Ashish Kamat: Welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, I'm a Professor of Urologic Oncology at MD Anderson Cancer Center in Houston, Texas and it's my great pleasure to once again welcome Dr. Makarand Khochikar to this venue. Dr. Khochikar and I did a bladder cancer case-based panel discussion a few episodes ago, and this was so well-received that we've invited him once again to partake in that sort of a discussion with us. Today, Dr. Khochikar will present a few cases and intraoperative consultations.

Makarand Khochikar: The next case I'm bringing for intraoperative consultation is many times you get a situation where people come for a particular, certain type of operation. This guy, I mentioned his religion here because he said his religion does not allow a single drop of urine leaking, and never ever wanted a stoma. So he came all the way from the Middle East and he wanted to come to our center and said, "We want new bladder only." Having said that, we all know when we counsel patients we do it first, second, third consulting, and never, ever you will be able to come, sort of promise patient that 100% you will have a new bladder, nine of 10 times I would be able to do new bladder, but I can't make any promise. So at the end of the day, he said, "Okay, try your best" and that is when we started.

Now, I took him for a cystectomy. I don't have any intraoperative picture itself, but I can show you a pictorial diagram that showed a complete malrotation of the gut. The cecum was on the left side, and I'm sure you all know when the gut rotates from right to left, the cecum goes higher and the mesentery is very short, and this is a technical challenge. And this is a pictorial sort of representation. This is a normal, and when you have a gut rotation across the axis, it just goes up on this side, and then you see this is how small the bowel is, and the mesentery is very short.

At any stretch of the imagination, I thought even I'm mobilizing that colon on a small level, this mesentery was coming very short, and I didn't know what exactly what to do. So the options I had were trying to create sort of a new bladder from a logic base type, and I don't think that's the right thing even if it did utilize a high-pressure system.

The second option I thought, just do a sort of ureterostomy, which you can't. I mean, he didn't want a stoma installed. And the third option, which I thought, which I was trained in the UK, is spinal injury-centered operation. Short time to create a minuscule pouch. In the hindsight, when we look at the CT scan, I think this was missed by the urologist as well as us, this is complete malrotation of the gut from the right and left.

Now, this was a dilemma I had and this is how the pictorial representation, how the Mainz II [inaudible 00:02:49] is done, and for the viewers, I'm sure Mainz II [inaudible 00:02:52] is not a real operation. The sigmoid colon has to be redundant, which was there in this case, and we did detubularise [inaudible 00:02:58] this, bring both the ureters inside and you have feeding tubes, I have a large sort of lattice tube-like thing which can drain the urine and then the bladder. And these are the pictures, this is a sigmoid colon, this was a large lattice tube here, pull urine to the catheters going into the ureter, and this how beautifully it was done. All sort of sigmoid colon was completely repaired here, and the procedure went off very well.

I went out of the operation theater, talked to the family, when he woke up I also told him I have been successful in not giving you a stoma. This is how we do not do neo bladder, but we had to correct this sort of ureterosigmoidostomy, Mainz II [inaudible 00:03:40]. Hard to accept, but he was happy that he didn't have a stoma. The problem in these sort of patients is they get ascending infections, but as long as you can make a low-pressure system and keep them on sort of backup and antibiotics, the recur chances for infection is pretty less. Luckily for six years, no upper tract deterioration, the renal function has been stable, he had two episodes of ascending UTI in the first year, and the imaging is the only problem because when you do an ultrasound scan you get a lot of gas into the pelvicalyceal system, so something like the "pneumourogram," I call it, so the assessment can be slightly difficult. But you can always do a CT scan.

Now, I just want to ask Ashish, would you have done anything differently? Any thoughts? Any other suggestions?

Ashish Kamat: No, I think you did everything right because obviously, in these situations the upper tract is something that we have to worry about and make sure that there's no potential for deterioration down the road. As you did, make sure there's no acute [inaudible 00:04:42] kinking, the usual precautions but malrotation of the gut does happen sometimes. Many times it's picked up on preoperative imaging so you sort of know going in that the patient would have malrotation of the gut, or just a variant in the rotation and plan accordingly. And moving the stoma from one side to the other is always an option, sometimes making a longer effort limb is an option. But the key thing, as you recognized here was whatever you do, make sure that it doesn't compromise the patient's quality of life and renal function.

Makarand Khochikar: Yes. Yeah, yeah. Absolutely right. And this difficult, a difficult case, what to decide on a table and this what I thought would invoke an interesting discussion.