Newest Surgical Option for Kidney Cancer Wake Forest University Baptist Medical Center Winston-Salem, NC October 15, 2009

Transcription

1 Newest Surgical Option for Kidney Cancer Wake Forest University Baptist Medical Center Winston-Salem, NC October 15, 2009 Welcome to this OR Live Webcast presentation from Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. Pushing the clinical and academic envelope is our mission here at Wake Forest Baptist. Ranked as one of America s best hospitals in U.S. News and World Report, we bring together the best of patient care, research and education. Our faculty members are internationally recognized as leaders in their respective fields. And our patients receive the benefits of their medical knowledge and expertise. We provide patients of all ages with top-notch medical care, often reaching beyond the walls of the medical center to help members of the community maintain healthy living. Teaching and learning are the mantra our physicians, surgeons and healthcare professionals live by, truly showing that at Wake Forest Baptist, knowledge makes all the difference. Hello, welcome to this Webcast from the Wake Forest University Baptist Medical Center. I am Anthony Atala, Chairman of the Department of Urology. We are very fortunate in our department to have with us one of the pioneers in robotic surgery, Dr. Asha Jamal. We will watch him perform a robotic-assisted partial nephrectomy, a procedure which is becoming the standard of care for kidney cancer lesions which are localized. Dr. Karim Kader, one of our urologic oncologists, will guide through this procedure. Let us go now to the OR, where we will watch this amazing team at work. Hello and welcome to Wake Forest University Baptist Medical Center. My name is Karim Kater. I ll be hosting our presentation today of the robot-assisted, laparoscopic, partial nephrectomy. Let s pass the mike over to our surgeon, Dr. Ayesha Jamal, one of the pioneers in robotic surgery in urology. Dr. Jamal? Yes, good morning viewer of the OR Live program; and we welcome to the operating room in Wake Forest University Baptist Medical Center. The patient we are going to demonstrate, this patient is a forty-eight-year-old male. And Dr. Kater will be telling you regarding the detail of the patient. But let me tell you in the meantime what we have done. We have just mobilized the colon of the kidney. You can see the colon? This is known as a descending colon. You can see the spleen up there in the left upper corner. And if I move to the right, you can appreciate the lower. This is the lower border of the liver. It is the omentum. And we have mobilized colon of the kidney, and you can see the hilum visible right there. Now, what we are going to do now, we are going to dissect the tumor all around. In the meantime I dissect the tumor, Dr. Kater will be telling you in brief about the patient. Kr. Kater, please? So we have assisting at the bedside one of our chief residents, Dr. Jake Richards. As well, we have Wanda Cruz, who is our scrub nurse. We re using a four-arm da Vinci SHD 3-D system, which is pretty much the most current robotic system. And I m just going to be talking to you a little bit about kidney cancer in general as a bit of a primer as Dr. Jamal continues to operate. Why don t they show the picture of this patient so the people they can see what we are dealing with? Okay, let me bring that slide up, okay. So you can see in this slide here a presentation of this particular patient. He is a forty-eight-year-old gentleman who had a workup for an employee annual physical examination. At the time of that examination, they did a urine test; and they saw microscopic amounts of blood. He was referred to a local urologist, who performed a CT scan which identified this mass. He had been seen by two other urologists who had suggested a

2 radical nephrectomy, but was sent here in third opinion; and Dr. Jamal felt that this lesion was amenable to this robotic-assisted, laparoscopic approach to partial nephrectomy. Can they see the picture inside? Okay,sSo if we look inside the belly right now -- Yes, let me explain you. This is --you can appreciate the lower pole of the kidney. I just lifted off the psoas muscle, and my fore thumb is holding the fat around the inferior pole of the kidney and the tumor. So we are trying to dissect tumor all around. Our goal is to maintain the fat around the tumor, and this is the lower pole of the kidney. Now I ll go /INAUDIBLE/ to the kidney. So now I can control all these four arms sitting at the robot, and I can swap from one to other. Now I m going posterior to the kidney. You can appreciate I m trying to leave the adhesions over there. Thus, we are trying to mobilize kidney all around before we release the peritoneal fat and peritoneal tumor. Dr. Jamal, can you point out the psoas muscle just to orient everybody? Sure, I ll do that. You can appreciate here that s the psoas muscle here. Can you see that? So that s the posterior abdominal wall on which the kidney sits. So he s dissecting that kidney free of that musculature right now. So now I m trying to lift this kidney all around. Why I m concerned because this is a big tumor, more than 4 centimeters size and /INAUDIBLE/ T1B. Since such kind of the tumor is important, we want to maintain fat around the tumor so it doesn't infiltration and we ll get to know what the distressed /INAUDIBLE/ is. So now you can see I have lifted the peritoneal fat with the fourth arm, and I m trying to move across laterally so I can go into the renal area. Now, here let me show you the urecta. You can see the urecta right here. Now the ureter, for those people who don t know, is the tubular structure that connects the kidney to the bladder. And you can see how it peristalsis or moves to assist in the urine going from the kidney down to the bladder. So he s dissecting now along the lateral border of the ureter and making great efforts to identify and protect it at all times. So now you can appreciate the kidney is coming into view. So to start off the dissection, he identified the gonadal vein, one of the big landmarks that we use in retro peritoneal surgery. So he actually traced the vein upwards from the pelvis to where it drains into the left renal vein. After having identified the left renal vein, it assisted in his ability to dissect out the renal arteries. And in this particular patient, he had three renal arteries, which made the dissection a little bit challenging; but Dr. Jamal is up to the task. So he s dissected out these three arteries and one vein, and that s been the extent of the dissection to this point. A little bit more on our patient, he has normal kidney function. The CT scan that was performed identified two renal arteries. The third artery was not identified on the CT scan. This is not uncommon. The mass itself was approximately 4.1cmm in size; and the extent of the metastatic workup included a chest x-ray which was also normal and blood work which was also normal. We really don t go beyond chest x-ray and blood work to look for spread of the kidney cancer elsewhere in the body. But if we do have a clinical suspicion to the lung, for example, we may add a CT chest; the brain, a CT or MRI of the brain; or a bone scan if there are signs either on blood work or symptoms of the patient to suggest that there may be spread of disease to the bones. Not all of these masses turn out to be cancers; but as we go up in size, the likelihood of it being a cancer goes up dramatically. There are emerging indications now for biopsy of these small renal masses, but this is quite controversial. Now Dr. Jamal has identified the renal capsule of the kidney, the outside layer of the kidney, and is now starting to dissect the fatty tissue surrounding the tumor around the mass itself. This fatty tissue, as Dr. Jamal said, is a good barrier against spread of disease; so he ll try to leave as much of this fatty tissue on the tumor as possible. As well, the fatty tissue really helps us dissect out the kidney because we can use it almost as a bucket handle we call it. So we can actually hold onto the fatty tissue to manipulate the kidney into a position which allows us to do a better dissection. So why don t we go to the slides for a second here. And I want to show you the CT scan a 3-D rendering of the CT scan that this patient had. And I m not sure if you can make out my arrow here; but you can see that there s a main renal artery here and a secondary renal artery right 2

3 here that was seen on the CT scan. In addition, the patient had a third renal artery to a lower pole right here, which we also dissected out. Now, we re going to be starting to rotate the kidney around in these subsequent images; and you re going to be able to see this renal mass, which is down here in the lower right-hand corner of the screen in greater detail as we continue to turn. Okay? So we re just turning on the mass itself, and you can see how it s what we call exophytic. It lies on the outer surface of the kidney. It does go deep to the capsule, which I m marking out now with my arrow; but most of it is outside, you can see. Okay? And we re just going to continue to turn. And you know, this picture here really highlights a very unique feature of this type of tumor in that it commands a tremendous blood supply. So you can see all of these new blood vessels here which drain in from the fatty tissue into the mass itself -- a unique feature of this type of cancer that allows us to see it in greater detail on CT scans with contrast imaging. Ayesha, how are things going? Yes, very good. We are trying to mobilize the kidney all around. And this tumor is a posterial lectal as you saw on the 3-D rendering CT scan. So I have mobilized the /INAUDIBLE/ of the kidney; now I have to go posterially, and then we ll be going posterior medially. So let me see. As you saw, this patient has multiple vessels, and the blood of parasitic vessels coming around. So we have to be very careful, sometimes these vessels they may bleed. That brings in a good point, Dr. Jamal. What are you using to cauterize or give energy to vessels right now? Here I m using a plasma /INAUDIBLE/ on my left hand and a /INAUDIBLE/, also known as a /INAUDIBLE/, on my right hand. And I m using a progress /INAUDIBLE/ detector for my fourth arm. And usually as you know, I mean because this this /INAUDIBLE/, and sometimes using a fourth arm gives a little problem because it does not allow manipulation in a small space, you know. I often have difficulty with that fourth arm, positioning it just right so [CROSSTALK]. So we have quite an active robotic program here at Wake Forest, and have done close to five hundred cases since January of Really the big interest with robotic surgery began with the robot-assisted, laparoscopic prostatectomy. And as well, Dr. Jamal during his initial experience with robotic surgery,started with the robotic prostatectomy; but obviously, we re branching into newer areas. We ve done close to a hundred robotic partial nephrectomies now. We re up to about fifty robotic cystectomies for bladder cancer. And we re exploring different indications for reconstructive surgery, pyeloplasties, fistulae repair, as well as some of the more rare forms of cancer surgery distal ureterectomy, for example. So here Dr. Jamal is mobilizing some more of the adhesions laterally and So you can appreciate this patient has so many multiple vessels /INAUDIBLE/. So here these are the parasitic vessels going to his ocumen, and I am on the posterior surface of the kidney. So it s very, very important. And here, as you know, when you are using robotic assistance for doing these kind of procedure, you have a fifteen time magnification. So even a little amount of the blood looks like a huge bleeding. So don t get carried away. This is because of the magnification. You have a fifteen time magnification while you are doing this kind of procedure. Do you agree, Dr. Kater? Oh yes, definitely. And, you know, the way you re dissecting things out here is a great way of demonstrating how we identify vessels. You can see with his right hand he does a little bit of blunt dissection until he meets resistance; and that resistance typically will be a blood vessel, especially laterally here to the kidney. Then he uses his plasma kinetic energy on his left hand to deliver energy to these vessels to cauterize them, and then he ll go ahead and cut it. This is the way we kind of sequentially go around, mobilizing the kidney in its entirety. But as you saw from the CT scan, those vessels going into the mass were quite significant. So again, one of the major advantages of robotic surgery and laparoscopic surgery in general is that because of the pneumoparitoneum, the carbon dioxide pressures that we have in the abdomen, we can really keep that bleeding under control. Here we see Dr. Richard in the foreground, and really the importance of the assistant cannot be underestimated during the surgical part of the operation. [CROSSTALK] the camera, please, quickly. So after this, I ll just dissect the tumor all around; and we are planning to use an intraoperative laparoscopic ultrasound which would help us to 3

4 delineate the tumor and we can score the margin of the tumor with the assistance of the intraoperative laparoscopic ultrasound. This is a newer technology that the Intuitive Company has developed for the da Vinci robot that allows us to really look at two images at the same time. We can look at the intraoperative image when you re dissecting out the kidney, and at the same time an ultrasound picture which you can really show the three-dimensional aspect of the renal mass. Okay, can you go here? Jake, an you grab that? Okay, pull down in medial. Very good. So Dr. Jamal is demonstrating that bucket handle use of the fatty tissue around the kidney; and Dr. Richard is rotating that kidney medially in order to demonstrate this mass, which is posterior. Yeah, so you can see this is the mass here; and this mass is located posterior medially. So that s how little these are kind of a complex tumor. Basically at our center, we are dealing with 60% or 70% tumors that are complex. And usually the definition for the complex tumor when you are dealing with partial nephrectomy, either the patient is obese, or there are multiple tumors, or because of the location what is located close to the hilum or running into the collecting system so these are the complex tumors to deal with. So now you can appreciate that tumor is coming into view, and I m trying to go around the tumor. So this is you can appreciate the normal /INAUDIBLE/, and I m trying to I want to leave the tumor fat along with the tumor; and even if this fat comes off, then you can send separately for the pathology to make sure there is no apparent tumor fat in invasion with the cancer, you know. That s very, very important for the staging purposes and in case some patient requires some additional therapy. But as Dr. Kater pointed out, it s very, very important in earlier days for this kind of tumors which are more than 4cmm in size. The standard of care was a radical nephrectomy. But with the evolution of the partial nephrectomy, these patients can be offered a partial nephrectomy and /INAUDIBLE/ of percents. Thus, it helps in the preservation of the renal function; and that /INAUDIBLE/ the deterioration of the renal function. No, I agree with you completely. So traditionally, this tumor would have been done open through a flank incision between the eleventh and twelfth rib. We would have gone into a space called the retroperitoneal space, which really does not contain any of the bowel. So by going into this retroperitoneal space, you dissect out this kidney tumor and really, essentially, remove it almost identically to the way we re going to be doing it today. So the goal of laparoscopic and roboticassisted laparoscopic surgery is to mimic what we do open, while minimizing risk of blood loss and facilitating earlier return to function. So a minimally invasive approach is the bottom line. So the flank incision that was used for the open procedure was fraught with many problems, mainly to do with pain; but as well with the way the incision heals, which can be problematic. The robotassisted laparoscopic approach overcomes this. Our demonstration today is a transperitoneal approach, so we re going through the lining of the bowel sorry, the outer line of the abdominal cavity to allow us to gain access to the kidney. There are newer methods of using the extrapertoneal approach both robotically as well pure laparoscopically. Dr. Jamal, do you have any experience with the retroperitoneal approach? Yes, I mean I grew up with open partial nephrectomy, so I initially learned open partial nephrectomy; and then gradually I moved on to doing a laparoscopic partial nephrectomy. And I have experience of doing laparoscopic partial nephrectomy by /INAUDIBLE/ approach and /INAUDIBLE/ approach. As you know, in the /INAUDIBLE/ approach, you can go behind the kidney without getting through the peritoneal cavity. So me just brief you see this case? You can see appreciate that tumor is here, and this is the normal renal /INAUDIBLE/. So I m going to score this posterior modem for the tumor. So basically you want to take at least 1cmmmargin beyond the tumor, and I m also trying to maintain fat around the tumor which it can go for the /INAUDIBLE/ pathology so you can make sure there is no involvement or invasion of the /INAUDIBLE/ tumor fat. Jake, can you flip it medially if possible? So you can see that the majority of the work of the partial nephrectomy is done in setting things up; dissecting of the hilum, which he s already done; exposing the vessels so that they may be clamped, because you cannot cut across the kidney without first clamping the vasculature in most cases due to a very high risk of bleeding. The kidneys see a tremendous amount of the overall cardiac output, so every minute the kidneys see a tremendous percentage of the overall blood volume. So you can imagine if you cut into the kidneys, they would bleed significantly. We get 4

5 around this problem by clamping the vessels. Unfortunately, we re under time constraints because damage to the kidney can ensue after well, there are various timelines given; but anywhere between thirty and forty-five minutes, significant damage to the kidney can occur irreversible damage to the kidney. So that s another reason why we like the robot-assisted approach in that pure laparoscopic surgery is difficult to work under these time constraints. There s suturing involved which is quite technically challenging. Several surgeons have been able to master the pure laparoscopic approach, and Dr. Jamal has done several of these cases. But the robot-assisted laparoscopic approach really provides the surgeon with the greatest advantage and the patient with the safest outcome. So Dr. Jamal is continuing to make his landing zone, so to speak, marking out the tumor by scoring the renal capsule with the electrocautery from his scissors in his right hand. Dr. Richard is retracting the kidney into a position which allows that mass to come into view, as well as using that suction to suck out the smoke that s created by Dr. Jamal s electrocautery. Beautiful, thank you. So Dr. Jamal is using a four-arm robot and is retracting the bowel with his left hand; and really this is an amazing advance, in my opinion. I think that fourth arm gives the console surgeon a great opportunity to minimize the potential impact of the assistant and frees up an extra hand for the assistant. He s still freeing up the fatty tissue surrounding the kidney. And the amount of fatty tissue is highly variable and hard to predict, and it can be quite challenging. You end up digging through several inches of this stuff before you actually see the renal capsule. Jake, be careful. Well, why don t we go to the slides quickly; and we can talk a little bit about kidney cancers in general. And the incidence of kidney cancer in the United States is going up, with about 55,000 new diagnoses annually with about 210,000 cases worldwide. Unfortunately, there are about 100,000 of these individuals who go on to die of the disease. Now, the type if kidney cancer that we typically talk about when we talk about a partial nephrectomy is Stage I, Stage IA in fact. These are masses less than 4cmm. Dr. Jamal talked about the relative indication for larger masses, which are T1B tumors, which are tumors really about 4cmm and confined to the kidney. There are merging indications for these cases, and patients seem to do quite well in selected individuals. In the United States, there are 13,000 deaths from this disease; but we re increasingly catching these tumors early on, with incidental scans done for other reasons. As a result, I m confident that we re making a huge difference on the natural history of this disease. Dr. Jamal is continuing to do a great job here of mobilizing this fatty tissue, identifying the tumor. And really the visualization you get with the robot-assisted laparoscopic approach assures the safest outcomes. We know where the tumor is. You ll be seeing the ultrasound pictures of the tumor, and we can get a better idea of how deep it s going within the kidney which affects the angles that we use to dissect out the kidney and the tumor itself. Okay, let s drop that, Jake. Grab this, good, and flip it. Very good. Very nice. You can suck a little bit if possible. So this fat around this tumor is little vascular and as I said, there are a lot of parasitic vessels; so I m trying to be because sometimes this can give rise to the nagging bleeding in this area, so we ve got to be careful. And also at the same time we want to go all around the tumor, making sure we got everything out. So you can appreciate very well the normal parenchymal here. So this is the inferior pole of the kidney. And let me dissect a little bit in this area. Yeah, you can see the normal capsule is that shiny layer overlying the filtration part of the kidney. And the type of kidney cancer we re talking about today arises in this filtration part of the kidney. There are essentially two types of kidney cancers: those that arise within that filtration part and then after the blood is filtered by the kidney, it produces urine and then it goes into the other part of the kidney which we call the collecting system. And the other type of kidney cancers arise from the lining of this, what we call collecting system. So the partial nephrectomy is really only indicated for those tumors that arise in the filtration part of the kidney. So Dr. Jamal you can see him at the console. Right now his head is immersed in a box, which gives him 3-D imaging; and it just gives a tremendous picture in high definition, three dimensions as we mentioned; and the console height can be adjusted so that he s as comfortable as he can be. Now, you can see his fingers are in two instruments underneath the head part of the console. And you can see how he s actually manipulating the arms inside the body. Everything he s doing 5

6 on the outside is transmitted to the inside. There are fine adjustments that you can make, and the computer can actually adjust for any kind of tremor that you may have or anything of this sort. You can see that really he only has two hands and is really only controlling two instruments at a time. But with the use of his feet, he can toggle. Okay? With his left foot, he can toggle between two instruments on his right hand that allow him additional access. So he can by clutching with his left foot move the camera; and with his right foot, he controls the energy that he delivers to both the scissors and the PK instrument, which he also uses as a grasper. So for us in neurology, we re one of the major users of the robot; and we re continuously finding new indications for its use and have found a great deal of benefit to it. With the emergence of newer instruments, it makes out job a lot easier. Now, why don t I talk to you a little bit more about kidney cancers. If we go to the slide here, you can see how in the past most patients presented with what we call a classic triad, which involved flank pain, that s pain in the back which cheated to a side overlying the kidney. Hematuria, or blood in the urine, as well as an abdominal mass. This classic triad is no longer seen today; and as I mentioned to you briefly before, these cancers are typically picked up on ultrasounds or CT scans done for other reasons. Another type of early pickup was this microscopic amount of blood that was seen in this patient and really highlights the fact that you cannot disregard blood in the urine. Blood in the urine is not normal, and you need to seek advice from a doctor if you ever hear of or see blood in your urine. All right, let me show you the laparoscopic ultrasound /INAUDIBLE/ ultrasound. So Dr. Richard now has a laparoscopic ultrasound instrument in the body. You can see this allows me to see the tumor. Can you go there and use your grasper to retract? So we re going to show you how we can bring up the ultrasound image at the same time as our robotic image here. And this gives us tremendous advantage and avoids the risk of what we call a positive margin. And a positive margin is when You can appreciate the tumor here, and I can see can you move it laterally? Yes. Soyou can see the edge of the tumor, so I m going to score here, which already I have made the mark you know, I have done the scoring on the renal capsule. So the advantage of the intralaparoscopic ultrasound to see that clear demarcation of the renal tumor vis-à-vis normal /INAUDIBLE/. Now, you can appreciate Dr. Richard has advanced the laparoscopic probe. Let s go on the other side, Dr. Richard. Can you come here near the tip of this? See how he uses that ultrasound to confirm that that mark he made initially is in the correct position? So I was talking to you before about positive margins. And the risk of positive margins seem to be comparable with the laparoscopic robot-assisted laparoscopic and the open procedures. And when we talk about positive margins, that s cancer that s kind of grown to the edge of our surgical resection. So the pathologists paint that edge; and if there s cancer that s coming up to that edge, the fear is that there may be cancer cells left behind. So now you can see the posterior edge of the tumor. Dr. Kater, can you appreciate that? Can you see that drop view come here? So to my mind, you see this is the normal /INAUDIBLEnear the tip of the /INAUDIBLE/. Very good. And also you can use a /INAUDIBLE/ doplar /INAUDIBLE/, so we can see the vascular flow with this technology. Dr. Richards, can you put the ultrasound probe back on? I just want to allow the audience a greater opportunity to see the mass itself and distinguish the normal kidney from the way the mass looks. You had a nice picture here a second ago. So I m going to score here, here. All right, so after scoring the tumor, now we ll be clamping our hilum vessels. And can we ask them to give us a 12.5 gram /INAUDIBLE/? So Dr. Jamal has asked the anesthesia team to give the patient a diuretic, okay? So this is some medicine that s given intravenously that will induce urine production. As well, there are benefits that are felt to be gained from this medicine as that it s felt to kind of suck up those toxic oxygen particles that can be created after you induce what we call ischemia. So once you blocked the flow of oxygen to the kidney, these toxic oxygen species can accumulate within the kidney and cause damage. So this medicine is felt to assist in that. So after several minutes of allowing this medicine to do its work, Dr.Jamal will start clamping the vessels. And you ll start with the arteries. 6

7 Sometimes you can get away with only clamping one artery if there are several arteries if that s to a certain area of the kidney where the tumor is. There s controversy really about clamping the renal vein. Some people like to clamp the renal vein; some people feel that you do continue to get a benefit, at least with respect to delivering oxygen to the kidney, if you leave that renal vein open. Dr. Jamal, do you like clamping the vein? Do you always do it? Yeah, see I like in this kind of situation where the tumor is more than 4.1cmm, it looks a little complex. There are multiple parasitic vessels. I would prefer to clamp. But I have been with various ways. I have clamped renal artery alone, renal artery and vein together, and sometime using a /INAUDIBLE/ clamp with /INAUDIBLE/. All right. Dr. Richard, can you change my /INAUDIBLE/ to the large needle driver quickly? So some surgeons prefer to use what we call Bulldog clamps, which is what we ll be using today. Other surgeons actually make a new incision in the belly and make what we call Satinsky Clamp on the renal hilum. It s really surgeon preference. Some think that one way works better for them; other folks feel that the other way works better for them. In my experience, I like to use two Bulldogs on the artery because sometimes fatty tissue or adjacent tissue will keep the Bulldog from really getting as good a seal as I would like on the artery. So you can see, he has already placed this vessel as we call it, this yellow rubber structure, around the artery; and it allows him to pull the artery into place. So he s now clamped one artery, and is now clamping the what structure are you clamping here, Dr. Jamal? Yeah, this is this patient has three arteries. We have clamped the renal artery, and this is the inferior polar artery arising separately directly from the aorta. So we are trying to clamp this artery separately. Okay, so you ll be clamping this. So once we clamp these arteries, timing is of the essence. And we ll be working diligently to make sure that we minimize the amount of time that the kidney is clamped. Okay, you may want to go there. And you can imagine without the assistance of a robot, this part of the procedure can be quite challenging. So All right, there s one more artery there, superior polar. So this patient had a male renal artery. Then there are two arteries: one artery arising cranially from directly from the aorta and another artery arising directly inferiorally which is going to the lower pole. So we need to clamp all these three arteries to control the blood supply to the kidney. Go ahead here. This brings up a very important point. You know, despite our best efforts with the most modern imaging technologies, there is always a chance that there are additional smaller vessels that aren t picked up on the CT scan or at least appreciated on the CT scan. So we re always wary, and we re aware of the potential for any additional vessels. So now he s clamped the three renal arteries. We re doing to be clamping the renal vein here shortly, and then we ll begin our dissection. And the dissection doesn't take that long. Most of the case, as I mentioned to you before, is involved in preparation. See you can see this long Bulldog clamp that s going to be applied by Dr. Richard, again highlighting the importance of the assistant at the bedside. This is a technically challenging part of the procedure, where complications can occur. Beautiful. Good, you re good. We haven t seen any of them, but they ve been described where a vascular injury can occur at the point of clamping these vessels. So now we ve induced ischemia, or stopped the blood flow to the kidneys. We re starting the timer, and now Dr. Jamal is going to get everything in place to dissect out this tumor in a rapid fashion here. Okay, so we had to flip the kidney laterally in order gain access to the vessels; now we re going to flip it medially. And you can see the lower pole of the kidney right there and the fatty tissue underlying the mass. So he s holding the fatty tissue up with his fourth arm, again giving him a tremendous advantage. He s setting things up now, and he s going to make his mark and run with it. So typically we use cautery on the capsule and then use sharp dissection on the renal parenchyma. Okay, Jake, don t come close to me for a sec. And Dr. Richards is sucking the smoke and will allow Dr. Jamal to see the parenchymal edge of his dissection by giving short bursts of suction. It s really important that you don t push the 7

8 suction button down for too long because the carbon dioxide pressure inside the belly will go down; bleeding will ensue, and you won t be able to see. So our pressures are typically in the 15mm of mercury range. Too low and we lose our exposure; too high and you risk complications to the patient. Alyssa, can you prepare the /INAUDIBLE/ in case we need? So early on in our experience with the robot-assisted laparoscopic partial nephrectomy, we used bolsters. These are pieces of hemostatic agents agents that help blood to clot. They come in various formats; but what we used to use was called Surgicel. We used to roll it up like a little cigarette, tie it with a dissolving suture, and then bury it within the defect that we ll be creating right here. But we found that we get such good control of bleeding with the use of the robot and the suturing that we no longer need to use these bolsters. We will, however, use other hemostatic foam-type agent;, and we ll probably use some of that today. So you see, I m cutting the /INAUDIBLE/. So this tumor is running very close to the hilum. I divided the renal vein here. You can see branch of the renal vein is divided. So you can see how Dr. Jamal s right side of the instrument was blocking his view; and just with a push of his left foot, he s able to move that camera into a position where he can see very nicely. So again, everything here with the surgery is all geared towards exposure manipulating things into a position that is just right for him to see his dissection and avoid entry into this tumor mass. So if we go to the slides for just a quick second, I want to talk to you about treatment options. As I mentioned to you before, this particular patient was offered a radical nephrectomy, either laparoscopic or open. He was actually being considered for laparoscopic nephrectomy partial nephrectomy which we re doing today or partial removal of the kidney containing the mass. At Wake Forest, we are leaders in ablative therapies, both percutaneously and laparoscopic. We do predominantly percutaneous management of these renal masses. We work closely with Dr. Ron Sagoria, one of our interventional radiologists who does predominantly radiofrequency ablation, which uses heat energy to destroy the tissue. An alternative approach is to use a freezing type of technique. And last and not least really, is observation, which is an emerging approach used for elderly patients with smaller renal masses that has been demonstrated to be quite safe. Dr. Jamal, how are things going? Going good; so far, so good. Okay. So you can see the difference in appearance of the capsule and the renal parenchyma. The parenchyma has a spongy type appearance to it, and we consider this to be a very minimal amount of bleeding. The edge of the renal parenchyma is just oozing a little bit, and that s very typical. And you can imagine what would be the case without clamping of the renal hilum. This is with complete vascular control there continues to be an ooze, which is very acceptable. Our blood loss on these cases are typically less than 100cc in general. Length of stay has been dramatically decreased with the use of the laparoscopic approach, and robot-assisted laparoscopic approach is no different. Typically our patients stay two, maybe three days which is a big difference as compared to the open procedure which was close to the five-day range. So you can see the importance of that fatty tissue overlying the tumor, both to protect from spread of disease but as well for us to exploit as a bucket handle. It s continuously rotating that kidney into a position which allows him greater access to the tumor. Now, many of my patients have questions about why we would do a partial nephrectomy as opposed to a radical nephrectomy. I guess you know when you look at it, it may make sense at first glance that you want to take out the entire kidney. But there may be well, there are definitely some advantages to performing a partial nephrectomy instead. Here we see Dr. Richard focusing, concentrating. And it s really important that your assistant can find his instruments inside the abdomen very quickly without any difficulty. So you can see the dissection is progressing quite nicely. And surgery is all about tension and counter tension. And he s really manipulating things into a position where he s achieving those objectives: tension, counter tension, cut; tension, counter tension, cut. And that s kind of the way things are progressing, and they re going very nicely. And with the magnification here, you really improve your ability to see any tumor that s extending beyond the margin at least grossly. Obviously the camera doesn't give you microscopic vision, but grossly at least you re pretty confident that all that cancer is gone. And if you look at most laparoscopic series, the potential for positive margins is in the 2% to 3% range. And the chance for cancer recurrence or the cancer coming back is 8

9 probably in about the 6% range, either if you take the whole kidney out or even if you take out part of the kidney. So things are progressing quite nicely now. He s well over halfway through the dissection of the mass, and we ve achieved really, really good hilar control. That means that this amount of oozing is typically what we would expect. And as Dr. Jamal mentioned at the outset of the case So you can see the border of the /INAUDIBLE/. We have taken quite a huge bulk of the parenchyma. Can you see that base of the tumor and parenchyma? Yeah, Jake, suck on the base of the kidney. All right, doctor, this I ll take /INAUDIBLE/ through the /INAUDIBLE/ vessels and the /INAUDIBLE/ system. So Dr. Jamal will be closing this in two layers. The first layer will be using a 30mm Vicryl suture. This is a dissolving suture. It s really important that we use dissolving sutures any time we come close to that area of the kidney, the collecting system; because if we don t use dissolving sutures, stones can form, and those can be somewhat problematic. Okay, so let s lift this tumor medially. So you can see that Dr. Jamal has been able to leave a bunch of fatty tissue on the tumor and has just the last little bit of fat here to go through before this tumor is free. As a laparoscopic and robotic surgeon, you re constantly having to orient yourself -- which may be difficult for our viewers here who may not be as used to looking at these types of images. But your brain is always processing landmarks, very rapidly, just to make sure you know exactly where you are at all times. And there s no substitute for experience. So once the mass comes out, you ll have a better picture of the crater that s been created within the kidney; and you can see the relatively small amount of kidney that s been taken even for a tumor of this size. And you can imagine it would be a great shame to get rid of the entire kidney, as maybe 90% of the renal parenchyma has been preserved here. So if you goto the slides quickly, I ll just point out some of the reasons why we like to perform partial nephrectomy. And, you know, paramount in all of this is cancer control; and our outcomes with respect to cancer control are comparable with radical and partial nephrectomy for these T1 tumors, especially T1A tumors those tumors 4cmm and less that are amenable to partial nephrectomy. So it s really important that you select your patients properly. In addition, there is a chance, albeit low, of a tumor arising in the other kidney. So why don t we cut back to the surgical field here. Dr. Jamal has completely freed up the tumor. You can appreciate that we have got all this peritoneal fat with the tumor. So this is all peritoneal fat, you can appreciate that. And this is the normal parenchyma. You can visually inspect another advantage here is the fifteen time magnification. So you can see the base of the tumor, but it looks all normal renal parenchyma; and the tumor is right here. You can appreciate that? Yes. So almost a 2cmm margin of the tumor beyond the tumor margin; you can see that. Beautiful specimen, Dr. Jamal. Yes, so that s the tumor; and we ll leave it at a separate place, and I ll just start with the repair of the renal parenchyma. So let me get to robotic needle driver quickly. So I m going to use the large robotic needle driver for repair. So you can see that you have to be a pretty cool customer to do this type of surgery. We re working under significant time constraints. Dr. Jamal is at fourteen minutes, which is a spectacular time so far. You can see the surface of the kidney. So Dr. Jamal will be doing a twolayer closure, as I mentioned to you before, suturing using the benefit of the /INAUDIBLE/ robotic device. Instead of tying, we ll be using various methods here. On the inner surface layer, we ll be using a kind of clip called a Lapra-ty. This is a Vicryl type of clip which will eventually dissolve. As I mentioned before, you don t want any non-dissolving substances close to that part of the kidney that collects the urine. We do a running suture. And that first layer is really not a strength layer; it s really just to make sure that that deeper collecting system doesn't leak any urine around the kidney at the completion of the case. This can happen and can be quite problematic. We are fortunate enough not to have seen any of these, but they can occur. So you can see Dr. Jamal has started his suturing. He s just going to grab the tip of his needle, and you can see how the end of his suture already has one of these Lapra-tys on it. It s that blue clip that you can see at the end of this 3-0 tie. And he ll now just do a running stitch and make 9

10 sure the deeper layer has been closed. He s got a perfect view of everything; he s set things up brilliantly here. Dr. Jamal, are you going to be using Flo-Seal on the base? I was not thinking to use like, you know, we started using all this /INAUDIBLE/ and Flo-Seal and the Surgicel. But gradually we stopped using it, and some of the cases we do without using a Flo-Seam or Surgicel. And in case individually but if there is a wide-based tumor, it s a good idea to use a Surgicel or Flo-Seal, you know. But if you can bring the parenchyma together with just putting what s Jake, what s going on? Keep no, no, watch your instruments. Hold on, hold on, don t suck it. So everything s progressing very nicely right now. He s probably got one maybe two more sutures to put in on that deeper layer. And rather than typing, in the interest of time, we ll just be able to get away with one of these Lapra-tys. Okay, these do not slip; once they re locked in place, the suture s locked in place. As I mentioned to you before, they just dissolve. Dr. Jamal is going to tie this one. You can see the small amount of suture he needs to just tie it himself. Okay, so that needle is going to come out. Okay, so you can get me another suture, Monocryl, and take this needle out with the suture. So, Dr. Jamal, you re going to be using some Monocryl right now? Yes, now I m going to use a CT-1 needle with 0 Monocryl; and we are going to do a repair of the renal parenchyma. Okay. As I sewed, I used a 3-0 /INAUDIBLE/ to repair the base of the renal parenchyma, taking care of the vessels. Now, so in this it is important I take all the big bite of the renal parenchyma and go across. And we are going to slide the Hem-o-Lok clip from the contralateral side, so that way it will bring parenchyma in close apposition -- Hem-o-Lok clip here. Now these are a different material from the Vicryl type clip that I described to you earlier. This type of clip does slip, and we use that slippage to our advantage by really cinching things down as you just saw. Get me another suture. Now, once we take our next bite, it will no longer slip; so we are kind of exploiting some angles and properties of the suture material itself in combination with the type of clip. If we were to use one of those Lapra-tys here, we couldn't cinch things down as Dr. Jamal has done. Okay, take here no, no, look at that here. Good. Let s get another Hem-o-Lok clip. And really the width of the clip itself prevents it from going through the renal capsule. We ll need another clip there. Sometimes these clips don t cinch, and you can see how these clips actually lock. You have a got that gets seated into the other side; and they tend to work very, very well. We use them for our radical nephrectomies to gain hilar control by clamping the renal artery. In fact we can also use them for So bring that suture in; take this out. You can also use them for the renal vein, but it s a bit trickier. It s really important that we have the full accounting of all of the needles and clips and everything that are in the body. You can suck the collected blood on the lateral side. You can see how the two edges of the renal capsule are opposing quite nicely. So Dr. Jamal is going to place several additional sutures to ensure that this repair holds and is safe. This is a critical part of the operation as bleeding is a real concern not necessarily just at the time of surgery, but even postoperatively. So it s really important that this type of repair be done thoroughly, meticulously, to avoid any kinds of problems postoperatively with this repair breaking down and the potential for bleeding as a result. Jake, if you can yeah, good, very nice. Well, things are going according to plan. Dr. Jamal, are you going to complete this second layer? Yeah, yeah, I m going to. I m just looking for my fourth arm so I can retract a little bit. Okay. Sometimes people intentionally take the Bulldog clamps off the renal hilum to see if their repair is adequate before really completing the -- what we call renoraphy -- or completing these sutures here. So essentially I think Dr. Jamal has two other sutures to place and will then take these Bulldogs off, and we ll be done. 10

11 You can see that the majority of the procedure is spent dissecting out the kidney, preparing, making sure that we get a good margin, a safe margin. The remainder of the procedure is really just taking the tumor out and doing the renal repair. Once that repair is complete, we take the Bulldogs off; and we re essentially done. The mass comes out. We put a bag in the belly. And the mass is put in this bag, and the specimen is just brought out through an enlarged incision on the skin. We typically do not send frozen sections as we haven t found a real problem with positive margins. So that s essentially the case in a nutshell. Dr. Jamal has done a tremendous job of demonstrating the procedure, and I thank you for joining us today. Thank you for watching this OR Live Webcast presentation from Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. 11