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The CurrenT STaTe of urologiC onCology | iSSue 1 | winTer 2012 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 recurrence 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
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uRoloGIC onColoGy - University of Michigan Health System

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