Retrocaval ureter is a rare congenital anomaly that we, as urologists, may treat only a handful of times in our careers. It’s a condition that is also conducive to robotic reconstruction as demonstrated by Temple’s Chief of Robotic Surgery, Daniel Eun, MD.
During a live robotic anterior and posterior spatulation with ureteroureteral, Dr. Eun demonstrates how retrocaval ureter can be successfully treated using a robotic approach. In this video, he outlines the importance of pre-operative imaging, and discusses with other leading experts, his clinical reasoning around:
Use of indocyanine green (ICG)
Advantages of the ureter scope in these cases
Preferred instruments and tools
Dr. Eun also shares with viewers some of his own novel approaches to suturing and stent placement.
Okay so while you're doing that we're gonna introduce the second case. Um I think we have slides for this. This is dan Yoon surgery Alex. I see you there, you wanna go through the slides, you want me to do it from paris. Um I can do it, I can go through the slides and just perfect. And as you do that I just want maybe I wouldn't say slow down Alvin but just maybe give us two seconds or go slowly. Yes because he's got like I can see markers and stuff but let's go to your slides stand, let's hit it. Alright so next slide please I'll let Alex go ahead with the introduction of the patient. So patient is a 47 year old male. He presented with right sided and peri umbilical pain and nausea and vomiting in April 2019 to the hospital. He had a ct scan that showed acute uh cystitis as well as uh mid urethral stone and hydra proximal hydro and hydro necrosis. Um The decision was made that his pain is from his acute cystitis. He had a lab collie pain persisted, you know post op day one and two. At which point uh my colleague dr craig Hunter did your microscopy on the patient. He found a mid urethral stricture just distal to where the stones were. And you treated some of the stones but left Stanton for passive dilation. Uh We came back, he came back uh in uh so so that you know after passive dilation. The remainder of the stones were treated and the patient was reevaluated. He had a mid urethral stricture And upon further investigation we found out that he has a retro cable ureter. The proximal portion wraps around the Vienna wraps around the vena cava and anterior to the vena cava is where the actual structure is. He had the Lasix renda graham that showed obstruction on that side. Uh Let's go to the next slide. So past medical history, just colds, cystitis and you know obviously the recent medical history and some back pain. Nothing else significant. Let's go to the next life. I think we talked about these findings that cat scan. Let's go to the images straight to the images. So um the urethral stricture is that 2-3 cm segment that you can see uh just when the your order takes a turn immediately. If you're looking from uh coddle to Cephalon's uh aspect. Do you have anything mike, can you click on that? That's a video showing the life laura. Yeah, it's it's going now and uh we can clearly see where that structure is and how it wraps around the cave? A beautiful. So we're gonna go back to Alvin now because he was nice enough to wait while we presented this. Why don't you guys get started and we'll be back to you shortly. So you'll be on the left screen. Michael. Could we switch over to dan now. Okay, so the reason why I wanted to go to the new set of films from today, it's the kind of outline the importance of getting really good road mapping images, I think mike you and I talked about this all the time And um also, you know, I always make it a point to re image. You know, we try to take the stand out for a minimum of 2-3 weeks minimum and this guy was relatively asymptomatic um, after stones were treated and you know, you saw those first set of retro games and how there was definitely a 2 to 3 centimeters stricture and there was tortuous city that proximal ureter. It's remarkable. After some time we, you know, today we started the day with a retrograde and the pictures are completely different. So this is the retrograde from today that that poor choo Aasif kind of angry looking your order. And when we inject we reject, in contrast under pressure, we see that stricture pretty much goes away. So we weren't sure what we're dealing with. So we drove a scope up there and it's wide open. So in my mind I was thinking the plan would be it's a retro cable ureter. So there's probably some redundant ureter, there were probably going to cut it and plan A would be a you you with saturation, generous patch elation and plan B would be maybe an augmented posterior urethral plastic repair with a back wall and they're doing and you're only with buckle. But as the situation now has shifted and changed. We're reconsidering our plans and I'm thinking most likely this is just gonna be a retro cable ureter with the U. U. And you think the strictures right? Where it's kind of exiting out the medial side of the cava there, right? Um it's it's the side of the narrowing was actually down here a little bit lower. So, so, Dan Dan, did you say that you your horoscope, the patient? We did just 20 minutes ago and you can you can easily drive the scope up. No, no problems. And so it's kind of remarkable how the inflammatory process with the stone had made such profound changes influence inflammatory changes in that your order at that time and with a period of stenting and then taking the stand out for a long time. Uh this ureter seems to have looked to look a lot better today and uh I think has made the case may be a little bit simpler. What does the kidney appear obstructed? I mean, is it or does the contrast drain you think there's definitely obstruction from the, from the retro cable ureter on prior Lasix renal scan there is obstruction, no doubt right. The kidney did not empty and drain right? The tea and half on the other side was completely normal. So let's bring the camera over here, I really quickly. So, and and so I just wanted to introduce the team here. So you guys probably all know Brandon liu, He's been um wonderful assistant throughout this uh conference has helped multiple surgeons through their live cases. He's uh jim Porter's P. A. And we really appreciate your expertise today. There's also analysts who is our surgical tech here today. Um and then we have over here Craig Hunter who's our reconstructive urologist who has been a part of this case today and he's the guy that would readily take Arbuckle if we needed it. And then of course you guys all know Alex Dasani and how he's just been helpful, so helpful in finding these cases for us. So dan thank you so much for those introductions. Those are fantastic. One of the things we were talking about when we started, we really want to focus on the how to piece again. We have a limited amount of time. So let's really uh we're gonna get you back into the console there and let's get started and you know, give us some great pearls that we can walk home with as you start that um let's just see where you are in the case and we may switch back to over two Alvin for a few minutes. Yeah. So the one thing, one thing like I want to show you is that we we put into a urinal i cg on this case. Here's my question, you had your reader scope up there literally had to your reader scope in the ureter where you could see where the narrowing was. Why not just use the reader a scope as you do that. We're going to do that but it was a digital scope. So the digital white light didn't show up too well. And so we went to plan B. Just put it up um quick uh downside of putting I. C. G. In the ureter. Um I know lee speaks about this a lot. Any downside at all. Yeah I mean I think the problem is that once you spill it then it loses its utility. So if you make an entry into the into the order then that everything is green. You also lose the ability to do kind of profusion of the of the order with an intravascular injection. If you give it into it dan do you see the I. C. G. Not draining? So so I would say that I went through that thought process and as our plan changed from from most likely we're not going to end up doing a buccal graft in this situation. So then I decided that I was probably less concerned about the vascular charity of of the situation. So that's why I switched to this plan. Again important take home points here. Right? So if you're looking to figure out where the actual ureter is great put the I. C. G. Through the ureter. If you're looking to figure out the vascular charity to the ureter when you hook it back up and you're gonna do a buccal or it looks a little tenuous do the I. C. G. Intravenously. Um You're you're dissecting that out that looks phenomenal with your hook. Um basically he's basically rotating the colon out of the way. I want to switch back over to Alvin and Alvin. I'm gonna hate to do this to you buddy but I'm gonna ask you to sort of walk, you know Alvin. Um We're gonna go back now to dan dance isolated out the ureter. He's firing the I. C. G. I mean the near infrared to make sure he's got the ureter. It's not this this does not look as easy. Um As I would have thought so dan it's all yours buddy. Bring us to speed where we are. Hey guys so you know going back to the earlier discussion about the I. C. G. You know I think that there's pros and cons to the various ways you can use I. C. G. And you burn bridges if you use this this method. And I just felt like because there was a less likelihood that we're going to go to a buckle in this case. That's one of the reasons why I went to introduce general option. You know because I thought that either way was cool to show to the crowd. Um But you know in retrospect I'm actually happy I did it because this section is not as as as quick and easy as I've seen in the past when I've done this kind of case. Uh, this guy is a little bit juicier and um, and so uh it's, it's one thing that you'll notice as you guys are watching this is I toggle the firefly on and off all the time. Right? So as you're going behind all these critical structures, you know, you don't um, it's a real easy thing instead of like going back and looking to see, oh is this this or is this, that you basically just flip that switch on and off and you immediately know where the ureter is. So when you're in this, so we're on the cable here and you're looking at this and you're in your heart, you know, part way through this dissection, you just confirm and this is the new firefly sensitive mode. When I go to the second one right, you can see this thing parasol saying I've been very considerate about the micro blood supply around this urine or to not overly dissect it. Um, if anything, you can see that, I'm on the working off the cave of fashion. Um, so that I'm not directly on the ureter itself, but the consideration here is that the stricture is actually was when it was on the first set of images was actually lower down here and ideally I'd like to cut, you know, so we saw that it was where this turns, I don't think it's as critical, but I think that I see a little bit of a narrowing here. Um and so I think and we parked au scope right here and it confirmed a little while ago um it slipped back a little bit from its original spot. So I think that this is the spot where I'm gonna do my urinal transaction and then uh just been very careful to make sure that we have all the attachments of the ureter off um so that we can unravel this thing to the other side of the of the cave. And I won't mind if we even resect, if it looks too redundant if we need to resect some of this. So I got a few questions and I'm gonna also open up to the panel um obviously if you could step back for one second, I think we all see it. I just wanna, you know, state the obvious if you can let that go, show us the Kaveh the gonad all got it. Alright, so here there was a Granada artery running right next to it. I didn't think there was any reason to take it. So I just left them both intact. You can see this model is splitting here and so you know, I always think that you're is the easiest to find on the right side, just behind the gun. It'll take off and sure enough we ran right into it here. So where's your fourth arm? Right now? I would be thinking I would use my fourth arm to for that traction. So that was part of the, you know, the kind of the thought process I had in the beginning and I actually didn't put in 1/4 arm on this case. So I would I would argue at this point, I would probably stop and put 1/4 army because then you could have your fourth arm lifting up on that traction now. You have your two hands to do that, you know, manipulation. I don't think I don't think I really need it. I mean, I have it all right. I feel like I'm looking at, I feel like I'm working with Ronnie Abaza right now. This is exactly what I feel like I'm like a one handed guy. So we get a little bleeder there, a little bipolar, a little suction. That's probably our organ. It'll artery, it looks beautiful. I'd like to open up to the panel. Yeah. Well, no, I was just gonna say, I agree with you. I think there's really, I'm not a minimalist necessarily, but so I would have put 1/4 arm and just because you don't have to use it, but um and I don't think there's a lot of pain and discomfort from an extra ports quite frankly. And so I would use it because you never know when you might need it. Plus again, it's you're you're working around the Kaveh. You know, you got your one hand is holding on the cable. You you're working with, I'm not trying to beat up on you Dan, but you're working with something that was developed 21 years ago. This hook thing, you know, you've got one hand holding up the kidney, one hand by setting under the cable with your hook. Like that's a recipe for disaster for me. I don't know. You know, you're a lot better than that. But I'm sort of nervous. I actually think this type of dissection very efficiently on critical structures like the Aorta. I feel less nervous about poking with the tip of a sharp scissor when I'm in and behind structures like this. So at this point I think I have enough freed up. I'm going to ask for a pair of scissors. So the question, when did you guys decide to release the urine or underneath the kayla versus just cut the ureter on, on either side of the cava. Does anyone ever just leave the ureter that's coming out of the cave of their or does everyone And would you everyone recommend cutting it and you know, sort of transposing it? Look at these images, that's it's the ureter. It take very long and tapered approach. And so that would be like leaving behind six cm of curator here. Um, I think on a robot there's no reason why you would would have to do that. Yeah, I agree. I think it's, it's gonna come easily to flip it around. I don't see much benefit to not dissecting it out and and leaving it there. I agree with lee and dan, I think that um I think you want to burn any bridges at this point and you never know what's gonna happen once you get it divided. So I would um I would save the entire year to divide it and then get it back together on the other side. Beautiful. So that's a good take home message right? Even though you think you could probably leave it divided and it's, and like you said it's insurance policy that looks great, I'm just gonna switch over really quick over to Alvin expensive, we're gonna switch back to dan. You know, one of the things I noticed dan is that you had a use scope where you were cutting, tell us how you use that to make your decisions where to cut and bring us back to speed. Yeah, so it's because you know, I learned actually that from you mike about the digital scope not being great with firefly and so I wanted to show how we use the scope and firefly but it just didn't work out too well because this is a digital scope that we had today um you know, we, we we use the scope to confirm that there was no significant structure today and we just decided to leave it up um in case we needed it for anything and we just I abandoned to the leg, right? So we just pulled it back. Um and at this point we're just going to do a generous patch elation and then we're gonna, so I'm gonna. And the plan was this is that if we were going to do um a buckle, we were going to do um an anti dispatch elation on both sides so we could put the back wall together given how the situation has changed. I don't think we need to do that anymore. And so at this point I think the plan will be to do an anti or post dispatch relation to a classic. You you go to firefly for a second, switch their firefly mode. I want to see something if you don't mind. So not bad actually, li I'm a little surprised. I thought I would see green everywhere. Uh Yeah, he's given a lot of time for ice. Get absorbed. Yeah, yeah, that's not, that's not spilling. So that looks great. And so a couple of things with you scopes in reconstruction. Um do you still use easily use scopes when you do these complex cases? Give me three reasons besides just looking for the stricture. What are the reasons you think this helps you? Well, you know, I think it helps with your eternal identity identification. Um you know, instead of giving a, I just drive the use go back and forth. Um I think I didn't know exactly where to cut. Um for the stricture like you mentioned, it is really, really useful and then you know provides retrograde access from the things. So if I, you know, I need a stent or anything like that. It's it's very, very, it's already there and it also helps calibrate the ureter, right? So when you're like putting your sutures in you can use it for calibration, especially when you're the buccal mucosa appoint dan may. And I just want to make sure every, I reiterate this concept when you use near infrared fluorescence imaging with a regular analog, your horoscope, the light from the Urethra scope shines brightly through, you know, at least a centimeter or two of tissues. So it's great to identify exactly where the structure is. When you use a digital scope though the light from the digital scope turns down when you switch to a nerve. So then it's more of a palpitation thing. You have to turn the the light source down on the robot. So I think that's what dan was saying before dan, You want to bring some other thoughts to us right now. Yeah. You know, it's really great. You know the fact that we collaborate together and I've learned so many things from you and from lee um regarding these things. So I think the calibration of the diameter of the ureter and trying to assess whether there's something significant there or not. Using the you scope is something that I learned from you guys as a way to see if it's significant or not. And so today, that was one of the thought process I had was as we kind of reassess the situation as the situation the retrograde had changed. Um you know, that that idea of using the the your your reader scope to help me make that decision. Whether we thought that um that you're that that narrowing was was significant or not was very helpful. So, one of things I'm noticing, I don't know if the panel notice is there is a tremendous amount of periodontal tissue that you left on the order, which I think from a blood supply standpoint makes a lot of sense to me. But does that hinder you at all when you do your anastomosis? Do you do anything distantly to help them anastomosis easier? Um Yeah, I'm trimming it back just a little bit just so that it's not all in my face when I do the work. So, you know, you want to be careful not to, you know, overly do that and d vascular rise the ureter. But I think just to be able to work at the edges, um it's kind of good to push it back just a little bit. That's what I'm I'm doing right now. So we're not transacting it, you're sort of just pushing it back a little bit. That's right. I'm just I'm just, you know, I'm saying this is the euro to proper and this is the period of your rhetoric fat. So I'm just pushing it just back a little bit in some of the blood supply just so that I have some room to work because I have two spatulas this back now. Do you ever have your assistant maybe drip a little bit of water or irrigation on that specimen? And just gently, if I don't know if you can do if he's used to doing that, but gently irrigate it. And I think you have to hopefully wouldn't, it's very gentle. I think that's just a trick. I want to show everybody that it's a great way we push that poured in a little bit and then um clean the lens so that as they do that we're gonna head on over to Alvin. So dan we're gonna go back to you Alvin some great work, some great tips really. And uh everything looks like it's lining up beautifully. So dan um you know, you've got two pieces of your inner, you've got a lot of fat around it, you need to orient it, you want to make it so it's tension free. Um you're thinking about all those things. Can you just walk us through what what you're thinking about to make sure we don't get a bad outcome in a year from now when we present it. Yeah, so you know um I think leaving a lot of that parry your attack fat is is you know, very important, you know, during the dissection my mind is not just on don't injure the structures nearby, but it's also I'm trying to preserve any kind of critical blood supply that I can preserve on the other side. Um and I think that really is important aspects of setting yourself up for success. Um you know here we didn't find that it was absolutely critical exactly where we cut it because we felt that it was pretty wide open but we localized the area with the use scope where it was more narrow than the others um as the location where to uh make are you, are you little transaction and here you can see we made a reasonably generous spatula ation here on the ureter and you know, just to remind everybody, you know when you have a ureter that you cut and you spatula and then you've got to actually over extend them to get the spatula ations to fit. And so you have to always consider that especially in a fiber optic ureter, luckily today we're dealing with a ureter that's not very fi broderick and and you know like concrete um so now that we have the spatula rations and one is anterior and posterior and that decision was was held until we realized what we needed to do because if it was gonna be a back wall augmented repair with an anterior only a buckle that would have to be anti virus patch elation and so that decision was talked about ahead of time with the team and then this is this is the way that it plays out and now you know, I wondered whether we would have to cut it out or not. I just, I do want to emphasize that point over and over again. So you know, you've cut out a piece of ureter and now you've got a decision to make um I going to do a spatula waited, you know, you you are going to do a buckle and so in one of the ways that we do that, you can just grab the ureter and pull together. You can also just put easy way of putting a state's future on the end of the, you know where the healthy ureter is and then just sort of put a stay suture and just pull them together and see if you can get out of, you know, you can do it with off tension, you can do it off tension, go spatula anterior posterior lee. But if you can then you've got a spatula and thoroughly on both sides, right? Because that way you're going to bring the back wall together and then build the buckle on top of it. So you know, you don't want to burn that. Make that decision like dan said until you know, you can reach together, I think that's an important take home message because you never know that back if they're going to reach together until you're there. So um just a little bit uh this is a five oh Monica girl. It's my future of choice to do your, it'll work. It's on the T. F. A. Thomas frank needle, it's a little bit smaller than an RB. One. If you ever play with a 50. In your hand and try to break it, you'll realize how how what how good of suture it is. It's actually very robust and and I I feel like what's the sutures name again? What's future? It's a monoclonal 50. On a. T. F. Thomas frank needle, the needle or is that it's a it's a tapered needle, monochrome tapered needle Alvin. What do you use your suturing right now? To your your order, What are you using and why? Um so that's a big question. So I have a large needle driver on my right hand and you notice I have a Maryland in my left hand and I do that on purpose when I'm using these very small gauge sutures. Because if you have two needle drivers you beat up the future twice as much. And so when you're handling an anastomosis with the future of this small, you really want to be considered on how you don't beat up this this and so whenever I can I will try to handle the needle and having one of the instruments being a softer touch instrument I think is is something that I think is very helpful so that you don't have kids of your future. Great point. So I see you're doing a you're going in and out and then out you go out to in into out right? And this fun around this was actually a post your dispatch elation. Alright let's go down the line we got before O pds pds. So I I like I like the same future that Alvin's and that's a USC thing. It's a reverse cutter. So you can't you won't cut through. It's on the back. It's very little tension on the border lee. I use a cutting nito also. Thanks. And the type of suture. Oh uh I frequently used like a strata fix actually. Which 1? The stratification stratification. What try to fix do you use? There's like a double there's like a double arm for so strategy fix barbed suture. Ureter. You're totally comfortable now. Yeah. I mean just don't pull too hard you know your brain tissue together. It doesn't slip back. Take home message. It probably doesn't matter. Just put them together stratification. Krill. Yeah. I think I like the vital because of the way six of the tissues. I do think that the strata fixes much less traumatic than a. Well then Vlach 100%. It's more like a quill. So again if you're gonna get a barbed suture. I think one of the things that's not all barbed sutures are the same. You've got the strategic which are very very small laser cut into into the future. You've got the Vlach which are much more bigger barbs. So we took to use that for partials and stuff. And then you have quill which is more like the stratification. I want to I'm gonna go back, wait a second, I'm gonna go back to dan. I gotta go back to dan and dan. You gotta show us that move one more time. The fish hook. So this is a fish hook. This is one of the kind of things like that. So if you had like a lot of fat hanging down here I would use a 30. V. Lock and I would grab some of that fat. And then what I would do is then suspended up here and then I would pull it through and it would be like a pulley system. And what I do is I fish hook the needle so you can set your attention. Sometimes you want a little bit of retraction when you do a little bit more destruction. Need a little bit more retraction. And so all you have to do is unhook it and then reset the tension and then pick it back in. And so this is probably one half of the anastomosis. And you do what you want to be a little bit careful on how you um you use their flesh and you don't like damage the needle. But you can slightly put a bend to it and then bend it back when you need to use it. Now, the reason why I don't use a cutting, you can't do it with a cutting needle, it'll break off interesting. So just go back if you could before you throw that suture to that fishhook thing, because that's that's like signature daniel right there. Um Just show us attention, like how you, how you adjust the tension. I think it's just so, so if you needed more attention, you just crank it up a little higher a little more and then put it over there and you see it just picked up the yard or more. Has everyone got that? You just take that and you create like a pulley system. But a little, I mean that's that's awesome. That's like, you don't need a whack, you don't need a a micro poor, you don't need anything. You just need the fishhook. I agree. Yeah, my intercultural divergence because I'll put holding stitch in, I'll leave the needle on and then I'll throw it in and pulls the bow away. I do the same. It's one of my favorite moves. Um I got away, I got I've moved away from the wax. I got moved away from like tacking it up with a whack, I just fish hook it and it's a it's a really simple, easy way to create exposure without having that extra arms. So dan tell me a little bit like you're right now, you're showing the post, you are part of the ureter, correct? How did you get the post? You're part of the order to stick right in your face. Can you walk us through that like, right, you know like this, Tell me, tell me what I very deliberately set my ports differently and for this one, you know, I use a straight line, lateral poor placements for all things in the kidney and ureter. But if I had four ports in a straight line um in like a mid clavicle, a line and I can show you guys my ports later on the one that's closest most cephalopod, that spot. I didn't put that incision in. And so that way everything shifted down. I'm gonna ask you if I did put 1/4 arm in, what I would do, probably start my position my camera put in position to and then if it's a lower your procedure like this, I would just pour top everything down. So the question I'm specifically asking, you see what your fishhook suture comes out and getting attention. This one here is that on the medial side of the ureter, or initially was put on the medial side or the lateral side. So this is the back wall here. So what I'm gonna do after I finish this side is I'm just gonna pull that through underneath. And again. What I'm trying to say is that he put the suture on the medial side of the ureter. He then passed it underneath the ureter. So the ureter now flipped over, you put the fish hook in and now he's got the back wall of the euro to rotate 100 degrees so we can. So on it, I just want to really make that point because when you're trying if you're trying to so posterior early in its in the year, there's anatomical position, sort of sewing like this and it's difficult but if you put, you know your future and you hook up your spatula on the medial side, pull it underneath, You've now rotated the whole year 200° and you get basically it looks like you're sowing anti. Really is that what you did Dan? I think that's yeah. Yeah and I think a lot of it is just set up, you know what a little tips and tricks that I've learned over time is just how to set yourself up. So it's pleasant and fun to do um where you're not struggling right? And so there's a lot, a lot of little little decisions I made to get me here so that I could just do it with ease and not have to struggle and you know like I know you guys can criticize me about not putting in 1/4 arm and I I agree with you guys when I need 1/4 and I'll put 1/4 arm and I'm not very dogmatic about it, but honestly I looked at this case and I said this is a retro cable, your order. I'm probably not going to do a buccal graft. So I skipped the fourth arm because you know, I have tricks like this to get me through. So clearly at this point I would agree with you, it looks absolutely perfect. You don't need 1/4 arm. Yeah, but you know, if I was earlier in my practice to the guys that are out there and want to do this kind of stuff and starting to do this stuff, But a 4th armin please. There were so I'd like to uh I know Ronnie's got a question Yeah, I just want to make a comment on this fourth arm a shoe. So earlier, you know the discussion came up and you were encouraging them to put 1/4 armin. Um and I'm a little surprised because you're telling us that we should be getting excited about sp and using sp and less ports and and I think we shouldn't minimize the the impact of adding additional ports, you know? Yes, they're just, you know, incisions. But I think, you know, adding these eight millimeter ports is not the smallest thing and there's also a cost involved. So when for example, Dan was holding up that fat and working with one hand and you said, Hey, you know, put 1/4 arm in, you can work with two hands. I would have just taken a hemlock clip and clip that fat to the side wall and that would have taken care of it and it would have been a $7 fix instead of a $200 fix for that progressive use. Exactly. The idea is just internal retraction rather than defaulting always to having 1/4. Although Ronnie, I would say that in someone that's less experienced if you believe that using that fourth arm may save you an hour or you know then operative time is expensive too. I agree. But what I'm arguing for is I'm arguing that people should become more experienced on the concept of internal retraction so that they don't use it as a crutch all the time. They learn how to do these internal retraction maneuvers so that they're not relying on that fourth arm. I agree but I also disagree a little bit right if you're working on the vena cava and you're trying to pass you know, you know, get underneath the vena cava, get it through your and you get into a problem. Guess what? You're gonna want that fourth arm and to do that when you've got a huge hole in the kava is a much more stressful situation than just setting it up. So I think there's advantages disadvantages. I totally agree with the The traction. I like I like the idea we need to reset our minds for the traction. But at the same time please don't walk away. That says I should never use 1/4 arm. I can do what you want. A 100%. So I think be safe. That's the most important thing. Be safe. I'd like to hear from uh you know it's not that much to talk about at this point but li you know you've probably done more, you read all complex reconstruction, anyone in the room, anything you want to add here. I mean I think this is it's actually pretty uncommon for me to do a you read or euros to me just because of of the practice patterns. I think dan set up very beautifully. Um You know I think one uh you know, question I would have is you know how to distinguish intrinsic versus extrinsic um obstruction in this kind of stuff, you know because we use the uterus cope, you know sometimes it's it's hard to tell like if you get the scope up um whether or not that um patients truly has a functional obstruction because usually things and so I think it's I guess the one question I would have to stand is you know, are you how certain are you that you cut this at the exact right spot? Um lee that's that's a great question. Um So I agree with you. I tend to I tend to do very few you use these days in the in the age of buccal mucosa grafting because I think that you can push that success rate higher. This was a very kind of different case because it was a retro cable ureter, otherwise healthy patient And had not, had only had two bouts of instrumentation and um and uh I knew that that the length was not going to be an issue. You know, the reason why you use fail is because there's a lot of fibrosis and then you, you have tension on the anastomosis, right? I had a feeling when I got in here, this being um the length probably not being an issue that I was going to be able to take two ends of healthy order and put it back together again. And so as long as you do a generous uh spatula ation and there's no tension on here. I had, I had a feeling that the success rate for you on this type of particular case, which is unique, Would be very high. So that's why in this particular case, but I do agree with you. Really, I don't do a lot of you use anymore because you know, if you can, if you get an 80% success rate to a 1995% success rate for a primary repair and not a redo. Um you know, why not? So, another trick here is as you're doing this, he could put the reader scope up to calibrate and make sure you don't back wall. Um you know, the downside of that is if you end up back wall in the reader scope, you put a hole in it. That's an expensive mistake too. So you gotta sort of, you know, um decide what, you know, but certainly when he flips it back over and this is this is what I really want everyone to see, right? So he's ran the back wall, he's now taking out his um uh you know his hook which which basically he's passing it underneath, he's taken out the pulley and this is this is going to end up or could end up being the anterior wall suture. So here we are passing it just a simple trick but really setting himself up so nicely and dan thoughts. You want to just, I think it's it's these little, these little tips and tricks I love watching other surgeons operate because I always feel like there's always cool little things, you know, when you really pay attention what somebody's doing that you you never know, you know who, who's going to teach you something cool and I think in recon upper tract recon cases, there's so many little things you can learn, there's so many things I've learned from you guys. So um it's it's really great to come to these meetings but forget all that, I just want to talk about how you did it. Like just I want I want everyone to get that printed in the brain what he did. So now the future that was initially on the medial side of the of the ureter that he pulled through is now it's now back is back on the medial side, he now took his lateral suture, which he just basically finished tying and used that to tack it up and now he's looking straight at the anterior wall. So again, I think I would I would argue that this is the really the easiest way to do these sort of complex you use. And do you have mark, you have any other tricks on that? How are you gonna put the stent in? Are you gonna put the stent in from underneath? So they're putting a wire up now. So what what would you do dance? I mean li yeah, I would do the same thing because you have a reader scope there, you just have uh your wire through the reader scopes pulled back and the things and then um you know, the trick is not putting it too far and one of these um so typically park the reader scope back by the Uo and then watch the stent in. Exactly. So I think there's two things we could do here with the reader scope. One is I would actually put the reader scope up into the kidney right now. I would finish the anastomosis and I would drive your reader scope up and down the anastomosis to make sure that it's you know, it's wide enough to make sure it's watertight. And then once I have that then you bring the reader scope, this is really important down to the europe, down to the office and then next to it past your past your wire. Um, but that's again lots of ways to skin a cat dan, Everything's looking awesome. Um we're gonna switch over to Alvin for a sec. We would like to just get some of your thoughts here as you're finishing up the second anastomosis. Um well, what I'm gonna do, um is I'm, what I'm gonna do is it's always really tricky to know how much stent to push up. So what I'm gonna do is before we push a stand up, I'm gonna actually ask them to pass it into here and I'm gonna shoot your tag once I see where it lines up, right? Um, and so that way I can look for that marker come up. I totally understand what you just said. Can you repeat that, Say that one more time? So this is the tapered side, this is the side that we're gonna push up from below. And so what I'm going to do is I'm gonna, I'm gonna, this guy's pretty tall, he's like 616 by 30 stent. So what I'm gonna do is say, if I know the general position, I didn't dissect out the kidney, but you know, we know that the renal heil, um is probably going to be about here. And so if we have this then pushed up to about here, this is, I think it would agree that's going to be in the bladder. Yes. So I'm gonna so you guys wanna give me some kind of future like small another five or something, maybe something died. And what I'm going to do is I'm going to tag this location right here or I guess we could look for the three mark here, three marks, three marks, fine, We don't need the future. All right, so go ahead and take this back out and make sure that we passed the stand up this way taper inside first. Great trick. Great trick. Um I'm gonna incorporate that. I like that, you know exactly where you are versus Alvin, what he just basically does and keeps pushing until he feels resistance was like, okay, that sounds good. This is another way of doing it as well. I'm gonna switch over to Alvin while you pass the stent up. Um because I think that should be pretty straightforward. The uh retrograde there, Alvin and you can see on the other screen dan has found the three hashtags on the stent. So he's holding it and they're pulling the wire out so it's really important as we're starting to finish up here. Um this is, you know, this whole time, but this is your opportunity to come and ask questions right? You've got, you know, some of the world leaders doing this, showing you how to do it really easy, I think, and they look really beautiful. So if you have any questions now, come on up and to the microphone. Okay, Parties. Yeah. And so where for a second not to be straighten out my official pretty good. So question um for the audience, how many people have managed a retro cable? Your door raised their hands. So like to how many after seeing this video we are just going to go home. If they see a retro cable ureter and be able to manage the retro cable, you're raised her hand. Alright, that's what it's all about. Everyone's gonna be able to do this now. Thank you, dan. But now you know how to do it and you'll have the video on narrow so if you forget anything, um how many you guys Duilio conduits. Okay, about half how many now after seeing Alvin set everything up and went over all the staples and how to put it together, I feel more comfortable putting doing Anillo conduit. Excellent. Again, I think that's sort of a testament, what we're trying to do is give you guys uh some confidence and some more tools and ideas to think about. So as we're sort of wrapping up here, what I'd like to do is go down the panel and if each of the panel members sort of maybe give us three or four take home messages that they saw today that each of the audience members should be thinking about when they come back and then I would like to also finally, you know, not only congratulate our searches, but give them the opportunity to uh send us off with some of their messaging. So if maybe start with lee. So, so I think from dan's case, his use of the sewing the back wall. So in the difficult side first, you know, I wrote with using the things that that I think that's the biggest thing to take home things. I think the um the for the conduit, you know, I think the use of the discard limb, I mean it's something I do anyway, but it's I think that's been a tremendous help, especially for patients with difficult mesen terry um thinks so. Great, great, great, great thoughts tim. So I think with the retro cable ureter, I think that not burning the bridge and not cutting off any ureter until you get it together. I don't think he's got a lot of extra room here. So I think that was, and the way he demonstrated, just like lee said to using that little guillotine statue of the pulley stitch was was an awesome trick. It's gonna make sure we're patting it's the hook, E H. Okay. I think it's brilliant. The marking of the stent as you pointed out. That's really something that I'm going to take home from this? How about dan? We heard some really great points from our faculty. Um would you like to sort of finish off and give us your take home messages um that you want everyone to remember on monday? Yeah, so we have some questions. Can you hear me? You can hear me, okay. So the one thing is I wanted to show a poor placement, if you guys can zoom up in here a little bit, um could you pop these arms up just so that we can see the line? Yeah. Yes, yeah, we can see perfectly actually. Yeah, so you know, so there's a straight line. So this is my midline here and I do four fingers which is eight centimeters lateral and that's normally from all my kidney and flank based cases. This is my go to support and it's support site number 1234. I left that spot open because if I wanted to put 1/4 arm and I was, that's where I was going to put it in, but I shifted everything down intentionally in the beginning of the case, knowing that I was working on, on the middle order. If I was, if I did put the fourth arm in there, that would have been my right arm, this would have been my camera, this would have been left arm, This has been my fourth arm in the beginning of the case. But if I found that I was reaching down the ureter to do the work, I would have to pour top and rotate everything up in the fourth army would come up here. And so that's one of the points I wanted to make was this setup and the work up to get here mike you and I and we we talk about this all the time at our course at the anyway, it's so important that you do all the work you need to do ahead of time so that you set yourself up for success. And I think that all the work you do ahead of time is so very important and not to be glossed over. Um I think that um one of the things I kept thinking about during the case when I was doing the repair uh putting in the sutures was um you know, it's so important to have that Maryland in your left hand and a needle driving. You know, I we don't want to grab the order but you can grab some of that real flimsy stuff. That doesn't really matter. But when you use a needle driver for it just crushes it. And so I just feel like it's much less traumatic. The last thing I'd like to say about that that fishhook stitch is you saw what, I don't know if you guys saw what I did at the end. You straight I straighten that out. If you leave that fish hook in there and you give it to your assistant when they pull it, the needle will pop and then you will buy my product, the melody device to go find it. So straighten out that needle, please. Okay, thank you everybody. And I just really want to thank the team here. This is my second time. They've just been so wonderful to work with in Summerland Hospital and Alex Dasani. And all the staff here has been so helpful to make this meeting so good. So thank you, everybody signing out. Thank you.