So welcome everyone. My name is Reitan Ribeiro. I'm from Erasto Gardner Hospital in Curitiba, Brazil. And I'm co-chair of the Surgical Education Workgroup of the IGCS Committee, along with my co-chair and co-moderator, Dr. Carrie Langstrath from Mayo Clinic. And I would like to welcome you today to this today's Surgical Film Festival on Urinary Reconstruction. That's gonna be an incredible panel of surgeons will be sharing their expertise with us. Before we get started, I want to mention a few housekeeping items. There will be ample time for discussion today. So we encourage you to submit your questions through the Q&A feature at the bottom of your screen. And we will try to address all the questions if we have time for it. The recording will be available at the portal at the IGCS Educational 360 Learning portal next week. And I will hand it to Dr. Langstrath who will be sharing this session with us. Thank you, Dr. Ribeiro. It's my honor to introduce today's speakers. Joining us are Dr. Roberto Angioli of Policlinico Campus Biomedico in Italy. And he will present on continent urinary reservoirs, Miami pouch versus the Rome pouch and partial uretero cystectomy with bladder preservation. Then Dr. Vance Broach, actually we're switching the order slightly today. Dr. Vance Broach will start today. He is from Memorial Sloan Kettering in the United States and will share his wet colostomy video. Dr. Marilo Luz of Hospital Erasto Gartner in Brazil will present ureteral re-implantation and psoas hitch. And then we will have Dr. Peter Lim of Center of Hope and University of Nevada Reno School of Medicine in the United States and his film on ileal conduit. Without further ado to kick off today's film festival, I invite Dr. Broach to share his film. Thank you so much for joining us. Thank you. Morning, everyone. Okay, it's a pleasure to be here. Thank you so much for the introduction and for the opportunity to share this video and this work. I'm gonna be discussing a double barreled wet colostomy as a option for urinary bowel diversions in patients who have a total pelvic exoneration. Just a little bit of background before I share the video. The first pelvic exoneration was described by Alexander Brunschweig, who was actually the first service chief of the gynecology service at Memorial St. Kettering. And this procedure was performed in 1946. And following the resection of the pelvic viscera, the patients that Dr. Brunschweig operated on had a wet colostomy, different from what I'll be presenting today. But in this schematic, you can see the ureters were re-implanted into the colon and that urine and stool mixed in the body and then exited into a single bag that's shown here. This had a number of problems associated with it. Patients have ascending pyelonephritis, electrolyte abnormalities, they developed adenocarcinomas of the colon at the site of urinary implantation and malodorous watery diarrhea, sometimes death as a function of the stoma complications. So given that this is not the ideal outcome and the best type of urinary reconstruction and bowel reconstruction, other separate reconstructions were utilized for really 50 years, including ileal conduits, which was first reported in 1950, which we'll see today. And then the concept of a double-barreled wet colostomy was introduced in 1989. And this was first described by Carter and 11 patients were included in this description for varying types of cancer. And the concept which is outlined in the schematic here is that the colon is divided into two limbs, one a urinary limb and one is a stool limb. And then the urine and stool don't mix in the body, but mix in the bag as they exit. And the benefit of this is that patients would have fewer bowel anastomosis, they'd have a single pouching system, presumably lower rates of electrolyte abnormalities, pyelonephritis, because the stool and urine weren't mixing in the body and potentially for shorter operative times. The other value of a single bag is that it allows for harvesting of a myocutaneous flap, a vertical myocutaneous flap to fill the pelvic defect after a exoneration. So we did look at our experience of doing this. And this is another schematic of what this looks like over here on the right. And this was recently presented at the European meeting in Barcelona by one of our fellows, Mo Byrne. And we looked at our 10-year experience of performing this procedure from March of 2013 to March of 2023, and looked at complications and outcomes among patients compared to those who had separate urinary and bowel diversions. And really what we found is that these patients don't have any difference in terms of complications, both short and long-term, but that they do have a significantly different operative time when a double-barrel wet colostomy is done, which sort of makes sense. And again, this also allows for patients to have a myocutaneous flap harvested from one side. So the conclusion from our review of our experience is that this is an acceptable alternative to traditional separate urinary and bowel diversions and something to consider for patients for whom it's appropriate. With that introduction, I'm gonna show you a video. This is a patient that I operated on with one of my partners, Mario Leteo, and it's gonna show an intracorporeal robotic-assisted double-barrel wet colostomy in a patient who had vulvar cancer and who was undergoing a total pelvic exoneration with curative intent. This is the defect. And this patient did have a right-sided VRAM placed for reconstruction. And then we, again, after counseling this patient, elected to have a double-barrel wet colostomy. And so that's what we did for her. So the first thing that we did is we find the area where we're planning for the most suitable side of the stoma. So there needs to be a sizable urinary limb and so that some of the urine can be collected and then drained. And so we typically look for about 10 to 15 centimeters of distal colon in order to have a suitable urinary conduit. And we mobilize the ureters to ensure that they're tension-free when we make our ureterobalanostomosis. So this is the left ureter here that we're mobilizing. Just anecdotally, left tends to be easier than right when we do this just because of the left-sided situation of the colon, but usually it's not an issue to get the right mobilized also, which we're doing here. And once we ensure that we have adequate length from both ureters, and this again is the right side, then we assess the sites where the ureters are gonna be re-implanted into the colon. Again, this is sort of midway in the urinary conduit and with enough space between the two ureters that they don't interfere with one another. And this clipped into the ureter, obviously is trimmed. There's the, yep, the obvious there. And then we put a staged suture here in the same way that you might with an ileal conduit, which I know we're gonna be seeing in a little bit. So that's very similar in the way that these ureterobalanostomosis are done. So this is spatulated to allow for a nice opening there and then open the side of the left ureterobalanostomosis. And then typically place a suture at the apex of the urethral spatulation and then tie this to the bowel. And then the plan is to circumferentially suture the ureter to the bowel, so we can nicely secure that anastomosis. And that's what we'll be doing here. This is what we use here as a 4-0 Vicryl. Yep, and don't want these to be too close to risk structure, but also not too far apart where there might be a leak. So ideally, these are about one to two millimeters apart and look for between four to six circumferential sutures. Do place stents, and I'm hoping we'll hear a little bit more about the value of stents for ileal conduits. I know there's some debate about that, although we do place stents here and we did place stents here, and then fed the proximal end into the renal pelvis and then the distal end into the colon and the side of where the stoma will be created. And then with that stent placed, then the circumferential sutures are placed to complete this ureter of bowel anastomosis. That should just about do it here. And then this is repeat this on the other side as well. Don't worry, this is faster. You don't have to watch me struggling with these sutures for a second time completely. That was a joke, not a very funny one. So the stent goes up into the renal pelvis again and then into the colon. So both stents are sitting next to one another. And then when the stoma is created, those stents are pulled out. And then this is when the stoma is mature. These are the stents that you can see. This is a malachite drain that sometimes we'll place into the urinary limb just to help with the drainage and healing to make sure there's no stenosis. Just one of the issues that we're seeing with our patients who have these double varroa wet colostomies is that pouching is a challenge. There's no pouch that really satisfies both the needs of a colostomy and a urostomy. And so we are patenting and developing a bag pouching system, which allows for stool to exit through a normal colostomy and urine to exit through a normal urostomy. It's basically a single bag that has a porous membrane that stool can't pass through, but that urine can. And so patients can wear a urinary collecting device like a urinary bag or a leg bag and can keep that on throughout the day. And then when they move their bowels, it doesn't require change of the entire pouching system. The other important component to this that I didn't mention is that, we really don't know the best patients to offer this to and who's gonna benefit most from this. And so PROs and qualitative interviews are ongoing to decide or to help assess which patients might benefit from this the most. And so hopefully we'll be able to share some of the results of that work at a later date. But I do think this is a reasonable alternative separate urinary and bowel diversions and something to consider for our patients. And I'd be happy to answer your questions. Thank you. So thank you so much, Dr. Birch. It was a beautiful presentation. I just want to let you know that it's open for discussion. So it's a reminder, if you wanna submit your questions through the Q&A button at the bottom of your screen, please do it. In the meanwhile, I have a few questions. So regarding patients who got irradiated bowel, we know this may be a challenge. So how do you decide where to place your ureters? Do you use any sort of evaluation? How do you decide where is the best point to do the anastomosis? Yeah, it's a great question. And certainly any bowel that has sort of been exposed to that radiation field, probably not the best place for that anastomosis. And so we do oftentimes trim the colon back to get really healthy tissue that was out of any radiated field to make sure that the urinary bowel anastomosis is in a site where there wasn't any radiation. So, I mean, ideally this is descending colon just from a functional standpoint for these patients, but sometimes it just needs to be a little bit more proximal to make sure that the tissue is healthy. Do you think that diverticular disease may be a contraindication or no? Yeah, in this video, this patient had some pretty significant diverticular disease, and it's definitely something that gave us a minute of pause when we were doing this. She did fine. Fortunately, the urinary bowel anastomosis is typically sort of really on the antemesenteric side of the bowel, ideally in a tinea, and there aren't really diverticular there. And so you can find a nice place to re-implant the ureters, but it's a great question and definitely something where we had a moment where we were sort of gasping whether we were doing the right thing or not, but this patient did great. And she's actually still alive and doing quite well. This was a couple of years ago we did this. So we have a question from the audience. It's how do you decide to use this instead of a yearly bowel conduct? It's the biggest question that we have now, and we don't have patient-reported outcomes or qualitative data to help guide that decision. On the one hand, you say, well, maybe for older patients it would be better because it limits the number of bags that they need and makes it simpler for them. But on the other hand, the pouching system is a bit more complicated. And when things go wrong, they go really wrong. And having a patient have to really change that pouching system multiple times a day if they had diarrhea or if they're really, the urostomy appliance is getting clogged, it's a lot. On the other hand, you say, well, maybe then it's better for younger patients who are able to do that. But we don't really know the 40, 50, 60 year outcome of these patients. And maybe they do have the same problems that the old-timey wet colostomies would have. And we just don't know it because we only have 10 years of follow-up. So I just, it's a great question and one that we really need to explore more and that we're actively doing. I can tell you the most recent patient I offered this to was a 47 year old, very active person who lived in Hawaii, actually had recurrent cervical cancer. And after thinking about it, she opted not to do this. And she ended up getting a continent urinary diversion and an end colostomy. And she's so happy with her decision. She self-caths her a continent urinary diversion. And actually she's gotten to the place where she has one very formed, regular predictable bowel movement in the mornings and then doesn't wear a pouch on the colostomy. And so, I mean, thank God we didn't do this for this patient because she really made the right decision. And so a lot of the discussion with the patients and figuring out what's important to them and in their lives and what their values are is so key, of course, in a big surgery like this, but particularly when making this decision. Yeah, no, I agree. There is another question and actually you just answer it. And I think that's a very particular because some very obese patients, maybe it will be very hard to pull it through the wall, maybe use a ileal conduct. Sometimes it's so short, the measles of the colon is maybe short. So it's going to be hard to do like a double colostomy. Yeah, but like a loop colostomy is so hard to get through. I mean, it's such a big aperture that you need for obese patients, it's certainly a challenge. Oh, awesome. I'm sorry we don't have much time for going through all the questions, but I'm quite sure Dr. Brocci will be happy to answer in the Q&A feature. So thank you so much for this wonderful presentation. And next I will invite, it's Dr. Murilo Luz, is it right? Yes. So I'm gonna invite my good friend, Dr. Murilo Luz, who's gonna speak about ureteral reimplantation in psoriasis reach. So welcome Murilo. Well, thank you, Aiden, for the introduction and thank you for the invitation and congrats for this nice format and this nice event and webinar. I'm really happy, it's a pleasure for me to be here. So I'm gonna talk about a bit more simple stuff here. It's a ureteral reimplant. I don't have slides, but I'll talk about the theory about that during the slides. And I'll show a couple of cases. This is not very complicated. It's quite easy to understand. So you can do this ureteral reimplant for many reasons. This is one case on left side, a stricture at the distal ureter on the left side. So dissection of the ureter is something that can be a bit challenging if it is a pelvis that is irradiated or is a pelvic malignancy. But most of the times, you're not gonna have a big problem. You can do this, I'm showing a robotic case here that's most of what we do nowadays. But you can do it open, you can do it from extraperitoneal access, actually, you don't even have to be intraperitoneal to do ureteral reimplant. You can do it open, laparoscopic very well, but we're using the robot most of the time nowadays. So what you see here is a dissection of the distal ureter. And you can use this technique for quite a lot of cases, even if you have like long strictures or you have to take it out a big chunk of ureter with a pelvic malignancy, you can go all the way up to the iliac vessels and still you're gonna be able to get the ureter there. The big challenge is the bladder. If you do have a small bladder, it's not a good capacity, then you have to take the decision using other kind of urinary reconstruction and not to do a reimplant, you're not gonna have success if you don't have a good amount of the bladder. So you can see this is quite a nice and juicy bladder, so you can bring it up, it's not irradiated and there's no disease in the bladder. So it's quite easy to get there. The planning for a ureteral reimplant is it can be intraoperative. Sometimes you're not expecting to do that, but you have to at the end of the case. Sometimes you have a leak after a case in postoperative day one or two, and then you have to take the decision, should we just stent this case or do a nephrostomy tube and then I'm gonna do the reimplant after a few weeks when the case is not as acute. This is a decision we can take or you can do it immediately right after the case or in the postoperative two or three. This is not an easy decision, people are stating that. We actually don't have the right answer for that. So you can see this, we're opening a nice part of the bladder, then having the ureter, you have to take a look and leave as much as possible the tissue around the ureter to keep well vascularized and healthy tissue. You can use the Firefly here at the robotic, if you have access, you can use the Firefly to see if your ureter is okay, is well vascularized, but you see this amount of tissue around the ureter is very important to keep it there. And then you take the decision if you need or not a psoas hitch to bring that bladder all the way up to the psoas muscle. So in this case, the second case I showed that for you, a psoas hitch in this one, that was not necessary. The bladder came very well, there was a bit of a big bladder and a bit of fat around that bladder, it came very well. So there was no need for a psoas hitch on this left side ureter. So again, you're gonna use some separate stitches, you can use two continuous stitches in one side or the other side, that's what we are doing. For those who are not aware, this is a 4-0 caprofil. What I think, you know, I have a bit of difficulty in using Ficryl, I think the chance of having a rupture using the robot, it's a bit higher. So I'm much more comfortable using BDS or caprofil. This is a 4-0, you can use a 5-0, it depends what you have there. And you can do this ureteral re-implant in a refluxing way or in a non-refluxing way. You know, you can create a kind of a valve using the bladder wall and the muscle of the bladder and trying to create a valve and not using a reflux and creating a reflux system, or you can just go straight and you're gonna have a refluxing re-implant. There are pros and cons for each case. You know, if you're using a refluxing technique, people would argue that maybe in the future you're gonna have some loss of renal function because of that refluxing, and maybe sometimes you can have some infection. So this is something I was, I'll just pause a second here. This is a good trick and a nice way to go all the way up with the double J. You know, I'm using double Js here and an endophilic guide wire. So I come with the two things together. If you see, I'm grabbing the guide wire and the double J in a single, just a single grasp. So I'm going all the way up. So in the old days, we used to go with the guide wire and then trying to go with the double J on top of it. So nowadays we're just going with both things together. So you can assure that your double J is inside the kidney, because otherwise you're not sure at the end of the case and you can end up having this double J like midway and still in the ureter on the top part. So after I finished my first layer on one side, then you've got the double J in, and then you can just suture the other side, getting a good part of the mucosa and doing a continuous suture. So I'm using two sutures, one on each side, like a pile of plastic, but you can do some separate stitches. No problem at all. We are keeping the double Js. There's a good discussion. If you need the double J in this case, people would argue that you can do this re-implant and keep it there with no double Js. That's an option. I'm keeping there. I'm not using JP drains. You know, we're not using even for, you know, some bigger pelvic surgeries. So we're definitely not using for a ureter re-implant. So just using a double J and keeping the folic catheter for five to seven days. So it's almost the final result. You can test the bladder. You can get some saline in the bladder and see if it works. And most of the times what we're doing, we do what I'm showing to you right now, which is this, you know, the second layer with the bladder fat just on top of the anastomosis, you know, just to feel better at the end of the case. But you can also use like a tunnel using the bladder wall, the muscle of the bladder wall to really trying to get some of the, of the anti-reflexes. So this is the psoas hitch. So on this right side, this is another case. So the bladder was not coming as easily. So then we using this psoas hitch and getting this stitch. So we'll come back just a second so you can, you can see it. Yeah, so here's what we do. This is a zero vicro suture. You know, you need a strong suture to get that bladder. And the important thing here is you have to dissect very well the bladder, not on this side, but actually on the other side, because then you can bring this bladder from the left side to the right side. And then you have a very easy and with no tension, a suture with no tension. So then, so after that, then the next steps are almost the same. It's not a big deal. So this is an endometriosis case when at the end of the case, they took the decision to take the part of the ureter out. That's what like three or four centimeters of the ureter. So there was not a big deal to get this ureter down there. You see, there's not as much ureter than on the other case, but again, with the psoas hitch and bringing the bladder all the way up to the psoas muscle was not a big deal to bring the ureter down and get the anastomosis. But you can see here, different from the other case, that there's like a bit of tension here, because now we took more of the ureter on this side. So in this case, I had the benefit of having a cystoscope and I actually put the double J up using a cystoscope because the patient had a cystoscopy for the case, not just because of the re-implant. And here we are kind of trying to do some of this valve to have some anti-reflex valve, and it's a different scenario. And as I told you, the pros and cons in each case. So I think it's this, and thank you. I'm happy to take some questions. Great, thank you so much, Dr. Luce. I look for some questions in the question and answer chat, if people have questions out in the audience. I will just start with one question. I think these patients were kind of healthy tissue type patients, but you'd mentioned if a patient had prior radiation, you'd want to check bladder capacity and so on and make sure that the bladder was sufficient. What is your typical workup when you're considering a patient that had maybe radiation, stenosis or stricture or something that distal ureter to make sure that this is going to be an option for them? Yeah, definitely you have to, thank you for this, it's a great question. And we definitely have to scope this patient, take a look at the bladder during cystoscopy. You can get some idea how the bladder is moving and how healthy is that bladder. Most of the times we also do some imaging and our cystography, or even in a CT scan, if you have a dedicated radiologist that goes in a late phase and really takes the time to take a look at the bladder and do after a contrast phase, they would just get a good idea what the bladder can do or where that bladder can go for the re-implant. But this is very critical because if you don't have a good bladder, there are two problems with that. One is technical. So it's going to be difficult for you to do that re-implant, the bladder is not coming up, it's not coming out from the bone, it's not coming out from the pelvis. And sometimes it's not going to reach there and then you're going to use some kind of other urethral reconstruction as an ileo ureter, or using some kind of a small bowel or any other reconstruction. But other than that, even if you succeed and you can do the re-implant, that patient is not going to do well after that. So those patients, they don't have a good bladder, they would have lots of symptoms, they're not doing well, they're urinating every hour or every half an hour. So they're not happy with that procedure. So for those patients, you have to take the good discussion and maybe go to a different, for a new bladder or for an ileal conduit or a continental version. Great, thank you. There's a couple of questions in the chat. One is, at what level of stricture fibrosis can you do a ureteric re-implant? So like what level of the ureter? You know, it's not like a very, there's not a big cutoff, let's say six centimeters, eight centimeters, depends a lot of things, depends on the bladder, depends on the patient anatomy. But, you know, overall, like eyeballing, you can go easily all the way up to the iliac vessels, which means, I mean, six to eight centimeters. But I feel patient that you can go even higher, like mid ureter, you have to, if you do a psoas hitch, and maybe if you do a boary flap, as using like a part of the bladder to get no three or four centimeters more, then you can go all the way up to the mid ureter, so sometimes like 10 centimeters. But, you know, you have to be prepared and talk to the patient before that maybe that's not gonna be possible. So this is a bit more challenging procedure, but you can do like long strictures, or if you need an excentration, or you need to resect, not excentration, but you need to resect a good part of the ureter, you can go all the way up, but then you have to use, you know, after those, the iliac vessels, you definitely need a psoas hitch, and a good part of the time, you're gonna need a boary flap also to help you to get a couple more centimeters there. Great, and then one final question, do you differentiate mucosa and the detrusor serosa layer in your closure for the ureteric implantation, or do you take all layers in one bite? I'll take all layers in one bite. You know, if it's a tooth, I mean, this is not common in women, but in men, sometimes you have a very thick bladder because of BPH, then sometimes you don't need to take like all the way, you know, the muscle is like a one centimeter muscle, you don't need to take all the way, but I'm gonna take a bit of the muscle and the mucosa in one stitch, like it's one layer. What we do, as I show you in those videos, sometimes I will put a bit of a fat on top of the anastomosis, and if I want an anti-reflexing re-implant, then I would do like a tunnel before the mucosa, and then I'll close just, you know, do the anastomosis and then a second layer, but just closing the muscle on top of that first suture. The problem with that, that you're gonna have a bit more strictures in your re-implant when doing that technique. Right. Well, thank you so much for joining us this morning, Dr. Luz, or today. Thank you a lot. All right, we next invite Dr. Peter Lim to present his film on ileal conduit. Dr. Lim, we appreciate your time here. Are you ready to take it away? Can we see your screen? Well, thank you. Good morning, everyone, and good evening. Thank you for giving me the opportunity. It is quite an honor to be invited to present the robotic ileal conduit. This video illustrates a robotic-assisted ileal conduit formation. A tape measure is introduced, and the ileal conduit is harvested 15 centimeters from the ileocecal junction. The length of the ileal conduit should be about 15 centimeters. A mesentric window is created at the proximal aspect of the conduit. Once that is done, robotic endo-GIA stapler is introduced via port number three for bowel transection. We then identify and preserve the mesentric blood supply to the conduit. Peritoneal incision of the bowel mesentery is made to delineate the borders of the mesentery and the endo-GIA stapler. The endo-GIA stapler is used to delineate the borders of the mesentric pedicle. The mesentric vascular pedicle to the conduit is fashioned and skeletonized. Using sutures, we isolate the staple line of the efferent limb. This helps to prevent urinary stone formation. The suture that we use here is a 2-O-micro, essentially isolating the staple line. Similarly, mesentric window, bowel transsection, and skeletonization of the mesentric pedicle is performed for the efferent limb of the conduit. Obviously, this is a very critical step in trying to preserve the mesenteric blood supply to the conduit. The afferent limb of the conduit is anchored to the sacrum for stabilization during the ureteral ileostomy. I think this is a critical step, primarily, because it allows to stabilize the conduit while you're performing your ureteral ileotomy anastomosis. Otherwise, the conduit's sort of dangling, and also it just stabilizes it, which allows us to do the re-implantation. To ensure tension-free anastomosis, the ureter is mobilized to the pelvic brim. Using the robotic pot's scissors, the left ureter is prepared and spetulated. My instrumentation now, my non-dominant hand, the forceps, these are force bipolar forceps, and I switched it to the diamond forceps, and I prefer to use this because of its fine forceps and all. You can see that these are my favorite forceps in the ureter work. The anastomosis begins at the apex. It is important to ensure the knots of the sutures are placed outside the lumen. Right, to place the knots outside. This is, again, 4-ovicle, RB1 needle, small needle, and the critical step in this, if we like to anastomose the back wall end. The farther aspect is sutured first. The base of the anastomosis is suture to ensure the back wall is sewn. And the next critical step of stenting in the ileal conduit, I think this is the... Then we excise the staple line of the efferent end so as to allow introduction of the ureteric stents. So, previous presentation, the stents are all placed, this is through trial and error after having done multiples of these, that we like to put a Red Robinson catheter that allows really a stiff rigid, and then this Red Robinson catheter and all. And the trick here to do when you're stenting is to keep your stent short and taut. If you let it extend, it will coil. So we basically position that Red Robinson catheter. Recurrent ureteric stenting is now performed. The guide wire is introduced into the ureter, then the open-ended catheter is removed before a single J stent is threaded into the ureter. It is important to stabilize the guide wire during this maneuver so that it does not slip out. And that's the other thing that we found out, these stents can... We use Chromic 2-0 suture to anchor the stent to the conduit to avoid displacement. The Chromic suture that we're using, so it dissolves... The remainder of the anastomosis is performed once the stent is in place. These steps are repeated for the right ureter. A Foley catheter is then inserted into the efferent limb of the conduit. It's balloon distended, and the anastomosis is tested using betadine solution. Any leaks or defects are reinforced. You can see the back wall, there's a little area of a defect that was still leaking. We then proceed to perform small bowel side-to-side anastomosis. Stay sutures between the two loops of bowel are placed. And we use these sutures as a leverage to mobilize, maneuver the bowel, as demonstrated here. These are performed in the two loops, and the robotic endo-GIA is introduced via port number three for small bowel anastomosis. We use the sutures to bring The anastomosis is reinforced with overrunning silk sutures. To prevent accidental displacement of the ureteric stents, they are anchored to the ileal conduit with absorbable chromic sutures. Finally, the stents are exteriorized. The ileal conduit is brought to the abdominal wall and the urostomy is matured. The stents can be removed after six weeks if a lupogram then shows no leakage of contrast. So post-operative care, as the video demonstrated, we typically perform a lupogram in six weeks to check for an asthmosis and if it's no leak, we remove the stents. I think it's important to establish a baseline renal ultrasound six weeks because these do reflux to ensure that they don't develop a hydro or potentially a stricture in the future. And we monitor creatinine and then we repeat a renal ultrasound in about six months to ensure that they have not worsened hydro. And if it's all stable and all, just monitor them clinically. So thank you very much. Thank you, thank you so much, Dr. Lim. Let's open up for discussion. If you have some questions, any questions you can send through the Q&A button. And I have a couple of questions. Can you use irradiated? I know this is always the same question. How do you decide, am I going to use this ileum that it was irradiated or you never use it? How do you decide it? I think it's a, there's no metrics per se measure and certainly that's a very valid concern. We look for the viability, if it's really, really fibrotic and all, in certain, we will not use the ileal, I may use a transverse colon as the conduit away from it, the segment of the bowel. I think it is very, very critical. We did have a patient that we use an ileal conduit and that was radiated and couldn't really tell, it looked healthy and all, but she had a terrible, terrible postoperative and of course, I mean, we resulted in the breakdown and all. So if it's really white and fibrotic on the ileum, I probably would not use it if it's nice and healthy and viable and all. The question is, is that with the advent of using, I've never tried it, but this is something that I was thinking about, ICG, ICG may be a role in that. I don't know, that's been, in fact, I don't think that everyone really has evaluated that, but we certainly use ICG for bowel anastomosis and all. Yeah, that's interesting because also if you have some ischemia, would you like change your plans just because of some mild ischemia using ICG, that's hard to decide. I could see that you use your arm number four for extraction of the ileostomy, right? So you put this arm exactly where you are planning to do the stoma, right? No, actually, yes, actually that's a port was really in arm number three. So ideally, that's where my main dissector instrumentations go in, because ideally that would be eight centimeter lateral to the midline camera, that's where the stoma site is. I think the critical piece in doing these and all is the stenting. I'm a stenter, I think, you know, someone had mentioned earlier about the value, I think it was Dr. Broach. I like to stent because these are radiated patients, I want to make sure that the anastomosis heals, there's no stricture. And the most important tips and tricks of this is as you pass the guy wire, you can't let it go, coil, so you got to keep it taught. So I always say, keep the guy wire in the disc, you know how the guy wire comes in a disc and you're just passing it as, and you want to keep it taught, number one. Number two, putting a Foley catheter in that ileal conduit is really a critical piece if you're doing an ileal conduit, because if you just put a open-ended ureteral catheter with the guy wire, it will coil in the ileal conduit and all. That's why we put the Foley catheter first, then the guy wire, remove the Foley catheter, and then put your ureteral stent in, in that fashion, in that order. I've gone through many challenges that way, that's what I've learned over the years and all. And then, that stays suture, because the stent will displace, you know, so those are the three key things, I think, in doing this. Yeah, no, that's a really important step. So there's another question regarding this irradiated ileum, and there is a limit how proximal you can go if you're selecting the segment of the ileum. There is a limit, I mean. Well generally, I like to harvest my conduit approximately 15 centimeters from the ileocecal junction. The other, obviously with these ileal conduits, and you have to be careful because in an obese patient where you have thick anterior abdominal wall, you may have to harvest a 20 centimeter, and then you might run the issue of hypochloremic acidosis. Ileal conduits are wonderful for thin patients where you have anterior abdominal wall, because in an ideal situation, it's between about 15 centimeters. As you can see on my video, my proximal and the efferent limb was a little bit dusky, and we had to shave that off a little bit. So you want to give a little room to fashion in such a way that, you know, your stoma is nice and healthy and all. Yeah, makes sense. So thank you, Dr. Lin, for this wonderful presentation and discussion. We will have to move forward. So thank you so much. Next I would like to invite Dr. Angioli to share his film. So Dr. Angioli, please proceed. Okay, well, first of all, you know, I thank you, thank you, Rita, and thank you, Kerry, for inviting me for this really prestigious session. And I'd like to thank Ashley and the entire IGCS staff working on the educational session. And of course, thanks to Mary. Mary's always behind each activity, and especially, you know, when there are educational activities at IGCS. So I will present the continent urinary diversion, a couple of options of continent reservoir. The Miami pouch and the home pouch, and then even an option which sometimes we have of concerning the bladder and to resect only partially the bladder and the ureter. What I like to stress, though, is the importance of the anterior parametrium. You can see in these slides, you can go even in the next slide, where you can next, you can go next, where you can see posteriorly the posterior parametrium, the superficial and the deeper part laterally, the lateral parametrium. But anteriorly, you can see the superficial component of the anterior parametrium and the deeper component. These, in my opinion, are extremely important when we do radical hysterectomy, because it's where the recurrence occur. As a matter of fact, you can go ahead. The next, we, in the majority of case, next, in the majority of case, when we do a pelvic accentuation for recurrent cancer, we perform either a total pelvic accentuation or anterior accentuation, because the recurrence starts in the anterior parametrium, which is the most difficult technically to remove entirely. But posteriorly, it's very rare to have posterior accentuation for recurrent cancer, because usually the posterior parametrium, as well as the lateral, we remove easily. Next slide. This is an example of anterior parametrium resection. So we have removed the lateral, we have removed the posterior parametrium, and I, for didactic reason, I isolate here the superficial portion of the anterior parametrium with a loop. And you can see it's about three centimeters, maybe four, and you can decide if you want to resect close to the bladder, which is the anterior part that you can see in the video, or closer to the uterus, the posterior. Once it's resected, the superficial component, then you have the ureter, we lateralize here, and then you have the deeper portion. With a loop, for didactic reason, we have now the deeper portion of the anterior parametrium isolated. And again, you can resect close to the bladder or close to the ureter, according to the extent of the tumor. So you really can tailor the resection. You can really decide how much of the anterior parametrium, but it's important to recognize the landmarks. Once it's resected, you have the ureter with the bladder that you can see without the parametrium. Next. Next. Next slide. Okay. Next slide. Okay. So during the last 10 to 15 years of my gynecological oncology activities, I was in the University of Miami and then later on in Rome, then the most of the bladder reconstruction were the Miami pouch. And later on, the last about 15 years, I moved to the Rome pouch. But they are quite similar. And I'd like to show you the difference of the two techniques. Next. You use the same segment of bowel. We use essentially the sacrum with the ascending column, the right colonic flexure, and the part of the transverse column. We use the last loop of ileum as a efferent loop that we use to anastomose to the skin for the stoma. Next slide. The difference is that with the Miami pouch, we detubularize. We open completely the large bowel, we flip it, and we close and we suture. And we obtain a low pressure reservoir with the efferent segment of the bowel being the last 12 centimeters about of a small bowel. And the continence is obtained with the ileocecal valve and reducing the lumen of the small bowel and the ureter anastomose inside of the pouch. Next. This is an example of the Miami pouch. The bowel, the colon is completely open, flip it, and fold it, and then we suture. Next. To lose the peristalsis, therefore, we obtain this low pressure reservoir. In the upper left corner, you see the calibration of the small bowel, which is going to be the efferent loop. And usually, we reinforce the ileocecal valve with a proline suture to increase the pressure inside of this efferent segment. Next. These are publications that we made, but next slide, on the Rome pouch, this is the Rome pouch. In this segment of bowel, maybe a little bit less than the T colon segment, we, instead of opening the entire bowel, we make the tineotomy. Next slide. So once it's filled up with water, or you could have, okay, next slide, go ahead. We do the tineotomy to decrease the pressure inside. Making the tineotomy, the pressure inside of the colon from, let's say, 120 millimeter of mercury drops immediately to 20 millimeter of mercury, 10 millimeter of mercury, and we do the tineotomy without entering the bowel, just the tinea, and the mucosa is preserved. But we have now a low pressure reservoir. So then we do our anastomosis of the ureter, and then we modify, next slide, the efferent. Next slide. Okay, this is the segment of the large bowel that we use, which is not open. It's quite important because these patients are previously irradiated patients, the majority of case, and to make many sutures increases the risk of complication. Next slide. This is the picture of calibration of the small bowel, as I mentioned before, in addition to calibrating the small bowel, which is the efferent segment of the reservoir, then we reinforce the idiocecal valve with some praline stitch, next. And this is the efferent loop, next. Next. The anastomosis of the ureter, initially we were making a tunnel. We were tunneling the ureter inside of the pouch. Then later on, due to the high incidence of stricture, we decided not to tunnel anymore, and nowadays we do not tunnel, neither for the Miami pouch nor for the Rome pouch, next. When it's possible, we try to avoid the removal of the bladder, it's more rare because in the majority of cases, the excentration is either anterior or total, but in certain occasions, we can do it. Next slide. This is an example of ureteroneal cystostomy, this is, you can see the cancer right there at the level of the anterior paramecium between where the ureter ends into the bladder. And this was the big recurrence. The hardest part was to dissect the recurrence from the rectum and from the side wall, was indeed a lateral one, and below from the vagina. We removed the vaginal cuff, which was involved with the tumor. We remove part of the bladder and we remove the distal portion of the ureter. And this is entering the bladder and dissecting part of the bladder. So the spacement composed of the vaginal cuff, the distal ureter, and a corner, the left corner of the bladder, made the patient free of tumor. Here is the ureter, it's spatulated with pot scissors, is introduced inside of the bladder and I make the anastomosis similar to what I do when I create a reservoir. So without tunneling, I anastomose inside of the mucosa mucosa and these are reinforced stitches, serosa serosa, serosa of the bladder with adventitia of the ureter, two or three stitches just to decrease the tension. And we place, in this case, a double J. When we do the reservoir, the continent, we use a single J usually with the stent going out of the abdomen. The foley that you see is inside of the vagina because with the spacement we remove the vaginal cuff so the foley is just like a drainage through the vagina, it's not inside of the bladder. The bladder is being closed, as you can see here, in a couple of layers. The first one is mucosal muscular layer, the second one is the adventitia, and then we made a psoriasis H to decrease the tension of the ureteroneal cystostomy. So basically, really, we tailor the procedure according to the patient when we can preserve the bladder we do it, otherwise, like in the majority of cases, the anterior pelvic excentration or total pelvic excentration is performed. This is just a recent case and the patient actually went home ten days after the surgery with no complications. Okay, thank you, I think to start the game, okay, thanks a lot, thank you, Ashley. I think you're on mute. I forgot to put down my mic. Thank you so much for your presentation, Dr. Angioli. Actually, it doesn't allow me to speak, you know. That's right. Dr. Roberto, did you have any questions for him? It's a very interesting presentation, and one of the things I was curious about is the vaginal drainage. Do you always leave vaginal drainage on those larger procedures? How do you decide to use it, and how do you manage it? Because we are not used to it. Yeah, I have to be honest. I like drainage a lot in these cases. We use no drainage in any case, but these cases. So I leave a drain close to the anastomosis of the ureter with either the pouch of the bladder. I use a drain as a sentinel close to the bowel anastomosis where I have to create the continuity, and in the majority of cases, yes, when I open the vagina, which is in the majority of cases for some reason, I like to use a drain in the vagina, which is the last one that I remove, because once the patient starts to mobilize, and then I remove, I see after a few days that there are no leaks, then the fluid goes down into the pelvis, and it's the last one that tells me that everything is okay, and it's the last one that I remove. So usually, yes, I leave a drain inside of the, between stitches of the vagina. That's why I use a drain with a balloon, I prefer. So it's a small, it's a small hole through the vagina. There is one question, or a couple of questions in the chat. The first is, where do you reimplant the ureter after partial cystectomy with distal ureterectomy? If I open, yeah, open the vagina, I like, in this case that I showed, the ureter was quite long, because I resected only three centimeters, four centimeters of ureter. So if I can, in the posterior wall of the bladder, and I try to avoid where I flap, I don't like it too much if I can't avoid, because there are too many sutures. But some, in the majority of cases, I prefer to have the bladder open and do the anastomosis as I show, instead of making the anastomosis like an end-to-end, like a cirrhosis, because of the risk of leakage, especially these are the majority radiated patients, and the risk is quite high. So I prefer to bring in, I do not tonalize the bladder ureter, but I reinforce a little bit with some stitches. So if I can in the posterior wall, to answer your question. So still in posterior wall, not anterior bladder. Okay, and then for your post-op management, is there any specific investigation that you do, or how do you follow these patients afterwards? I have to tell you the truth, we have a luxury to have a very good radiation oncology and interventional radiation team. So actually, we check with our radiologist, the ureter, the bladder, so we do radiologic investigation, which in the past I never did it. But if you can, actually sometimes you discover a small leak, so maybe you leave the drainage longer, or if you need to make a nephrostomy, you do a nephrostomy. So really, we have great help from our radiologist, and I use it. Right. Thank you so much for your great presentation. Okay, thank you, thank you, Carrie, and Rhydon. I'll let you close us out here. So see you at the IGCS in October. That's for sure. So I would like to thank you all for attending this very special session, and I also would like to thank Carrie, my co-chair, and the recordings will be available in the IGCS 360 learning portal next week. Keep watching and keep following us for more educational content, and I wish you all good and a healthy week, and see you in the next seminar. Bye.

Dr. Angioli

surgical techniques

continent urinary reservoirs

Miami pouch method

Rome pouch method

anatomy

pelvic exenteration procedures

ureterotomy

bladder resection

continent urinary diversion