Cryosurgery and other minimally invasive techniques are instrumental in operations to treat patients with kidney cancer.
“Minimally invasive techniques have had a tremendous impact on the management of renal malignancies,” said William Flanagan, M.D., FACS, who estimated he performs at least 95 percent of partial nephrectomies and total nephrectomies laparoscopically.
Minimal access approaches dramatically shorten recovery time in urologic surgeries. When renal tissue must be spared, laparoscopic cryotherapy is the optimal approach. By freezing the mass, the surgeon leaves the remaining renal tissue intact. This approach is particularly beneficial to patients with only one kidney who would otherwise need to go on dialysis if they underwent a partial or full nephrectomy, said Brant Mayher, M.D., FACS, of Palmetto Greenville Urology Associates.
When it is necessary to remove the entire kidney or a portion of it containing the mass, some surgeons are using a relatively new technique called hand-assisted laparoscopic nephrectomy (HALN). Dr. Flanagan is among area urologists who use this technique. Others who employ it include William Cobb, M.D., FACS, and Alfredro Carbonell, D.O., FACS, FACOS, of ’s Division of Minimally Invasive Surgery.This technique involves making a six- to seven-centimeter incision around the umbilicus to place the surgeon’s hand for dissection and removal of the specimen. Two additional one-centimeter incisions are made to place instruments and the laparoscope. HALN allows the surgeon to gain the benefits of laparoscopy and maintain the “feel” of open surgery. This combination ultimately leads to improved patient outcomes as compared with traditional open techniques.
“The hand helps us manipulate the kidney, shortens the operating time and makes the procedure safer,” said Dr. Flanagan.
Drs. Flanagan and Cobb and GHS surgical resident Christopher Schneider, M.D., published a research paper analyzing the impact of an initiative driven by the Minimally Invasive & Bariatric Surgery division to reduce the HALN learning curve for urologists and improve patient outcomes. They documented how nephrectomy patients benefited from collaboration between a urologist and a minimally invasive surgery specialist.
Their study found that when the urologist collaborated in the OR with the advanced laparoscopic surgeon to perform nephrectomies, some outcomes were much better compared with those from cases performed by urologists working alone. In the collaborative cases, there was significantly less blood loss (107 milliliters vs. 757 milliliters), need for transfusion (two patients vs. nine patients) and conversion to open surgery (one patient vs. nine patients).
Kidney cancer, also known as renal-cell carcinoma, is a disease that will affect approximately 65,000 men and women this year. Approximately 14,000 men and women will unfortunately die of this disease. The disease is most common in men. Risk factors for the disease include smoking, as well as misuse certain pain medications. The initial signs may include blood in the urine or an abnormal physical examination. Generally, these cancers are picked up more and more frequently with the use of routine imaging studies, such as CT scans. Fortunately, the majority of the patients are found to have the disease in the early stages, and therefore their prognosis or long-term outcomes have improved with time.
As with all cancers, the tumors need to be staged, or quantifying how much cancer the patient has, and graded as to how aggressive the disease is. Fortunately, the majority of cases are now diagnosed when they are still localized or confined to the kidney. As a result, the patient’s survival increases. As mentioned, most of these masses are found incidentally on routine imaging studies. However, if a patient presents with blood in the urine, also called hematuria, your doctor may order urine and blood tests, as well as imaging studies, such as a CT scan, MRI, or kidney ultrasound. Once these imaging and laboratory tests are performed, your doctor will better counsel you regarding treatment options. Fortunately, at Regional Urology, we provide a diverse range of options for treatment.
For the most part, surgical intervention is needed in order to cure patients of renal-cell carcinoma. However, an in-depth discussion with one’s doctor will establish whether a patient is a candidate for surgical intervention. Options for surgery include ablative techniques, such as cryotherapy, laparoscopic techniques, which allow the surgeon to perform the surgery through small holes, as well as the traditional open technique. Again, this is based upon the patient’s medical history as well as the size and location of the tumor.
Currently the physicians in the Greenville Health System use cryotherapy as the preferred modality for ablative therapy. This works by essentially causing “frostbite” in the tumor. Not only do we apply this technology in the treatment of prostate cancer, but we also use this for kidney cancers. Typically, the use of cryotherapy is limited to tumors less than 4 cm in size. Additionally, we also use percutaneous cryotherapy where no incision is made, but a needle is placed through one’s back while under anesthesia where the tumor is frozen.
Robotic/laparoscopic partial nephrectomy
Emerging data indicates the more kidney tissue one has, the better the long term outcomes. That is, the ability to cut out the tumors from a kidney cancer is shown to prolong a patient’s life in comparison with those who have the entire kidney removed. It is because of this that we perform laparoscopic and robotic partial nephrectomies. This procedure is performed through small keyhole-sized incisions where the tumor is accurately removed from the normal surrounding kidney tissue. Fortunately, hospitalization is dramatically decreased, and patient’s pain levels are also dramatically decreased with this mode of therapy.
Despite the fact that we have seen smaller and smaller tumors with the increased use of imaging, there is still the time-honored approach of open surgical removal. In this case, the tumors may be too large to be taken through the keyhole-sized incisions of laparoscopic or robotic surgery and may need open surgery to remove them. Additionally, circumstances may be that the patient has other medical problems or the location of the tumor necessitates an open approach.
The doctors at Regional Urology also incorporate the use of medical oncologists in the treatment of certain renal cancers. Fortunately research continues to provide newer and newer drugs to target and destroy these cancers. We also provide nutritional and counseling support if and when the patient desires such intervention.