Surgical waiting time from initial urological consultation to operative intervention does not adversely affect the outcome of renal cell carcinoma within the time frames analyzed in this study, in which 94% of cases occurred within 3 months. Individual urologist judgment remains a critical factor in the appropriate and timely care of the patient with a suspicious renal mass.
Patients often ask how soon they have to have surgery when diagnosed with a likely cancer. This study shows that for kidney cancer it does not seem to make much of a diffference. The main problem with tihs study is that patients with larger tumors often get counselled to have surgery right away, whereas smaller ones are often given the option to wait a few months if the patient wants to.
First Annual Worldwide Robotic Renal Symposium
I had the honor of being selected on the faculty for the 1st robotic conference dedicated to kidney surgery. This should be an excellent conference for urologists who are performing robotic surgery for prostate cancer and would like to learn about current techniques for kidney surgery including partial nephrectomy. Transplant surgeons who currently perform laparoscopic donor nephrectomies and would like to learn about robotic surgery are also good candidates.
Eric P. Newman Education Center
Washington University Medical Center – St. Louis, Missouri
Sam B. Bhayani, M.D.
The Division of Urologic Surgery
Washington University School of Medicine
Continuing Medical Education
This review of an article by one of the founders of laparoscopic urology shows that with one of the common laparoscopic method to remove a kidney, ureter, and bladder cuff for transitional cell caner of the upper urinary tract lining there seems to be a higer recurrence rate and positive margins.
Our current technique is a robotic approach to remove the whole specimen intact with 2 robotic operations at the same setting. Prior to this I usually would remove the kidney with the laparoscope and then the ureter and bladder cuff with an open incision. Without robotic surgery, I never felt that I would obtain as good a specimen as with open surgery for the bladder part of the operation. With the robotic nephroureterectomy, I think the specimen is equal and there is no need to make a large incision or to open up the bladder like I did in open surgery.
Oncologic Outcomes of Extravesical Stapling of Distal Ureter in Laparoscopic Nephroureterectomy
The local recurrence rate (17% vs. 0%) and the bladder recurrence rate (50% vs. 33%) were higher in the laparoscopic stapled group (p = 0.090)
Of note there were 3 patients (25%) with a positive margin in the laparoscopic group vs. none in the open group.
To be sure, as a frequent user of the stapler to remove the ureteral cuff, I have over the years altered my technique in order to improve removal of a larger cuff of bladder along with the entire ureteral tunnel:
As my friends and readers know, in May of 2007 I performed a live right kidney and adrenal gland removal for intuitive surgical. This was telecast to the AUA conference in Anaheim. My hospital helped me edit the video which I did a voice-over for and made into a nice 7 minute piece. I was told it was going on our hospitals website.
I then received an email that it was put on you tube. I am not sure how I feel about this. Exposure is good, but is this the correct forum? I have personally put videos on google video before, but not you tube.
I think the piece is pretty neat and can be viewed below.
I welcome comments about using youtube or other media to promote work. I think surgeons can learn by watching this piece and will find it interesting, but I wonder how it will be perceived.
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The FDA has approved the enzyme inhibitor temsirolimus (Torisel) for the treatment of advanced renal cell carcinoma.
The approval of temsirolimus follows the December 2005 approval of sorafenib (Nexavar) and the January 2006 approval of sunitinib (Sutent), which represent a new class of targeted therapies for advanced RCC.
The authors report on 301 patients who underwent nephron sparing surgery for a localized renal tumor. Of these, 181 patients had renal artery occlusion with cold ischemia, while the remaining 120 patients were managed with external compression alone to control hemorrhage. Mean tumor size was 3.56cm and there was a higher incidence of centralized tumors in the arterial occlusion group (p less than 0.05). The authors noted no difference in blood loss, transfusion rates, tumor size, or complications between the two groups. Two renal units (1.2%) were “lost” due to ischemic damage in the renal artery occlusion group, which was not a complication in the external compression group. More importantly, there was a significantly higher incidence of positive margins in the external compression group (4.2%) relative to the group with renal artery occlusion during resection (0.6%), (p less than 0.05).
Renal artery occlusion during partial nephrectomy may result in ischemic damage to the remaining renal parenchyma, particularly if prolonged, but is clearly superior for optimal visualization during tumor resection. This study demonstrates that external compression (the “grip of death”) does not significantly minimize morbidity over renal artery clamping, and may, in fact, be associated with an increased positive margin rate due to poor visibility during tumor resection.
Thursday, 15 March 2007
BERKELEY, CA (UroToday.com) – Positive margins following supposedly curative surgery can be devastating for patient and surgeon alike.
The implication that cancer was “left behind” implies a continued biologic threat, although little is known about the impact of positive margins following nephron sparing surgery, because, thankfully, it is a rare finding. Here, two leaders in laparoscopic renal surgery (Gill and Kavoussi) combine their experience to examine oncologic outcomes in patients undergoing laparoscopic partial nephrectomy found to have positive surgical resection margins.
These 2 surgeons are among the best in the world in minimally invasive partial nephrectomy. I would think that there margins were very close to being negative and management should be dictated by close followup of these patients if the surgeon felt he had removed the whole tumor. It is certainly a controversial topic.
“Antibody PET could end up changing the standard of care for patients with kidney cancer,” said the study’s senior author, Paul Russo, MD, a urologic cancer surgeon at MSKCC. “The excellent sensitivity and specificity of this tool supports the utility of G250 PET imaging in the work-up and management strategies for clinically localized renal masses and as an alternative to biopsy for distinguishing renal lesions.”
In the study, 25 patients scheduled to have surgery to remove a renal mass received intravenous 124I-cG250. PET images obtained prior to surgery were graded as positive or negative for antibody uptake. A pathologist unaware of PET scan results then classified resected tumor specimens as clear cell renal carcinoma or otherwise.
According to the authors, G250 PET may ultimately be used not only to determine the aggressiveness and extent of a patient’s disease prior to any surgical intervention, but also to measure the therapeutic effects of a particular treatment, and predict the likelihood of recurrence.
“The promising results of this trial have stimulated interest in a larger, prospective multi-center trial to confirm our findings, and ultimately greatly improve the clinical management of patients with kidney tumors,” said Dr. Divgi.
I would not agree that I would consider a negative PET with the new antibody to mean that I would not operate on a renal mass, but this is an important study,
I look forward to hearing about newer studies for PET and to see if treating lesions with cryosurgery or RF ablation may allow for a followup with this type of study.