This was the first live televised kidney surgery. I performed it at Newark Beth Israel Medical Center in May of 2007. We telecasted it to Anaheim at the Intuitive Surgical display at the AUA national meeting.
The median follow-up for patients still alive at the last follow-up was 8.3 years. The estimated overall survival rates at 10 and 15 years were 69% and 53%, respectively, for RN compared with 80% and 74%, respectively, following PN. Compared with PN-treated patients, patients who underwent RN were 75% more likely to die from any cause and more than four times more likely to develop stage IV chronic kidney disease, after adjusting for covariates, according to findings published online in European Urology. All of these differences between the RN and PN group were significant.
There have been several studies that concluded that patients that have kidney tumors and have only part of their kidney removed (partial nephrectomy) vs. the entire kidney removed (total or radical nephrectomy) have less kidney problems in the future. They patients with nephron sparing surgery (partial) lived longer as well.
Not all patients are candidates for removing only part of the kidney, but most with tumors under 4cm and most with tumors not in the middle of the kidney should have a partial nephrectomy as a consideration.
At Newark Beth Israel, I have been performing robotic partial nephrectomy since 2005. In 2007 I started using intraoperative renal ultrasound to better show the kidney anatomy. In 2012 I started using firefly to help me perform more accurate kidney surgery for suspected kidney cancer.
We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.
This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.
The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively.
RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.
A friend and expert robotic renal surgeon, Dr Bhayani, discusses his results with robotic partial nephrectomy.
The most important finding is the improvement in warm ischemia time, the amount of time the kidney is not receiving blood supply.
Another important finding is that the operation can be done quicker robotically, which can translate into a cost savings that will partially offset the increased cost of the robotic equipment.
A researcher has found a potential therapy for patients with kidney cancer, which historically hasn’t responded well to other therapies, such as radiation and chemotherapy.
Most cancerous kidney cells — also known as renal cells – have lost a gene called VHL, says Amato Giaccia, a cancer researcher at the Stanford University School of Medicine. And as he reports in the journal Cancer Cell, Giaccia has found a new compound, STF-62247, that causes death to kidney cancer cells missing VHL.
The drug works by altering a natural process inside cells. All cells have a kind of internal recycling process, called autophagy, where compounds inside the cell are broken down and their chemicals re-used. But Giaccia says there is normally a balance.
This is likely many years away, but likley will be the future for treatment of various cancers. This particular therapy is a medicine, but I believe that gene therapy, vaccines, and targetted medicines will one day be able to cure many cancers without the need for surgery or radiation.
Source: Washington University Website
“Robotic surgery is more efficient and precise than either open or laparoscopic surgery for tumors confined to the kidney,” says Bhayani, assistant professor of surgery and a leader in the field of robotic surgery. “Rather than operate with two hands, I can simultaneously control four robotic instruments with mechanical “wrists” that rotate more than 360 degrees, giving me far greater maneuverability than human hands or laparoscopic instruments.” Bhayani led a team at Washington University to develop the procedure for kidney tumors.
Dr Bhayani is a friend and excellent surgeon. Check out his website for a video clip of the partial nephrectomy. I was recently invited as a guest faculty at his conference (First Annual World Robotic Renal Symposium) and had the privilege of watching him perform 2 live surgeries, a robotic nephrectomy and a robotic partial nephrectomy. Both went very well.
Dr. Rubin and colleagues calculated standard incidence ratios (SIRs) of observed to expected cases of invasive colorectal cancer for each urologic cancer site and vice versa.
The analysis showed:
* Patients with previous ureteral cancer had an 80% increase in the risk of subsequent colorectal cancer, with an incidence ratio of 1.80 and a 95% confidence interval from 1.46 to 2.20.
* Those with renal pelvis cancer had a 44% increase in the risk of colorectal disease, with an incidence ratio of 1.44 and a 95% confidence interval from 1.20 to 1.72.
* Patients with bladder or renal parenchymal cancer had small but statistically significant increases in the risk of subsequent colorectal cancer, but the researchers concluded the increases were probably not clinically significant.
* The risk for any urologic cancer was increased after a diagnosis of colorectal cancer, with an incidence ratio of 1.24 and a 95% confidence interval from 1.20 to 1.28.
This study showed an increase risk of colon cancer after urinary tract cancers.
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.
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.
|The authors conclude that there is no reliable
indicator of benign pathology preoperatively in solitary renal masses, as
all of these were considered to be renal cell carcinoma on preoperative
imaging. Overall, management of these tumors should favor parenchymal
sparing approaches that can be both diagnostic and therapeutic, while
preserving functional renal mass.
Urologists once told patients that 90-95% of solid masses were malignant. We are now finding smaller tumors incidentally (by ultrasound or CT Scan done for another reason) and the likelihood of not having cancer has increased. I currently tell patients they usually have about a 15-20% chance of having a benign lesion if it is small (under 4 cms). I agree that in most cases, nephron sparing procedures (partial nephrectomy, cryosurgery or RF ablation) should be recommended.