So in the interest of time, we're going to get started. I'm very excited about today. Hopefully this is a helpful and practical session for everyone. We'll have a few series of these over the next few months. So my name is Mario Leteo. For whoever doesn't know me, I'm a gene oncologist. I am also the fellowship director and director of minimal access and robotic surgery in the department of surgery at Memorial Sloan Kettering Cancer Center. I would like to welcome you to today's webinar, genital urinary system for the gynecologic oncologist, which is in partnership with Intuitive. Get that going. Oh, that's me. So just a few housekeeping notes relevant to the Zoom platform of this webinar. Please adjust your screen to full screen mode in the top right corner of your screen and adjust your view to settings to fit window. Second, the quality and clarity of the video presentations are linked directly to the speed of your internet connection. High speed and wired connections are best for viewing these videos. If the quality of your video stream is poor during our presentations today, this webinar will be available to view on the IGCS education portal in a timely manner. We have an incredible panel of surgeons who will be sharing their expertise. There'll be time at the end of the webinar for discussion. So we encourage you to submit questions via the Q&A feature at the bottom of your screen. And we will do our best to address as many questions as possible. We may not be able to get to all questions, but we will do our best. Now, to get started, it's my honor to introduce today's speakers. Joining us are Anne-Gerda Eriksson from Norway, Kyung Dong Hyuk from South Korea, and myself. Thank you, Dr. Eriksson and Dr. Hyuk for joining us today. Without further ado, to kick off today's webinar, I invite Dr. Anne-Gerda Eriksson to present the Surgical General Urinary System Anatomy Identification Prevention of Injuries. Dr. Eriksson, please share your screen and get us started. Yeah, we'll stop my... There you go. Hi, everyone. Good morning, or good whatever it is where you are in the world. Let's see, I'm just gonna share my screen here. Okay. Can you hear me? So, thank you again. I'd like to thank the IGCS and Dr. Lateo for including me in this session. And I look forward to talking to you about the anatomy and identification and prevention of injuries of the genital urinary system. And I mean, let's be blunt. If you know your anatomy and we can identify structures, that's actually how we prevent injuries. So, let's go through it. We're gonna talk about anatomy, then about developing the spaces, the retroperitoneal spaces. They're really important for us to view the pertinent structures. Also, identifying the ureter, either with or also without stents. And then we're gonna touch briefly on the role of routine cystoscopy with minimally invasive surgery. So, anatomy. This is just a review. You're all very aware of this. The kidneys are retroperitoneal structures. Embryologically, they start in the pelvis and move upwards into their final position, which I also explained some of the vasculature related to the ureters and the kidneys. But anyway, at the utero pelvic junctions is where the ureters start. And then as they descend in the abdomen, laying anteriorly on the iliopsoas muscles. And as you see here on the right side, the ovarian vessels typically then come from the aorta and the vena cava, whereas on the left side, from the renal arteries and veins. And so that also has to do with your structures and on the left side, knowing that the ureter is usually lateral to these vessels when you're up by the renal vein and doing your periortics. I'll show this later in the video. As we come down towards the pelvis, the ureters cross at the bifurcation of the common iliac and then traverse further down into the pelvis and at the level of the ischial spine going anterior medially and into the bladder. And as you know, bridge over water, the ureter goes under the uterine artery and then into the bladder when we're down in the pelvis. And this is relevant for any hysterectomy, but particularly for radical hysterectomies when we want to lateralize our ureters to avoid damaging it. I mentioned that the kidneys ascend from the pelvis and up to their final place. And because of this, the ureters have both an abdominal vasculature and also a pelvic vasculature. So in the abdominal part of the ureters are vascularized both from the renal vessels or the renal artery, the ovarian or gonadal and directly from the aorta. And then in the pelvis from the iliac vessels, the rectal and also the vesicle arteries and then drained by the corresponding veins. So it's just good to keep in mind that there can be accessory vessels to the kidneys, so-called polar. So the poles of the kidneys, arteries and veins. And so particularly when we're doing surgery along the abdominal aorta, it's good to be mindful that these accessory renal arteries are there both to avoid them. And you can see on this image to the left how they come and how they can vary in their structure. So we want to do safe surgery. And in doing safe surgery, it's important to be aware of the spaces of the pelvis. Now there's the bilateral structures or spaces, which are the pararectal and paravesical. And those are, we're going to go into, look at those in a little bit. And then in the midline, we have our prevesical space, the rectovaginal space and the rectorectal or the presacral space. And these are all delineated in the image here too, the right. And again, I know that you're very familiar with these structures. And so if you look at the pararectal space and its boundaries, the pararectal space, you can see here on the image to the right, eventually it's the cardinal ligament, dorsally the presacral fascia, but then more importantly, perhaps laterally, the internal iliac artery and then medially the rectum. And then also mindful of that, the ureter actually divides the pararectal space into medial and lateral pararectal spaces. And then they have names after surgeon and the medial pararectal space, particularly with Okabayashi in regards to the nerve sparing radical hysterectomies that are performed. And some people say that it's not the ureter that divides the pararectal spaces, that it's the hypogastric nerve. And honestly, that's just six and two threes because those are in the same plane. So importantly, you know, about two centimeters dorsally to the ureters is actually the hypogastric nerve. And so that's what we want to save when we do a radical hysterectomies. So those are in the same plane. And then if you look at the paravesical space and its boundaries, then eventually it's going to be the pubic bone, dorsally the cardinal ligament again, and then more medially the bladder and laterally the external iliac, the vessels. And then if you want to divide the paravesical space into medial and lateral, the obliterated umbilical artery is that structure that's going to divide your space. So these are the structures that we want to identify. This again is just image from a cadaver. And as you see, particularly in blue here is divided the pararectal space. So the Okabayashi and the let's go spaces with the ureter crossing in the middle there. So this would be the right pelvis. I think that it's easier to see these things on video rather than just talk about them. So unfortunately from the time I knew about this talk until now, I hadn't scheduled any radical hysterectomies on the robot. So this is from just a simple hysterectomy, but just to show some of the spaces and the identification. I sped it up a bit. So obviously this is the right pelvis, the common iliac. This is a woman whose body habit is she's quite slim. So you can see the ureter there just through the peritoneum. So I already know a good idea about where it goes and then dividing the round ligament and opening the peritoneum there now to dissect out my spaces or the vital organs that I want to be mindful of when going in the pelvis. And so this is also, this was a case with a sentinel node dissection. So I wanted to keep everything bloodless and just gradually as I move by trying to buzz the small vessels to avoid any bleeding and obscuring my space. And as you see, when I pick up a tissue to buzz it, to coagulate, I lift it up from the underlying structure. And this is just also a small thing to do. And just it's second nature really to do these things because when you do pick up that tissue that you want to buzz, you're less likely to injure any other structures that are laying right next to it. And so I know here that my ureter is going to be coming up because I've already seen it through the peritoneum. So there's, I've got my iliopsoas muscle, the external vein, iliac vein there. And the ureter is running along here. And then the next structure I'm going to open up here is I know that my obliterated umbilical is going to be up here. So just dividing that as well to make sure that I can see that space. And you can see the patient jumping a little bit and that's because I'm also going to get to my obturator nerve in a little bit. And then what I do here is I follow the obliterated. And so this is going to be my internal iliac artery and the uterine artery at its origin. So that's readily available for me. I wouldn't necessarily do this much dissection for a simple hyst with sentinels, but I wanted to demonstrate to you guys just how to find it. And then here again is the ureter. As you see, it can bleed easily because of the vasculature and just picking that up and pulling it away from the ureter before I buzz it, but that's then how pulling it off. And again, I just wanted to show a little bit in regards to the bladder. I know you can all develop this bladder space really easily, but when I do divide the peritoneum here and then pushing down the bladder, whenever, so the fat obviously stays with the bladder and then I'm just pushing it down. And if I do want to buzz anything now on the cervix, I guess I'll use my other instrument actively to push away, to remove the bladder tissue. So you see here, when I'm buzzing, just to at all times really keep in mind that any adjacent structures, I don't want to get any thermal injury because thermal injuries are the ones that then are the ones that are most likely to not be noticed necessarily. And that there'll be late injuries that can give your patient serious complications or more serious that you have to go in and rectify later. Again here, and I'm just going to show a little bit the medial pararectal space because I delineated my ureter and I'm not going to go deep down for this patient just because I'm not doing a radical procedure, but this is the general area that you'd go down. And this is after the uterus is removed. And just again, seeing those spaces there with the structures and there's the obturator nerve as well that we've identified. Let's see, I think that's the end of that video coming up now. Right, the next video I wanted to show you also in regards to periortics. I know there are internationally, there's a huge variance in if we do periortic nodes anymore, particularly for endometrial cancer, but some places it's still done. And for staging of ovarian cancer, you might want to do periortics. So I just think it's good to know about this. This is a video that was shared with me by my colleague, Vridhini Dood, she uses this when she, oh, sorry, that's the wrong one. Let's see. There we go. There we go. For periortic nodal dissection. And the first point here just is removing the sigmoid colon. So always when we do surgery, we want to make sure that we have good access. And that means also mobilizing other structures. Now, a lot of the time there are physiological adhesions in the left pelvis that'll keep the sigmoid colon away. And depending on the body habitus of the patient, you might not need to do anything, but this is just very simple with epiploica to tag that and get it out of the way. And then we always enter along the right common iliac. And you can see here again, that we're already seeing the ureter through the peritoneum, because this again is a patient who doesn't have all that much intra-abdominal fat. And just opening the peritoneum here and we're tenting it up. And what's really important is obviously to visualize your structures, just like in the pelvis, because if we see the ureter, we're much less likely to get an injury. So opening up here, then we're going to see our vein coming first and then lateral to the vein, we're going to see the ureter coming up over here just so that we always, here we go. We can, what we can see, we're less likely to injure. I'm not going to show you this whole dissection going up the aorta just in the interest of time. So I'm going to forward to a little bit later in this video. Let's see. Here we go. So now we're removing nodal tissue. Up until now, we've, you know, we've really opened all our spaces. We've mobilized the duodenum so that everything is ready before moving any nodal packets. And now she's removing the pre-cable nodes. And in doing that, you can now see that since we've opened our spaces, it's really easy. We have our ureter here laterally where my pointer is. And so we can keep an eye on it while we're doing the dissection. And I know I've said these four times already, but when we see it, we're less likely to injure it. So this is all just about identifying that structure. And then when we get higher up in the abdomen, forward to that now, let's see. There we go. This is our renal vein that was going up across there, crossing over the aorta. And we're defining our lateral boundary because as we said, now what we're looking for here is we're dissecting out the ovarian vein that comes down from the renal vein. And by doing that and delineating the ovarian vein clearly, here, we then know that as long as we stay lateral to that, it's very unlikely that we will get into trouble with our ureter. And obviously as we come further down, we know that the ureter traverses differently and depending on how laterally you're going to go there, if you want to find it or not. But we don't always visualize the ureter on the left side. But if we stay within those boundaries, you can feel pretty safe. But then if not, then just dissect it out. And that's the best way really to make sure that we're safe. Okay. So in regards to stents, I don't routinely use stents when I do surgery, particularly not minimal invasive surgery. But it's not a difficult procedure to do. And depending on the logistics really in your institution, this is something that either some people do a day in advance at a cystoscopy unit or intraoperative at the same time as the procedure. And again, just depending on local customs and traditions, this might be done by the gynecologist. You can do it yourself with cystoscopy of you or have one of your urology colleagues come and place the stent if you feel the need for it. And obviously placing a stent could be if you feel that identifying it can be difficult. I'm aware that in some countries, gynecologic oncologists also do complex benign surgery. So maybe for endometriosis or other cases where you might think it's difficult to identify the order, you can place a stent. And so there's different types of stents. There's just the regular JJ stent, which is then a tactile. Really you can feel it. There are stents that have infrared light. This is a publication by Dr. Mishra demonstrating, as you can see here, this infrared light delineating the stent. This is also gaining popularity with some colleagues within colorectal service when they do colorectal surgery and when they see technique. And then here, this is off-label use, but there's publications out there when using ICG as well to delineate the ureters. And then finally, the role of routine cystoscopy. Again, this is not something that I do in my practice or in our practice at the Norwegian Radium Hospital, but it has come up, or actually not that recently. The AAGL supports the use of cystoscopy at the end of the minimal invasive hysteroscopy. And so the reason why would be then to detect injuries and to detect injuries that you haven't detected, that the surgeon hasn't detected intraoperatively. And in regards to the ureters, obviously they can be lacerated, divided, or completely ligated. Those are the acute injuries that you're likely to see. The delayed thermal injuries, so the vascular necrosis, which are going to lead to leaks. These leaks aren't going to happen right away, right? That's afterwards when the necrosis actually happens and then you're going to get a leak. And then obviously there's bladder injury as well. And so per the publication of the AAGL, up to 3% of cases there is a urinary tract injury and the sensitivity of the cystoscopy is 80 to 90%. And I read somewhere else that they say that surgeons only detect up to 25%. Anyway, that's out there. However, there are downfalls. It's that increasing risk of urinary tract infections. And then also the fact, as I mentioned, that these thermal injuries, they're not going to be noticed. So for me, again, I don't do this, but I think if you wanted to, for select patients, you certainly could. Patients where you think you might not have been able to see your structures. If there's a morbidly obese patient where dissection is difficult, if there's been large blood loss and you've not been able to evacuate blood, but maybe used your thermal instruments without really visualizing all the adjacent structures. If the masses themselves have obscured the ureter. Having said that, I do find that if you are in a situation like that, commonly then you can, after you've stopped the bleeding or removed the mass, you can then actually dissect out and have a look at your ureters if that's what you're worried about or the bladder. But in these cases, then you could maybe select to do this cystoscopy. And so just finally, and preventing injuries, I think we talked about this briefly when we looked at the video, but just knowing our anatomy, knowing what to expect and where the structures are expected to be when we operate is a good help. Also, most of our patients these days have a preoperative CT scan. So just looking through the CT scan to make sure that the roadmap of this particular patient is in accordance with what we know from our anatomic practices. It's not always the case. And if you're not comfortable looking at these on your own, you can sit down with your radiologist and have a look. Open the spaces, make sure to identify the structures, the structures that we do see we're less likely to injure, identifying these landmarks, and also follow the same steps. One of my mentors who happens to be here today has told me that if you follow the same steps, even though it's easy for a simple procedure to think that you don't have to just do it, do the same steps every time, because then the difficult cases do become easy and you know what to expect and you know what to find. Thank you very much. Great. Thank you, Dr. Erickson. So if you can stop sharing your screen. Next, I'm going to invite Dr. Hyung Dong Yuk to present on the topic of managing bladder injuries. Dr. Yuk, please go ahead and share your screen. And a reminder, please type in your questions into the chat area. We will save them all for answering at the end of the session so that we can stay on time with our presentations. But we will try, we will answer as many as we can once all the presentations are complete. Thank you. Dr. Yuk. Thank you. I am Hyung Dong Yuk of Seoul National University Hospital. Thank you for the opportunity to participate in ITGS. I was impacted with COVID-19 two days ago, so my throat hurts a bit. So I prepared a video. Thank you. Today's topic is bladder injury managing. Urinary tract injuries after gynecological surgery are 33% to 4.8% overall. As for the injury type, the bladder was 76.1%. Although benign gynecological surgery, it is known that the possible frequency of bladder injury after gynecological surgery is higher with laparoscopic hysterectomy than with open surgery. And it is known that the rate of detecting intraoperative damage in laparoscopic hysterectomy is also the highest at 46%. Comparing the complications of robotic and laparotomy and robotic and laparoscopic surgery, it can be seen that there is no significant difference depending on the surgical method. Common risk factors for urinary tract injury include obesity, bleeding, adhesion, mass size, malignancy, prior radiotherapy, inflammation, endometriosis, and cesarean section history. Methods to check bladder injury during surgery include a bladder filling test, cystoscopy, and administration of indigo carmin. Intraoperative recognition is the most important step for bladder injury treatment. Bladder injury repair is recommended to be done in two layers. It is recommended to remove the Foley catheter after maintaining it for about a week and performing cystography. Bladder injury repair is recommended to be done in two layers. The urethelium layer is sutured with 3-O-absorb thread. I mainly perform continuous sutures using V-lock barbed sutures. A water-tight suture is recommended. When the suture is complete, finish with a lipper tie. The serromuscular layer is sutured with 2-O-absorb thread. The serromuscular layer also performs a continuous suture, mainly using 2-O-V-lock barbed sutures. When the suture is completed, it is recommended to check whether there is a leak by performing a bladder filling test of about normal saline, 100 mL. Fistulas related to gynecological surgery include ureterovaginal, ureterouterine, vesicovaginal, urethrovaginal, ureteroenteric, and vesicoenteric fistulas. Among them, the most commonly seen is the vesicovaginal fistula. Urinary tract risk factors include previous pelvic irradiation, complicating the difficulty of fistula repair, infection, inflammation, foreign body, and malignancy. Urinary fistula diagnosis methods include physical examination, IVU, cystography, CT, MRI, cystoscopy, RGP, and vaginal packing by test. These pictures are visible to vesicovaginal fistula and vesicouterine fistula when they were conducted by cystography. Look at the management algorithm of vesicovaginal fistula, a spontaneous repair can be expected if it is less than 5 cm. And if it is more than 5 cm consider repair. In complex cases, delayed repair may be considered. Look at the cystoscopy of the vesicovaginal fistula patient as shown in the photo, you can see that the fistula area is smaller at 4 months after surgery than at 1 month after surgery as it ray. On CT, the vesicovaginal fistula is visible as arrows. This patient is a vesicovaginal fistula patient as shown in the previous endoscopy and CT scans. Due to adhesions from previous surgery, we approached the retsius space and dropped the bladder to approach the anterior wall and dome of the bladder. Indigo carmin was administered for differentiation of ureter, orifice. An incision was placed in the bladder dome to open the bladder and a fistula opening was found. The fistula is found and an incision is made on the blue line to divide the vaginal side and bladder side. Then the vaginal opening is closed by suturing the blue line and the bladder opening is closed by sutured by the green line. This scene follows the blue line and puts an incision and it pushes the fistula tract from the bladder towards the vagina. This is to block the fistula tract on the vaginal side. After closing the fistula tract on the vagina side in this way, close the bladder side with a suture. In this way, the operator opens the bladder to access it, finds the fistula tract in the bladder, and separates the tract. The separated tract is blocked on the vaginal side using a suture, and also on the bladder side. Then, it repairs the bladder like the previous bladder repair video. Previous surgical images show an approach to opening the bladder and performing surgery. However, this video shows how to find the fistula by accessing it between the uterus and bladder as shown by TH. Since the preparation time is very short, I could not record a video suitable for the method, so I will show you how to approach it with my surgery and for the actual VVF repair method, I borrowed a As shown in the video, after finding the boundary between the uterus and the bladder, the robot arm performs appropriate coagulation and traction of the tissue and enters between the vaginal and bladder. If you approach the bladder and the vagina in this way, you will find the fistula tract, as shown in the picture. After cutting the tract, the bladder and vaginal side are sutured to perform VVF repair. First, block the cervix side first. As shown in the image, the bladder is above and the vaginal fistula tract is below. After closing the vaginal fistula tract, close the fistula tract on the bladder side. Thank you for your attention. Ureteral injuries and repair. Let's see here. Let me start sharing my screen. Good morning, everybody. Let me restart this here. Okay. So, I'm going to discuss about managing ureteral injuries, as well as this will also apply for those of us who are doing our own urologic-based resections for usually tumors involving the ureter. So, these are my disclosures. So, in terms of injury, what's reported in the GYN literature is that there's a few main sites that are injured during a hysterectomy for gynecologists and gynecologic oncologists. It's usually one is when you ligate the gonadal vessels, and that's why I feel opening the retroperitoneal spaces, as Dr. Erickson showed, is extremely important. It's extremely hard to injure something when you can see it. I'm not a fan of just using a ligature or vessel sealer device across the IP and hoping you don't catch the ureter without opening the spaces. So, I routinely open the spaces. The other site of injury, especially for us as gynecologists, is when we're dissecting the lymph nodes, and I'll show you actually a video of mine where that happened. If the beta was where the most common site is, it really matters not. But another area of high injury is when there's ligation of uterine vessels. Again, that's where upward traction of the uterus actually is very important because that separates and stretches out the pedicle when you're ligating uterine vessels. And then, again, you can injure the ureter if you're not careful and you're going too deep on the vesicle-vaginal dissection. So, those are the main sites for us as gynecologic oncologists that we can injure ureters. It also happens to be some of the more common sites where we do ureter resections for pelvic recurrences. So, how to avoid? This was already discussed quickly, and it's very simple. You just open the space and identify this. I don't feel that stents help. Actually, all they do is make a nice click when you cut them. Lighted stents are out there, ICG. I mean, those things are all fine options. It comes down to your preference, but I don't – there's no literature that supports that they help prevent any injuries. You need to know your anatomy. Upward traction of the uterus is helpful. Avoid extensive cautery, especially lateral extension or inadvertent clamping without knowing where you are. Again, you have to be very careful when you're mobilizing the ureter, especially during a radical strectomy, to avoid devascularizing the periuretal fascia. There's no reason to, but folks sometimes put these very wide sutures at the vaginal cuff angles. It really is unnecessary. And if you really have a difficult case, no matter what the indication, just dissect it out. So, in general, this is an older diagram, but it still kind of applies. If you identify an injury during surgery, if it's a very minor injury, you can actually stent the ureter and then leave it in. About six weeks later or so, this is older, it says IV polygram, but often we'll have our urologists do a cystoscopy with retrograde fluoroscopy, and if there's no leak, they'll pull the stent at that time. Now, if there's a major injury or major resection, you know, there's sort of guidelines as to whether it's an upper, middle, or distal ureter location. Now, for post-op recognition, hopefully this is a small part of what happens, is that you have either transient elevation of creatinine or costrum 2 or angle tendinitis, and that should also always raise a flag that you might have injured a ureter somehow. Now, this, again, being older, it says IV polygram, cystoscopy, or fluoroscopy, which are reasonable things to do, but honestly, nowadays, all we do is you order a renal ultrasound if there's hydro that leads to concern, and a CT urogram is often performed here to actually help us localize the injury. Now, when you're in the OR and you're trying to pick, when you're trying to decide what kind of stent to choose, well, what size do you pick? And this was actually a nice study done a bunch of years ago, too, but looking at using patient height versus actually measuring the ureter directly, and that actually using patient height to decide whether it's the American system, feet in inches or centimeters, as you can see here, that this is actually probably the better way of picking the correct stent. Now, you'll never get it 100% correctly, and if these grades are minus two, it means that it's really inappropriately too short, two is sort of excessively too long, and that really that using patient height really provides probably the most accurate, which is a grade zero perfect placement of stent. So that's what I use, and since most women are less than 5 feet 10 inches and 178 centimeters, 22 stent usually works very well, especially if you're placing within the GU system. Now, if you're exteriorizing them, as for condos, that's different. Again, the location of these injuries can be lower. This is where 90% occur. This is defined as below the inferior sacroiliac joint to the bladder, where it's sort of this mid-ureter is between the superior and inferior sacroiliac joint, which you don't see during surgery, so it's kind of approximations, and then a small portion of injuries will occur in the upper ureter as defined in this. And this may happen during a periodic nodal dissection or resection of tumor up in this area, so very unusual for a standard pelvic surgery to have an upper ureter injury. And the decision how to repair it is kind of based on lower, mid, or upper, but it really ultimately comes down to whether they've been radiated, the extent of the injury, do you have to resect a large portion of the ureter, all that will add to the decisions. So ureter or ureterostomy, if it's more than three centimeters from the UVJ, is usually preferred. If not, then if it's close to the bladder, you really don't have a lot of distal ureter attached to it, ureter or neocystotomy. Now, both of these can be performed with or without a psoas stitch depending on tension. You really want to do these anastomosis with very low tension. If it's a mid-ureter injury, pretty much a ureter or ureterostomy is preferred unless there's been a large portion resected. This is also where you start to think of maybe having to do a buary flap along with a psoas hatch and a transureter ureterostomy, which I've never personally done or seen done, is also an option. That's usually a last resort. If it's an upper injury, I mean, at this point, you may want to start getting a urology colleague involved if you do this. And again, if it's possible, ureter or ureterostomy is the preferred method. You can now, instead of mobilizing bladder, now you're doing the other end and mobilizing the kidney, and you can get up to four centimeters if it's properly mobilized. This is where ileal interpositions, the penicillin interpositions are considered. Autotransplantation, if you get to that point, you really have taken a humongous part of your ureter, and then nephrectomy is the last ditch resort, and this usually would be involved when you're actually taking a large portion of your ureter. So again, there's a lot that factors into these decisions. They're just general guidelines. Simply put, a ureter or ureterostomy is somewhat straightforward. This is an example of a ureteral stricture, but, you know, it's the same concept. If you have an injury, you would take out the injured portion, any cauterized portion, you clean back, you spatulate the ends of either ends, and then you sort of approximate the spatulated ends to each other. So this end goes to here, and this spatulated end goes to here in the middle, and then you basically just sew these. You can do a running suture, interrupted sutures. I use interrupted sutures, but I think it matters not. You just don't want to have too many sutures also, because that could actually lead to devascularization of your anastomosis and strictures. So this is a video. It's a little older case of mine, but again, this is a patient whose BMI is 41, which, you know, as mentioned before, is a risk factor for injuries. This is a complete lymphadenectomy, which we're still doing complete lymphadenectomies for service cancer, the evil robotic radical hysterectomy here. So we were doing a full pelvic lymph node dissection here. As you can see, a lot of adipose tissue in the area, and here in my younger days, and there's a little bit of extra bleeding here around the lymph nodes. You probably should just stop, think about where you are instead of just trying to keep going, and learn from recording videos of all your surveys, because I went back, obviously saw this and realized quickly why this occurred, and this was me, and there you go. That's the year of being injured live. All right, so as soon as it happens, it's kind of obvious. And the key is identifying things intraoperatively as opposed to postoperatively. So the robotic platform really has made this much easier to repair these things, especially when you're doing suturing of smaller structures laparoscopically. I probably wouldn't have done this, but that's me personally. But again, there are great laparoscopic non-robotic surgeons who probably could do this. I'm not one of them. This really makes it much easier to steady view, control motions with such smaller structures. And again, all we're trying to do here is we cut back the cauterized end and then spatulate. Fortunately, this ureter injury was a partial transection, so it actually was nice in that the posterior aspect of the uterus of the ureter was still attached, which kept these two ends approximated together. When it's a complete transection, it's a little more challenging to try to approximate them as they're loose and hanging out. But again, here we were fortunate in that there was a piece of ureter still attached that helped keep the cut ends in close approximation. And again, the basic concept, you want to cut out any of the vascularized tissue here. You can see nice ureter urine coming out, clean edges of the proximal distal ureter. This is a really a probably a mid ureteral transection. Therefore, we did a ureterostomy. The stent can be placed as a double J stent. You can pass with the guide wire, you pass into one of the trocars, either your assistant trocar, you can pass the whole stent in. There's lots of different ways of doing things. There's no one best way always, but there's different ways. You can see the guide wire there is passed through one of the side holes of the stent. It is passed proximally up into the renal pelvis. Then you have to, this is the tricky part is now holding the ureter steady while you pull the guide wire. And usually if you saw the guide wire sticking out of the trocar, you can just hold the stent and ask your assistant to pull the guide wire. And that's what we do here. I think, no, here we pulled it ourselves. But that is something to consider. If you keep the guide wire outside of the abdomen through a trocar, you can hold it steady and then have your assistant pull it. Actually, here we actually had our assistant hold the stent and then we pulled the guide wire ourselves. Then once it's done proximally, then you obviously want to insert the other end distally. And again, this is just sort of managing these things. The robotic platform really has made these sort of repairs much easier for me, at least, and I think for many others also. And then you place it distally. And then it's just a matter of suturing things. And it's just placing. It's always the trickier part is the placement of the stent. And then once it's placed, we put interrupted sutures here. These are three ovipros. Usually three or four ovipros are perfect on an RB needle, RB1 needle. Here I probably wouldn't do running and these are interrupted sutures. Again, you don't want to put too many sutures because that actually devascularizes the approximated tissues. If you overly suture this, then you want to just do probably four to five, at most four or five interrupted sutures here. And the rest is history. Just suture these things and tie them down and then that's it. So that's this video. The next video is going to have sound over it. This is really a resection of a tumor involving left ureter. So it highlights sort of a resection with the ureteral neosystotomy as well as psoas hitch. And I may fast forward it for time's sake, too. This is a surgical teaching video demonstrating a robotic-assisted ureteral reimplantation with a psoas hitch. In this video, we will review trocar placement and a robotic arm docking strategy suited for pelvic recurrence involved in reimplantation. This patient is a 62-year-old otherwise healthy woman with a history of advanced-stage high-grade serosovarian cancer. She experienced a localized left pelvic sidewall recurrence, which was increased in size on interval imaging, causing hydronephrosis. Typical port placement for pelvic surgery is illustrated here. The assistant will stand using the SI system to avoid instrument collisions. She will hold the polar scissors in the right hand and the assistant arm on the right side. The tumor was palpable in the left pelvic sidewall, initially found to be densely adherent to the rectal mesentery and investing the left ureter below the pelvic brim. The tumor was dissected away from the rectal mesentery using a combination of blunt and sharp dissection with frequent reorientation to ensure preservation of key structures. The fourth arm was used to medialize the colon and provide traction to dissect within the correct tissue plane. The ureter is kept in view and carefully mobilized until it is seen traveling into the soft tissue mass. The ureter is then transected just above the site of the tumor and mobilized for implantation into the bladder. It is important to avoid excessive dissection, as this can disrupt the ureter's blood supply and compromise healing and function. Additional mobilization can always be performed later on if needed. The soft tissue mass is then sequentially fed into the ureter. The soft tissue mass is then sequentially freed from surrounding structure, including the rectal mesentery, pelvic sidewall, and dome of the bladder, and is placed in an endocatch bag via the assistant port for subsequent removal. Bladder mobilization is the next key step in this procedure. The bladder is placed on traction using the fourth arm, and using traction-counter-traction maneuvers, the avascular planes of dissection are entered. If any small vessels are encountered, they can be addressed with monopolar cautery. The paravesical space, once developed, will lead anterior to the space of retzius. It is important to frequently reorient to avoid injuring the bladder. It is also important to preserve as much paravesicular fat as possible when mobilizing the bladder to avoid tissue devitalization. Gradually, the bladder is mobilized. It is helpful to pan back with the camera to determine when the bladder is mobile enough to hitch to the psoas muscle. Repeat this maneuver periodically until it appears sufficiently free from its attachments. The bladder is then backfilled to allow the surgeon to determine the ideal placement of the ureteral re-implantation, and also better assess if further mobilization of the bladder will be needed. This is a key step in the procedure to ensure the anastomosis is tension-free. At this point, the bladder is fully mobilized, and the surgeon is ready to place anchoring sutures from the bladder to the psoas muscle. A 3-0 proline suture on an SH needle, cut to 6-inch length, is passed into the field via the assistant port. The first stitch is placed into the distal-most portion of the exposed psoas muscle. The fourth arm is used to keep the bladder in position during suturing. The stitch is connected to the distal portion of the bladder, and then tied down using instrument tie technique. Cutting the stitch to 6-inch length means instrument tying can be completed with more efficient movements. We prefer to use a regular needle driver in the left hand, and a mega suture cut needle driver in the right hand for this portion of the procedure. Using the same technique a second anchor stitch is placed by moving proximal along the psoas muscle and bladder. In this case a total of three anchoring stitches are placed and any additional stitches can be placed at the surgeon's discretion. There's multiple ways of doing things, this is just the way we do this one. You can use a barbed wire, barbed suture if you prefer and this actual suture material doesn't matter as much. I would probably use a delayed resorbal such as we use here PDS. I'd probably not use Vicryl, I wouldn't use any permanent sutures. Those are just general guidelines. Beyond that it really comes to whatever your comfort level is. The ureter is examined to determine where it can be implanted in the bladder with zero tension or angulation which would compromise function and healing. In this case you want to place it in the dome of the bladder or anteriorly. You don't want to place it on the side of the bladder because it can kink the ureter as the bladder fills up in the future. Just another little tip. In the ureter it is important to inspect for adequate hemostasis in the pelvis to avoid manipulating the bladder later on which can disrupt the anastomotic suture lines. Preparing the ureter for re-implantation is a step in the procedure that will require frequent changes in robotic instruments. To start the monopolar scissors are placed in the right hand in order to trim the ureter and remove the denuded portion. It is important to stop before completely trimming the end of the ureter. A tack stitch is placed on the ureter and the remaining portion of denuded ureter is trimmed away and removed. The ureter can now be handled with gentle traction on the scissors to make it easier to spatulate the ureter using cold shears. Place the mega suture cut needle driver in the right hand, the spatulated end, and then stash the needle safely. Place the monopolar shears in the right hand and perform a cystotomy in the dome of the bladder using cautery through the layers of perivesical fat. As the serosal layer is visualized, avoid using cautery at this point which can help preserve the vital tissue for the re-anastomosis. Place the mega suture cut needle driver back into the right hand and reload the 4-ovicral stitch. Place your next bite from serosa to mucosa of the bladder and this will complete the first anastomotic stitch. Using the instrument tie technique, tie the suture down with care to avoid twisting or strangulating the ureter. These are 3-ovicral sutures, that's a preferred suture choice for a ureter. This is an anastomosis on an RB1 needle. You can also use an SH but RB1 seems to be better. The second stitch is placed moving from mucosa to serosa of the bladder, then serosa to mucosa of the ureter. It is important to move counterclockwise around the lumen of the ureter as each stitch is placed to ensure clear visualization of the tissue. Using the Maryland Bipolars, gently spread the ureteral lumen open when placing each stitch. Half of the anastomosis is complete, a stent is placed to protect against stricture or stenosis. In this case, we used an 8 1⁄2 French double J stent with a guide wire. The stent is inserted into the ureter guiding its cephalad, then the guide wire is removed using bedside assist. The caudal portion of the stent is gently guided into the bladder. And the remainder is just placing down additional sutures, so just for time's sake, I don't want to, you can see here towards the end, this is the completed anastomosis here. All right, so additionally, just some quick kind of highlights. A wire flap here is if you really need to, the psoas, if the ureter doesn't reach the bladder, you can sort of create this flap here and a rectangular incision, bring it up. There's different ways of doing this. You can attach the ureter and sort of overlay the flap, if you will, and suture it down as you've seen here. This is another way of doing it, this tunneled bowiary flap. I mean, tunneling of the ureter is controversial about these quote-unquote anti-reflux things. I mean, many urologists here do not do this tunneling and that actually might add to additional stricture impossibly. So there really is no reason to tunnel anastomosis. But this is an example of a wire flap with a tunneled ureter on anastomosis. Bowel interposition, I have used this in the past. This is when you really cut the ureters pretty long and the wire flap even is not enough. Or you take both ureters, which we did recently, and you just can use a piece of bowel instead of, as you would an ileal conduit, but instead of bringing the stoma to the skin, you're basically attaching the bowel to the bladder dome. Appendix interposition, I have never used this, but again, this is just like any other piece of bowel, I guess, and you can use this also as an interpositional segment. Transureter or ureterostomies, at this point, I probably have a urologist involved for sure, and I've never seen or done this, but it's something else that you should know is a possible option. Now, in terms of managing these cases, the Foley, you know, these things are very somewhat subjective and based on quote-unquote experience as the literature is kind of very weak to guide, but in general, if we do a ureteral neocystotomy or a ureteral ureterostomy, we keep the Foley in for about a week. Stent, I use, it's actually an 8 1⁄2 French, depends on the size of your ureter, but I apologize, it's an 8 1⁄2 French, and again, like I mentioned, mostly a 22 or a 24 if it's a tall or female. Double J works for most. We use bar stents here, but there's a lot of stents out there. We usually have the stent removed in about four to six weeks, and that's done in the office by one of our urology colleagues using office cystoscopy. We do put a drain in, and we keep it in until, for about two to three days. Imaging after these things is controversial, and depending on which urologist you speak to, because most leaks would be symptomatic, but if this is, you do these things because of an injury, probably better to make sure everything is okay, so usually we do a cystogram just before we move the Foley if we've done a ureteral neocystotomy. If it's a ureteral ureterostomy, it's unnecessary, and then we have been doing a CT urogram prior to stent removal, especially if it's from an injury, but a lot of times what happens is our urologist will just do cystoscopy with the retrograde fluoroscopy and then pull the stent at the same time, so there's lots of different ways you can consider doing this, but again, if you are doing this because of an injury, you're probably better doing some imaging just to make sure things are okay before you pull stents, so in terms of injuries, I always like this quote, you know, we all can make mistakes, that's always forgivable, but you have to at least admit that it was a mistake, reassess what you did, and then I'll learn from that, so you know, again, this is a very short session, and we can keep talking about this forever, and thank you for this portion, so at this point, I'm going to stop sharing, and I'm going to ask the three, our speakers to come back on. Thank you all, so now we will have time for question and answers, and we have Dr. Erickson and Dr. Yocan here, now I know there's been a lot of questions coming up, some have been answered already, but I think I'm going to go back into some of the answered ones, so that we can all sort of learn from this, I think there was a question about routine putting a double J stent prophylactically after a rat hyst in general, or a site of reductive surgery where you believe the urea has been extensively dissected, so maybe Dr. Erickson, what are your thoughts on routinely stenting cases? Yeah, I don't use routine stenting, no, if, as you say, you know, if you expect an injury, if you see an injury, that's the best thing, you can repair it there, and then obviously, if we think we've damaged the ureter, we'll put a stent in, and then over-sew it, if not, but also the way we do it, you know, I'll definitely take responsibility for my complications, but I want the patient to do as well as possible, and because it's just the policy at our institution, we would always call a urologist, one of our urology colleagues, they have great experience with robotic surgery, and so it's good to just have their set of eyes, I think, to assess the ureter and see their opinion, obviously, this is their organ that they work with, although we see it very frequently as well, and just get their opinion, and also if we do need a repair, we'll do it with them, I think this is in the patient's interest, at least it's the structure that we have at our institution, so, but yeah, no, I wouldn't put any routine stents in. Yeah, neither do I, and in terms of how extensively dissected a ureter is, that's such a subjective call, and depending on who you call in, if you are calling urology colleagues, one will say one thing, the next one will come in and say something different, so it's very hard to come up with hard, fast criteria, I think if somebody's been radiated, I think you have to be a little more careful with radiation, I think you might be a little quicker to place a stent, but I mean, you really have to, you really have to denude the whole adventitia and that periuretal vessels to really start worrying about excessive dissection, so really just avoid doing that in general, would be my answer. For Dr. Yuk, there's a question here, we always ask this, especially in GON, do you have to do two-layer closures, or is a one-layer closure acceptable? We can't hear you, you're on mute, buddy, you're muted, there you go. Yes, sorry. Yeah, it's possible, but yeah, when considering bladder puncture or reoperation in the future, yeah, it would be better, yeah, to layer by layer. Yeah, I think, yeah. Do you do anything different if there's prior radiotherapy when you're doing a bladder procedure or repair, and a patient's received pelvic radiotherapy? Pardon, please, previous question, yeah. If someone has received, and our patients, especially in GON oncology, many of our patients have been given radiation therapy in the past, do you do something different, or recommend something different if you have to operate on the bladder, either for injury or for planned resection in someone who's received radiation in the past? Uh, yeah, it is not different, yeah, to repair bladder, yeah, but it is different time to keep polycatheter or, yeah, previous, previous RT patient is more longer, yeah, more longer keeping the polycatheter. So, longer, prolonged catheterization, possibly, maybe consider imaging in that kind of person to make sure that there is no hole that's developed, possibly. There's a question here about, about urinary implantation, I guess that's for me. Why do you put suture knots inside the lumen of, well, you know, this whole thing about knotting inside or outside, I mean, there's really, again, the literature on that is very weak, it's all based on opinion. Sure, ideally, you want to put your knots on the outside and not put them in within the bladder lumen. But sometimes you do what you can with the anatomy you have, and it doesn't always work out that perfectly. And if you notice the vesicle vaginal fistula repair that Dr. Yuk showed, all those sutures are inside the bladder, and all those knots are inside the bladder. So, yeah, in an ideal world, based on expert opinion, you would want to leave the knots outside. And usually that's what happens, but some occasionally, the knot winds up on the inside of the bladder. And honestly, I don't feel like that's a real problem. And no one ever has shown that it is a real problem, as far as I can tell. There's also a question about using a feeding tube instead of a stent to cut down costs. Yeah, you know, we actually use pediatric feeding tubes for our conduits. You know, we don't have to deal with the J and straightening it out. But, you know, using a feeding tube within the GU system that you're going to leave within the system, there's a higher risk of it migrating. If there's no J in the pelvis of the kidney, you run the risk of it migrating down into the bladder. So, you know, if you are doing a conduit and it's exteriorized, when you put the pediatric feeding tube, you can secure it at the skin. But if you're doing an intra-urinary system stenting, as you do with a ureter, ureterostomy and ureter neostostomy, I think you run the risk of migration of that stent over time. Dr. Yuk, there's a question about, do you notice any differences between use of non-barbed and barbed sutures for bladder repair? Yeah, if only tension is maintained at the suture, there seems to be no difference. But, however, if practical use, barbed suture is more, yeah, more, yeah, tension, more maintenance the suture tension. Yeah, so this reason I like to, yeah, use the barbed suture, yeah. Yeah, you know, I think many folks probably saw that for the first time and, you know, are shocked that you're using a barbed suture. There's so many sort of myths out there about what you can and can't do. I use the barbed suture all the time for colon also. And when you actually, as a GYN oncologist, if you actually go in and watch other colleagues operate, you realize that that barbed suture is used for just about anything. And there's really no restrictions on that barbed suture. And it actually just makes things go faster, in my opinion. So it's five minutes after. There's a lot of questions here. Many were answered by our speakers as we were going. I'm always available. If you contact IGCS, I'm always happy to answer additional questions. But there's so many great questions here. I think we've run out of time for today's session. And thank you all for coming. Hopefully, this was helpful. Again, this will be recorded. Thank you both, Dr. Erickson, Dr. Yook, for your time. It's all the time we have for today. I would like to thank all the IGCS staff who made this possible. I would also like to thank our speakers today for their time, of course, their expertise and insight. Lastly, I would also like to thank all of you for attending the recording of today's session. We'll be available in the IGCS members education portal by the middle of the next week. Upcoming IGCS education may be found on the IGCS website. And also remember, our annual global meeting will be in my hometown of New York City, September 29th, October 1st. Abstract submissions are open. Please submit your abstracts. And there will be an in-person as well as virtual participation options offered. Please go to IGCS2022.com for more information. I wish you all continued health and safety. Dr. Yook, please feel better and recover quickly and stay well, everyone. Bye.

educational webinar

genital urinary system

gynecologic oncologists

surgical anatomy

injuries prevention

bladder injuries

ureteral injuries

repair techniques

Q&A session

IGCS education portal