uRoloGIC onColoGy - University of Michigan Health System

the MIChIGAn dIFFeRenCe 

department of urology 

3875 taubman Center 

1500 e. Medical Center dr., sPC 5330 

Ann Arbor, MI 48109-5330 

InsIde thIs Iss ue... 

A Tailored Approach to the Management of Small Renal Masses . . . . . 2 

Recent Developments in Kidney Cancer Treatment . . . . . . . . . . . . . . . . 3 

Minimally Invasive Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . 4 

u n I v e R s I t y o F M I C h I G A n 

dePARtMent oF uRoloGy 

the CuRRent stAte oF 

uRoloGIC onColoGy 

At the unIveRsIty oF MIChIGAn 

issue 1 Winter 2012 

GreetinGs from UroloGic oncoloGy 

our division has grown from four clinical urological oncologists 

in 2006 to our current status of eight clinical urologic 

oncologists (one full time at the Veterans Administration 

Hospital) and three basic scientists. this increase in clinical 

research has allowed us to better meet the urologic cancer 

needs of michigan’s population. With the aging population 

and better treatment for cardiovascular and pulmonary diseases, 

urologic cancer is becoming a more frequent issue in 

the health of our patients. the incidence of prostate, bladder, 

and renal cancers continue to increase with the aging population. 

With improved early detection methods, the average 

age of surgical treatment of our patients with urologic cancer 

continues to decrease, suggesting that long term functional 

outcomes will be critical. 

our division is saddened by the loss of Dr. Dave Wood 

who recently accepted a position at Beaumont Hospital 

as President of Beaumont Physician Partners and clinical 

faculty effective January 1, 2012. His main responsibilities 

will be to facilitate physician-hospital integration, establish 

clinical faculty responsibilities with the newly established 

William Beaumont/oakland University medical school, and 

lead quality improvement. His departure is a loss for us but a 

unique and challenging administrative opportunity for Dave. 

Personally, i have known Dave since he was a medical student 

at U-m and have tremendous respect for his character, 

judgment, and clinical skills. the Department of Urology 

at U-m wishes him nothing but success in his new venture. 

filling his shoes is not really possible but we have initiated a 

search process to identify a new division head. 

We have decided to dedicate this newsletter to our advances 

in renal surgery. Due to the wide spread use of abdominal 

imaging the identification of small renal masses less than 

4cm in size is more common. management of such tumors 

is complex since many of these may have little impact on 

the patient’s life, yet renal cancer is one of the more unpredictable 

malignancies that we deal with on a regular basis. 

therefore, over the years we have pioneered the development 

of minimally invasive techniques to identify, characterize, and 

treat these small renal masses. this includes sophisticated 

abdominal imaging, routine use of percutaneous biopsy of the 

small renal masses, and employment of minimally invasive 

continued on p. 2 

Managing Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Rising Incidence Rates of Renal Cell Carcinoma . . . . . . . . . . . . . . . . . . 6 

Urologic Oncology Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The CurrenT STaTe of urologiC onCology | iSSue 1 | winTer 2012 

continued from p. 1 

laparoscopic and robotic techniques for 

partial nephrectomy. Despite the early 

detection of many renal cell cancers, there 

is a stable population of patients who 

present with very large renal masses that 

have vascular extension into the vena 

cava and occasionally into the heart. the 

management of these patients is quite 

challenging; at the University of michigan 

we have developed a coordinated team of 

urologists, vascular surgeons, cardiovascular 

surgeons, and support staff to manage 

these complex patients. With this team 

concept, we have significantly improved 

the outcomes of these patients with lethal 

cancers and have been able to offer sophisticated 

adjuvant clinical trials using newly 

available biological agents. 

Because of our clinical and research 

growth, within these pages we also highlight 

and introduce the members of the 

Division of Urologic oncology with brief 

descriptions of their clinical and research 

focuses. if you have any patient care questions 

or concerns or have any patient with 

a urologic malignancy that you would 

like to refer to the University of michigan, 

please do hesitate to contact us: 

University of michigan cancer center 

Hotline : 734-647-8903 

or contact me personally at: 

734-936-0054. 

Best Wishes 

Jim montie, mD 

Interim Head, Division of Urologic 

Oncology 

Valassis Professor of Urologic Oncology 

2 

A tailored Approach to the management of 

small renal masses 

Alon Weizer, MD, MS 

Assistant Professor of Urology Surgery 

renal cell carcinoma affects more than 

50,000 people each year and roughly 14,000 

die of the disease annually. However, most 

people diagnosed with kidney cancer have 

small tumors (< 4 cm) that are picked up 

when they undergo radiographic evaluation 

because of other symptoms. on cursory 

review, it would seem like this would lead to 

more people getting treated earlier and fewer 

people dying from kidney cancer. there are 

several problems with this logic. first, it is still 

the people diagnosed with large tumors that 

die from kidney cancer, while a much smaller 

number of people with small renal masses die 

from their disease despite receiving aggressive 

surgical treatment. second, many of the small 

renal masses identified incidentally on imaging 

are non-cancerous, so treating these patients 

not only does not impact survival but also 

exposes them to the risk of surgery. finally, 

many patients continue to undergo radical 

nephrectomy (removal of the entire kidney) 

despite the fact that partial nephrectomy 

(removal of just the tumor) might be equally 

affective as might be ablative therapy, which 

destroys the tumor in place. the chief benefit 

of removing the tumor while preserving the 

kidney over total kidney removal is that preservation 

of kidney function protects patients 

from the risk of chronic kidney disease over 

a long period of time without compromising 

cancer control. 

over the last several years, we have worked 

to improve the treatment of patients with 

small renal masses. for instance, we now have 

a team of urologists dedicated to individualizing 

treatment for each patient who is seen 

at U-m’s Department of Urology. this means 

that we first try to determine whether a person 

with a newly diagnosed kidney tumor 

needs treatment at all. most of our patients 

with a tumor < 4 cm are evaluated with a 

renal mass biopsy, which our radiology colleagues 

perform as an outpatient procedure 

in patients under sedation. this well-tolerated 

biopsy allows us to identify the almost 30 percent 

of patients with non-cancerous tumors 

who do not require any further treatment. 

A biopsy positive for kidney cancer provides 

us with information about the type of cancer 

and its aggressiveness, allowing us to counsel 

patients regarding the best treatment option 

for them. treatment options include close surveillance 

of patients with non-aggressive kidney 

cancers, kidney preserving surgeries (ablation, 

partial nephrectomy through an open 

incision or a laparoscopic/robotic approach), 

and complete kidney removal when the biopsy 

findings identify a very aggressive cancer that 

would benefit from this approach. 

in conclusion, we’re working 

hard at U-m to find the most 

effective treatment regimen 

for each individual patient 

with a small renal mass. 

However, our personalized 

care program for patients 

with small renal masses and 

early kidney cancer is at an 

early stage. through cuttingedge 

translational research, 

we hope to further refine 

our ability to determine 

who can avoid treatment 

for their renal mass, who 

would benefit from nephron 

sparing procedures, and who 

requires multidisciplinary 

care by our excellent team of 

doctors at U-m.

ecent Developments in Kidney cancer treatment 

Bruce Redman, DO 

Professor of Internal Medicine 

in the past five years, the fDA has approved 

six new agents for the treatment of metastatic 

kidney cancer. though the common target 

of these agents is angiogenesis, they can be 

grouped into three distinct classes based on 

their mechanisms of action. 

1. tyrosine kinase inhibition (tKi): 

represented by sunitinib, pazopanib, 

and sorafenib 

2. monoclonal antibody: represented 

by bevacizumab 

3. mammalian target of rapamycin 

(mtor) inhibition: represented by 

everolimus and temsirolimus 

the fDA approved all of these agents 

because they demonstrated clinical benefits 

in randomized trials. specifically, these compounds 

delayed metastatic disease progression; 

temsirolimus was the only agent, however, 

to show an overall survival advantage 

(albeit compared to the inactive interferon 

alfa). yet none of these agents are curative 

for metastatic clear cell carcinoma of the kidney, 

the only curative therapy for metastatic 

kidney cancer remains high-dose interleukin-2, 

and it only works in highly selected 

patients. Patients with metastatic clear cell 

carcinoma should be referred to a cancer 

center that has experience in, and expertise 

at, utilizing high-dose il-2 to discuss this 

potentially curative treatment option. for a 

more detailed discussion of the agents and 

how they fit in the treatment paradigm of 

advanced kidney cancer, visit the national 

comprehensive cancer network treatment 

Guidelines webpage (www.nccn.org). 

As in the case of all clinical research, advances 

lead to additional questions. the following 

represent several of the more prominent 

research questions that have arisen in regard 

to the care of patients with kidney cancer. 

1. What role does cytoreductive 

nephrectomy play in the treatment 

of stage iV kidney cancer in the 

current era of targeted therapies? 

2. What are the mechanisms of resistance 

to targeted therapies? 

a. in primary failure (no 

response to initial therapy) 

b. in acquired resistance (initial 

response followed by disease 

progression) 

3. What is the role, if any, for the 

adjuvant treatment of high-risk 

patients after definitive surgery? 

4. When and how do we evaluate 

novel investigational therapies in 

the treatment of stage iV kidney 

cancer? 

Cytoreductive Nephrectomy 

there is currently no clinical trial data defining 

what role cytoreductive nephrectomy, in 

conjunction with the use of targeted therapies, 

plays in the outcome of patients with kidney 

cancer. Previous clinical trial results supported 

the use of cytoreductive nephrectomy plus 

interferon in selected patients with metastatic 

kidney cancer, but these results are difficult to 

translate to other targeted agents. interferon is 

now considered an inactive therapy for kidney 

cancer. the current front line tyrosine kinase 

inhibitors (tKis) have much greater clinical 

activity than interferon and thus may abrogate 

any benefit from cytoreductive nephrectomy. 

the question of whether cytoreductive 

nephrectomy, followed by the use of a tKi, is 

most effective is being addressed in ongoing 

national and international trials. 

Mechanisms of Resistance 

At the present time, we have no definitive 

answer to the question: What are the mechanisms 

of resistance to targeted therapies? We 

are, however, testing multiple hypotheses in 

our active clinical research. 

Adjuvant Treatment 

there is currently no validated adjuvant 

therapy for the treatment of high-risk resected 

kidney cancer. However, at U-m, we are 

participating in a national cooperative group 

trial, led by the southwest oncology Group, 

of a randomized double blind placebo controlled 

trial of everolimus as adjuvant therapy. 

Investigational Therapy 

there are no curative treatment options for 

patients who have not responded to il-2 

or who are not candidates for il-2. While 

current targeted therapies can meaningfully 

improve progression free survival, resistance 

ultimately develops in all patients. At U-m, 

we are performing clinical trials to evaluate 

new novel therapies for patients with metastatic 

kidney cancer; these are either part of 

our ongoing Phase ii trial of anti-PD-1 immunomodulating 

trial or they are part of our 

Phase i program. 

3


minimally invasive treatment options for Patients with Kidney cancer 

J. Stuart Wolf, Jr., MD 

David A. Bloom Professor of Urology 

Co-Director, Michigan Center for Minimally Invasive Urology 

most kidney cancers are localized to the 

kidney and can be addressed with minimally 

invasive techniques. Broadly speaking, there 

are two surgical procedures (nephrectomy 

and nephron-sparing surgery) used in treating 

the disease, two methods of getting rid of it 

(tissue removal and tissue ablation), and two 

minimally invasive surgical approaches (laparoscopic/robotic 

surgery, and percutaneous 

techniques) (see figure at right). Among these, 

laparoscopic radical nephrectomy was the first 

procedure offered to patients. it took almost 

10 years from its inception in 1990 to achieve 

widespread use, but it is now accepted as a 

standard treatment for cancer requiring complete 

kidney removal. the first laparoscopic 

radical nephrectomy in the state of michigan 

was performed at U-m, and our pioneering 

work with this hand-assisted laparoscopic 

technique enabled many practitioners to start 

using this approach. 1 our extensive experience 

at U-m with renal laparoscopy allows 

us to offer this procedure even to patients 

with adrenal, renal vein, and/or lymph node 

involvement; only renal tumors with extensive 

regional involvement are managed with open 

surgical radical nephrectomy. 

one of the unfortunate downstream effects 

of the popularization of laparoscopic radical 

nephrectomy, however, is that it may have 

retarded the promulgation of partial nephrectomy. 

At about the same time that laparoscopic 

radical nephrectomy was introduced, 

data was established suggesting that partial 

nephrectomy for small renal masses provided 

cancer control equivalent to that provided by 

radical nephrectomy. Because urologists were 

motivated to deliver the “latest” care, and 

patients were understandably attracted to the 

less-invasive technique of laparoscopy, many 

laparoscopic radical nephrectomies were 

performed in patients who should have been 

managed with partial nephrectomy. the technical 

difficulty of partial nephrectomy, even 

when performed with open surgery, undoubtedly 

contributed to its slow gain in popularity 

as well. more recent evidence suggests that 

4 

partial nephrectomy may provide a long-term 

survival advantage over radical nephrectomy, 

owing to the health benefits of better renal 

function. 

thanks to the advent of laparoscopic partial 

nephrectomy, there is now a solution to the 

problem of offering patients a less-invasive 

procedure while also sparing nephrons. 

Having performed the first laparoscopic partial 

nephrectomy in the state of michigan at 

U-m and since then 500 more, we now have 

an extensive experience with this procedure. 2 

more recently, we also began to perform 

robotic partial nephrectomy, and already have 

an institutional experience of more than 150 

cases. 3 our ability to offer both laparoscopic 

and robotic partial nephrectomy, performed 

by surgeons with extensive experience, is a 

distinct advantage of our program. 

finally, renal tumor ablation offers a management 

option of considerable benefit in certain 

situations. there are a variety of reasons why 

partial nephrectomy might not be the right 

option for some patients: recurrence of renal 

cancer in a previously operated site, whether 

it be a fossa recurrence after radical nephrectomy, 

a local recurrence or multifocal recur- 

rence after partial nephrectomy, or continuing 

development of renal tumors in the setting of 

a hereditary syndrome such as Von Hippellindau 

disease, presents great surgical challenges. 

second, surgery might be more dangerous 

for patients with hostile abdomens (owing 

to prior surgery, radiation, crohn’s disease, 

etc.) than a renal tumor ablation. finally, 

some patients have normal life expectancies 

but cannot tolerate surgical complications 

such as a hemorrhage. With these patients, 

renal tumor ablation offers a good alternative 

to partial or radical nephrectomy. 

At U-m, we work closely with our colleagues 

in the Department of radiology, who perform 

percutaneous radiofrequency ablations and 

percutaneous cryo-ablationa. less commonly, 

a tumor that we would prefer to treat with 

ablation is not accessible through the percutaneous 

route. With these cases, we perform 

laparoscopic cryo-ablations. 

in addition to publishing reports on the 

surgical developments described above, the 

Department of Urology has played a leadership 

role in assessing problems in the management 

of kidney cancer that have arisen 

given nationwide trends in the disease. these

include the rising incidence of small renal 

masses, 4 the underutilization of partial 

nephrectomy, 5 impediments to the adoption 

of laparoscopic renal surgery, 6 and 

unintended consequences of laparoscopic 

radical nephrectomy. 7 

care for localized kidney cancer at the 

University of michigan is provided by 

urologists who are clinical pioneers, 

experienced surgeons, and innovative 

researchers. 

references 

1. Wolf, J. s., Jr., moon, t. D., and nakada, s. 

y.: Hand assisted laparoscopic nephrectomy: 

comparison to standard laparoscopic nephrectomy. 

J. Urol., 160: 22–27, 1998. 

2. Weizer, A. Z., Gilbert, s. m., roberts, W. W., 

Hollenbeck, B. K., and Wolf, J. s., Jr.: tailoring technique 

of laparoscopic partial nephrectomy to tumor 

characteristics. J. Urology, 180: 1273–78, 2008. 

3. ellison, J. s., montgomery, J. s., Hafez, K. s., 

miller, D. c., Wolf, J. s., Jr., and Weizer, A. Z.: 

tumor characteristics and outcomes of robotic 

assisted laparoscopic and conventional laparoscopic 

partial nephrectomy. J endourology, 24 supplement 

1: A152–53, 2010. 

4. Hollingsworth J. m., miller D. c., Daignault s., 

and Hollenbeck, B. K.: rising incidence of small 

renal masses: A need to reassess treatment effect. J 

natl cancer inst, 2006; 98: 1331–34. 

5. miller D. c., Hollingsworth J. m., Hafez K. s., 

Daignault s., and Hollenbeck, B.K.: Partial nephrectomy 

for small renal masses: An emerging quality of 

care concern? J Urol 2006; 175: 853. 

6. filson, c. P., Banerjee, m., Wolf, J. s., Jr., ye, Z., 

Wei, J. t. and miller, D. c.: surgeon characteristics 

and long-term trends in the adoption of laparoscopic 

radical nephrectomy. J. Urology, 185:2072 – 77, 

2011. 

7. tan, H-J., Wolf, J. s., Jr., ye, Z., Wei, J. t., and 

miller, D. c.: Population-level comparative effectiveness 

of laparoscopic versus open radical nephrectomy 

for patients with kidney cancer. cancer, in press. 

managing Patients with locally Advanced 

Kidney cancer and familial/Hereditary renal 

cancer 

Khaled Hafez, MD 

Associate Professor of Urology 

in the past, patients with renal cell carcinoma 

(rcc) commonly had locally advanced rcc 

at the time of their diagnosis. today, however, 

approximately 70 percent of patients are 

diagnosed incidentally as a result of enhanced 

imaging techniques. nevertheless, rcc is a 

highly vascular malignancy with a tendency to 

invade the venous system, resulting in a tumor 

thrombus in the renal vein or in the inferior 

vena cava (iVc). 

Although a majority of patients with rcc 

are now diagnosed with low-stage tumors, in 

the case of four to ten percent of them, the 

tumor is present in the venous circulation, 

specifically in the renal vein or in the iVc. 

Despite recent advances in systemic therapy, 

the standard treatment for patients with rcc 

with tumor thrombus remains removing the 

kidney with the attached tumor thrombus, a 

complex procedure often requiring a multidisciplinary 

approach. surgeons are required 

to utilize techniques commonly employed in 

cardiovascular surgery, such as extracorporeal 

circulation and hypothermia, as well as liver 

mobilization techniques derived from liver 

transplant surgery. in patients without evidence 

of metastasis, surgery is performed with 

curative intent. 

for patients with distant metastasis, we use a 

multidisciplinary approach at U-m, consisting 

of cytoreduction followed by possible immunotherapy 

and/or targeted therapy. our team 

of specialists includes a specialized anesthesia 

team with expertise in cardiac monitoring 

using trans-esophageal echocardiography, 

while our surgical team includes nurses, circulatory 

bypass technicians, and surgeons 

familiar with the nuances of this high-risk 

procedure. the latter consists of a urologist, 

a liver transplant surgeon, and a cardiac surgeon. 

With this team of specialists in place, 

we are well prepared for those cases requiring 

extensive liver mobilization and/or venous or 

cardiac bypass. 

At the outset, we perform a pre-operative 

evaluation of the patient in order to determine 

the extent of the disease. our postoperative 

care includes routine admission to the surgical 

intensive care unit for close monitoring. 

Improving Outcomes for Hereditary 

Renal Cancer Patients 

the true prevalence of hereditary renal cancer 

(Hrc) is poorly understood since many cases 

go unrecognized. According to conservative 

estimates, three to five percent of renal 

cancer patients have inherited forms of the 

disease. to improve their survival rate, it is 

critical that we identify familial renal cancer 

syndromes. By doing so, we can provide early 

screening of, and careful follow-up for, these 

individuals and their relatives. Known hereditary 

kidney cancer syndromes with identified 

genetic mutations include von Hippel–lindau 

disease (VHl), hereditary papillary renal 

cancer (HPrc), Birt–Hogg–Dube syndrome 

(BHD), hereditary leiomyomatosis renal cell 

carcinoma syndrome (Hlrcc), and tuberous 

sclerosis. recognizing the clinical features 

associated with Hrc is often the most important 

step in establishing the diagnosis. 

At U-m, we have developed conservative 

management strategies for Hrc syndromes, 

including the use of nephron sparing procedures 

aimed at limiting treatment-related 

morbidity, and the use of renal replacement 

therapy for patients with chronic kidney 

disease. A well-coordinated and experienced 

team of specialists evaluates patients with 

Hrc, which is led by a geneticist and includes 

physicians and surgeons from several other 

disciplines including urology, general surgery, 

neurosurgery, endocrinology, ophthalmology, 

otolaryngology, radiology, and social work. 

U-m is currently preparing to host the 

Annual national VHl conference in 2012, 

which will provide us with an opportunity to 

highlight the exceptional VHl clinical care 

Program available here. 

5


rising incidence rates of renal cell carcinoma: 

challenges for the 21st century 

David Miller, MD 

Assistant Professor of Urology Surgery 

national incidence rates for renal cell carcinoma 

(rcc) have risen steadily during the past 

two decades. this trend is mediated mainly 

by an increase in the number of patients with 

early-stage cancers. During this time period, 

the treatment paradigm for solid renal masses 

has favored their expedient removal upon 

detection. consequently, an increase in the 

frequency of kidney cancer surgery has paralleled 

the rising incidence of rcc. Although 

it is not endorsed universally, the current 

treatment paradigm is based on the assumption 

that early intervention (i.e., treatment of 

patients presumed to have early, low-stage 

disease) will result in better survival outcomes. 

in many ways, the rising incidence of renal 

cell carcinoma, and the concurrent increase in 

surgical therapy, provides a useful framework 

for considering the major challenges and 

opportunities for improving care and outcomes 

for patient with renal cell carcinoma 

in the 21st century. first, there is still a need 

to continue improving surgical patterns of 

care among patients with early-stage rcc. 

open radical nephrectomy has long been the 

standard treatment for this group of patients. 

in recent years, however, easier convalescence 

and equivalent cancer control established 

laparoscopy as an alternative standard of care 

for most patients treated with radical nephrectomy. 

concurrent with the gradual dissemination 

of laparoscopic radical nephrectomy, 

studies have demonstrated that for patients 

with small rccs (i.e., generally those ≤ 4 

cm), partial instead of radical nephrectomy 

achieves identical cancer control while better 

preserving long-term renal function and 

reducing overtreatment of benign or clinically 

indolent tumors. 

from a clinical perspective, therefore, it can 

be argued that the benefits of partial nephrectomy 

and laparoscopy support the application 

of one or both of these techniques for a 

vast majority of patients with organ-confined 

rccs. However, recent studies suggest that 

6 

open radical nephrectomy remains an all-toocommon 

surgical treatment for many patients 

with early-stage rcc. Among the many factors 

that may be impeding the adoption of 

laparoscopy and/or partial nephrectomy are 

the technical complexity of these procedures, 

and a lingering absence of professional consensus 

regarding optimal surgical therapy for 

patients with small rccs. in light of these 

concerns, several mentored- and simulatorbased 

types of training have now emerged to 

facilitate the development and transfer of minimally 

invasive surgical techniques, including 

both robotics and standard laparoscopy. in 

order to complement these efforts, members 

of the urology community now also have a 

clear opportunity (and arguably strong motivation) 

to support additional research and/or 

development of clinical guidelines that clarify 

optimal treatment algorithms for patients with 

kidney cancer. the recently released AUA 

guidelines for management of patients with 

small renal masses represent an important 

step forward in this area. 

in many ways, the rising incidence of renal 

cell carcinoma, and the concurrent increase in 

surgical therapy, provides a useful framework 

for considering the major challenges and 

opportunities for improving care and outcomes 

for patient with renal cell carcinoma 

in the 21st century. 

A second, and related, challenge stems from 

the biological heterogeneity of rcc and 

the physiological heterogeneity of patients 

presenting with these tumors. in particular, 

the growing recognition that a non-trivial 

proportion of rccs may have an indolent 

clinical course, and that many patients with 

these tumors ultimately die from other causes, 

has heightened interest in the expansion of 

active surveillance as an initial management 

strategy for patients with early-stage kidney 

cancer. the potential merits and pitfalls of 

this approach, including the potentially pivotal 

role of percutaneous renal mass biopsy 

for patient selection, are discussed in a separate 

section of this newsletter. moreover, the 

evidence base and rationale for active surveillance 

would also be enhanced greatly by a 

better understanding of the implications of 

co-morbid disease among patients with kidney 

cancer. in fact, at least one recent study suggests 

that nearly 25 percent of patients with 

rcc have at least two significant comorbidities 

at the time of their cancer diagnosis. 

Given this, an important 21st-century challenge 

for urologists is to better define longterm 

survival outcomes among patients with 

rcc, including the frequency of deaths due 

to causes unrelated to the cancer diagnosis. 

these data, when combined with detailed 

information on the duration and severity of 

comorbid conditions, may prove invaluable 

to understanding and predicting competing 

causes of death among patients considering 

surgical treatment for 

kidney cancer. this 

information will, in 

turn, inform ongoing 

debates surrounding 

the appropriate treatment 

intensity (versus 

expectant approaches) 

for populations of 

patients with earlystage 

rcc. 

in summary, the 

incidence of rcc continues to rise in the 21st 

century. As the physicians responsible for the 

treatment of a majority of patients with this 

common malignancy, we in the urology community 

have a tremendous opportunity to 

work together to continually refine and optimize 

the surgical and non-surgical treatment 

of patients with renal cell carcinoma. i look 

forward to joining you in this effort.

UroloGic oncoloGy fAcUlty 

Clinicians 

KHAleD sAmir HAfeZ, mD 

Faculty Appointment: Associate Professor, Department 

of Urology 

Degree: 1988, mD, cairo University school of 

medicine, cairo, egypt 

Residency: 1993, Urology, cairo University school of 

medicine, cairo, egypt 

2004, Urology, University of michigan 

Fellowship: 1997, Kidney cancer, renal-vascular and 

kidney transplantation, cleveland clinic foundation, 

cleveland, ohio 

Clinical and Research Interests: Dr Hafez’s clinical work focuses on urologic oncology, 

including bladder, kidney, and testis cancer. He has extensive clinical expertise 

with advanced renal cancer and with nephron sparing surgery for treating the 

cancer. He also has vast experience in the treatment of bladder cancer and such 

surgical options as radical cystectomy with neobladder urinary diversion. He has 

conducted multiple basic science projects, investigating renal physiology, oncology, 

and immunology, and performed multiple clinical trials to investigate the benefits 

of using adjuvant therapy with high-risk renal cancer. 

Brent KeitH HollenBecK, mD 

Faculty Appointment: Associate Professor, Department 


Degree: mD, 1997, indiana University 

Residency: University of michigan, 1997–2003 

Fellowships: minimally invasive surgery, 2004, 

University of michigan medical center 

Urologic oncology, 2005, University of michigan 

medical center 

Clinical Interests: Dr. Hollenbeck has become increasingly specialized in the care 

of patients with prostate and bladder cancers. this has afforded him the ability 

to maintain his commitment to research while continuing to deliver cuttingedge, 

high-quality care. His research interests are policy-oriented and are focused 

squarely on understanding the upstream influences and downstream consequences 

of variation in physician practice style. His current initiatives include measuring the 

effects of physician financial incentives and identifying best practices for early stage 

bladder cancer. He is firmly committed to training the future leaders in urologic 

health services research. further, he strongly believes that populating the surgical 

specialties with health services researchers will yield long-term benefits to both our 

specialty and our patients. 

7


cHeryl tAylore 

lee, mD 

Faculty Appointment: 

Associate Professor, Dr. 

robert H. and eva m. moyad 

Professor, Department of 

Urology 

Degree: mD, 1991, Albany 

medical college 

Residency: University of 

michigan, 1997 

Fellowship: Urologic oncology, 2000, memorial sloan- 

Kettering cancer center, new york 

Clinical Interests: Bladder cancer, urethral cancer, pelvic 

tumors, and urothelial cancers of the upper tract. 

Research Interests: cancer survivorship, quality of life, 

and novel multidisciplinary treatment strategies for bladder 

cancer patients. 

for more than a decade, Dr. lee has dedicated her practice 

to the treatment of high-risk bladder cancer in a 

wide spectrum of patients spanning the range from early 

stage to locally advanced disease . this has been possible 

because of long-term partnerships with urologists, medical 

oncologists, and general healthcare providers. During 

this time, she has explored strategies to improve surgical 

and cancer outcomes and has worked to optimize quality 

of life in patients requiring radical surgery. she specializes 

in organ and nerve-preserving radical cystectomy in 

men and women, and performs a range of incontinent and 

continent urinary diversion that will suit the needs of the 

patient. in an effort to treat the whole patient and improve 

their cancer survivorship experience, she has recently 

focused greater attention to the physical and psychosocial 

impairments that patients experience after treatment. 

8 


DAViD cHristoPHer miller, mD, 

mPH 

Faculty Appointment: Assistant Professor, Department 


Degrees: mD, 1999, Washington University school of 

medicine, st. louis 

mPH, 2005, University of michigan school of Public 

Health 

Residency: University of michigan, 2005 

Fellowships: Urologic oncology, 2008, University of california, los Angeles 

Urological Health services research, 2007, University of california, los Angeles/ 

rAnD 

Health services research training Program, 2006, University of michigan 

Department of Urology 

Clinical Interests: Dr. miller’s clinical interests focus on providing high-quality and 

compassionate care for patients with urological cancers. He has extensive experience 

and particular expertise in performing minimally invasive surgical treatments 

for prostate and kidney cancer, including robotic-assisted radical prostatectomy, 

partial nephrectomy, and laparoscopic nephrectomy. He also performs focal and 

total cryosurgical ablation of the prostate as a minimally invasive treatment option 

for patients with prostate cancer, including those with radio-recurrent prostate 

cancer. His overarching emphasis is on partnering with patients, primary care 

physicians, and his colleagues in urology to achieve the best possible outcomes for 

patients with prostate and kidney cancer. 

Jeffrey scott montGomery, mD, 

mHsA 



Degree: mD, 2001, columbia college of Physicians 

and surgeons 

mHsA, 2007 University of michigan school of Public 


Residency: University of michigan, 2007 

Fellowship: Urologic oncology, 2008, University of texas mD Anderson cancer 

center 

Clinical Interests: Dr. montgomery’s clinical practice focuses on the diagnosis and 

treatment of bladder, prostate, kidney, penile and testicular cancers. His advanced 

training in urologic oncology and minimally invasive surgical techniques, such as 

robotic and laparoscopic surgery, allows him to deliver state-of-the-art care to his 

patients. He also conducts clinical research focused on the management of bladder, 

prostate and kidney cancers, including cost-analyses and health-related quality of 

life outcomes.

JAmes eDWArD montie, mD 

Faculty Appointment: Professor, Department of 

Urology, Valassis Professor of Urologic oncology, 

cancer center member 

Degree: mD, 1971, University of michigan 

Fellowship: Urologic oncology, 1979, memorial sloan- 

Kettering cancer center, new york 

Certifications: Urology 1978, American Board of 

Urology 


Clinical Interests: Dr. montie’s clinical interests comprise cancers of the bladder, 

kidney, and prostate. His research interests include active surveillance for prostate 

cancer, the identification of prostate cancer biomarkers, performing urinary diversions, 

and, most recently, health services research in urologic oncology. He has 

been active in the development of physician-led collaboratives for progress in quality 

of care and care delivery. 

teD AlBert sKolArUs, mD, mPH 



Degrees: mD, 2003, Wayne state University school of 

medicine 

mPH, 2010, University of michigan school of Public 


Residency: Washington University school of medicine, 

2008, st. louis, missouri 

Fellowships: Urologic oncology, 2011, University of michigan 

Health services research, 2010, University of michigan, Department of Urology 

Research Interests: Health services and implementation research, improving quality 

of care for urologic malignancies 

Dr. skolarus provides urologic cancer care at the VA Ann Arbor Healthcare 

system. As part of the U-m Department of Urology and the VA center for 

clinical management research, he is part of a team of experts who work together 

with other physicians, nurses, and managers to test innovative solutions to health 

care challenges as well as to translate research into meaningful strategies and best 

practices. Dr. skolarus’ research interests aim to better understand the delivery of 

prostate cancer survivorship care, support the ongoing needs of prostate cancer 

survivors and identify opportunities to improve care coordination among cancer 

specialists and primary care providers. His current projects focus on engaging 

patients and their primary care providers in prostate cancer survivorship care 

through tailored self-management strategies and guidelines. 

Alon ZADoK 

WeiZer, mD, ms 


Assistant Professor, 

Department of Urology, 

Director of the clinical 

Urologic research endeavor 

Degrees: mD, 1999, Baylor 

college of medicine, Houston, 

tX 

ms clinical research statistical Design and Analysis, 

2009, University of michigan 

Residency: Duke University medical center, 2005, 

Durham, north carolina 

Fellowships: Urologic oncology, 2006, University of 

michigan 

minimally invasive surgery, 2007, University of michigan 

Clinical/Research Interests: Dr. Weizer brings expertise in 

minimally invasive urologic oncology procedures, including 

robotic-assisted partial nephrectomy, nephroureterectomy, 

distal ureterectomy, cystectomy, and prostatectomy. 

However, he is also proficient in the breadth of procedures 

in urologic oncology, utilizing the surgical approach 

(open, robotic, laparoscopic) and management regimen 

that is appropriate for a particular patient. His research 

interests include risk stratification of non-muscle invasive 

bladder cancer, the role of active surveillance in small 

renal masses, and understanding the outcomes of minimally 

invasive urologic oncology procedures. He currently 

directs cUre (clinical Urologic research endeavor), 

which comprises prospective clinical databases for a variety 

of urologic diseases, as well as a robust clinical trial 

program offering cutting-edge care. 

9


J. stUArt Wolf Jr., mD 

Faculty Appointment: Professor and David A. Bloom 

Professor of Urology, Department of Urology, 

co-director, michigan center for minimally invasive 

Urology 

Degree: mD, 1988, northwestern University, chicago 

Residency: University of california, 1994, san 

francisco, california 

Fellowship: Urology, 1996, Washington University, st. 

louis 

10 


Clinical Interests: Dr. Wolf specializes in minimally invasive surgery of the kidney, 

ureter, and related organs. He performs such procedures as laparoscopy (surgery 

performed through small incisions with the aid of a telescope, and with or without 

robotic-assistance), endoscopy (a procedure using a telescope that is moved into 

the lumen of the urinary tract), and percutaneous routes ( a procedure conducted 

through a single small incision with the use of a non-visualizing “needle”). Dr. 

Wolf treats such common diseases as stones, obstructions, and various other noncancerous 

problems of the kidney and ureter, as well as cancers involving the kidney 

(kidney cancer) and the lining of the kidney and ureter (urothelial cancer). Dr. 

Wolf pioneered many of the treatments for kidney cancer in the state of michigan; 

he performed, for instance, the first laparoscopic radical nephrectomy and the first 

laparoscopic partial nephrectomy. 

Researchers 

mArK DAy, PhD 


Professor, Department 

of Urology and the 

University of michigan 

comprehensive cancer 

center 

Degree: PhD cellular and 

molecular Biology, 1992, 

Washington University 

school of medicine 

Research Interests: Dr. Day’s laboratory focuses on the 

regulation of cell surface proteins in prostate and bladder 

cancer. recent findings from the Day lab indicate 

that these proteins are promising targets for therapeutic 

development to prevent the metastatic progression of 

these tumors. Dr. Day has also trained a large number 

medical students, graduate students, urology residents 

and fellows who continue to pursue research careers in 

Urology and GU oncology. 

Jill A. mAcosKA, 

PhD 


Professor of Urology 

faculty, Programs 

in cancer Biology, 

computational medicine 

and Bioinformatics, and 

cellular and molecular 

Biology 

Degree: PhD, Biochemistry, 1988, city University of 

new york (cUny) 

Fellowship: Harvard University, cambridge, mA, 

1989; michigan cancer foundation, Detroit, mi, 1991 

Clinical Interests: Dr. Jill macoska is performing laboratory 

studies in collaboration with Dr. Wolf to identify 

new biomarkers to predict renal cancer prognosis 

and response to therapy.

leADers AnD Best in UroloGic oncoloGy 

the University of michigan Hospital and Health system is in the top 5% nationally in these procedures. 

UniVersity of micHiGAn comPreHensiVe cAncer center 

At the University of michigan comprehensive cancer 

center, our goal is to provide our patients with strategies 

to optimize their overall health and wellness—now and in 

the future. 

Our physicians are available 

Monday - Friday, 8 am to 5pm 

Average wait time is one week* 

*Wait times may be longer if a specific physician may be requested 

2010 QUAlity metrics 

Procedure Median Length Average Blood Loss Surgical Volume 

of Stay (days) (cc) 

radical Prostatectomy 1 149 286 

robotic cystectomy 8 380 35 

open cystectomy 7 555 88 

endoscopic Bladder cancer Procedures n/A n/A 329 

laparoscopic Partial nephrectomy 2 269 29 

open Partial nephrectomy 3 374 35 

robotic Partial nephrectomy 2 336 56 

radical nephrectomy lap 3 237 33 

robotic 3 331 5 

open 5.5 994 19 

caval tumor thrombus 7 1464 8 

nUmBer of UroloGic oncoloGy Visits 

Type of Visit 2009 2010 

new Patient Visits 2,293 2,338 

total Visits 12,737 13,373 

To make an appointment: 

call (734) 647-6743 

cancer Answer line (800)865-1125 

referal line (734) 763-9114, 1 (800) 211-8181 

1500 e. medical center Dr. 

Ann Arbor, mi 48109-5913 

room 229 reception D, level B1-229 

Phone: (734) 647-8903 fax: (734) 647-8860 

www.med.umich.edu/cancer 

11

the MIChIGAn dIFFeRenCe 

department of urology 

3875 taubman Center 

1500 e. Medical Center dr., sPC 5330 

Ann Arbor, MI 48109-5330 

HOld tHe dAtes! 

Health services research symposium: 

sept 6-7, 2012 

this symposium will bring together leading clinicians and researchers 

from within and outside urology to discuss the current and future impact 

of health services and outcomes research in urology, including its relevance 

for patients, policymakers, payers, and practicing urologists. We 

anticipate a novel and provocative program that will include lectures and 

participation from Peter Carroll, Mark litwin, Joel nelson, david Penson 

Khaled Hafez, MD 

Associate Professor, Department 


Brent Hollenbeck, MD 

Associate Professor, Department 


Cheryl T. Lee, MD 

Dr . Robert & Eva Moyad 

Research Professor, Associate 


Urology 

David C. Miller, MD, MPH 

Assistant Professor, Department 


Jeffrey Scott Montgomery, MD 



James E. Montie, MD 


Urology 

Valassis Professor of Urologic 

Oncology 

Alon Weizer, MD 



J. Stuart Wolf, Jr., MD 

David A . Bloom Professor of 

Urology 

COntACt us 

If you have any questions regarding the Renal 

Carcinoma database, please contact Rick saur 

at 734-615-5446. 

to learn more about giving to the department of 

urology, please contact steffanie samuels, director of 

development, at 734-615-9843 or send an e-mail to 

ssamuels@umich.edu. 

and other thought leaders in the field. this edition of The Current State of Urologic Oncology 

at U-M was compiled by department of urology 

students/researchers: stephanie durphey, Michael 

Coelho, Peter Blank, and Will Kane. 

KiDney cAncer reseArcH teAm 

Executive Officers of 

the University of Michigan Health System 

ora Hirsch Pescovitz, executive Vice President for medical Affairs; 

James o. Woolliscroft, Dean, U-m medical school; Douglas strong, 

chief executive officer, U-m Hospitals and Health centers; Kathleen 

Potempa, Dean, school of nursing 

The Regents of the University of Michigan 

Julia Donovan Darlow, laurence B. Deitch, Denise ilitch, olivia P. 

maynard, Andrea fischer newman, Andrew c. richner, s. martin 

taylor, Katherine e. White, 

mary sue coleman (ex officio) 

the University of michigan is a non-discriminatory, affirmative action 

employer. 

copyright © 2012 

the regents of the University of michigan 

Ann Arbor, michigan, 48109 

mmD 110410

uRoloGIC onColoGy - University of Michigan Health System

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