This article is more than 5 years old. Information may no longer be current.
Advances in robotic surgery have transformed renal cell carcinoma care
Click Here to Manage Email Alerts
Recent innovations in the management of renal cell carcinoma have helped clinicians preserve the kidney during surgery and with it, kidney function for their patients. Ketan K. Badani, MD, professor of urology at the Icahn School of Medicine at Mount Sinai Hospital and director of the comprehensive kidney cancer program at Mount Sinai Health System in New York, spearheaded one of these advances: the first assistant sparing technique for robotic partial nephrectomy. In an interview with Healio, Badani spoke about the advantages of this technique, the limitations with current robotic nephrectomy, how he handles patient education and more.
What was the catalyst for developing the first assistant sparing technique (FAST) for robotic partial nephrectomy, and how did it address a previously unmet need in the treatment of renal cell carcinoma?
The goal of the FAST approach is to minimize ischemia time, when blood flow is temporarily stopped to remove the tumor, even in the most complex settings. With open surgery, if the surgeon expects the procedure to require more than 30 minutes of ischemia, then he or she would ice the kidney to safely preserve kidney function for a longer time. Historically with laparoscopy and robotic surgery, however, it is not standard or easily feasible to ice the kidney.
My colleagues and I developed the FAST procedure for robotic surgery and figured out ways to minimize aspects that are not vital during ischemia time, and we first published our findings in 2012.1 Eventually, this led to the creation of instruments that allow us to treat patients much faster and more efficiently. As a result, we no longer get the kidney into the danger zone of ischemia time that is more than 25 to 30 minutes.
What are the current limitations of the robotic approach to nephrectomy?
For a patient who has a tumor that is amenable to a partial nephrectomy, I do not think there are limitations to using the robotic approach compared with the open approach. In fact, I think robotic is better than open surgery because of the technological improvements in reconstruction and ischemia time.
The robotic approach may not be ideal for patients with extremely large tumors requiring radical nephrectomy, however. Large tumors occupy a lot of space and limit the working room inside the body, which is challenging to overcome robotically. On the other hand, this is not an issue with the open approach because the surgeon can make a bigger incision, although an open incision does prolong recovery time.
In your practice, how do you approach patient education for renal cell carcinoma?
With early incidental renal mass, a significant amount of patient education revolves around discussing active surveillance vs. active treatment. I explain that both are good options for small tumors; however, most patients will choose treatment because metastatic renal cell carcinoma is a very bad situation, and a contained renal cell carcinoma is about as curative as solid tumors get.
Additionally, I focus on preserving kidney function once the renal cell carcinoma is excised and contained. Patients should know that they may experience kidney failure in the future and that there are various ways to preserve kidney function. In addition to ischemia time and preserving as much normal kidney as possible during the procedure, lifestyle factors such as smoking or increasing age, or having hypertension, diabetes or high cholesterol, also can influence outcomes. Therefore, once I have treated a patient for renal cell carcinoma, I have to make sure we manage these common problems that will hurt the kidney over time. This is all part of the education.
Are you currently involved in any research that aims to answer a lingering question in the field of renal cell carcinoma?
At my institution, we are conducting an ongoing study, and patients who consent are randomly assigned to either receive amniotic stem cells, after the tumor is excised, into the bed to see if we can regenerate some of the kidney function, or be in the control group. This has been shown to work in the lab and in other organs, but we have never really looked at it in the kidney before. There is hope that we might be able to salvage some kidney function, which is the ultimate endpoint: removing the kidney tumor without affecting kidney function.
Presently, we are enrolling patients with the goal of accruing 100 in our study. Right now, we are roughly halfway there. We will then follow participants for up to a year because we want to see the extent of their kidney function over time. We have very sophisticated MRI metrics to look at perfusion and volume, and to see how much of the kidney volume functions vs. the scar, so we can fine tune how much kidney we are regenerating. If the results are positive, we will conduct a larger, multicenter study.
In 2017, the American Urological Association (AUA) published guidelines on renal mass and localized renal cancer.2 What was the most impactful change to the standard of care?
The big change in the AUA guidelines is that for all stage 1 renal tumors, partial nephrectomy is recommended over radical nephrectomy. Even for a larger mass of up to 7 cm in size, the AUA recommends partial nephrectomy over radical because of the long-term benefit of saving part of the kidney. Historically, especially in the United States, radical nephrectomy has been more commonly used to treat small renal masses than partial. One of the big challenges we have had as a field, and personally as someone who performs many partial nephrectomies, is preventing radical nephrectomies when they are unnecessary. Before, the guidelines never strongly pushed partial nephrectomies, so these new guidelines for the first time make strong statements to perform a partial unless it is absolutely not an option. Hopefully this will increase the national and international utilization of partial nephrectomy when it is appropriate.
How do you predict the treatment of renal cell carcinoma will evolve in the next 5 years?
Treatment of renal cell carcinoma will become more individualized. For those who have an aggressive tumor needing further therapy, for example, we will be able to individualize the medication regimen that will work best for that person’s tumor. This is being done with some other tumors, like breast and colon, but renal cell carcinoma is uniquely an immunogenic tumor. Our program is currently banking tumor cells, blood and urine to conduct this type of research. We do not yet know exactly how to determine which drug is best for which person, but I suspect we will in the next 5 years.
References:
- Berg WT, Rich CR, Badalato GM, et al. The first assistant sparing technique robot-assisted partial nephrectomy decreases warm ischemia time while maintaining good perioperative outcomes. J Endourol. 2012;26(11):1448-1453.
- Campbell S, Uzzo RG, Allaf ME, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198(3):520-529.
Disclosure: Badani reports no relevant financial disclosures.