Dr. Jim Hu was the first to take the stage and spoke about tips and tricks in robotic radical prostatectomy. The lecture was about the challenging bladder neck scenario. He started by reviewing the technique of bladder dissection and the importance of the use of traction and counter-traction such as by use of the 4th arm to lift the prostate as soon as you divide the posterior bladder neck mucosa.
He then went on to speak specifically about scenarios in which bladder dissection is challenging, such as when there is a prostatic median lobe or in case of prior transurethral resection of the prostate. He emphasized the importance of releasing the bladder from the prostate laterally and minimizing the use of the cautery as it can disturb the visualization of the anatomic tissue plans. He showed videos of the technique (available online) commenting on these important steps.
The next presenter was. Dr. Ketan Badani. He showed two cases of challenging partial nephrectomies. The first case was an endophytic tumor. He talked about the importance of prior 3D reconstruction to better understand the anatomy and the use of ultrasound transoperatory to identify the tumor and adequate clamping. Then, he showed his technique of excision of the cortex ("skullcap" technique) above the tumor to better identify the tumor margins, which improves the understanding of the deepness of the tumor. He states that this is important because depending on the deepness a radical nephrectomy might be more suitable for some cases. Also, the excision of the cortex allowed for better visualization during the renorrhaphy.
The second case was a 6.3cm vs 4.9cm partially endophytic renal tumor. He used the same principles, with ultrasound guidance of the margins. In this case, he did the resection of the tumor but after the resection, he identified that he went too deep into the renal hilum. He chose to present this case to emphasize that sometimes a partial nephrectomy may not be the procedure most suitable for the patient and this decision might be taken intraoperatory – as, in this case, he chose to convert to radical nephrectomy. The viability of the remaining kidney, as well as the margins, should be taken into consideration, and he stated that it is important to offer patients partial nephrectomy but there should be any resistance to convert to radical nephrectomy in cases in which a partial excision might not be the best option for the patient.
Lastly, Dr. Ashok Hemal took the stage to speak about robotic ureteral surgery. He started his lecture speaking about the guidelines of upper tract urothelial cancer and the presentation, diagnosis, evaluation and choice of treatment for these patients. He then proceeds to present three videos of surgeries in which preservation of the kidney was indicated.
He talked about the importance of early clamping of the ureter above and below the tumor to avoid spillage. After the dissection of the ureter, a circumferential dissection of the ureterovesical junction was performed and a stay suture was placed to facilitate the later anastomosis. He also showed a tip on avoiding bladder urine spillage by using suction through the Foley catheter. Later, he talked about the importance of using a frozen section when performing kidney-sparing surgery for upper tract urothelial cancer. Another tip was regarding the mobilization of the ureter which can diminish tension and facilitate anastomosis. In his last video, he showed a case in which direct anastomosis was not possible, to emphasize the importance of having in the surgical plan the possibility of using some tissue to perform the ureteroplasty – in his case, he elected to use small bowel. He finished the lecture by talking about the concepts of kidney-sparing ureteral cancer surgery and his conclusion.
Presented by:
- Moderator – Dr. Raju Thomas, MD, FACS, FRCS, MHA, Tulane University School of Medicine
- Panelist – Dr. Jim Hu, MD, MPH, Weill Cornell Medicine
- Panelist – Dr. Ketan Badani, MD, Mount Sinai Hospital
- Panelist – Dr. Ashok Hemal, MD, Mch, FACS, FRCS (GI), Wake Forest Baptist Medical School and Medical Center
Written by: Antônio Rebello Horta Görgen, MD, Research Fellow, Department of Urology, University of California Irvine, @antoniogorgen on Twitter during the 39th World Congress of Endo urology and Uro-Technology (WCET), Oct 1 - 4, 2022, San Diego, California.