when you spatulate it, you end up running it like you are with the Wallace.

I noticed that you kind of cut your suture. I mean you cut your tail. I would've probably left the tail long and had something to hold on to.

KHURSHID GURU: Yeah. Yeah. That's a good point. But my thing is even if you are holding with the suture-- so let's say you still have to add that much trauma. But the trauma is not that much unless you're manhandling the ureter.

BERNARD BOCHNER: I think that over the years, the no-crush technique-- not so much a no touch, but no-crush technique is really accepted as probably best practice. And so stay stitches rather than grabbing the tissues or the periurethral tissues.

These tips are surviving on those periadventitial blood vessels, which are coming down from above. And they're small, and we don't know exactly where they are. But I guarantee you that they're easily damaged. And I do think that that may be contributing the stenotic rate.

So putting stays in, as Khurshid said, whether you leave the end of that suture line. Or as Peter would have a separate stitch, I would have a separate stitch typically. I mean I think just getting into the habit of just not grabbing the tissues when possible is would be considered probably best technique.

KHURSHID GURU: Yeah. No. No. That's why I wanted to ask this question. [INAUDIBLE] looking for that end.

KARIM CHANIE: Yeah, I noticed.

KHURSHID GURU: I set myself up for a problem.

KARIM CHANIE: I noticed your Wallace is not that big. I tend to be a lot more. Generous and I don't know whether I'm doing it right or wrong, so it's nice to see what other people do. Mine tends to be a little longer because I'm always fearful that the longer it is, the lower the stricture rate. I don't know whether that's true or not.

KHURSHID GURU: Maybe. No, you're right.

PETER WIKLUND: I will also do a longer Wallace. But I mean, if you have a stricture, it's actually at the part which is-- whether you're [INAUDIBLE] anyhow. So maybe it doesn't really matter. But I would do it longer, actually.

KARIM CHANIE: Yeah, I do it longer. The other reason is that it's easier to sew. And in order to get it to the butt end of the conduit, where I cut out the staple line, you need a fair amount of length to get it down there.

KHURSHID GURU: Good points.

SPEAKER 2: Yeah, I still do the Brickers. I'm just wondering from the panel members, did you try them both, and then you found Wallace is better or quicker, or what's the experience?

PETER WIKLUND: So I tried both, both in open and robot. And I started with Wallace in open, and then went to breaker open. But my stricture rate increased, so then I went to Wallace again. And when I did go to the robot, then I continued with Wallace. But at one time, a lot of people were doing Bricker, and I thought maybe it's faster to do a Bricker. So then I did some Brickers But also, in my hands, I have the highest reach rate for Brickers. But that's my technique. I don't know whether-- because when you actually study this in the literature, it doesn't really seem to be a big difference.

KHURSHID GURU: But Peter, if you look at our paper, the majority of our sutures were when we were doing Brickers. I stopped doing Brickers.

BERNARD BOCHNER: Yeah, I think Peter's right, in that the literature actually demonstrates both low and high rates for both techniques. Its variable. And so personally, I've always done Brickers, and I've been happy with the rate. It's been very reliable. And it's been the low mid single digits, and so I've stuck with that. That's why I haven't changed.

And I review the literature to see if things are getting better. The Meince experiments, which is huge over the decades, also used Wallaces pretty routinely. And their numbers were really no better. It's still low, but no better. So that's why I've stuck with what's worked.

KHURSHID GURU: Yeah, no I had those. And when Chung was asking the question, what do you do different, one is I kind of used to cut that opening much smaller for the bile. And now I make it wider. Number two is I kind of went to Wallace. And number three is you don't reduce the stricture rates to zero, but it definitely is half of what we used to have. And the third thing is I retroperitonize a lot. No, I don't need that yet. You think we should put the stent?

KARIM CHANIE: Yeah. I mean, every stricture that I've ever had-- and I've operated on the vast majority of them-- I can tell you that it's never usually a technical thing. It's not like, oh, OK, I crushed it, or it's a focal stricture. It's always an ischemic structure. It's always--

[INTERPOSING VOICES]

KARIM CHANIE: It's like 2 centimeters long. So that's why I think, for me, it's devitalized. But I don't know what it is for others.

KHURSHID GURU: Yeah, no, I'm really open to kind of seeing if there is a better way of doing a stent. That's good form to ask that question.

[INTERPOSING VOICES]

PETER WIKLUND: Yeah, so I think I agree that you should really try to make as short ureter as possible, so that you have--

KHURSHID GURU: I think that's another thing which I kind of honestly was doing wrong. The ureters were longer. See, a lot of things kind of being changed, it's better. They're probably half of what we were. So I just want to make sure there's no bleeding [INAUDIBLE]

SPEAKER 3: [INAUDIBLE]

BERNARD BOCHNER: Move that stricture [INAUDIBLE]

KHURSHID GURU: Right there? [INAUDIBLE] I can see it. OK, let's do this.

[INTERPOSING VOICES]

KARIM CHANIE: [INAUDIBLE] 30? [INAUDIBLE]

SPEAKER 2: Now he's going to put the stents [INAUDIBLE].

BERNARD BOCHNER: He had zero. We [INAUDIBLE] up here. [INAUDIBLE]

[INTERPOSING VOICES]

BERNARD BOCHNER: Short term time dependent outcome.

[INTERPOSING VOICES]

[INAUDIBLE]

SPEAKER 3: Let me tell you, I'm always a little leery about--

[INTERPOSING VOICES]

SPEAKER 2: He's using the suction tip and an 8 French feeding tube. So just wondering, for the panels, how do you put your stents?

PETER WIKLUND: I think this is a good technique. I would prefer not to use the needle driver to grab the bubble all the time. I have more sort of gentle instruments. I will use the bubble grasping instruments, rather than a needle. With the needle, it's a very strong instrument. And if you look here you see on the intestine, every time you touch it with the needle driver, you will have a [INAUDIBLE] damage, almost. So I think that it may be better to have it a little bit less traumatic. But otherwise, the technique to having [INAUDIBLE] is perfect.

SPEAKER 2: And he uses--

[INTERPOSING VOICES]

PETER WIKLUND: So you have to feed the intestine up on the sucker.

SPEAKER 2: Do you use a suction tip as well?

PETER WIKLUND: Yes. Well normally, I don't need to do that when I do them. The way I do my Wallace, actually, I will put the stent through, but then I'll come from the other side and pull the stents through, and then put them up. So that's a little bit backwards. But this is a fine technique. If you do it like this, I think it's fine.

KARIM CHANIE: Yeah, I would have wanted to see Khurshid do the Foley with the 5 cc balloon inflated to see how that looks.

KHURSHID GURU: Oh, yeah. We use it for [INAUDIBLE] So the concept is-- I'll tell you in a second, hang on. Let me just do this.

KARIM CHANIE: Because I use single-j Bander stents for my conduits.

KHURSHID GURU: So the single-j Bander stents cost you how much?

KARIM CHANIE: Oh, I don't know.

KHURSHID GURU: It's probably $120 or $160. Guess how much mine cost?

SPEAKER 2: Cents?

KARIM CHANIE: No, no, it's got to be $5-$10.

KHURSHID GURU: $0.46 per tube.

KARIM CHANIE: Really?

KHURSHID GURU: Yes sir.

KARIM CHANIE: $0.46?

KHURSHID GURU: Yes sir.

KARIM CHANIE: That's cheaper than a chocolate bar.

KHURSHID GURU: Yeah, because you buy them bulk, like 300 of these [INAUDIBLE] feeding tubes.

SPEAKER 2: So Karim, do you use a suction tip to feed the tube as well?

KARIM CHANIE: No. I do what Peter does. I put my stents in up the ureter. And then I re-implant them into--

SPEAKER 2: The other way?

KARIM CHANIE: --into the conduit in a retrograde fashion. What I tend to like about that-- there's a pluses and minuses. The pluses is that you don't get any urine leaking into the abdomen. Your distal staple line is closed. And you reanastomos your ureter. It's really nice. You don't get leakage of anything into the abdomen. The two downsides are that you don't really get the chance to test your anastomosis aggressively. That's one. And two, sometimes your stents curl up in the proximal limb.

KHURSHID GURU: [INAUDIBLE].

KARIM CHANIE: And when you bring it up to the skin, sometimes you don't know which end is which.

[INTERPOSING VOICES]

SPEAKER 2: Now, where do you secure your stents?

KARIM CHANIE: Never. I don't secure my stents.

SPEAKER 2: At all?

KARIM CHANIE: They're single-j's.

KHURSHID GURU: You don't secure your stents, so they just sit there?

KARIM CHANIE: Yeah, they're single-j stents.

SPEAKER 2: Curl.

KARIM CHANIE: Yeah.

SPEAKER 2: And this feeding tube is straight?

[INAUDIBLE]

KHURSHID GURU: I'm having trouble with this instrument. [INAUDIBLE]

KARIM CHANIE: The [INAUDIBLE]

KHURSHID GURU: So how do you keep-- [INAUDIBLE]

KARIM CHANIE: [INAUDIBLE]

SPEAKER 2: So you don't open your staple line on the stoma side?

KARIM CHANIE: I don't. It's actually--

KHURSHID GURU: At the end.

KARIM CHANIE: --until the end. It's actually very secure. You get less tearing, less trauma. It's one of the things we were talking about yesterday, when you close the mesenteric window-- sometimes when you take the stapler through the mesenteric window, that staple line is very strong. So all you need to do is just take a stitch through it. And it's the same thing with--

KHURSHID GURU: But do you leave a long single-j 10?

KARIM CHANIE: Yeah.

KHURSHID GURU: So do you have enough protruding out.

KARIM CHANIE: That's right. Yeah, you have a long single-j, yeah. It's the full length Bander stents, my $120 stents, apparently.

[INTERPOSING VOICES]

SPEAKER 2: --at the end of whatever--

KHURSHID GURU: I thought you knew all this health economics, man.

KARIM CHANIE: You know, honestly, for every-- what is it?-- for every 15 minutes, you're in the operating room that adds $2,000? I don't know.

[INTERPOSING VOICES]

KARIM CHANIE: Yeah, time is money. But yeah, you're right, Khurshid.

KHURSHID GURU: No, you're right. It's just a headache also.

KARIM CHANIE: I know, but you're flying through this. So time is money, and you're definitely saving a lot of time here.

KHURSHID GURU: Well, no, it's kind of--

SPEAKER 3: This is a 8 French tube?

KARIM CHANIE: Yeah, these are 8 French feeding tubes, Khurshid?

KHURSHID GURU: Yeah. The 6 Frenches I've used, they're too small. And the problem with them is when you put the stay suture, it doesn't kind of sit that nice.

KARIM CHANIE: So Bernie, I know you use 8 French feeding tubes. What do you use, Peter?

PETER WIKLUND: So I used single-j stents, actually. I use single-j--

SPEAKER 1: 7 or or 6?

PETER WIKLUND: [INAUDIBLE]. But I pay so much for my robots, I don't think it matters so much.

KARIM CHANIE: Do you use the 7 French or the 6?

PETER WIKLUND: So we use, actually, 6 now, but I'd like to use 7. But we could not order, because there was an issue with financing of the stents.

[LAUGHTER]

[INTERPOSING VOICES]

PETER WIKLUND: This is the Mount Sinai rule. So they have 10 robots, but you cannot buy the proper catheters and stents and so on.

KARIM CHANIE: Yeah, they couldn't afford the 6 French, because they had to pay Peter's salary.

[LAUGHTER]

KHURSHID GURU: OK.

SPEAKER 1: Buy your own stents.

KHURSHID GURU: Now see that [INAUDIBLE]. I don't think I want to comment about that.

SPEAKER 1: (WHISPERING) Oh boy.

KHURSHID GURU: Now what I have been doing just to do a Brickers. And I kind of irrigate it to make sure it's water tight. Then I don't put the stent. It has been fine, like Dr. Bochner mentioned. It works for me.

KARIM CHANIE: So you do an anastomosis and you don't stent it?

KHURSHID GURU: No, I don't.

KARIM CHANIE: Wow, that's brave.

KHURSHID GURU: For a while.

SPEAKER 2: These Memorial guys are pretty brave.

KARIM CHANIE: Yeah.

[INTERPOSING VOICES]

KARIM CHANIE: And you guys were picking on me for not leaving a drain.

SPEAKER 5: So there are some faculty who've been who probably have 40-year experience with doing diversions, and they do not use stents. And that's based on a pretty long experience. We've looked at leak rates, and they're really not significantly greater than the group of us that use stents.

BERNARD BOCHNER: How about stricture rates?

SPEAKER 5: We're not seeing any differences.

BERNARD BOCHNER: So they're 6% as well?

SPEAKER 5: Yeah, actually going to show the-- yeah, it's actually fairly low.

KHURSHID GURU: That's exactly why I did this. [INAUDIBLE]

KARIM CHANIE: Wow.

KHURSHID GURU: One group of attendings always stand together about stenting, so I didn't think it's [INAUDIBLE].

PETER WIKLUND: So do you have the same amount of nephrostomy tubes after surgery? And then obviously, you don't see any increase [INAUDIBLE]? We had one of our faculty in Carnesca did it like that. But he actually had to stop, because there was higher leak rates.