Daniel Eun, MD discusses strategies for enabling complex robotic reconstruction of the upper urinary tract.
to keep us on time. Today we're going to move right into our next lecture and that's by dr yun, who I am pleased to introduce. He received his bachelor's in Biology from Penn State. His M. D. From Temple did a surgery internship at University of Pennsylvania and then went on to do his residency um and minimally invasive robotic oncology fellowship at Henry Ford. As robotics was just gaining ground in urology Um completing his training in 2080, then um became assistant professor at the University of Pennsylvania and then ultimately director of robotic urology, Urologic oncology and reconstructive surgery at Pennsylvania Hospital. He built this program into one of the busiest robotic surgery programs in the world. Um getting a reputation for handling complex oncological reconstructive cases. In 2012, Dr Yun was recruited to bring his robotic surgery program back to his normal moderate temple. He currently runs a high volume referral practice for robotic treatment of guiyu oncology and complex reconstructive surgery, kidney ureter, prostate and bladder. He has performed over 3000 robotic procedures and more than 50 different types of procedures. He's regarded as a thought leader in advanced robotic surgery techniques, um robotic procedure development and training Since 2008. He's had he's been training fellows and now has a one year fellowship in advanced robotic oncology and reconstructive surgery at temple. Of course. He's um extensively published in peer reviewed articles, book chapters. He does a lot of teaching, um both in the United States and internationally, um as an invited lecturer and doing some live demonstrations of course at meetings around the world. So without further ado dr yun, I'd like to introduce your first lecture strategies to enable complex robotic upper urinary tract reconstruction. Thanks for being here today. Thank you so much for the kind introduction. Can you guys hear me okay? Yes, we can. The slides are looking great. All right. Um, I um, had some technical issues with my prerecorded slides. I defaulted to doing it live. Also, if you guys hear me call throughout this, I have a chronic cough that's going on for five years. So please don't worry about me having some covid. Um, so, uh, here I'm going to talk about um, about upper urinary tract reconstruction, an area that I never really planned to go into when I left my residency and fellowship and something I've kind of stumbled upon uh, through throughout my career. So I'm I'm very honored to be here to address you guys at the Wisconsin Urologic Society. Thank you so much for allowing me to be here today. And also, Hi, Kendis Gibson is my buddy. Mm All right. So here are my disclosures, uh, uh, financial partnerships with intuitive surgical. I do some consulting, uh, speaking and a lot of teaching based activities. I also act as a consultant for johnson, johnson. Um, I don't get any money directly from the medical, but they do support my fellowship, um, with a small amount of money every year. And then Melody Corporation is a needle finder that I off that we essentially, with a medical student developed this corporation. It's now FDA approved. Uh, so I, I, you know what, I wanted to start off a little bit just about telling you guys a little bit about myself. Um, I, um, and so I'll try to rush through this because I think I'm trying to get a lot accomplished here. I was born in Korea. My father met my mom in post post korean war where the country was very poor. Um, we, uh, this is a picture of my brother locking me up in the, in the chicken coop. I thought I was going to become a chicken from then on. But there are some pictures from my early childhood in Korea. Um I, my father almost died at a young age and he essentially after he got better, we sold everything and he became a missionary and so um I know it's a very unique background. I uh I grew up in Palestine in the West Bank. My father was a missionary physician. We were, I can guarantee you were the only asian family that lived here at that time. Um or only korean family that lived there at the time. We um well um he ran a clinic near Hebron. We lived in Bethlehem for a while. I went to a british international school in Jerusalem and I I spoke british english. I wish I still had it uh korean Arabic and Hebrew, but pretty much since then I've lost everything and just know english and can speak a little bit of korean. But some pictures from my international school and it's just a really a wonderful way to have been raised with kids from all over the world. Um you know, just understanding diversity and that everybody didn't have to look like you. Anyway, we eventually moved to the United States. My father's health started to bother him again. He needed medical care. Ultimately I went to penn State for undergrad. I met my wife there, I took a year off. I had a very kind of nontraditional pathway where I didn't go straight through schooling. Uh ultimately ended up after delivering pizzas for a year, doing some research. I went to uh couple university for medical school. The time off was probably very good for me to be able to then decide I wanted to focus. Uh I applied into urology and I didn't match and it really really just crushed me. And here what I'll tell the residents and the fellows and students are there is that I think that if you encounter a failure episode in your life sometime um use it to your advantage is probably one of the best things that ever happened to me. So I think it really developed. My character, developed a true resolve to want to become a urologist. I reapplied, ended up in urology and Henry Ford hospital having no idea what it's just about to happen there, robotics was just exploding. Um and so I walked into a program that it was just getting off the ground. This is a little three D. Projector box that traveled all over the world with us as we were setting up programs around the world. Just truly had a unique experience in a, in a window into uh procedure development. Um, in the middle of controversy. I remember being terrified as representing at the a way because I would read that guy's chapter and then he would be up there shaking his head, looking at me going, I don't know if I agree with you, this doesn't sound like a good idea and so you have to get a lot of thick skin as we went through this program. And by the time I graduated in 2008 there didn't seem to be there that much controversy. Now I love this slide because it's contrast old boss, new boss, all right. Dr men who want to do everything robotically and then Alan win who was more cautious and that was really good to have bosses on two ends of the spectrum. They were both very good for me in the early part of my career because I realized after Allen said, you know, dan, let's be careful what we claim to do. I really had to seek out, you know how to do things carefully and to uh to give data to publish and to show that this really is, you know, good what we're doing. And so I I really appreciate having both perspectives and since then it's about 13 years in practice, literally Over 50 procedures. I've done robotically, I don't expect you guys to read the slide, but essentially over the years, what I've found is that in my practice in my hands, the robot can be a very useful tool to treat a lot of disease processes. And uh, I kind of look at the robot as uh, as a, is a swiss army knife in my practice. One of the unique things I was able to do when I moved from the University of Pennsylvania to temple in 2012 was to build a system, we. mm we were doing a lot of volume. I wanted to do it more safely. I didn't like running back and forth between two rooms. And since then there's been a lot of issues with overlapping and concurrent surgery. And so the system that we have right now, we do do overlapping surgery. I do tell all of my patients about it. Um, but we do it in a way that I think that I allows me to teach without freaking out and having to rush through cases. Um, it allows me to be essentially two rooms at once in both room environments and I never feel like I have to leave the room to go to another room. And so here's a picture of what that looks like in my daily practice, a chief resident, one runs one room, a fellow runs the other, we stagger cases off of each other so the critical parts are not overlapping and uh this is kind of every Wednesday and thursday how I operate and so a little bit about pushing boundaries over the course of my career. You know, looking back at it, you know, obviously you have to have a excellent training foundation for to be able to start doing new things or innovative things are trying to reinvent ways to do things. You have to be honest with yourself first and foremost and you have to be honest with your patient. You know, I did a year ago, kayla costumey revision uh this week and I told the patient I've never done one of these before, I think that I can do it, I'm not 100% sure it's gonna turn out, I have a lot of tools in my tool chest and I'm going to try to figure it out, but I've never done it before, you know, luckily for me and the patient turned out really well, but you know, I still have these conversations with my patients, you know, you have, it can be controversial, you gotta have some thick skin, you got to be able to take some criticism, you're not always right. And so I've learned that lesson, you know, several times in my career and you have to really be honest with what you're really doing. Um is it the right thing? Um and then if you're going to do new things, you have an obligation to publish and to present to share with your community what you're doing and what I've really seen is this parish in in my career, you know, I really was trained in urological oncology Nowadays. I see probably 50% of of my volume in my case is in my referrals are benign and reconstructive urology, which is really a huge shift over the years. And um, and so I I really do think that, you know, as the community grows in robotic ability, the academic centers job is really to not do the same thing as them, but they also offer above and beyond and so that they can send their complicated patients to you. So going on about reconstructive urology, I think that this paradigm for me, especially when it comes to a lot of upper track things, but also some lower things in the bladder. Um Blatter net contractors are slowly starting to shift into a robotic paradigm. Is is uh an option at certain centers with certain surgeons. Um, and so especially when it comes to your it'll surgery. You know, there's endoscopic management and it does have its role in some cases. But I think that there is uh, as we all know, there's a high failure rate and a lot of these especially significant structures in the mid to distill your, you know, you have some forgiveness because the bladder in most cases are mobile and you can move it to the urine or even though the ureter doesn't move that well towards the bladder, but in the proximal and mid, uh, your, you know, you have, you have, you don't have as much uh, mobility. And so historically speaking, you know, if you didn't have a really favorable stricture, um, you you had a high failure rate where you had to go to something big, right? An illegal order and all the transplant or just manage them as long as you can until you do enough to me. And so what I'll share with you guys is three kind of general concepts here. Um, that, um, I'll say the first point very carefully here. Um, not everywhere, but in certain practices. Uh, you know, I think that, uh, certainly in my practice complex anatomy, hostile abdomen are not contraindications. Um, I routinely will operate on people with multiple colon surgeries, colostomy, colostomy reversal, colostomy still in place. X lab gunshot wounds. Um, and we have a lot, sometimes, uh, you know, an hour, hour and a half, two hours of license before we go down there. And typically the type of cases that we're talking about warrant, at least to try to fight through all that to try to permanently fix somebody for the better, Especially in young people. Also near infrared fluorescence. It can be an amazing tool, give us information that we've not had before in the operating room. And uh, it helps us to make better decisions and try to avoid failure scenarios. And then there's a lot of reinventing old principles into new ones, buckle graphs using the appendix in various ways. Uh, and then these kind of side to side re implant is the concept where we leave the Euro or inside you the disease, your door inside too. And just kind of make a side hole on the earth or above the area of structure and reroute uh whether it's a re implant or whether using appendix. And so over the years as a technology has changed, I think that our capabilities and what we're able to do certainly has enhanced and I haven't even shown the Sp model here, but um, with the ability for the rope for the technology to shift our abilities have been able to shift. We've been able to do much more. And the things that I do today, I remember years ago I would have thought to myself, there's no way you can do that robotically and now we do it all the time. Um and so this is one of the slides I used from a you a uh course on upper tract urinary reconstruction. Uh If you guys wanna are interested in this area, please attend. We go into much more depth into this, the techniques. But you know this essentially, you know, you look at this, I mean this is either robotic or open essentially the same. You know, these are your options, your primary and your adjunct options here. And really the challenge for me is to try to end these kind of type of cases understanding profusion, What kind of blood supply exist there. Trying to identify the precise location of the yard or sometimes or trying to find the order when you can't find it, especially if the urine has been cut and there ends have been retracted. You know, extremely difficult to find them. And then um, and so these type of uh, you know, tools that we have now help us, you know, in these goals as we're trying to do repair. And one of the cornerstones is is like I said, near infrared for essence. And you know, a lot of different companies now have some version of this, whether your stores a striker. Um you know, they have even open options to use near infrared. And uh it's a way to tag albumin. Um, and to be able to turn on near infrared and see green. Right. And so I'll show you a bunch of videos. This is a typical it's a narrative that we see in the clinic woman who had g wine based cancer. I think this was cervical cancer, high dose radiation to the pelvis. So I'm here I'm just doing a simple re implant. But you know where is the blood supply? I think I see the scar. But why not use this? Simple Inject uh two CCs. I. C. G. And uh 30 45 seconds later. You see the earth or light up, You can see where it's cold, You can see where it's got good profusion and it helps you to make a decision. So I'm just showing you video examples rapid fire. Just all these examples where you would use it. This is a suspect in the operation. This is that left ureter, it's been spatula already the left side of dispatch. Elation looks like maybe a little bit dusky, a little bit slow to perf use moving over to the right side. Look at this 4-5 cm distal ureter now under regular colour vision. You can't tell. But that that your order I'm sure would become structured. If we had to assume that in I'm going to cut it short I'm going to cut it down to where the I. C. G. Has guided me. And then I also check the balboa anastomosis as well. So this is another patient who had a double level big structures. I'm not gonna buckle this this is going to be a little yard a robotically and at the end I thought I stretched the volume a little delia order too far on the end so I'm a little worried about that nasty moses. So injecting I. C. T. Just to check my nass demotic line um profusion. And there's my elio yarder that's my renal pelvis looks great right? So I'm like you know really happy about that and I'm looking down to the bladder and say let's see what that looks like And that's my kind of you know will you order to bladder nationals? That looks really good. So a little peace of mind move on. So there's a lot of ways during planning and then during the middle of the procedure. And also to confirm at the end of the procedure. Um This is um during a ureter and terek structure is just a really quick video. Um This is towards the end of the repair. I've gotten the back plate together. I'm about to so the front side there's my stent in place and I'm checking I. C. G. Intravenously great profusion. I'm very pleased with that. And so we can interrogate and re interrogate the tissues using intravenous. Now I'll talk about something that's you know off label here. This is intra urethral aluminum injection. We've published on this. Um but a lot of G. Y. N. And colorectal surgeons and urologists are now using this but we describe this and it was basically out of just desperation. I was doing these really terribly complicated patients. I knew I was going to have a heck of a time trying to find your order. And so I told the patient look I don't know how I'm going to find your urine or I'm gonna try something on you and I swear to you I said you up to your order and everyone told me this wasn't gonna work because you have to do mix it with the help human. I'm kind of a simple guy. So I just squirted it up the ureter and lo and behold it started to light up. And so we we started to try to figure out in the beginning we went crazy and we used it on everybody now. We only very selectively use it for for cases, but you know, especially if the your the urinary tract doesn't have a lot of fiber optic grind on it. It's a great way to localize the ureter. But as soon as you spill it, it kind of smears everywhere. And so you have to understand its limited its limitations in the juice book. We published on it in a few journals. Got the word out there that that this is you know, a tool in my chest. I don't use this very often, but I do use it um at times during in the right situation for early your. it'll identification and avoidance type of scenarios, um difficulty finding that you're that's usually the scenario where I use it. But here I'll show you this is a young woman, you're a double triple occasion anomaly. She had upper upper mobility that was uh you know obstructed causing pain, infections followed Weigert. Myers law beautifully. And so before we even opened the retro parody and I squirted I. C. G. Up the order of interest that we're going to remove that segment and there it is before we open up the retro peritoneum. Now here's the three year orders, right? And so the crime here would be to injure the wrong. You're right. And so turned on I. C. G. It's like cheating. Alright so we've already pre injected it. There it is. Follow that your order. Leave the other ones alone and then see where it leads up to. it will lead you up to the uppermost uppermost hoity. And then you can do your partial hysterectomy there and remove this. Uh This might be um This is a uh So this is the one another use of of I. C. G. Which I'm sorry, another use of near infrared. This is without any I. C. G. And just using a white light source. And so this is a patient who had recurrent. Um Sorry this video doesn't play right for somebody. So I'm just gonna drag it along Patient at like two or 3 recurrences of low grade. You're a troll tumor that we endoscopic humanity kept happening. So I decided I was going to take out that segment. Um And uh and so here what I'm doing is I have a use scope in my residence running that. And I'm basically poking. I want to get just just the segment and nothing else. Right? So I'm going to get very precise, so I'm using the white light from the use scope to tell me exactly when I'm above the tumor. And then I'm gonna stick tie or you know, wrap tie this uh with a silk and segment that off. And then I'm going to drop the scope below the tumor and I'm gonna do the same thing above and below. And so that way I I cut out the minimal amount. Maybe it'll play down. So um here, so we're removing the segment and I thought I was going to do it, you know, um you know, uh either are you you or a uh appendix uh in a position here. So plan A. Was you, you didn't work? Plan B was appendix in a position. So here we are now into injecting intravenous to two CCs intravenous. I C. G. To see that pencil artery. I'm a urologist. I don't normally operate on the appendix. I don't know where this appendix artery is. I don't want to hurt it. I want to continue with the blood supply. So I inject big. I can see where their pencil arteries. So I don't go messing in that neighborhood. And so um I pack see the coal into the side in the most favorable position so I can roll the appendix in. And guess what? This is one of those dependencies that have obliterated, right? And that was kind of unplanned. So Plan C. Now is I'm going to switch to an augmented uh penicillin on les. So I put the black back all together under a little bit of tension. Right? So but you know the your orders have freed up enough so I can at least put the black back plate together. I think if I ran a U. U. And completed the nasa most anti really it would have been too too much attention. It was structured so we're gonna open up as much of this appendix will give me and then we're just gonna roll it on as an online. So you know a lot of these cases you have tools in your tool chest and you have to be able to adapt uh to what happens. I mean that it is reconstructive surgery. So here in this case we went from plan A. To plan B. To plant see um and here now we're doing a pencil online and so we've now you know I got half of the appendix on and we're running up the stent and then at this point it's like a pile of plastic skill set. The difficulty isn't in the sewing part, you know, the decision making and the getting here is the is the challenge. And so I always tell people, you know, don't stare so hard at the sewing in part because that's uh, you know, a skill set that is more straightforward, but it's the complex decision making, fighting through the anatomy, making your decisions where your segment is. That's really the important part of these procedures. All right. So we saw that in um, and so this is kind of the money slide three ways that I see to use near infrared fluorescence imaging. The first one is the on label by FDA is the intravenous injection. I typically use two CCs and I push a 10 CC sailing Chaser. I always caution and I typically use the same man steve jobs, but I always say do not inject it until I tell you to. We're all set up we're ready to go. You don't want them to give it a head of times. But the good thing is that it washes out. Typically as long as that area has profusion um It will wash out and uh in about 20 minutes you can repeat it so you can re interrogate the tissue planes. And so for example like in a pile of class D. What I nowadays do um For fun kind of I look at the anatomy do minimal dissection. I hit a little bit of I. C. G. I look and see where the arteries come in and sometimes it makes me change the way I'm going to do the pilot class D. I'm gonna do a Y. V. I am I going to do a dismembered pile plasticky? Yeah. Um Am I going to leave that back played alone because there's a major artery coming up the yarder. Um And am I going to cut that? So in some cases I'll be very delicate with how I will not do a transaction on a pile of capacity. So sometimes changes my mind. And then um and then afterwards the procedure is finished. I might check to see what I've done. Uh intra urethral is you inject five CC's um You know either down a P. C. N. Or up to your little catheter. And transected yours are both five down the order and up the order. And then you wait you have to wait about 5 to 6 minutes for it to progressively increase. And they're pretty much all day. And if you spill it then it smears and so be very so you can't use intramural and then switch to intravenous because there's already green stuck in the field. Um so I'm very careful when I use intramural because I may want to use intravenous later on in the case. And then as I discussed, um you know, there's a lot of different ways to use white light, you know, a white light in the rectum. You know, if the prostate is stuck down during um a salvage prostatectomy, you know, a white light down the illegal conduit if you're trying to do or your directory structure, anastomosis revision. So there's a lot of different ways you can you can use white light. I threw in this picture because this is a bar a flat. This is a boring flap that um that that was that I did on a patient who had uh a high dose radiation to the bladder. This is earlier on in my career. I kind of thought sure about war flap high uh your infrastructure, high dose radiation. And um this was in the early days when I started using my cd and I shot and I said this flat batter flat looks cold. I didn't know what else to do because I've already made the decision. And um I uh did a bari re implant and five days later this whole thing fell apart and it just started a domino effect for this poor woman who underwent about 1 to 2 years of just nutritional, you know, building up to get her to the point where she could take on surgery again and eventually ended up with another conduit. So um the the my my my main point here being if you've got a high dose radiated patient, don't try try to do everything. Um to not make a huge bladder flap decision that has to heal right? Just you know, try not to you know, so I'll try to do anything. Um To not do end up with a worry uh scenario on a patient with high dose radiation. Anyway, moving on. So talking about buckle graphs um um really the true credit goes to Doctor Nady, a South african reconstructive surgeon who back in late nineties uh mid nineties and late nineties started doing baboon survival models using the you're using buckle graft in the ureter as a proof of concept and it worked. Um You know, there's a few other uh you're all just that played around with this and try this on humans in small open series. And I really credit Liza uh my buddy from N. Y. U. Who I think is one of the leading minds progressive minds in um in reconstructive surgery and robotic surgery and marrying the two fields. Um And since we've become good friends um And so he he talked mike stifle man. He finished his alan moore fellowship came up to N. Y. U. Dusting off this paper and said we should try this. And they did and I remember being in 2014 W. c. e. in Taipei and I walked by their poster and it was so hot so human I was kind of irritated. And then I walked by this thing and something caught my eye and I stopped and stared at it for about 15 minutes as abstract and I said this is going if this is right this is gonna change everything. Uh I found like I literally grabbed him and took him. I didn't even know him back then. I said is this real or is this bs? And he said no this is real. So I did one the next week I called him back uh I flew back to temple. I did one the next week. I called him back immediately after I said, I think we're onto something crazy here. This is you know this is really an opt in. And so we then started putting our data together, studying what we're doing. Since then we've presented this at multiple meetings, won multiple awards, published on this a numerous times. Really excited about this because it really um um Okay, can you guys hear me? I just got a message my my internet is unstable. We can hear guys, we can hear you. Okay, great. Um and so um You know now that we've I've done probably I have to update my series but I think uh I've done personally over 50 of these and uh you know these are kind of the key points I got here. And one of the main things about buckle grafting is it doesn't want, it doesn't preclude the traditional options. You can do this, you get one shot for free, do this. And if it fails, you can go back to whatever you're planning to do right. The other thing is that you don't have to over dissect and over mobilize the, or to try to bring the answers back together. You can minimize your dissection, just get to the site and and get a good look at where the structure is and then make your decision. But in many cases, especially with just direct on lays, you don't have to even dissect the back wall of that you're off because usually it's stuck to, you know, something you don't want to dissect it off of, which is the order of the cable or something, you know, all the scar planes. So if you can find kind of the hourglass deformity and you're going to plan on doing an online. And usually the main decision here is if there's a looming or not, right? If it's there's an aluminum obliterated, you gotta cut that structure out that obliterated segment. You gotta put the bags altogether. Doing augmented only. But if there is a loom in there, right? Um, then you can open it up. Just put a launch to a decision on, do an answer immediately. I always bring momentum on um, and uh, to supplement it and then um, you know, so you don't have to over over mobilize because the spatula ation on both ends and then trying to put it together. It just causes an increasing gap problem. All right. And so the other thing is that in the beginning when I did these, I got nervous, I thought, you know, tissue shrinks a little bit. You know how that feels. So I would over oversize them. And what happens is that it turns aneurysm all and I have one guy that just passes crescent stones every once in a while, which I know where it's coming from. Um and so I always say kind of fitted like a custom suit like fitted uh exactly to size. Don't oversize it. Um And so uh I'll show you guys a few points in their data. I think that are coming out or that we've recently published on one is you read a little rest. Right? So we've learned a lot of lessons. We put um N. Y. U. Hackensack and Temple, a huge database of our all of our reconstructive cases together. And so here we looked at the question of rest. Right? You know, in reconstructive surgery, the idea of urethral rest for urethra plastic is a mature idea, right? And and so we applied that same question to urethral strictures. And although this wasn't the perfectly done study, you know, we did look at this and we did see a difference in success rate, a difference in BBL. Um, and so, um, you know, one of the things that we now do as a routine is, uh, you know, three, four weeks, I try to do four weeks of your little rest. If the patient can just tolerates that removal. And I'm not worried that kid is going to shut down, we'll just pull it and try to get the patient to surgery that way. But if I am worried that they're going to have pain or they're going to have sepsis or they're going to have their kidneys shut down because they have CKD, I will put a park tube in And what you really realizes that, you know, the retrograde with a stent that's just been pulled versus a retrograde with the stent that's been pulled four weeks ago. Looks different, right? The structures matured. And I think the reconstructive surgeons that do Urethra plasticky, they're probably chuckling saying, yeah, we already know that, right? And so we wanted to show that we recently just published on that um, you know, this was a philadelphia, philadelphia, your logic uh project that eric show one of the residents just presented on essentially. This makes sense to write. It probably makes sense of the recon surgeons that do Urethra plastic, you know, the estimated structure length and the actual graph length. There is a difference, usually about 30 to 50% longer than what you estimated the structure to be. Um looking at. Uh you know, what, what, what characteristics in certain structures really are significant uh predictors of complexity. We find that it's obliterated and that really shouldn't be a surprise, right? If it's obliterated takes a lot longer to work on, there's more time more bleeding, more dissection, it has to be done. And so if you look on the on the on the table on the bottom left here, you can see when we when we look at the top here, When you look at, when you compare approximately mid, there's really no difference in operative time Andy bl but if you look at uh the subsets of proximal timid, we put those groups together and then distal. What we find is that there is a difference in operative time in a bell for the proximal mid structures and then a difference and operative time for uh the distal as well. We also see that there's uh in the obliterated there's a lot more adjunct mobilization procedures like um mori flap or like a downward after pixie. When we see much more complications. Um When we see when we do obliterated cases just there's much more dissection, there may have been more done there, there may be more bleeding. Uh And so uh what we see is that obliterate. We look at glittering uh stricture cases after a period of your, it'll rest with much more gravity and we can kind of anticipate more operative time. Right? And so looking at our buckle graft, this was 2019, so it's a couple years old. Probably need to update it. But 51 cases across three institutions. And when we see that about a quarter of our patients came in with previous failed reconstructive attempt. Um we did uh about almost 90% of the cases and on les. And about 12% of the case is an augmented on les. Um And uh what we found was that uh uh Patients with greater than I think mean follow was 12 months I think we we excluded the patients had really short follow up. We have roughly about a 94% overall success rate, both clinical success and radiographic success rate. So what happens in these patients with really long strictures? I get this question all the time. Um We looked at the subset and we published on this and we found was that um if you if you compare buckle versus the patients who had kind of a more traditional approach uh an aggressive downward never pixie. And you you all right? We found that they had a higher failure right now. The pop the numbers are small here. So I don't know how constantly I can say that but that's the suggestion that to me it makes sense right when you try to overcome all mobilize and try to put on tension I think that the failure rates higher. Um So here's um a trying to stand up time I have here. Um um Here is a video showing um uh one of my earliest uh buckle graft cases. It's a patient who got was a wheelchair bound big mack truck turned the corner, somehow caught his his wheelchair dragged him about two blocks down. You got an ex ex lap in effect splenectomy and they put apart Toobin for yours that completely repulsed. And um um Let's see how much time I have here. I have to uh 35 well 10 minutes left. And so here I used I. C. G. To find my end because there's no way I would have been able to find it as you guys saw. I mean these orders refused into the retro peritoneum. I could not see a plane. Um So we chip away, We chip away. We keep talking on a near infrared. Suddenly you see a little gleam of green, the operating room erupts in and you know, yeah, we see the ureter and then we dissected out. So I knew I would never be able to pull these things together because they were way we retracted back. It's been over a year. Right? Um, so and there's been a lot of things done and infections that have happened. So, you know, Alan moore's literature that he published says, you know, downward from Brexit gives you about 4 to 5 centimeters. Absolutely correct. Right. And so here we we don't cheat. We do a true uh complete kidney mobilizations, about an extra 45 minutes worth of work and we crank this kidney down after full mobility. And um, there we go. And then we measure that. That's about 5cm. I'm going to move this along just uh, I can try to fit the rest of my slides and so we do about 3 to 4 points of fixation. Um, you know, I either use an O. Or 20 V. Lock and they use a sliding clip, like a partial as a winching mechanism. So I don't have to tie on tension. Right? It works great. Um, and uh, and then we put a back wall together and then, um, and here I'm using 50 P. D. S. I've since using Pds. I can always tell my older videos because I use Pds, I now use five oh Monica role on A. T. F. Thomas frank needle. It's a little bit smaller than our B. And I'm very careful not to handle um the future directly with my needle driver. That if you notice on my newer videos here, I'm using to needle drivers on my newer videos. I always so with my left hand instrument as a Maryland and I do most of the future handling with the left with my left hand so as not to crush and and erode and degrade. The future is 50 S. Um will degrade quickly if you keep grabbing with your needle driver. And so at this point, you know, again, this is a pilot plastic skill set here. It's uh just careful, methodical little bits of travel and and just putting this together. Running the stent up. We usually uh replace au cap so you can run a wire up from my bedside assistant. We saw this on, we get momentum on. And uh this patient did actually did very well. This is probably like my third or fourth buckle graph. They did um uh this was back then when I think I was getting my auntie guys. Now I have a reconstructive surgeon that operates next door to me. So I always put buckles on on Thursdays, we typically do do about two a week Every Thursday. And um and I have might come in like metro come in and you harvest my graph, he's fast, he does it about 20 minutes, certainly a lot faster than the NT guys. And so um we kind of have a system in place now that works really well. Um looking at my time here running out of time here. So this is the side to side, you're going to implant. What I basically tell you, there's a terribly complicated patient who has a colostomy, high dose radiation. And the idea is that on the stricture right what I want to do is leave the inside to your door distantly alone. I don't want to be vascular because if I cut it and transact into a traditional re implant I will take some of the actual blood supply that still exists on that your honor. When I turned on firefly I see that there's still blood supply there. And so what I don't want to do is take little blood supply that's there. And so what we do is we leave the ureter alone and I'm just gonna zoom up on the video just to show you here's my I. C. G. Showing the blood. So you can see I've purposely left the blood supply that I can see that the I. C. G. S. Telling me where it is, the near infrared. And then I'm essentially gonna just cut the little side slit above the structure. I can see where the structure is tapering where the radiation effect is happening. I'll run a side slit on the ureter above the level of structure. I'll bring the bladder over to it and then I'll essentially do a side to side anastomosis like that. Right. And so it's different than a traditional re implant. I like to use this typically for for radiated patients as so as to not disrupt whatever blood supplies there because you guys all know when you mess with radiated tissue and you suddenly the vascular rise it further. You know the structure may extend or you may develop a new structure which I'm terrified of and I've seen in the past. And so I use the near infrared repeatedly during the case to not cut the actual blood supply of that your order and to uh to check where to cut and make my your garage to me. And then essentially we're featuring the ureter there. And so uh this your uh bypass concept with which is borrowing the same idea leaving the inside your yard or distantly alone. And we're going to bring in the appendix. And this is typically the pre existing condition is it's got to be on the right side. Typically a patient has got high dose radiation that bladders all shrunken down. I don't want to run a bari can't bring the bladder up to the stricture. And so I need to I need to fill a large gap. Right? And so an appendix works really nicely for this because usually the appendix sitting above the radiated field. And what we'll do is do and then decide uh on the ureter and then do and decide on the bladder right and truly um and truly do a bypass procedure. Uh so that the the existing you're under the old order still has a looming, you can still run a wire up there, right. And um and so this is the concept and you know uh we're very proud to get this picture published on the february uh journal of and the endo cover. Um and so I am going to bypass this video for the sake of time. And um and I wanted to leave a few minutes uh for a question but you know this last little quick video, I'll just only show a few minutes of it. One of my what the heck am I doing here? This is early part of my career. The neurosurgeons at pennsylvania Hospital at penn had asked me to help them with lumbar in her body fusion using a robot completely off label. And uh we were co docked with the C. Arm so we can see what level we were at. And they started with the L. Five S. One which I think is easy to get to. And then they asked me to do L. Four L. Five and then they asked me to L. Four, L. Five, L. Five S. Um double level. Um And uh you know when the L. Four L. Five is a monster of an operation because you have to completely mobilize the or to completely mobilize the Kaveh. And then my bedside assistant will pull on these features outside of the body to essentially part the waters the garden Kaveh. We have to clip off all the lum bars. And then we use laproscopic hardware um like you know, gel point, you know, ports to put in hardware to drill out the spine and put everybody cage, you know, and you know, chuckle to myself, what the heck am I doing here? And and my point here being that, um, yeah, this was an impressive video to show. Um, you know, um, it was cool to be able to push the envelope. But, you know, in the years of doing various procedure development, that that operation is terrible. The reason why it's terrible. It's too risky is not reproducible. It's not something that you can share with the community and have people do safely. And so although we did it safely without hurting people and causing a lot of bleeding, you know, I I just I I I've realized over the years that you have to focus and develop your skills and techniques in areas where you make a difference where things can be teachable and things can be reproducible. And so, um, to contribute to the field techniques need to be translatable to the greater surgical community. Um, you know, for the students, the residents, the fellows and the young doctors on in in the field. You know, I am I'm a guy who didn't match neurology at the first, you know, my first go around in neurology and um and I find myself kind of on the cusp of just really cutting edge and exciting surgery and I tickle myself, pinch myself every day and ask myself, how did I get here? You know? And so, you know, you guys have to be inspired. Uh look at the people, wonderful people around you, the talented people around you that are teaching you, that are guiding you, be inspired by them, be passionate and find a way to change the world for the better. At least you're urologic world if you can, but you're greater world in general. And this is coming from a guy who failed at first. And so um, that pretty much concludes my talk. I do have a fellowship one year. We've closed the applications for 2022 to 23. This is a picture of the holy, one of my superstar fellows that went on to do a second fellowship at U Dub. Um um, and then as uh now signed on at Northwestern to run uh a robotic and reconstructed program and he's going to be a rising star. But we took them all over the world um, and uh able to present a lot of great things, meet a lot of friends and uh doing the first buckle case rhinoplasty and um in uh in china and they were so interested and took a lot of pictures. So it's just really fun. Um You know, if you are interested in a fellowship with me, there is an opportunity to travel around the world except for covid years. Uh But anyway, thank you everybody for allowing me. I think I just stayed under my time. I can open the floor to any questions um if you guys want at this time. Mhm. Yeah. Hey dan, it's amazing talk, really, really enjoyed it. Um questions about your proximal um yuri Toral surgeries. How often are you deciding in advance, but it's going to be a buckle graft and how often is that a call that you make in the end? Yeah, that's a great question. Um that's that that that answer has changed in my mind um in the beginning I was so very cautious about executing a buckle because you know, I was careful to test this technology or this technique out and so um if I found any excuse to not do a buckle and to do a traditional repair And we had good results with the right right selected you you you know, you're costumey cases with a downward network prexy. I mean we could achieve probably about an 85% success rate in most of these well selected cases, But what I've realized in time is that our success is a little bit higher with buckle right reaching around 92 closer approaching 95 we have a little bit less success about 88% in redux pile classes for various reasons, you know? Um but you know, so nowadays uh in my mind, when I look at a case, I see a stricture, even if it's short, I typically go that's just gonna be a buckle and that's typically what we just go to now and, and and it's taken me years to arrive to that point. It's my crown. The question when are you harvesting the buckle? Is it while the patients in position and the robots docked or do you harvest it up front and just stick it in some saline and then use it. Yeah. The great question I get asked from time time um we always do it um um After we get there after we open it up and we stick a ruler in and we measure, we really, you know, I've done it only once and I'll never do it again where we pre dissected because my mike had to go somewhere and so I asked him to just please come in and just pre destructive and you know that worked out fine. He took out more than they needed to just in case. But I think that you get potentially into trouble if you're structures a lot longer than you thought. And we've had a few cases like that. And so I always recommend do not pre dissected out. You know when as soon as I measure it, as soon as I I realize what I need that you're just open, I know for sure on both ends its open. Um and I said that's about 3cm. Um That's when we uh you know, dC inflate the abdomen. Uh We leave the robot doctor in and then um I go out and grab lunch real quick and mike comes in. We already have the buckle tray opened and then he goes in and and and harvest. And so that's that's the way we do it and that's the way I recommend it.