Topic: Kidney Cancer

PCNL: Obtaining Access and Preventing Infection

PCNL: Obtaining Access and Preventing Infection

by | Jun 2023

Benjamin K. Canales, MD, MPH, discusses Percutaneous Nephrostolithotomy (PCNL), how to mitigate the risk of SIRS and sepsis associated with the operation, and various techniques used to perform the PCNL. In this presentation, Dr. Canales discusses, the importance of prophylactic antibiotics in infection prevention and mitigation, the history of PCNL, the risks and benefits of various sites for obtaining renal access, and the pros and cons of the known techniques for performing PCNL.

Read More
Mutliparametric MRI for Solid Masses: Accurate Detection of Clear Cell Renal Cell Carcinoma to Direct Patient Care

Mutliparametric MRI for Solid Masses: Accurate Detection of Clear Cell Renal Cell Carcinoma to Direct Patient Care

by | Oct 2022

Jeffrey A. Cadeddu, MD, Ralph C. Smith, MD, Distinguished Chair in Minimally Invasive Urologic Surgery, Director of The University of Texas (UT) Southwestern Clinical Center for Minimally Invasive Treatment of Urologic Cancer, and Professor of Urology and Radiology at UT Southwestern Medical Center in Dallas, Texas, discusses multiparametric magnetic resonance imaging (mpMRI) for small renal masses (SRM). Dr. Cadeddu emphasizes the use of mpMRI and a clear cell likelihood score (ccLS) as a promising, reliable, non-invasive, and cost-effective means of renal tumor characterization that can eliminate the need for biopsy in most patients.

Read More
Kidney Tumor Ablation in 2022: Optimal Outcomes

Kidney Tumor Ablation in 2022: Optimal Outcomes

by | Jul 2022

Jeffrey A.Cadeddu, MD, discusses optimal outcomes in kidney tumor ablation. He reviews reliable and reproducible 5+ year data comparing ablation effectiveness and outcomes to that of surgery and emphasizes that for tumors of <3 cm, tumor ablation is indicated. Dr. Cadeddu explains that ablation is nephron-preserving and minimizes chronic kidney disease progression, is less expensive than conventional surgery, reduces risk of metastatic potential associated with AS, and in addition to tumor size, histologic subtype is an important consideration in treatment decision-making.

Read More

Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making

by | Feb 2022

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine in Houston, Texas, discusses the evolving standard of care for renal tumors, and how to determine whether someone should have nephron-sparing surgery. He provides some history, explaining that radical nephrectomy used to be standard for all patients with renal tumors, but that due to improvements in technology and technique, partial nephrectomy is now used in a large percentage of cases. Dr. Link argues that with this great power to perform partial nephrectomies on almost all renal tumors comes a great responsibility to make sure that patients receive appropriate care for their individual cases. He observes that this can be complicated for multiple reasons, including that: decision-making about suitability for nephron sparing is not solely an oncologic decision; resecting more complex tumors may be associated with higher perioperative complication risks and likely results in more renal function loss; older or sicker patients tolerate complex or more lengthy surgery less well and may be less ideal candidates; and older patients likely have less to gain from nephron-sparing due to life expectancy. Beyond those concerns, Dr. Link lists and discusses several fundamental oncologic questions to consider in determining whether a patient is a good candidate for partial nephrectomy or not. These include assessing the risk of pathologic upstaging of “resectable appearing” tumors, the impact of tumor complexity on positive margins and how positive margins after partial nephrectomy alter outcome, the risk of de novo ipsilateral second primary tumors in the future and whether pathology and stage alter this risk in some fashion, and whether the patient would benefit more from a radical nephrectomy. Dr. Link concludes that: upstaging of cT1 tumors to pT3a at partial nephrectomy is relatively rare and portends a statistically significant if rather modest negative impact on recurrence free survival; risk of upstaging appears to be higher for larger tumors, higher RENAL scores, higher grade tumors, and those with irregular morphology; renal sinus fat invasion does not appear to be higher risk for poor oncologic outcomes than perinephric fat invasion; there is little data supporting better oncologic outcomes for radical nephrectomy as compared to partial nephrectomy for completely resected pT3 renal cell carcinoma; true positive surgical margins after partial nephrectomy have a significant negative impact on oncologic outcomes; larger tumors with higher RENAL scores raise the risk of positive margins at partial nephrectomy; and since little data exists about risk of second ipsilateral primary tumor development this should not drive decision making today outside of a genetic “diagnosis.”

Read More

Is Open Partial Nephrectomy Still an Option for Challenging Renal Masses?

by | Jan 2022

Michael A. Brooks, MD, Assistant Professor of Urology and Oncology at Baylor College of Medicine in Houston, Texas, evaluates open partial nephrectomy as an option for challenging renal masses and compares it to the robotic retroneoscopic and laparoscopic techniques. He begins by discussing three patient cases, each one using a different treatment option. The robotic retroneoscopic partial nephrectomy patient experienced minimal blood loss, an operation time of 4 hours, and was discharged on the 3rd day post-op. The laparoscopic partial nephrectomy patient also had minimal blood loss, a 3-hour operation time, and was discharged on post-op day 3. The open partial nephrectomy patient experienced greater blood loss, a 5-hour operation time, and was discharged on post-op day 2. Dr. Brooks also explained the technique for each, highlighting the importance of port placement for robotic surgery, a lack of cortical stitches to avoid compressing the kidney for open partial nephrectomy, and the use of intraoperative ultrasound for all three procedures. He then considers two papers, the first of which found that oncological outcomes for open and robotic patients were very similar but that open partial nephrectomy produced higher blood loss, longer ischemia time, and a longer post-op course in patients. The second paper focused on the impact of specific surgeons and found that surgeon skillset and experience created high variability in outcomes. Dr. Brooks concludes that open partial nephrectomy remains a good option for complex renal masses, that the approach can vary from patient to patient based on tumor characteristics, and that the approach is likely less important than surgeon training, experience, and case volume.

Read More

Updates in Treatment of Renal Cell Carcinoma

by | Dec 2021

Robert R. Dreicer, MD, MS, MACP, FASCO, Associate Director for Clinical Research and the Deputy Director of the University of Virginia Cancer Center, discusses the challenges in picking an optimal front-line regimen for the treatment of renal cell carcinoma and the impact of adjuvant immuno-oncology (IO) therapy. He cites data from four trials (CheckMate 214, Keynote-426, CheckMate 9ER, and CLEAR) before outlining the challenges in choosing an optimal front-line regimen. Dr. Dreicer points out that there is no comparative data currently available before explaining that tyrosine kinase inhibitors (TKIs, formerly the standard of care for kidney cancers) are toxic, challenging drugs that impact a patient’s quality of life. Dr. Dreicer outlines the therapies available today, including ipilimumab plus nivolumab (IPI-NIVO) which he characterizes as challenging for the first couple of months but well-tolerated in the last ~20 months during which patients undergo a maintenance regimen of nivolumab. He points out that treatment can be stopped after two years for patients that respond well. Dr. Dreicer asserts there is no equivalent conclusion with a TKI checkpoint. Dr. Dreicer then turns his discussion to the KEYNOTE-564 study on pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for patients with renal cell carcinoma. He outlines the study design and eligibility criteria before displaying the disease-free survival (DFS) data showing the adjuvant therapy resulted in a 32 percent reduction in recurrence or death. Dr. Dreicer argues that for patients who can access an IO-based regimen, IPI-NIVO should be the standard of care, advising that while there is not one “right answer” to the optimal treatment question, practitioners ought to use one regimen, figure out what it’s toxicities are, and learn how to use it well. Dr. Dreicer then outlines questions that will emerge if an adjuvant checkpoint inhibitor becomes a standard of care, citing disruption to the front-line paradigm, the role of subsequent IO therapy, progression while on adjuvant therapy, and progression following adjuvant therapy. Dr. Dreicer emphasizes the need for other trials and the need to develop therapeutics that work in immune-checkpoint resistance.

Read More

Retroperitoneoscopic Kidney Surgery Tips and Tricks

by | Nov 2021

As part of Grand Rounds in Urology’s ongoing series highlighting urologists working in Asia, Qian Zhang, MD, PhD, Professor and Vice Director in the Department of Urology at Peking University First Hospital in Peking, China, presents surgical tips and tricks for performing retroperitoneoscopic kidney surgery. After an introduction by Peter K.F. Chiu, MD, PhD, FRCSEd, Associate Professor of Urology at the S.H. Ho Urology Centre of the Chinese University of Hong Kong, Prof. Qian goes over the advantages of the retroperitoneal versus the transperitoneal approach, highlighting the shorter operation time, the ability to directly control the renal artery, and the lack of gastrointestinal interference. He also discusses some improvements to patient positioning, including placing the patient’s head as far forward as possible while placing their hip as far back as possible. Dr. Qian then looks at trocar placement and considers the importance of practicing 6 basic surgical skills, including cut, twist, rip, open up, pull, and push. He summarizes the 3-step and 2-step methods of needle adjustment, and then follows this by showing videos demonstrating his 6-step partial nephrectomy technique. The 6 steps include: (1) open fascia; (2) find tumor; (3) artery dissection; (4) tumor resection; (5) surface suture; and (6) unblock artery. Dr. Qian also shares some tips and tricks, focusing on his blocking method. The presentation concludes with a question and answer session led by Dr. Chiu. 

Read More

Renal Mass and Localized Renal Cancer: Active Surveillance and Follow-up After Intervention

by | Oct 2021

In part 2 of a 2-part series, Steven C. Campbell, MD, PhD, Professor of Surgery, Associate Director of Graduate Medical Education, Program Director and Vice Chair of Urology, and Eric A. Klein Chair for Urologic Oncology and Education at the Cleveland Clinic’s Glickman Urological and Kidney Institute, presents significant 2021 updates to the American Urological Association (AUA) guidelines on localized renal cancer, focusing on active surveillance (AS) and follow-up. Dr. Campbell, who served as Chair of the AUA Guidelines Panel for Management of Localized Kidney Cancer, begins by looking at the major revisions made to the AS guidelines, particularly with regard to specifications on which patients really should be considered for AS, the intensity of surveillance in different settings, and the role of renal mass biopsy. He then considers the revised guidance around follow-up after intervention. Dr. Campbell explains the general principles behind follow-up, highlighting the need to discuss implications of stage, grade, and histology including risks of recurrence and possible sequelae of treatment, as well as the importance of performing periodic imaging, lab studies, and medical histories in patients with treated malignant renal masses. He also covers what to do if surveillance suggests metastases or local recurrence. Dr. Campbell concludes by discussing risk-based protocols and follow-up guidelines based on risk categories and prior treatment.

Read More

Renal Mass and Localized Renal Cancer Evaluation and Management

by | Oct 2021

In part 1 of a 2-part series, Steven C. Campbell, MD, PhD, Professor of Surgery, Associate Director of Graduate Medical Education, Program Director and Vice Chair of Urology, and Eric A. Klein Chair for Urologic Oncology and Education at the Cleveland Clinic’s Glickman Urological and Kidney Institute, presents significant 2021 updates to the American Urological Association (AUA) guidelines on localized renal cancer, focusing on evaluation and management. After an introduction by E. David Crawford, MD, Professor of Urology at the University of California, San Diego, and Editor-in-Chief of Grand Rounds in Urology, Dr. Campbell, who served as Chair of the AUA Guidelines Panel for Management of Localized Kidney Cancer, explains that the primary focus of the panel was clinically localized renal masses suspicious for cancer in adults, including solid enhancing renal tumors and Bosniak 3 and 4 complex cystic renal masses. He then summarizes what has changed since the last guideline update. For evaluation and diagnosis, he highlights that MRI with contrast can now be used even in patients with severe chronic kidney disease or with end-stage renal disease since the risk of nephrogenic fibrosis with 2nd generation gadolinium agents is extremely low. Dr. Campbell also notes that language has been changed around renal mass biopsy to emphasize a utility-based approach, and that there are expanded indications for genetic counseling since 4 to 6% of cases of renal cell carcinoma are now thought to be familial. He then moves on to look at the revised management guidelines, pointing out a new statement advising that patients with high-risk or locally advanced, fully resected renal cancers should be counseled about the risks/benefits of adjuvant therapy and encouraged to participate in adjuvant clinical trials, facilitated by medical oncology consultation when needed. Dr. Campbell concludes by looking at new guidance on thermal ablation indicating that renal mass biopsy should be performed prior to thermal ablation rather than at the time of thermal ablation.

Read More
Endoscopic Challenges in the Renal Transplant Patient

Endoscopic Challenges in the Renal Transplant Patient

by | Apr 2021

Wesley A. Mayer, MD, outlines common urologic complications of renal transplant patients and discusses surgical options and endoscopic strategies to build confidence in managing these patients. Some of the urologic complications for renal transplant patients include ureteral strictures and urolithiasis. Dr. Mayer discusses using endourologic treatment, ureteroscopy, and PCNL to treat these complications. He discusses that there are more kidney donors accepted with stones and how to select patients for these transplants. He explains that ex vivo ureteroscopy is a safe, quick, and relatively straightforward and effective management option for donor kidneys with stones. He suggests working with an endourologist in complex cases.

Read More

Can You Drive a Stick? Prevention and Management of Bleeding During Minimally Invasive Renal Surgery

by | Feb 2021

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine, discusses techniques for preventing and managing bleeding during renal surgery, emphasizing the importance of maintaining laparoscopic surgery skills that have eroded with the increased use of robotic surgery. He explains that major bleeding complications can occur during abdominal access, critical dissection steps, or during exit from the abdomen, and surgeons need to be prepared with the correct tools and skills. Dr. Link presents a two-phase system for assessing danger and formulating a plan when major bleeding occurs. Phase 1 is short-term damage control, and involves evaluation of blood loss potential, determination of whether the blood is venous or arterial in origin, and a decision on whether the surgeon can handle the bleed laparoscopically with their skill set. Phase 2 is permanent control, and features a reassessment of response to damage control and a decision on whether the bleed can be solved laparoscopically or if the surgeon should facilitate safe open conversion. Adequate assessment is key to proper management. Dr. Link explains that robotic cases should be approached similarly, but emphasizes the importance of good teamwork and being slow and deliberate when there is a bleed during a robotic surgery.

Read More
Loading

Join the GRU Community

- Why Join? -