Daniel Eun, MD, Fox Chase-Temple Urologic Institute Provider, discusses the management of complications in robot-assisted surgery.
we're going to move right into dan's second talk. He's going to give us a talk on robotic complications and management. So, dan, you can take the floor. Thank you. Uh, let me set this up. Uh, as I'm setting this up, I didn't realize there's another U dub University of Washington withdrew my my talk, but there's also Wisconsin as well. So, of Sorry if I confused anybody. zero. My former fellow went to University of Washington. Um All right. So here we go. Um All right. So, I guess I don't know. We'll have a little bit of fun with this. I'll cry a little bit about my own complications while I'm doing it. Um You guys can hear me okay? Yes, we can. Great. All right. So, I'll talk not just about robotic complications, but also how to manage some complications with the robot itself. I'll introduce some maybe some concepts that you guys have not seen or heard of before. Uh, kind of uh, you know, be provocative here. Um, so here's my disclosures that I shared with you guys uh an hour ago. Um None of them has changed since. All right. So first when I got invited by you guys, I'm from the Philly Urological Society and this is the Wisconsin urological Society I thought which society name is worse and uh puss or was. And so I kind of looked this up and kind of put the slide together and I kind of it's pretty obvious pluses worse. Mhm. Um Anyway, moving on. So I hope, you know, try to keep the time on the clock and try to fit what I can in here. But there's a bunch of different um complications. I'll talk about your either basketball anastomosis and how alternatively how I treat them with after prostatectomy. Uh You can't have a good complication. Talk without, you know, some gladiator uh induced blood. So I will show some of that. Um There uh show a quick video on a trick I we use for pneumothorax. We haven't had many of these. But um one of my students have come up with one of my residents to come up with a solution. We'll talk about the lady stitch and how key it has been in preventing lymph vessels. I'll talk about Phil pile plastic, but it's really similar to uh you know, the video that you just saw for buckle graft. Um So I won't dwell on that too much. And then I'll talk about your entire strictures after urinary diversion. Uh Kind of a cool case that I came across last month and I had my fellow ended this down really quickly for this meeting. You're an entire uh your I'm sorry, an arrow conduit fistula after a little conduit. And then I'll show you kind of my worst nightmare case, which was a complete your little avulsion case that we and I'll try to get to that one. So this this complication, this particular patient happened. I don't know a couple of months ago. 50 young guy, bad cancer, high pizza every core positive took them after a negative imaging took them for surgery, uneventful operation. A little bit of blood loss. Things were stuck down. Um, and then in the pack you um, he just put out low urine output. We initially tried to send all these patients, especially done earlier in the day that don't live too far away home on the same day and gave him a couple of units blood. Um, really didn't pick up. Um, check some labs. Um, hemoglobin was a little bit low, but not nothing spectacular. And I remember walking away from my uh my junior resident saying treat this as bleeding until proven otherwise, admit the patient canceled out patient discharge and then follow urine output. Let me know what's going on and so continues to have lower urine output over the next two shifts, hemoglobin is kind of fine, right? It's kind of stable. Um And they're they're doing serial labs overnight. Um And this creatinine is rising. Um You know, I always tell the residents, challenge me if you think differently. Um You know, tell me why my chief resident made the right decision. Uh Junior resident in house said the abdomen feels slightly distended. They ordered a ct. They didn't even tell me about it. I actually commended him for making uh executive decision on his own, called me at three o'clock in the morning, said we got free fluid in the belly, um Track along the gutters. And I thought to myself, I can only be one thing, right. Um, He's not bleeding, he's not making in urine, He's got a big leak. And so, um, the options here, you can upside the catheter, try to put the catheter on section, try to continue to suction, placing higher drink. What would you do right for me? I said, let's immediately book this occasion is post op day one for the O. R. I'm going to go back and fix it, right? So, um, this is not a decision that I made. Um you know, you know, just once I've made this decision on other cases, not so early after surgery and I've done this a few times, so I'll tell you my rationale for it. Okay. And so, um and so this is what we did. So because I do so many simple prostatectomy Zay, do a transvestite will approach to do 200, 400, grand plants. We come transvestite all the time. So it developed a comfort level with this over the years. So my thought is, you don't want to drop the bladder, you don't want to cause more traumas area. The uh destruction is almost always posterior early. I switched to a third degree up ones I think here, and usually you're staring right at the defect, right? And so there it is, right. Um and so, uh, this guy, we had to open a fairly large sized hole in his bladder because I had done an anterior urethra, pixie and bladder, um suspension afterwards. Um and so I had to take all that down. The bladder just wasn't situated. Well, because he was so, firstly after, you know, freshly post off, but we put villach features in Randallstown closed, um, basically backed out close the bladder patient stayed overnight for uh for one more night and then you're not but picked up drain stopped, send him home. And he's basically otherwise had a uneventful postoperative course, which we all know that had we not um we've been kind of more conservative approach. You know, this course would have not been so predictable, right? And so I want to kind of challenge everybody there. You know? Um It's not that the traditional way of managing your either vessel anastomosis leaks are is wrong, but is that the only way to do it? Right? So let me I'll show you some other cases, right? This is probably about eight or nine case we've done. Right. So, you know, this is a scenario that we see from time to time. I don't care how good you are. You get a leak every once in a while, right? That's a standard of care, prolonged catheterization for X amount of weeks or months. I've heard I think up to six or nine months in some cases just, you know, you feel guilty, the patient feels bad. Um you know, you feel like somehow this is technically related. Maybe it was bladder spasms, Maybe it was a big a big blood clot that pushed, you know, I don't know what it is, but in the various reasons for different cases, but you know, you you end up as the operating surgeon with this terrible amount of guilt with it. And so what we started doing was for years ago we started approaching these. I think the first one came at us for me around four or five weeks after surgery. And so we decided that we would give the patient an option for conservative management versus taking this patient back to the operator. I don't know why this video stopped. Well, this is typically what you see here, right? Um, this huge defect that's almost always posterior, right? And you there's questions in your mind how is that going to heal? You know, is there is that going to turn into a stricture? What's the continent's gonna be like? Is there gonna be a pocket that stays there? You know, there's there's these concerns, but, you know, the biggest problem just being unpredictable ways that, you know, when you drop the Catherine there, there's a if you're a suspicion of a leak, I always say put a code a in or scope it in and get a sista graham afterwards, right? Because I remember as a resident putting a scope and on one of these patients and the balloon got blown up host eerily. And I'll show you an example where this caused a devastating problem for another patient. And so that's what it looks like. And so I'll show you what it looks like when we take the patient to the operating room. So this is what the cats can look like. Um Sorry I somehow I think one of my slides okay, so oh I see what I'm doing here. So um that's what it looks like um problem on the next slide here. So um this is another case where we run the scope in. There's kind of two disruptions at four and eight o'clock, right defect, Their defect there, right. And then uh this is a patient that was shipped up to me, got on a plane, you're all just from texas called me. Set this patient off. This guy unfortunately had some small leak. I don't think it was picked up, went to the emergency room. The paradox never called him. Put a foley in thought they saw some urine and they just blew the balloon up in the in the in the defect happened actually twice without them calling the urologist. And then you had a complete 360° uh disruption. This urologist had heard somewhere that I have talked about this and called me and I was at my son's football game in the fall and he said dan will you take this guy uh and possibly fix him? And I'd never fixed a 360 degree. This is what it looks like. Um When we when we you can see that's that's the complete disruption, right? It's terrible. It's completely distracted bloom had blown up in your a few times in the er did not call the urologist. You're all just kinda hit him out of the blue that this patient had this problem. Um And so I took this I said sure. So I took this patient on, we arranged for a flight to come up in office hours and then maybe like a day or two later I would take him to the operating room. Right? And so I'll show you what some of these things look like. So we make a hole of the dome, you know and these really kind of favorable cases where the patient skinny and you know the bladder is given a few weeks of the bladder to reposition itself back and forth ecologically. We typically can get away with a really small cyst autonomy three incisions. I'll often go without even a suction right and I'll just take my arm out and suction through it. So three incisions. We use the old position sites and then as soon as you make a hole in the dome and you drive your robot in. I mean you're staring right at the defect, right? And so you have the ability and to to close these in many cases right now. I just recently did one where I couldn't get to it. It was uh uh he was uh freshly post op and I couldn't get to it. And I actually tried this close it and he continues to have a leak. And so I can tell you that this works 100% of the time. But I think that's my 11 failure after maybe eight or nine of these type of repairs. Right? And so This is a patient with a 360 degree. This is the guy that came up from Texas, right? Um and I basically did the anastomosis. Just like I do on my simple prostatectomy is where I do a full 360° re anastomosis. I do a watertight anastomosis of his urethra and bladder. All right. So that's what I do for every single simple prostatectomy. You know, I've done probably around 250 of them, right? And so this is a skill set I'm very familiar with, right? We do a full bladder, neck advancement and anastomosis. And so that's what, essentially, I'm basically copying that technique and basically re advancing it and bring it back in. And so that's what we're doing here and it worked out it worked out beautifully, right? And so after I put two or three in, then I just kind of guitar string these things together and pull the whole post your plate in. Um that's how we start our symbols. And then we start just going around and taking them sequentially all the way around for a watertight repair. And so uh just take your time. You know? Watch your tension. The Villach. I don't like the locks for regular, posterior regular. Uh And your approach. Excuse me. Uh Interior approach prostatectomy. And that's Nasa jeez sorry about that. But for um but for red sea sparing, prostatectomy is and for symbols, I like Villach because the way that the future keeps tension on and it doesn't allow the tissue to slip black except slip back. And so here I'm actually bypassing, I'm coming all the way around. I actually bypassed the post your plate again to reinforce. Mm. We then uh close the back wall of the bladder water test that this guy did find. So we could, you know, I think we Presented this at a few of the, you know, meetings in a way where we showed uh different times from the index surgery. Uh and now we've done one on post op day one um where the patients did well, they may have stayed a couple extra days um and uh the fully catheterization, um you know, some of this determination of capitalization is by their own home urologists. And so they may have stayed in for longer, but they all ended up having good continents. So this is an option in some cases if if you want to talk to your patient about Yeah. About this is an option. Uh Here we're gonna look at uh complication of bleeding. Um This was really early. Kids, you can look at this video and you know, this is a davinci ass, right? And so it's a really old video. It's not even high def. Um I'm doing a partial and I see this little artery that's definitely not the real hard, you can see it's off to the right there and so I'm not really sure what this I hum and haw all over this for a while now. What I do here, this is just pure laziness, right? I don't feel like getting a scissor and I like to use it for a lot of my dissection. So, you know what's the problem here? Wet clips work really well, except they need a little bit of a stump. I mean, that's the reason why there is a black box warning on transplant effect. Amis right, Is that they used to cut these real short with no stump? The the clip would fall off and the patient would lead death, right? And they had a few incidences like that. And so here we get further back and I'm looking at this going, I don't know if that's going to the kidney either. You can see the direction of renal arteries, wait off to the right. I'm not sure what this is. I don't think we need this. Uh, you know, and what I essentially do is the risk of my right instrument just bumped that wet clip, but it didn't take much to just since it's gotten, it's got no no extra tissue there. Um, it just slipped right off, right. And so it's already pressure, right? This thing is bleeding fast. And so, um, you know, here, I always tell people, don't raise your voice, don't start screaming at everybody because you're nervous. You know, a lot of times I'll put compression on it, I'll go to the bathroom. I'll actually let my adrenaline um calm down so I'm not shaking. Right? Uh, if you need to get blood in the room, you get blood in the room. if you want to get an open tray open trade. But you have a few shots now I used I had them build a bolster this was my P. S. Idea, just like it very efficiently caused precise uh pressure on you know like a finger pressure pressure on the on the area that's bleeding. So I could take it on and off once you decide you're going to commit to the future. As a figure of eight, just really watch your resting and you're turning your wrist and your technique here. Try to ignore the bleeding. Try to keep the camera off of the bleeding trajectory. You know, everybody is just, you know, you know, you're all tense watching this, you know, it's very tense when you're actually fixing this. Um And so um you know as much as you can uh you know you have to this, you have to force yourself to really kind of um you know go through this process with not overreacting. You have two very intentionally try to not scream at people because you're nervous and um and as much as you can try to try to get yourself through that adrenaline curve so that you're not shaking, I've actually had shaking through the tremor filter of the robot in times when I've done very kind of high risk things like this. And so um your figure that the one thing I also learned when you're when you're fixing the aorta, it's happened to me more than I want to admit in my career when you're fixing the aorta, It may take about three knots before it finally tensions down so it stops bleeding because the pressure in the aorta will blow back just enough pressure to open up the knots to about the third or fourth. Not okay. And so you have to be kind of be prepared for that. Now, I kind of know that and I will expect that when I let go, you know, or I'll do a surgeon's knot first. But you know, I'm just so careful to get that first, not down quickly. Sometimes I don't want to get caught up in doing a surgeon's knot and then getting my wrist caught up in the future. Mhm. And so here, you know, my P. A Lindsay's adding a little bit of pressure um on, you can see she's very very gentle at what she's doing to get that off. Finally, it's down to just a low trickle. And then we got this thing closed, right? And so uh now I call that a smaller or simply because Mhm. My next one here um is probably my worst vascular injury that I had. Um This was a redo uh affected me. So patient already had a partial and I thought I'd gotten the vessels uh dealt with. I thought I got the only artery. And uh so I I kind of went in too quickly. Too cavalier, you know, thinking I was I was past the critical planes and I went charging in and remember, this is all fiber optic pre operated violated tissue planes. And so these this with this wet clip. Um you know, so, I'm making bad decisions here, right? I'm in a rush. I'm making bad decisions here, putting a wet clip, you know, robotic wet clip, you know, on fiber optic tissue where you don't have a back window. Not a good idea, right? And so, as I keep my left hand on that, I'm doing one handed surgery right to try to get that back of the wet clip freed up. I get into a second leader. All right. And so this is going downhill very quickly. So, well, you don't realize between that last sequence in this sequence here. Is that a lot of time has gone by. I knew that I was in trouble here. So the trauma, we have really good trauma surgeons at temple because the amount of penetrating gunshots we have. So I called, you know, my colleague bobby in there, he's open table, we've got a central line in the patient now. Um there is uh blood hanging pace is probably I think already gotten one or two units in. So, um, you know, every time we looked at this day and see just scream at me, we lose, we've lost pressure, right? The bleeding was rapid enough and I've never got into a situation where I was pleading with the trauma surgeon to open and he kept looking at me going dan, put a sponge stick above robotically and sponge stick below and compress the order enough so they can slow down the breathing. I think you can fix this. And so we got in this really awkward situation and he said, don't worry dan, I won't let the patient die, I'll open and get my finger down there fast if I need to. And I was so scared. Um you know, I'm not saying that this is necessarily the right thing, It does show incredible ability um you know, um of of this technology and experience to be able to get down to this. I wouldn't say that this is probably the right thing to do in in many situations. I think you have to very individually look at the scenario in this situation. You know, I did try it. Ali talked me into it and um and so we decided to um to try it. So I put an extra port in, I got a sponge stick above, we compress the aorta enough. I readjusted my, my fourth arm to compress on one of the bleeders. It was a little awkward because there was a lot of collisions where we got one of the bleeders control so I could work on one of them at the time. And we finally got this one fixed, the one to the right fixed first. And then as soon as I got this one fixed, I knew it was gonna be okay because we could fix the second one. Um But uh yeah, this is probably my worst vascular injury. You know, this is the, I'm a avulsion we did in the post kim more appealing the um but, you know, this is just a lot of bleeding very quickly. But the level of complexity on this was great because it was two sources of bleeding off of the order. But I think um my heart, my heart rate and my blood pressure is a little too high right now. So I'm gonna I'm gonna move on. But we eventually got figures at eight down on this. Got the bleeding to stop, got the other one fixed and uh very humbling every time I look at this uh this and so, you know, I could have used more caution that day as I was going through the rest of it. Um And so um you live you learn and hopefully change and get better. And so I obviously have gotten much more careful about redo cases now. And so vascular injury protocol, uh you know, uh you know, if you can try to get compression and time, that's really what you need, right? Uh If you can compress and and get time then you can change the outcome because you can get prepared. You can open the back field, you can get blood, you can get a central line and you can get the right surgeon in there to help you. Um You know, if you need to emergency open. And so that's that's my main, my main point here is uh try to control your environment. Um You know, don't keep looking at it and lifting it up because you just will make the bleed or worse, right? And then when you're already and when the when it's optimal and go in and try to fix it, every time I'm in the upper perineum I don't do this for prostate. But every time I'm preparing the um I have a 24 Oprah leans on preloaded on needle driver ready to go at a moment's notice they always have a tape ready to go as well to be able to, to grab something and push it in and compress over 12 moment of port. So this is just a really quick trick we presented. This is what I think France, abdominal chest tube for the management, sorry. Um, for one of our local society meetings. So there's a, the, the diaphragm defect. This is from delivery tractor on the right side of partial. So what I'm basically doing is putting a purse strings future in here. Nowadays. I um, I probably would have used maybe like a vicryl, just that I've had a little bit more traction um, on the not. So, you know, you guys are familiar with this concept, right? You're putting a JP drain right way into the pleural space, right? There's no lung injury there, it's just a plural defect, right? So I tie this really tight so that later on, um I can pull it from outside the body and then this personally has closed tight so that it collapses and stays closed. Right? I don't think that trying to do this while you have numerous inflation, you're looking at it is a good idea because you just force abdominal air into the lung space and so it may look fine, but I think there's always a little bit of a new mo there. And so what I like to do is put this in, leave it alone, back out completely, get all the air out of the belly. The trick here is I learned that these JP drains is 15 JP drains actually fits. You can really snug it over like a sock on a foot onto the five millimeter port um suction port. And then that's a great suction device so that while you tell anesthesia to give a huge breath and all the air is out of the belly. We do we repeat that a few times and and put, you know, turn up our section all the way and it seems to work really well. And in the case where we did it, we didn't have any um any residual air in the lungs. So it looked really good afterwards. And so we kind of showed that technique, The next slide and the next complication I'll talk about is as limp fossils. You know, I used to do a lot of big lymph nodes sections and probably about 8%, of my patients would get really admitted after prostatectomy with Lynn fossils or some type of infected lymph vessel or some lymph vessel related complications. Right? Or you know, pressure avoiding. And they often happened 4 to 6 to 8, 12 weeks after the surgery. But you know, um I had one patient that died. Um I went home and got re admitted. You know, a bunch of conflicting studies. I asked vascular to help me essentially. They said this patient does not have a limp a seal. Um I'm sorry, does not have a DVT. We put a drain into it, we decompress this Olympus seal. Um They said you don't need anti quiet. This person doesn't have DVT patient went home and like the next day he died. Right. And that just you know that I always stayed with me and really hurt me to see that this happened. And so I think the problem with lymph vessels is it sets up a scenario where this can happen, right? You get a large, very compressive lymph seal right off of the object of lymph node chain. You dissected out the bladder reattach is back up. It seals off the area. Now it's compressive, Right? So if it gets big, it leans on the external iliac vein, you create a huge dvt. And so I I had the scenario happened all the time, and from then on, I was terrified of these readmissions. Um and then um at the boston au eight years ago, I saw the lady guys present this and I just thought to myself, huh? Right. And so they presented their data and we've since then, um uh since then, we've reproduced a similar study and I contacted ali uh ladies and this is honestly one of the best contributions to prostatectomy in my eyes. That's been recently in recent years. And he really credited David canes for coming up with this. And so this is, I'll show our video, it's basically a modification of the of the late and essentially what you're doing is you're preventing um that that bladder from resealing onto the parent alleges to reseal. So what you're doing is basically outwardly averting the bladder perineum to face into the lymphatic channels. So that when the bladder heels, there's a channel that persists right? Um into kind of where the lymph nodes are done. And so um I use a V lock stitch. I don't use bike girls, like the way the lady guys, but the concept is the same. Right? And so I I that is basically, I modified this for efficiency purposes. I use a V lock, I use sliding clip, I don't want to sit there and mess with knots and all that. So I just basically sliding in and I'm using absorbable uh clips here. Uh huh. And so I just slide it down and then cut it short. And basically what it does is what you want to see is you see how the bladder parody um Evertz out towards the lymphatic uh towards the bone and towards the iliac fossa. That's what you want. And so I'll basically uh you can cut it, you can put it on it and just repeated on the other side. So you really you don't want to go right where the where that junction is, where the vast meets sapir vessel. You wanna migrate away from there and give it some room. And then I land this clip on the bladder um anterior to where my pentacle of clips are. Because I don't want to nail the your your inner right? And so I take a pretty deep bite here above or anterior to um the medical clip right? And then I send it back out around there and then I just cranked this down and throw another clip on. And what it does is basically permanently fixes. And so the lady guys actually have this really cool video they showed we're gonna get a lot of holy like a year or two years later and they show that on both sides there's a gutter is still there, right? Although the bladder it clearly reattach is the side gutters are still there. And so that Olympus still cannot be created. And the and the crazy thing is is that in their data, I mean they did uh a randomized study with about 77 patients HR basically zero officials on on on their series. And we repeated very similar study. And it also same with us. Zero official. So I guess since my my fellow kevin Yang that came from lady that convinced me to start doing them. Um Since now it's been almost three years ago. I've not had another olympus ill readmission since then since we started it. And so it's really powerful statement to say that you make 15 minute adjustment in your operation and it completely gets rid of a complication that you that you are so terrified of. And so um so my next complication, I'll talk about this failed pile plastic. Just this is kind of a bane of existence of a lot of urologists do pile pasties. You know because a redo pile passage is really tough. And so at this point now I pretty much do all of them as buckles. You know part of the problem with this is that now you're over mobilizing you know further the vascular tissue, you know, then your spatula eating and then you gotta pull it, you know. So we talked about this concept in my last um uh lecture on your it'll reconstruction. And so this is a classic what you see, right? You see this renal pelvis, you see this smooth tapering um just tear terrible tissue, right? Um And uh here what I'm going to do is not trying to cut down to where it's open and then try to pull them all tightly together. I'm just making a launch total yuri keratotomy pilot to me, right? And um and then uh so I'm gonna cut down till I'm convinced it's open, right? Um And I think the reason probably why we have higher failure rates on this buckle on the redo pilot classic series may have something to do with paris a peristalsis, but also probably has something to do with the fact that we probably just didn't cut down enough. Right? And so, um, you know, nowadays I will I will, you know, really make sure I cut down low enough. Again, this is one of my older videos, because you can see, I'm using Blue Pds future here. I don't think it really matters. The PDS has a little bit too much memory for me, coils around. And so now I switched to Monaco, but here, you know, um, you know, we dissected out launch tool, your reader, artemis pilot to me. I do it, answer immediately. Stick a stent in, take out the park tube. And uh, so this craft and then I swing momentum up and just really carefully. Very, very considerate way pixie the momentum and so that it doesn't disrupt or cause additional tension. Um, and and so here, you can see me running momentum here. You know, I didn't know how to do this in my residency. They never taught me how to do a mental flap. Um, I had a general surgeon actually teach me how to do this uh, laparoscopically. And then I just uh, then I saw him do a couple for me and then I've been started to figure out, I think I can do this robotically and then started doing these on my own. But it's just not, it's not very hard to do. Um You just have to kind of see it done once or twice before. Um You know, there's no real rule here. Um I think you can take it off the left or right side. You know, I would kind of look at it and see what looks easiest to me. Make sure that if you see a big blood vessel coming through, then you would want to consider uh you know, putting a clip on and uh because it could re bleed, you want to watch your windows because I think the worst complication you can have from momentum other than injuring bowel is uh is causing an internal hernia scenario. Uh We have a closed loop of bowel stuck somewhere in there, and I saw that once during my residency where we did an open momentum flap, and I saw somebody lose like two ft about. Um and so I'm always worried about that. I've not seen that in my career yet, but uh I always kind of tell people that's what you should be worried about since I saw it once once is enough. And so here we're just closing uh the so we're sticking this a mentum in and then closing the retro peritoneal fat around it uh to secure it so that and I really like to fix it in multiple places so that it doesn't slide around, it doesn't tug and pull off. And so um You go, I have about 10 minutes left your your entire structures. So this is actually a manuscript in progress. I'll just share with you. There's multiple centers around the world. Um I'll show you my my poor placement is almost always this one to the right, right. I circled it because they put poor placements for various surgeons in here. Seven institutions. Um You know, we we, you know, we that this is probably the same as my series, Roughly about an 80-85% success rate. I tell patients 80% success rate um for this um neo bladders and um And illegal conduits. This is an 80 year old guy who came to me um from Florida after he had a prostatectomy. And then years later developed bladder cancer from his uh, salvage radiation. And then ended up with uh suspect emilio conduit um by a well known surgeon. Very competent place happens all the time, unfortunately, um, to our urinary diversions and so there's a difficult complication to deal with. So I started doing these robotic because I first started saying these recon surgeons and I realized they weren't fixing them. And so I I started doing this robotically. And then years later I found a lot of other people were to. Um, and I think robotic is a really good option for these. Um, you know, allows you to sneak in under the conduit. You know, you have to do a fair amount of license adhesions to kind of figure out where everything is, where the military is, see where the future lines are. And once you get to a point and I always the residents always go is that it is that it? I always stay quiet. I go, I don't know, I don't know. Let me keep going. And at some point what you have, everything laid out in the light of the sun is completely done. It becomes very obvious where everything is, right. So if you start looking at different approximately, this guy had the left side of structure. So this I suspected that this was the right side. We actually injected I C. G. Down is uh pc. It was left P. C. N. So we toggled on the I. C. G. In the in the near infrared. It did not glow green. You know, as I keep going down and dissecting down. Lower, I see something tubular. Ha ha! That's probably it. So I turned on my indian friend. There it is. It lights up. That's my left side of your order. There's a complete bird's beak. It has completely distracted off. I think what happened was after the numerous IR attempts to balloon this. They must have completely just distracted this thing off. I found this a number of occasions now. I used to uh send these guys off the I. R. Balloon dilation three times before I re implant them. I just realized all I do is just make my job worse. Unless it's an early development of a your entire structure, I might try to send for one gentle balloon in a very early development of a structure. I almost always will just take these guys just straight to surgery. I'll put a park tube in and just take these guys directly. Because I our management fails often, and I are management makes this much much worse. Right? This complication happened to me about 2, 2.5 months ago, we had a guy that I did this uh case I did your uh, suspect me and Elliot conduit we did into corporal lee. So, uh, he was doing fine all of a sudden he started passing food particles, right? This is years after. So he had this uh, he had solitary kidney, um, suspected me, he's passing food particles through here. He had high stage urethral carcinoma. I try to manage him conservatively for a while. He kept on getting infected. He kept on passing food products in and I realized conservative management was just not fair to ask this guy to keep going this way. And so I decided to bite the bullet and go in. But I really realized was this case really wasn't that bad. Um we went in um uh you can see a system like optically you can see some of these staples have kind of eroded through. We found the fistula site um and I passed the you cath in the first time we tried, we couldn't get it through when we were studying this thing on the second go around, we're able to pace passing you Catherine wire, you can see in the small bowel there's a wire going through there, right? So the urinal Catherine, the wires passing from the, from inside the conduit into the fistula into the small bowel. And so you can see this is our poor placement. Just like I told you um you know, showed on the picture, this is our poor placement. Um there's a stoma basically do a gentle arc. Uh always used the excise system uh since it has much more mobility and axis of rotation. And so here we do the dissection, we do the licensee asians because this is all inter corporate really done as a as a conduit creation. Uh adhesions were really not bad, right? So I pretty much get down to the area business really fast and I'm starting to look at this where the future line is and I realized there's something going from where the ball bell future line is right to the conduit. And we asked them to wiggle the Euro catheter. I can see the Euro catheter in the bowel segment, right? Um when you wiggle it and pull the wire. And so here we're starting as we start to dissect out towards the base of the conduit, we see what really starts to look like. That's where the where we wiggle it and when we kind of manipulate it, that's where it's coming from, right? And so um there's a urinal Catherine, the bowel, that's the actual bowel lumen, right? And so we basically just put a stapler across there um you know, and um and we added this out really well, you know, in all honesty, my my chief resident took over at this time too, so I'd like to try to get these guys in as much as possible. He forgot to pull out the you cath at staples, stable across it. So we have to take everything out and then pull everything apart and then so we have to show some of this back together primarily. But at the end of the day we got back together again, close this up and the patient really did well after this. And so this was an interesting complication, interesting way to manage this. Uh maybe not the way that a lot of percentage would have managed it for us. We felt completely comfortable doing it this way. A lot of extra staples that we took out of there and and I'll move on. So this is my I have uh four minutes. This is my worst complication I've ever had. At 6 30. I got a call from a private hospital that our residents rotate through the uh B. M. I. 61 diabetic woman. The G. Y. N. Was doing history RosCO P. And biopsy for dysfunctional uterine bleeding. She didn't realize she had perfectly your uterus and ended up in the retro peritoneum. And she decided to biopsy something long and squiggly and kept pulling on it and 15 cm of your came out right? And when the uh it was right before christmas I remember saying shipping the patient and had a perk Cuban and this patient didn't make urine for a while. And if you look at this, the renal pelvis is gone. And I didn't believe it. I actually thought it was scar or something. But she really did pluck the ureter and the renal pelvis out with it. Right. And so, um initially I didn't believe it. So I thought I was going to do an illegal your order here. Right. And so that's what I came in planning for. This is me looking into the renal pelvis at um, in the hill, um, there's really no usable renal pelvis. So what am I going to do here? Right, Am I going to do a your it'll kill a cost. I mean a real conduit to a killer cost me. You know, I'm thinking this is a bad scenario, is diabetic woman uh found the world's longest appendix. I'm not joking. This was a 12 centimeter appendix. So it's 12, it's not 18 centimeters, still not enough. So I decided to do go for it. So I decided to do, you know if I there was nothing to. So too, so I decided to do a kayla cost me right. So I I put the kidney on client to dissect at the highland, which was terribly scarred down, I I got an artery clamp on, put the kidney on clamp and I basically did a lower pole excision to a low cost me set up. And uh, and then I realized that was still not enough. I got a couple of cm that way downward. Never practice advised me about 4-5 cm. So aggressive renal mobilization downward after pixie. So, I bought myself probably about Maybe 5,6 cm here by doing a kill accosted me with the downward never pixie. Right. Once I got to this point I'm thinking this might work, right? So at this point I commit to it and um I uh amputate the appendix and I now in flank position uh semi flying position in A B. M. I. 61 woman I am able to uh mobilised as much of the bladder as possible to associate. So I bought myself another maybe 34 centimetres there. So now I think we were in range right for a 12 centimeter appendix to make it right. And so here that's our bladder defect or re implant site. So it was really hilarious listening to me try to dictate this uh op note because I was just making up procedures, append a co re implant, pentacle, kayla cost me, you know? But I was able to finally put this thing together and um and there's the appendix now stretching and making it and there is our, so it's hitch site where we of got the wire up, passing the stent up through the 12 centimeter long appendix finally got into the kidney and and after a long day we got it in and this is a, the six week retrograde, you can see the kidney moved down a lot. Pre op and post op. The patient has preserved renal function and t one half less than five minutes. I see her back once a year and she's doing great. So anyway, this is my worst, worst complication. I'm sorry, I'm one minute left here for questions. But again, thank you again so much. I'm so very honored to be here as I guess for the Wisconsin urologic. Thank you for inviting me any questions being dan. I think right now with time let's save any questions possibly for the panel this afternoon. Okay. Um, that sounds okay. Sorry. No, no worries. It was a great lecture. I enjoyed it. Uh, I do all endo urology so that much bleeding is certainly puts me on edge. All right.