Jehovah's Witness Patients Undergoing Major Urologic Surgery in ...

Jehovah’s Witness PatientsUndergoing Major Urologic Surgery inthe Robotic Surgery EraDaniel Eun, MDAssistant Professor of UrologyDirector of Minimally Invasive Robotic Urologic Oncology & ReconstructionPennsylvania HospitalUniversity of Pennsylvania

Welcome to the City ofBrotherly Love!

Pennsylvania Hospital: Nation’s 1st- 1751Penn Med: Nations’s 1st Med School- 1765

The adoption of robot-assistedradical prostatectomyCourtesy Intuitive Surgical

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Robotic Prostatectomy:Positioning & Incisions

What else beyondprostatectomy?

• Urology residency &18 month robotics fellowship• 2001-2008: 4500 cases performed (peak: 800 cases/year)• 4-7 cases/day (local/regional/interstate/international patients)• 3 years spent on dedicated robotics trainingTraining at Henry Ford Hospital, Detroit:2002-2008• 2001: Prostate program• 2003: Nephrectomy and cystectomy program• Intro DV-S platform 2006-2007: Kidney protocol formalized @ Intuitive HQ• Cooperative with Mansoura, Egypt and Kuala Lumpur, Malaysia• Numerous travel opportunities for residents/fellows• Multi-specialty collaboration & procedure development• GYN• Bariatrics• Transplant: donor nephrectomy• Hepato-biliary: partial hepatectomy

“Danny, One day this will justbe urology”-Mani Menon 2005(Urology Chairman Henry ford Hospital)

“Danny, let’s be careful inadvertising what we reallycan do”-Alan Wein 2008(Urology Chairman university of Pennsylvania)

• UreterolysisCurrent Robotic Urology Program:• Ureterolithotomy• Cystolithotomy>30 robotics procedures offered• Pyelolithotomy• Pyeloplasty• Intracorporeal Ileal Loop Diversion• Radical cystoprostatectomy• Anterior/total pelvicexenteration• Partial cystectomy• Urachal resection• Bladder diverticulectomy• Simple prostatectomy• Radical prostatectomy• Extended template pelvic & periaortic LND

Regional Referral Center for HighRisk patientsJehovah’s Witness patients: > 30 patients in 3 yrs“Hostile abdomens” (Whipple, TAH/BSO, EC Fistula, Mesh)Previous radiation, brachytherapy, TURP/KTP laserMedically complex patients: cardiac stents/ASAMorbidly obese: up to BMI 71 (flank) & BMI 45 (pelvis)Iatrogenic injuries needing reconstruction “High litigationpotential” (ie: Mid ureteral avulsion)Advanced/complex cancer cases: solitary kidney, horseshoe

Current Experience: Pennsylvania Hospital 2006-11Refer to posterGolan, Llukani, Eun: Comparison of robotic vs openurologic patients in Jehovah’s Witness patients: A singlecenter experience

Challenging Cases

Case #1: Adrenal Lesion

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Case #2: Painless gross hematuria• 62 yo female w/painless GH w/clots• Referring urologist did a 88 gm TURBT• “I think there’s a lot more in there!”• Pathology: grade 2 SCC w/ deep muscularispropria invasion

Case #2: Painless gross hematuria• MRI showed posterior 5 cm bladder masswithout hydronephrosis or lymphadenopathy.• Bone scan neg.

Case #2: Painless gross hematuria• 62 yo female with muscle invasivesquamous cell carcinoma of the bladder• Options: Open vs Robotic AnteriorExenteration.• Plan: Opted for robotic ant exent withextended pelvic lymphadenectomy andileal loop urinary diversion

Bladder Cancer:Extended Template Pelvic LND

Bladder Cancer:Extended Template Pelvic LND

dder Cancer: Extended Template Pelvic LND

ILEAL LOOPUROSTOMY & BLURETERAL STENTSIncisions

UrachusOvariesFallopian TubesUterusBladderCervixAnterior VaginaUrethra with Foley

Postop• Discharged: POD#6• Final pathology:• 5.5 cm G1 SCC invading through detrusor andinto peri-cervical tissues (T4a)• All margins negative• 56 lymph nodes: Neg• 18 months: NED on CT, Bone scan

Case #3:Renal mass on a solitarykidney

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Case #4• CC: Abdominal pain• 59 year old JW female• PMH: BMI 61, HTN, CHF, MI, Afib,Ischemic Cardiomyopathy, OSA,Pickwickian syndrome on Home O2• PSH: Gastric bypass, BL TKA,Pacemaker• Creatinine: 1.0

Case #4• CT A/P: Enhancing 6 cm solid renalupper pole mass c/w maligancy (90%endophytic)• CT Chest: Neg• Bone scan: Neg• Renal Bx: Clear cell RCC

Case #4• Assessment: Morbidly obese JW cardiopulmon-vasculopathfemale with 6 cm(cT1b) RCC• Plan:• 1) Open partial nephrectomy on iceslush Vs Lap radical nephrectomy VsRobotic partial nephrectomy• 3) Cardiac & pulmonary clearance• 4) Bloodless medicine consult

Case #4• Bloodless medicine: Preop Hgb 11• Ferric gluconate and darbepoetin• Preop cardiac cath: EF 30%, multipleocclusive coronaries• Undergoes 4 vessel CABG

Case #4• Return to office 1 year later• Creatinine up to 2.5, now 1.3• New CT C/A/P: Mass now 7.5 cm. Nolung lesions, LA or renal vein invasion• Bone scan: Neg• Renal scan: 60% right/40% left splitfunction

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Perioperative course• Operative time 120minutes• Warm ischemia 45minutesExtraction incision• EBL: 500 cc• Postop Hgb nadirto 6.7• D/c Home POD #7

Case #4: Pathology• 7.7 cm Grade 2 Clear Cell RCC• 4 Hilar Lymph Nodes Negative• Margins: Negative

Case #5• Cc: R testis mass• 27 yo healthy JW male• Scrotal U/S: 4 solid masses in right testis(largest 2.7 cm)• Markers elevated: Hcg 624, AFP 161• Social: Recently married, no kids

Case #5• Banked sperm• Right Inguinal Orchiectomy: 2.5 cmchoriocarcinoma 50%/embryonal 50%;tumor confined to testis; cord marginnegative• CT C/A/P: Neg• 4 week serum markers: Normal

Case #5• Assessment: 27 yo recently married JWmale with Stage 1 NSGCT (50%embryonal) and normalized markers• Options: Surveillance, Chemo, RPLND• Plan: After careful considerations, patientopted for nerve sparing robotic rightmodified template RPLND

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Case #5Extractionincision• Operative time 3 hours• EBL: 100 cc• D/C home POD #1

Case #5• Pathology pT1, N0, M0:• Cord margin negative• 0/26 Para-caval & interaortocavallymph nodesPre/Para-AorticInter-Aortocaval

Case #5• Successful antegrade ejaculation on POD #5• NED @ 18 months• Baby boy “that looks just like me!” born 3 weeksago

Robot not only enables execution of theseprocedures...But allows recovery from vascular injuries• Weck clip applicator• Robotic Weck clip applicator• E Tape: 4X18 Lap sponge: introduced via 12 mm port• 4-0 Prolene on RB-1 needle- cut to 4”• Robotic needle driver X2• Vascular surgeon/vascular instrument tray on backtable

Vascular injury protocol• Compression + Time= Control your environment• Compress or grasp bleeding• Suction field• Recover pneumoperitoneum• Sequentially change arms to needle drivers• Make sure you have everything you need• Deep breath, focus… repair• Let everyone go to bathroom

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“Auribus tenere lupum”(“I hold a wolf by the ears”)- TerenceInterpretation:I am in a dangerous situation and dare notlet go.

THANKYOU!!!daniel.eun@uphs.upenn.edu