Surgeons: Kristen Greene and David Duchene

Moderator: Lee Richstone

Discussant: Benjamin Chung


Kristen Greene

Kirsten Greene, MD, MS, FACS received her undergraduate training from the University of Virginia where she obtained a degree in Interdisciplinary Studies on full academic scholarship. She received her MD from the Johns Hopkins University School of Medicine in May 2000. She then completed her general surgery and urology training at the University of California, San Francisco. Kirsten combined her interest in urologic oncology, minimally invasive surgery and outcomes research by completing a master's degree in clinical research at the University of California, San Francisco in 2008. She specializes in urologic cancers and minimally invasive surgery. Kirsten was Chief of Urology at the SFVA and Professor and Vice Chair, Associate Chair in the Department of Urology at UCSF until 2019. In 2019, she became Chair of the University of Virginia Department of Urology and holds the Paul Mellon Endowed Chair in Urology. She became Associate Chief Medical Officer for UVA Health in 2020.  Her research interests include minimally invasive surgery, novel imaging technologies in prostate cancer, resident and physician well-being and burnout, and outcomes in bladder, kidney and prostate cancer. She lives in Charlottesville with her husband her three spoiled Labrador retrievers named Fletch, Bella and Sully.

David A. Duchene, MD, FACS

Dr. David A. Duchene is an Associate Professor of Urology at the University of Kansas Health System and the Director of Minimally-Invasive Urological Surgery.  He previously completed urology residency training at the University of Texas Southwestern Medical Center and then finished an Endourological Society fellowship at the University of Iowa Hospitals and Clinics.
Dr. Duchene is a graduate of the American Urological Association Leadership Program Class of 2014-2015.   He is the Kansas representative to the Board of Directors of the South Central Section of the AUA.  He is the South Central Section member on the Health Policy Committee of the AUA.  He also serves on the New Technologies and Imaging Committee of the AUA.  Dr. Duchene participates on the AACU UROPAC Board on behalf of the South Central Section. 
Dr. Duchene is a past-president of the Kansas Urological Society.  He enjoys being a section editor for “New Technologies in Endourology” Section of the Journal of Endourology.  Dr. Duchene has written several peer-reviewed journal articles and text book chapters in the field of urology and serves as a reviewer for multiple publications, including the Journal of Urology, Urology, and the Journal of Endourology.  

Lee Richstone

Lee Richstone, MD is the Chairman of Urology and Director of Laparoscopic and Robotic Surgery at Lenox Hill Hospital. He is also the Director of Urology for Northwell Health, Western Region. Dr. Richstone is full Professor of Urology at The Hofstra-Northwell School of Medicine. Dr. Richstone completed medical school at the Cornell University Medical College in New York City. There he won early acceptance into Alpha Omega Alpha (AOA), the prestigious national medical honor society. He pursued his urologic training and chief residency at New York Presbyterian (Weill-Cornell) and Memorial Sloan Kettering hospitals. Dr. Richstone completed his fellowship training in Endourology, Laparoscopic and Robotic surgery with Dr. Louis R. Kavoussi.   Dr Richstone has over 100 peer-reviewed publications in leading national and international journals including The Journal of Urology, Urology, The British Journal of Urology, The Journal of Endourology, Cancer, and Cell. Dr. Richstone is a member of the Society of Urologic Oncology (SUO), the America Urological Association (AUA), and the Endourological Society (EUS). Dr. Richstone is the recipient of numerous honors and awards, including acceptance into Alpha Omega Alpha (AOA), the E. Darracott Vaughan Prize for Excellence in Urology (2000), The Ferdinand C. Valentine Urology Essay Prize (First Place, 2005), The American Urological Association-Ambrose Reed Socioeconomic Essay Contest (First Place, 2005), and the Weill-Cornell Distinguished House Officer Award (2005). Dr. Richstone was awarded the Stryker and Nagamatsu Fellowship (2007), and won first prize at the Endourology Society Fellowship Paper Award the same year. Dr. Richstone won first prize at the AUA Research Foundation for Outstanding Research awarded at the 2010 AUA National Meeting in San Francisco. 

Benjamin Chung

Benjamin I. Chung, MD is Associate Professor of Urology at the Stanford University School of Medicine and a Urologic Oncologist specializing in the treatment of prostate and kidney cancer. As Director of Robotic Surgery at Stanford, he has one of the largest robotic surgical experiences in California and has been elected both to Castle Connolly Top Doctors and Best Doctors in San Francisco. He is a graduate of Amherst College and Sidney Kimmel Medical College at Thomas Jefferson University and completed his residency training at the Lahey Clinic and continued on in fellowship training in minimally invasive urologic surgery at the Cleveland Clinic. He also has a Masters degree in Epidemiology from Stanford. Dr. Chung's research has garnered international recognition and focuses upon robotic surgical adoption and “big data” outcomes projects designed to improve outcomes of surgical management of urologic cancers and in better understanding the causative factors in the formation of these malignancies to allow for future preventative action.

 

Webinar Transcript

Dr. Ash Tewari:

Welcome today to this exciting event which is sponsored by Endourology Society and Society of Urological Robotic Surgeons, Masterclass in Endourology and Robotics, which is going to highlight an important topic which will help robotic surgeons in handling a complex case like a robotic radical nephrectomy. Endourology Society wants to thank our sponsors ConMed and Intuitive who have given substantial grants to help us organize this event, which is of a tremendous educational value. Today's topic is Robotic Radical Nephrectomy: Troubleshooting & Difficult Cases, and this program is being run in a very structured way.

Dr. Ash Tewari:

The key person managing this is Dr. Lee Richstone, who will be the moderator and will introduce everyone else who is in the panel. Dr. Lee Richstone is a professor and chair at Lenox Hill Hospital, part of an institution right here in New York City. Dr Lee Richstone has gone to Weill-Cornell for his residency, he did his fellowship with Dr. Kavoussi. He has published over 100 manuscripts, he has won many awards, and he happens to be very close to all of us in this program. Dr. Lee Richstone is an gifted robotic surgeon and he will now run the show for the Robotic Radical Nephrectomy: Troubleshooting & Difficult Cases. Lee, this is your panel, please go and highlight.

Dr. Lee Richstone:

Thank you, Ash, for that kind introduction. It's really an honor to be here as part of this activity. Thank you, Ash, for all that you've taught me over the years in robotic surgery, and I'm excited to be here and congratulations on this wonderful program it's really an amazing activity with the great attendance and it's so valuable to all of us, so thank you. So, welcome to the Masterclass in Robotic Radical Nephrectomy looking at Troubleshooting & Difficult Cases. I'm the Lee Richstone and it's my pleasure to introduce our esteemed panel.

Dr. Lee Richstone:

Dr. David Duchene will be presenting first. David is an Associate Professor of Urology at the University of Kansas Health System and Director of Minimally-Invasive Urological Surgery. He trained first at the UT Southwestern campus and finished his Endourological Society fellowship at the University of Iowa Hospital and Clinics. Dr. Duchene is the Kansas representative to the Board of Directors of the South Central Section. He is on the Health Policy Committee of the AUA, the New Technology and Imaging Committee of the AUA, and has made a lot of contributions to our MIS field. He's the past president, as well, of the Kansas Urological Society and the Section Editor for New Technologies in Endourology for the Journal of Endourology, so we welcome Dr new Shane and his expertise.

Dr. Lee Richstone:

Next, we'll have Dr. Kirsten Greene. Kirsten did her medical degree at Johns Hopkins, she then went to UCSF in San Francisco for her residency. She obtained a master's degree in clinical research, also at UCSF, where she joined the faculty. Was the Associate Chair of the Department there before becoming, in 2019, the Chair of the University of Virginia Departments of Urology. She has an endowed chair there and she's also the Associate Chief Medical Officer for UVA health. So, we welcome Dr. Greene.

Dr. Lee Richstone:

And we also from the West Coast are privileged to have Dr. Benjamin Chung, completed his residency at the Lahey Clinic, before doing his fellowship in MIS surgery also at the Cleveland Clinic. He got a master's degree in epidemiology at Stanford where he currently is an associate professor, he is specializing in prostate and kidney cancer and he's the Director of Robotic Surgery at Stanford.

Dr. Lee Richstone:

So, we will begin our presentation looking at some of the potential advantages to robotic radical nephrectomy, we will look at some technical tips for success, difficult cases and challenges. We'll also make an argument against robotic nephrectomy, trying to balance laparoscopy and robotics. As a disciple of Louis Kavoussi and a lover of straight lap, it'll be my pleasure to bring that to the table, and then we'll also look forward to some Q&A. And I'm going to hand it over to Dr. Duchene who's going to begin with the technical aspects of the procedure, tips and tricks, and the potential advantages of robotics for radical nephrectomy. Dr. Duchene.

Dr. David Duchene:

Excellent. Well, thank you Dr. Richstone. I'd also like to thank the Endourological Society and the Society of Robotic Surgery for allowing me to give this talk, that includes Dr. Tewari and Dr. Badani. Again, I'm David Duchene, I have no disclosures. I'm at the University of Kansas Health System. I'm going to go over some troubleshooting and difficult cases, but really, I'm going to set the stage for what a robotic nephrectomy should look like and why we do robotic nephrectomies in certain cases instead of a laparoscopic nephrectomy. So, I will cover the advantages, I'll also go over some trends in the use of robotics for extirpative procedures, go over some positioning and poor placement. I do have a quick case presentation of just a standard robotic nephrectomy in an obese patient. During that time I'll go over some tips and tricks, and then do my conclusions.

Dr. David Duchene:

So, why robotic instead of laparoscopic? We're all well-trained laparoscopic surgeons, I love a laparoscopic nephrectomy, so why would I switch from laparoscopic to robotic or what type of cases would I want to do a robotic case instead of a laparoscopic case? And I was really a non-believer in robotic nephrectomy for a long time, I've actually been won over where I do the majority of my nephrectomies now robotically, but I can still do them laparoscopically. I think robotics does give you advantage of better visualization, both with 3D visualization and the cameras tend to be better than our laparoscopic cameras here at the University of Kansas, anyways.

Dr. David Duchene:

You do have a better array of instrumentation, you have better control for hilar dissection. You have the robotic stapler technology which, I think, has been a key and my switch to robotics. I'll go over that some more later. You have the ability to control the fourth arm for independent retraction and take your assistant a little bit out of the picture. And it really has allowed for greater utilization of minimally invasive surgery for nephrectomies. And as a last point, not just in an academic centers but just in everyone that does laparoscopic surgery, a lot of people weren't doing pure laparoscopic nephrectomies and have switched and are now doing robotic nephrectomies.

Dr. David Duchene:

Here's a large multi-institutional study of robotic surgery for large renal masses group, which shows at their institutions, their laparoscopic approach has declined as a robotic approach to again radical nephrectomies we're talking about has increased. And you can see in the first quarter in 2016 those lines crossed to where they were doing more robotic surgery than laparoscopic surgery. Intuitive's own data in 2018 suggested a third of their market share was involved in radical nephrectomies, so a third of all nephrectomies done in the US were done robotically. Again, that was done in 2018.

Dr. David Duchene:

What cases do I think are well-suited for a robotic nephrectomy? Well, those with central or hilar masses which are not amenable to a partial nephrectomy. Morbid obesity, I think, is easier with a robotic approach. An XGP kidney where the hilum dissection is very difficult. Surgery with concomitant procedures; if your general surgeon was going to do a ventral hernia repair, or other kind of organ removal, they often like to use the robotic approach at this time. And then a nephroureterectomy; that's not really what we're talking about today, but with that bladder cuff closure.

Dr. David Duchene:

I also think difficult hilar anatomy, anatomic variants like a pelvic kidney or horseshoe kidney, and the need for extensive retroperitoneal lymph node dissection. Any renal vein or IVC tumor thrombus involvement, and really anything that you're going to need to suture or reconstruct vessels would be nice to be done robotically. And here, that same multi-institutional group of the robotic surgery of large renal masses show that that's been the trend, in the United States anyways, where they favor a robotic approach if there's a hilar tumor, if it's metastatic disease, or if it's pathological T3 or 4. So again, most likely with hilar adenopathy or a more difficult dissection.

Dr. David Duchene:

Some of the disadvantages, of course, is the cost; there's really no way to mark it up and if you have to buy the robot to say it's any less expensive, I think laparoscopic is less expensive than robotic. You're not at the bedside in some of these difficult cases, if you do need to convert to an open approach. I think in robotics I'll go through where you have a linear port placement, you don't do the traditional triangulation of a laparoscopic case and it does sometimes make lateral retraction more difficult. You often do end up using one or two more additional trocars in a robotic approach, and it often results in overall longer OR time when you take into account the robotic setup and the docking needed.

Dr. David Duchene:

Positioning is just like a laparoscopic procedure. The modified lateral position with a break in the table, arms usually out. I use arm boards, as you can see in this picture, I had my patient's arms on arm boards. Some people will place the arm laterally along the body side, either one is acceptable. I do like to have a flex in the table, and I use a beanbag to secure them in that position. Port Placement. I'm going to go over for the Xi robotic platform, anyways. The robotic arms should be in the midclavicular line. That's pretty consistent line if you have an obese patient or a skinny patient.

Dr. David Duchene:

They do need, ideally, 8 cm of separation if possible, but often that's not the case if you have tried to put all four ports in. In difficult cases I use two assistant ports, otherwise I just use one, but I use a 5 mm assistant up high and then a 12 mm Airseal port for my insufflation. And I actually don't initially place the fourth arm in all these cases, but I do always have it available. And this is just a schematic of those port placements. Again, you really want to linear port placement with the Xi robot. You don't want to stagger those ports, robot's actually designed to be docked in a linear position, so you avoid arm clashing.

Dr. David Duchene:

I'll put my 12 mm port down low near the umbilicus, and then my 5 mm port up higher. If you have real thin patient, which is rare, sometimes in order to get those ports all the way spaced appropriately so we can get that fourth port in, I will stagger them and bring the robot in slightly above the shoulder. Here's my port placement for the case I will discuss. Again, I just have the three robotic ports to start with; a 5 mm port and the 12 mm Airseal port.

Dr. David Duchene:

This is an obese patient with an 8 cm central mass who elects for radical nephrectomy, and again my choice here for robotics as opposed to laparoscopic is due to obesity and the need for the hilar dissection. Here's the mass. You can see a large central mass not really minimal to a partial nephrectomy. Some of the tricks I'll go through, especially in an obese patient, we get a lot of perinephric fat that pushes you medially. It is just identifying the gonadal vein is the first step, we're on the left side here. A lot of times my residents will think this is the gonadal vein down here but that's actually the mesenteric vein. We've just been pushed medially by this fat, you can see that gonadal vein is going to be actually hid up here in this fatty tissue, and we'll just uncover it at that point.

Dr. David Duchene:

Next, we'll find the psoas muscle and the ureter. This patient had multiple kidney stone surgeries in the past, and has kind of an inflammatory rind around her ureter, it's a little tough to see, the ureter's right above me though. I'm just freeing this up, doing this very nicely, and then the psoas muscle is right back here. We'll get on that psoas muscle and sweep this all together. A lot of times you'll find these adhesions and flimsy tissue, especially in an XGP kidney or somebody who's had prior stone surgery or infections.

Dr. David Duchene:

I just wanted to demonstrate here, again, because of that perinephric fat, it pushes us medially, as we kind of free up the upper pole the kidney. In this case, the splenic vessels are very close. I have had people mistake these for the renal vessels but those with splenic vessels, pancreas is right here, everything is just pushed medially in those obese patients with a lot of fat. As we get up to the hilum, I usually leave the gonadal vein intact, especially in males where if you take the gonadal vein, they occasionally will get testicular pain. But in this case, I did choose to clip the gonadal vein.

Dr. David Duchene:

Because of this fatty tissue surrounding the hilum, I couldn't get real good visualization posterior to the vein to find that artery, so I did clip the gonadal vessels. And you don't necessarily need to clip them, you can use bipolar electrocautery or any type of energy to divide that gonadal vein before you continue. After I do the division of the gonadal vein, I do like to clear up above the renal vein. You can see the adrenal vein is right here, we're going to spare the adrenal gland in this patient. So, I'm going to leave that adrenal vein intact, but clear up above the hilum. In that case, in an emergency or the need to quickly clamp, you have a space there where you can put a staple load in or a Satinsky clamp.

Dr. David Duchene:

This next video's just demonstrating how you want to use two hands to operate. So again, one of the other advantages of a robotic approach is you can use both hands. In this case, I actually have my assistant pulling up here on the side, but this is also where I would put the fourth arm in and use that fourth arm to really retract all that fat laterally, lift that out to the side and again dissect free with two arms, as I'm freeing up the artery here just getting a space there for the stapler. I do like to take the artery and the vein separately; you definitely can take them in block. But again, I think, with the nice dissection of a robotic approach, it is something that you can take individually.

Dr. David Duchene:

The robotic stapler's the next thing I'll show here. Again, I'm not a salesperson for Intuitive but I do enjoy the robotic stapler. I think they have done a great job with the technology; it does have feedback so that it will tell you if you have too much tissue grasp or not, let you know if you have to readjust. And it really it sets down a nice stable line, occludes those vessels nicely. So, I'll put my stapler on the artery there. I do always back my camera up, make sure that this is the renal artery, that I'm not anywhere else. I ask my anesthesiologist, make sure they're not having blood pressure changes, make sure I'm not side-biting the aorta, especially in those cases with a lot of hilar adenopathy where you're unclear where you're at. And then we'll fire that staple load, and you can see it's a nice, clean staple line.

Dr. David Duchene:

The vein, the same way; we'll take the vein separately. I have the vein clamped here, it's above my clip so I don't get that clip in the staple line. And I'm just checking to make sure everything looks good before I fire that staple load, the stapler go down nicely. And, again, really no fear that there's going to be any bleeding after I come off the staple line. Again, sometimes, this is more difficult in really inflammatory cases. But again, that's where I think the robotic stapler does a nice job of giving you that feedback of maybe you got too much tissue or tissue that's not going to be stapled adequately.

Dr. David Duchene:

In the end, you'll see the hilum is nicely stapled. We're right on the aorta there, we're freeing up this tissue. Some small neural tissue in there, but nothing major that we'd have to take out in this case. We will adrenal spare; I wish there was some good trick for these obese patients of finding that plane, but again you want to keep some fat on the adrenal gland, some on the kidney, but you don't want to find that plane right next to the kidney because this is an oncologic surgery, we want to put some fat on the kidney as we free up that plane.

Dr. David Duchene:

You always will run into these small adrenal veins and adrenal arteries, they're easily bipolarable. In these cases, I do just use a bipolar and a scissor for the whole case. Obviously, you can use the vessel sealing device or other instruments that the robot has available. I just prefer the Bipolar and the Scissors. And again, here we're just showing some of these veins that you can encounter as you come up through this superior fat. You can see the spleen back here in the background.

Dr. David Duchene:

Again, the spleen as well away in this case. In some other cases, where the spleen may be involved either by tumor or by inflammation, I think the robot helps coming up around that spleen. If you get a few capsular rents, it's not bleeding too bad, you can leave those alone or sometimes try to bipolar them or put a little Surgicel down. Obviously, if you get bigger rents in the spleen, you'd have to take the spleen out. Again, that's something that you can very easily do robotically; the robot has plenty of reach to get up around the spleen.

Dr. David Duchene:

Then everybody's favorite part of the case here at the end, we're just on the psoas muscles sweeping all this tissue off. Very nicely free up the kidney, and again, this is where it's kind of the bread and butter; you've already gotten the kidney out, you've gotten all the key parts, and you can just have a quick run going up to the psoas muscle. And then the end, you get out this kidney, you can see all the fat around that. And a lot of times when you're looking at these smaller windows you lose appreciation for how big these kidneys are, how much that perinephric fat adds around that kidney. In this case it would not fit in an Endo Catch bag, so I just made an incision and took it out without placing it in a bag first.

Dr. David Duchene:

So, that was my short video there of how a standard robotic nephrectomy would go. And again, why robotic nephrectomy? My conclusions; again, better visualization with the 3D view. It facilitates a hilar dissection, you have better range of motion, you have that fine dissection ability to really free up that artery and vein separately. You have that ability to use the fourth arm. If you use that fourth arm you have a lot less reliance on the assistant. And of course, you can put your own hem-o-lok clips on with the robotic instruments also. That involves a robotic technology, in this case I love to use their stapler, and it does increase the cases of minimal to minimally-invasive surgery, not just in my hands but nationwide.

Dr. David Duchene:

Some tips, just brief tips. Again, it's a linear robotic trocar placement, I see a lot of people have a difficulty time placing the trocar so they can use them throughout the case. Even in these tough cases with big, hilar adenopathy, renal vein involvement, the like, you just have to remember; always use your key landmarks and anatomy, make sure you know where you're at, what you need to find. Use that fourth arm for retraction, work with both working arms, and feel free to use additional system ports. Thank you.

Dr. Lee Richstone:

Thank you so much, David. We do have one question that just popped up. That was a really nice job walking us through the rationale for the use of the robotic system for this operation, and also walking us through the technical steps and some potential pitfalls and how to approach this. Jack Barkin asked the question, "If one is using an Si versus an Xi, any thoughts, David, on the port placement on an SI?"

Dr. David Duchene:

Yeah. I mean, the Si would be a more traditional staggered positioning of the port, so you do tend to drop the robotic camera medially, use your two robotic parts up more laterally, and then put your system ports down more medial than your camera ports. It always makes either an M or a W depending on how you place those assistant ports.

Dr. Lee Richstone:

All right. Great. Well, again, feel free in the audience to ask questions on the Q&A. Most of our Q&A we'll save to the end, but use that rather than the chat. All right. We're going to move on to Dr. Kirsten Greene who's going to share with us some difficult cases and some thoughts on how to approach the unusual difficult challenges that you may face. Dr Greene?

Dr. Kirsten Greene:

Hi there. Thank you so much for having me. I am so excited to be here on Masterclass. I love these and I try to watch them as much as I can, and I know my residents sometimes sneak out of clinic to watch them. So, if you are one of my residents sneaking out of clinic to watch today, good choice. I'm going to build on some of the ideas that Dr. Duchene shared and talk just about case selection because I think if you don't choose the case correctly it always is a difficult case.

Dr. Kirsten Greene:

So, a couple different key points I want to touch upon; tricky hilums, how to manage them, because that's critical. That's the hard part of the case, that's the scary part. How to manage polycystic kidneys, because they can be a unique challenge. The issue of hilar nodes; when are they going to block you and when can you get around them? And then other organ invasion, especially you're thinking about your pancreatic tail, your duodenum, your spleen. And really, which cases can we do robotically and which ones should we not do? So, I have a couple examples.

Dr. Kirsten Greene:

This is a case of a complex hilum and I'm going to say right off the bat this case, to me, didn't look like it was going to be trouble. He is not high BMI, he did have quite a bit of retroperitoneal fat, as I'll show. But the artery, to me, looks like it's right behind the vein, no big deal, a little bit separate. And if you noticed here, it makes almost a little dog-leg going up, but again, this does not look like a tricky case. He does have a lower pul artery and vein, and just full disclosure I was going to do a partial on this case because it was multiple small renal masses, but for the purpose of discussion, think about it as if it were a radical.

Dr. Kirsten Greene:

Have a little video here to show, because the artery is not at all where I thought it was going to be. So, I started out the same way as Dr. Duchene, I free above and below. So, you see this is completely free, I've looked up there for the artery. Now I'm looking behind the gonadal, went medial to see if I could spread and I'm expecting my artery to be right here. Looking there, can't find it; pretty sure it should be right there. I mean, that's where the artery is. Now, see a nice lumbar, think maybe the lumbar's blocking me. Figure maybe if you get the gonadal up, free it just a bit, and again, this is easy to do with the robot. Ultimately, decided to clip the lumbar just for that added retraction because sometimes that really helps.

Dr. Kirsten Greene:

And again, really sure that I'm going to be able to find the artery in this area. He had a very fatty hilum and really bled very easily. For me, this is a pretty bloody field, I like to keep things super dry. I'm looking out laterally, come back here, and at this point in the case, I feel like I think there's the artery right there. I think I see pulsations. What I was discussing at the time was, if this were radical, I think we'd probably just put a stapler in there, fire because we think we see the artery. That's where it should be on the film, so that's where it should be.

Dr. Kirsten Greene:

Now, it was partial, thank goodness, so we didn't do that. Continue dissecting and then after much frustration decide, "Okay, let's go out to the psoas and work our way in." Now this is sped up because, intentionally, you can see the artery beating right there when it's sped up. And this was very lateral out on the psoas. The rest of the lower pul arteries were easy to find down low. And what was challenging for me for this case is I'm going to show you the films again.

Dr. Kirsten Greene:

Again, artery looks like is right here. If this were a radical, it seems like if you're struggling at a fatty hilum and it's bleeding a little bit and it's been a while, you should be able to clear both sides, put the stapler in. Just like Dr. Duchene said, you have a nice robotic stapler, it's going to tell you if you have too much tissue or not, and fire right there, take your vein and go on. Had I done that, I probably would have fired in this fatty space, it would've fired because it wouldn't have been too much tissue, then taken the vein and then I probably would've come through with energy out here either LigaSure or a Vessel Sealer and potentially gotten the artery.

Dr. Kirsten Greene:

And that's why I show this because I think sometimes you have to just take that extra moment, go a little bit more lateral, and work your way in to make sure that you're not missing an artery in an unusual location. Like that artery, it was far more lateral than I expected. So that was, I'd say, a tricky hilum not a complex hilum. I think the second question, really, is when are there too many lymph nodes? And for, me I think about this pure mesenteric artery because as urologic surgeons, the worst thing we can probably do on a radical nephrectomy aside from cutting across the aorta on the left side, would be cutting the SMA. And it's so close with some patients and if there's a lot of lymph nodes, that can be catastrophic. So, when are there too many nodes? I think, "What if the SMA's encased in nodes? What if I can't see the artery at all?" And then, lastly, this is more rare, but when the nodes are invading the wall of the aorta or the vena cava.

Dr. Kirsten Greene:

And so, I'm going to show you a recent case. This is a film that we're just going to run through. Not big of a renal mass, totally a reasonable radical nephrectomy. At this point, we're going to go so I'm going to stop it right here. The SMA just went by, here's right around our hilum. The artery you really can't see, it's actually right there. I'm going to continue to play because you might've just passed it as it went by, but that artery really wasn't visible. And then I'm going to play it again.

Dr. Kirsten Greene:

If you look here on this film, you can almost see how the lymph nodes are starting to indent the wall of the aorta. And so, this case fortunately, was done by one of my partners open. And what they found at the time of surgery was they could not identify the artery, but more importantly, the nodes were actually invading the wall of the aorta. And this was a cytoreductive nephrectomy, and they felt that doing an aortic replacement to get the kidney out just wasn't going to be the right thing to do. So, I wanted to show that because it is a really unusual case to actually have the nodes invading the outside wall of the aorta like that, but it can happen.

Dr. Kirsten Greene:

So, now moving on to adjacent organ injury. This is a case where the renal mass, again not that big, I'm going to show it and stop it a little bit. So not too bad, kind of close to the hilum, right-sided, no vein thrombus, no IVC thrombus. So, again, not an unreasonable radical nephrectomy. The question comes in here, the duodenal invasion, and also the pancreatic head invasion. So, as you take a look, there's really loss of plane here, we see a nice little plane out in this area, but there's really loss of plane here and without broad contact with the duodenum. It just really isn't clear if the duodenum was invaded or not, and certainly at the lower pul, things look reasonable.

Dr. Kirsten Greene:

Now this is a case I was going to do robotically; it turned out one of my partners had earlier time and the patient wanted an earlier surgery, and he approached it open and in fact, the duodenum was not invaded. But I think it's really hard to tell on the scan, and I just show that because sometimes you can't tell. And from my standpoint, I think it's okay to start robotically, and then if you find that the duodenum really can't be peeled off safely, you can always convert to open or you could do a complex repair.

Dr. Kirsten Greene:

So, looking at this next case, this is an XGP kidney and the usual phlegmon back here. But anteriorly, organs are fine, the hilum is fine, it was just really stuck posteriorly. What's interesting in this case is that as we get down low, going to draw your attention to the ureter. The ureteral wall, because there's so much inflammation, is actually plastered right on the duodenum. And so, it doesn't always have to be a renal mass and it doesn't always have to be malignancy. You can see here's the stone but the duodenum was very stuck. One of my partners did this minimally invasively and was able to get the duodenum off, just peel it off carefully and keep it as a minimally-invasive procedure. But just both sides of the organ invasion in point.

Dr. Kirsten Greene:

And then, last topic is polycystic kidneys because I think, certainly for benign cases, it's really great to do these robotically if we can for patients. But there's two key problems that I find. One, the bowel is often pushed against the abdominal wall because there's just no space intraperitoneally. So, when you go to pass that Veress needle, it's scary because you don't want to put it right into the colon. So one way to make additional space is to aspirate the cyst potentially percutaneously, just to get those cysts a little smaller, or to potentially do it intraperitoneally. And so, I have a couple of videos just of this.

Dr. Kirsten Greene:

This is a case I recently did, not very bad polycystic kidney disease. But as you see here, this is the gentleman's colon, and it's right up against the cyst. And so, the hope was maybe when we turned him sideways, that would fall away just a little bit, but in polycystic kidneys, if you can't aspirate percutaneously, which is what I usually like to do if there's a big cyst, you do risk a little bit of injury just with that first Veress needle.

Dr. Kirsten Greene:

And so, what I'm going to show you right here is that's the first look inside. And of course, tiny little poke, not a full thickness injury, just a little serosal poke right there, easily fixed with the robot just throw a couple of silk stitches in, no big deal. And you can see the polycystic kidney right here and this cyst right there. One thing I think is really useful on these polycystic kidneys, when you keep them full, they provide such nice tension to take down the colon. I like cigarette sponges so there'll always be cigarettes sponges in my videos.

Dr. Kirsten Greene:

But at some point, the polycystic kidney just becomes too large and you really can't get under it and you risk having your anatomy distorted. So, this is nicely showing that there's tension, but we really couldn't get under the kidney anymore at this point, so we just chose a good spot, tried to really keep the cyst fluid contained. Aspirated that kidney, that's really satisfying too, I have to say that's a very fun part of the case. And then you just lift up this really big, baggy kidney, leaving the other cyst tense so you have that tension to continue your dissection.

Dr. Kirsten Greene:

Now if you don't have enough hands to do this you don't want to put in another port, another nice trick that I like is if you put a Keith needle percutaneously through the skin, you can just loop through that empty cyst and tack it up to the abdominal wall to give you extra tension without another hand. This I just want to show as we really can't see the pancreas here, and we can't see any of the splenic hilum because the cysts are so big up top.

Dr. Kirsten Greene:

So, we aspirated this cyst which was bigger than we thought it was going to be, and it just sucked right down so nicely. And then all of a sudden, there's your pancreas, that's probably the splenic vein, and it just shows the anatomy a lot better. I do think this is a good thing to do on the left side, especially, because you can get so lost with SMA when the anatomy gets distorted because of these big cysts. So, next time you're doing a polycystic kidney, consider doing this because it does really help quite a bit. It also helps with the extraction.

Dr. Kirsten Greene:

So, my final tips are I think robotic nephrectomy has a huge advantage of easier reconstruction, not only of adjacent organs, maybe of the bowel if there's a problem, certainly of vessels. I think it's a lot easier to see invasion of organs, the duodenum for example, if you're doing it robotically rather than laparoscopically. With the case I showed you, again, not a really complex hilum but just a tricky hilum. If you can't find the artery, maybe look a little laterally, work your way in. Hopefully this will help someone next time you have that problem.

Dr. Kirsten Greene:

For the polycystic kidneys, I think aspirating them percutaneously for the really big ones will save you a bowel injury. Certainly, intraperitoneally can just speed the case along. When you get frustrated, take a breath, suck down a cyst; it's kind of nice, it's kind of fun thing to do, but it does make space for you. And then lastly, sometimes you have to do it open, don't be afraid to convert to open. It doesn't hurt to put in a camera, take a look, do what you can do, and make an open incision if you have to do that. So those are my tips and tricks, and I can't wait to see Dr. Ben Chung's video next.

Dr. Lee Richstone:

All right. Thank you so much, Dr. Greene, a lot of great information there. Just a couple of considerations that I'd throw in there. I think 90-something percent of the time when your radiologist suggests a loss of a plane between the kidney and the liver or the kidney and the duodenum, 90-something percent of the time it's not an issue. It's pretty rare and they call that a lot in my experience, and it's usually not an invasive process. But certainly, obviously, something that you have to be mindful of, particularly of the duodenum because of the grave consequences of injury especially unrecognized.

Dr. Lee Richstone:

I also think you point out well with XGP kidneys, they're kind of more invasive than most cancers, frankly, and it can get very ugly and you have to be extremely careful. I'll point out maybe later on when we're talking briefly about laparoscopy, I find that some of those cases when things are really, really stuck and whatnot, the haptic feedback and the manual aspect of laparoscopy, I find just tremendously helpful. And also, the ability to sweep and dissect; some of these cases, you wind up having to do almost a little bit of carving. I mean, there's this really manual aspect of taking apart some of that tough anatomy sometimes. But I think those are all great points.

Dr. Lee Richstone:

And maybe I'll also ask at the end, just another point of consideration for these huge tumors and especially really big polycystic kidneys, some of the difficulty in retraction and mobilization of these things using the robot and it's another thing I enjoy with laparoscopy. When these things are really big, and I've done a lot of polycystic kidneys, you have to wrestle. You have to move this back and forth and up and down and retract, I mean especially doing bilateral polycystic kidney kidneys, and so we'll talk about that later. But for now, Dr. Chung is going to entertain us by talking about some of the tiger country bleeding that can occur and I think a little bit of talk about thrombi, in terms of challenging cases. So, please Dr. Chung, it's all yours.

Dr. Benjamin Chung:

Thanks for inviting me. I'm honored to be part of such a esteemed group of colleagues and professors. And I think in the same vein and tone with doctors Duchene and Dr. Greene, we're going to talk about situations which might be well-suited to a robotic approach. So, question again, I think as part of this talk is why robotic nephrectomy and my answer is why not robotic radical nephrectomy? And we can go into some of those reasons.

Dr. Benjamin Chung:

As Dr. Duchene showed, there was a recent paper from a multi-institutional study looking at the adoption of robotic radical nephrectomy. I published this paper back in 2017 in JAMA looking at the adoption of robotic radical nephrectomy, not knowing at that time what it would look like. And not surprisingly, it looked very similar to what Dr. Duchene showed. So, the laparoscopic and robotic nephrectomy curves cross around the year 2015 when they both occupy somewhere in the 20-plus, almost 30%, market share of radical nephrectomy in the United States.

Dr. Benjamin Chung:

And at the time, that was quite shocking to me because, although at that time I had been basically a convert to robotic radical nephrectomy, it's not a procedure that, as Dr Richstone has pointed out, is mandatory to do this way. So, what are the reasons? Well, I think doctors Greene and Duchene have really gone into that, but another reason is trying to take on a more complicated case. And again, why the increase? I think surgeons, urologic surgeons especially, are very familiar with the robotic platform, doing robotic prostatectomies and partial nephrectomies.

Dr. Benjamin Chung:

And obviously, we've all been in a situation, as Dr. Greene and Dr. Duchene have pointed out, where you try to do a robotic partial, doesn't really work out, and you do a robotic radical nephrectomy. And it's not a hard thing to convert to and I think that's what opens your mind to, "Okay. Well, if I need to do this in a situation where I know it's going to be a radical nephrectomy, we can still do it this way robotically and quite fast. You take the camera completely out of the hand of your assistant and, obviously, there are good assistants and not so good assistants, but now it's basically you're autonomously controlling the camera however you want to.

Dr. Benjamin Chung:

On Si where you need to switch the 30 up and 30 down, for example, if you want to get a better look at the hilum or under the kidney, especially in a kidney with a lot of perinephric fat like both Dr. Greene and Dr. Duchene have shown, going from 30 up to 30 down in a Xi is very easy to do, simply a push of a button. The robotic stapler is also a nice feature to have. I rarely use it but nonetheless it is a good backup plan in case you don't have a good angle to get to the hilum and staple it with a manual stapler in your system. Having four arms with the Xi, for me, was a real game-changer.

Dr. Benjamin Chung:

Once you are able to put the arms in a line as Xi, it just makes it easier to put four arms in, whereas with the SI, a lot of times those arms needed to be staggered and sometimes the ability to place a fourth arm could be contingent upon patient's body habitus, the length of their torso and the like. So, I think all in all, although it's not mandatory to do a radical nephrectomy robotically, it does give you a potentially more flexible platform with which to do your case. And again, with the ports, they can be placed in a straight line that makes it a little bit easier, as far as how to plan out where these ports can go, and there's less ability or need to stagger ports reports based on patient anatomy and alike. And as you can see, they just end up in a straight line as Dr. Duchene has showed, it's actually quite easy.

Dr. Benjamin Chung:

The other thing that the robotics platform of the Xi has given me is ability to do more retroperitoneal cases robotically. And it much easier to put these ports in because again, for the straight-line configuration, but because you're placing that first port as a Hasson or a balloon port, you can actually double-dock the 8 mm port straight into the balloon port as such and do your robotic case very easily. And basically put them in a straight line and has really changed my ability to do these cases retroperitoneally with the robotic approach.

Dr. Benjamin Chung:

Now, obviously there are more complex cases that we're going to take on, and for example, when patients have renal vein thrombi or a cable thrombi, the advantage of doing this robotically is that with the four-arm robot, it really gives you two hands free for tumor extraction, suturing, troubleshooting, placing the Rummel tourniquets, the vessel loops, the staplers, and obviously makes it easy enough to suture, which could obviously be difficult except for the most skilled of laparoscopic surgeons intracorporeally.

Dr. Benjamin Chung:

I'll show you this video and I will take credit, it's not my video. But let's see if I can get this thing to work. Uh-oh. Here we go. So, I'm going to skip forward to the most exciting portion of this to illustrate what can go wrong. So, here's the right renal artery, there's the cava down here, and this is not my video so I'll take a caveat because I can't take questions as to how or why the approach was done the way it was. Here's the right renal artery, here's the cava's exposed, here's a manual stapler which is trying to take on the right renal artery. But you can see that yes, occasionally as in life and in surgery, bad things can happen and you have to find a way to get out of them. Okay. You have two arms so you're able to grab hold of this thing which appears to be where the clips for the gonadal vein have been placed on the cava.

Dr. Benjamin Chung:

But again, you have two arms to help you to address the situation appropriately, but you still have to get yourself out of there somehow. I'll tell you, my 13-year-old son watched this video while I was looking at it and had this look on his face and just ran away. It'd be nice to run away but, nonetheless, you can gain control of the situation. Everyone can take a deep breath, the adrenaline comes down. I hope you guys in Europe are awake now, I'm not sure what time it is there but this will give you a little bit of adrenaline rush. This was sutured up. I'm not going to go through all that, very facile, and now you move on to basically the meat of the case which is to try to get the tumor thrombus out. But you got to control now you just need a suture to take out that staple and put a needle driver in. Let's go back a little bit. So-

Dr. Lee Richstone:

And how are you prepared for bleeding like that? What kind of sutures do you have ready for that?

Dr. Benjamin Chung:

Yeah. So, I recently did a case where it was nephro-u, but the patient had extensive retroperitoneal lymphadenopathy which we did take out. So, I had a Bipolar, I had a Vessel Sealer, but I also had some rescue sutures; I had 4-0 PROLENE and a fiber Prolene, a Vicryl with a LAPRA-TY in the back end. In case you get in trouble, you can throw that and you don't have to tie it, you have a clip on the back end, like a LAPRA-TY or a hem-o-lock, and then you can just take control, get everyone calm down and then basically do what you need to do to move on with the case. But I think in situations where you could have bleeding complications, it's always best to be prepared for something like that. So here's the tumor-

Dr. Lee Richstone:

Always important to have a Prolene pre-made with a LAPRA-TY. When that happens, you don't want to be getting your techs to go get a suture, so it's good to always have that on the field ready.

Dr. Benjamin Chung:

Exactly. And that's my point because-

Dr. Lee Richstone:

So, what are you doing here now? Take us back to the video here.

Dr. Benjamin Chung:

Right. So, the tumor thrombus is being extracted and the nice thing about the [inaudible 00:44:19] is that it can give you the ability to facily try to excise... there was portions of the thrombus that were adhering to the cava wall, so you can try to work around that. Again, this is not my-

Dr. Lee Richstone:

And in this case, you're controlling with Rummels not bulldogs or whatnot?

Dr. Benjamin Chung:

These are Rummels. Again. it's not my case, but nonetheless, the entire cava was controlled with Rummels, you can place the tumor thrombus in a Endo Catch bag. You don't have to just put Rummels because sometimes I see people put Rummels and a bulldog on there to make sure you get as much control as possible. Most of the times, Rummels seems to do the job. In this case it did as well, and then now it's basically a question of just suturing things up in this case with a GORE-TEX suture. Let me go back here little bit.

Dr. Benjamin Chung:

So again, one of the areas where the robot excels is for intracorporeal suturing, hence that's what brought it to the forefront with prostatectomy and the like. Of course, if you needed the suture like you did back there where there was a rent in the cava at the level of the gonadal, of course, now you're able to do that but also here where things are controlled and the thrombus is out, you can do the same thing without much of an issue.

Dr. Lee Richstone:

Great. All right. We have 10 minutes remaining, Ben.

Dr. Benjamin Chung:

So, I'm going to finish up and say well the robotic process, surprisingly high rates of adoption, not so surprising now. It's amenable to complex surgical situations as you've seen. And I've hand over to Dr. Richstone.

Dr. Lee Richstone:

Thank you so much. Those were great videos and great points. A couple of the questions that came in, actually it's interesting, they're two different questions from two different people that do relate to one another in a way. Peterson Moreira had asked, "When do we use 3D reconstruction?" and Ruggerio Mathos had asked, "Any tips on nephrectomy for horseshoe kidney?" Well, I'll tell you a horseshoe kidney is certainly one example where you would want 3D reconstruction, so one of those answers the other.

Dr. Lee Richstone:

Horseshoe kidneys are famous for their aberrant vasculature; multiple arteries, the arteries are not necessarily emanating from where you think they may be, so that's certainly a great case to get reconstruction. In general for radical nephrectomy, I don't find it typically necessary, we'll see what the other panelists think. I will say that it's very important when you do assess the hilum not only looking at how posterior or lateral as Dr. Greene was saying, but I always run the aorta from a cranial to caudal and then back to see if the artery looks like it's coming off cephalad or caudal to the vein. You know you're going to see it behind, almost always, but are you going to expect it from a inferior poster view or do you feel like it's going to be above the vein? Any other thoughts from the panelists quick and then I'll do a little bit of lap video? Any other thoughts on 3D reconstruction?

Dr. Benjamin Chung:

I concur. No further strategy with that.

Dr. Lee Richstone:

In terms of horseshoe kidneys, also, I've worked on a bunch of horseshoe kidneys robotically, it's a beautiful use I think of the robot. The patients can be put in T-Burg port selection, and is performed just like a robotic RPLND and you get amazing exposure, mobilizing all the bowel, flipping it up towards the head. Just be careful with the vessels. So I'm going to share my screen now just to give another take, and I think a couple of thoughts.

Dr. Lee Richstone:

So, I would just say, especially for the Europeans who're probably less quick to uptake the robot versus us in America, I get it completely. Radical prostatectomy, intracorporeal neobladders, complex partials, no question. Suturing, complex stuff here, no argument, I do almost all my work that way in that regard. Although, partials are about 50/50. In my opinion, really, the only advantage of the robot for radical nephrectomy is that if you're doing a bunch of robotic cases in the morning and then you got to wheel this thing in and switch equipment.

Dr. Lee Richstone:

I thought it was funny, Craig Rogers, a while ago had said, "You don't carry two phones," and it seemed like a little bit of flip, but he makes a point. I mean, if you're using all this equipment in the OR and then to change everything over, that's a pain in the neck. Other than that, I don't really get it. I think the vision is outstanding lap, you don't rely on the assistant for any key functions like the stapler, suction, God forbid in emergency, a crash needs to open and convert if you're at the console scares me.

Dr. Lee Richstone:

Superior ability to handle and retract large tumors and tactile feedback, which I'll show. Switching instruments back and forth just no issues whatsoever. There's almost never a need for suturing during radical nephrectomy, let's be honest about it. You maintain your laparoscopic skill, we do walk into cases where GYNs and other people are doing laparoscopy, we don't want to lose this skill, it's also a lot of fun. It's better for you to stand once in a while. This is the pandemic, come on, we don't need to be sitting anymore.

Dr. Lee Richstone:

So let me just show you this video. This is a huge mass that's visible through the skin and you see the contour of the mass coming out of the abdomen there. And as you go in, the first thing you notice here, I wonder if any of the robotic surgeons have ever encountered this, but the tumor is really big. It's something like a 20-something centimeter mass and 18 or 20 cm. You can't see the colon, you can't see the white line. It's a really big tumor.

Dr. Lee Richstone:

So, a nice thing that laparoscopy affords you is I just popped the camera out and put it through my other ports and started working in different ways. But I can't see the white line. So, I go down through the lateral trocar and from this view, I see the white line. And you can start dissecting here, you see it beautifully. I take down what I can do from this vantage point, get things started, and take it down. This is going up towards the head, this is a left-sided tumor. Go down a little bit towards the feet and take some of the white line there. Quickly identify some of the landmarks like the gonadal and the ureter.

Dr. Lee Richstone:

There's our ureter there, we know where we are. We pop the camera out, [inaudible 00:50:48] three, not a big deal, put it into the subxiphoid trocar. By the way, only using three trocars for the whole case, not five or six. You see the white line from this direction, take that down quickly. By the way the optics, to me, even looking at this on Zoom looks like a pretty good image. For all the talk about superior optics, looks pretty darn good. Finish taking this down, and then all of a sudden come back to our periumbilical trocar and all of a sudden, we see the white line. We [inaudible 00:51:23] in the neck with the robot, and this is really just a facile ability to move around. And then you see here, I like to Scissor, obviously people use harmonics, this and that. I've always just loved the Scissors.

Dr. Lee Richstone:

And you can pop in big LigaSure here. There's a lot of thick tissue instead of going through with the bipolar one, obviously you can use the Vessel Sealer but then your coccyx is going up. All of this quick and facile. This video won't be more than about two minutes, so we'll finish on time. But if you get into some of these retractions, this is the big heavy hidden kidney. And that is tough, just to be able to lift that kidney with that left hand and not put that thing through the kidney, hard to do with the robot. Those instruments are sharp, you can't feel anything.

Dr. Lee Richstone:

Again, trying to retract that kidney up, it was difficult. Had a good amount of experience but it's heavy, and you see it's one-handed, but it is fun and it's very effective. You see we're moving, we're getting it done. As I go, you'll see more of this issue in terms of the weight of the kidney. The speed of dissection with a sucker and being able to bluntly dissect like that, so effective. Difficult to do. I don't let my bedside assistant sucker do that kind of work. I don't trust them enough.

Dr. Lee Richstone:

Here, again, in a moment you'll see around behind the hilum this patient has lymphadenopathy. This stuff is thick and, again, all this refraction issue, I'd be very concerned about my robotic arm digging in. Efficacy of spreading and dissecting with the suction. In a second, you'll see here, this tissue normally being under the ureter, I'd march to the hilum with a combination of sharp and blunt dissection. This stuff is thick. And you'll feel here I could feel it. You could feel it, I'm feeling to the pulsation of the artery. How am I going to get through this thick stuff? There is a certain tactile feel here which is very, very valuable.

Dr. Lee Richstone:

I'm worried about what's going on [inaudible 00:53:35]. You're limited with the robot in a way with your instruments and there's the detail to it, but there's a limitation to it in terms of blunt effective movements that come with this. Again, the vision is excellent and I'll come up to the hilum here and I'll advance this for the sake of time just a little bit because we really are coming up to the end. And you'll see that I found the adrenal vein, I took it. I come in with a stapler. You're right that the robotic stapler nice but if you're relying on a bedside assistant to do it, sometimes I get quite nervous. As I said, this is tiger country, if you have any kind of misfire or problem, then you're in trouble.

Dr. Lee Richstone:

And then you'll see here the [inaudible 00:54:23] with different veins and artery. I can feel it, this is expeditious. [inaudible 00:54:31] couldn't or take it and then go on. There is another vein, complicated hilum, and then go on and do a lymph node dissection as this patient had concerning nodes. Looks ugly most of this [inaudible 00:54:50] extensive periaortic lymph node section.

Dr. Lee Richstone:

So, I'll stop there. So, I think the jury's out. You guys made outstanding points, the robot's a wonderful technology and I think the jury has spoken in terms of the trends and the diffusion, it is a great technology. So, I don't see any additional questions other than we have the 3D reconstruction and anatomy, I don't see any other questions. We just hit one o'clock.

Dr. Ash Tewari:

I want to talk about the spotlight event which is going to happen coming Wednesday at 8:00 PM and we have to do some housekeeping for the CME discussion. So, I will encourage everyone to join back, coming Wednesday at 8:00 PM where my friend, Dr. Ketan Badani, is going to highlight all what you have talked, and maybe throw in some extra flavor, and you won't be there to defend the laparoscopy there.

Dr. Lee Richstone:

Fair enough. Well, thank you all. Thank you, Ash.

Dr. Ash Tewari:

Hey. You guys were great. And I'm so grateful to all of you coming together and talking about this and in a different technique. These points and key points make all the difference for an surgeon who wants to embark upon radical nephrectomy using a robotic platform. This series. Thank you again.