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Dr. Andrew Wagner is co-director of the Kidney Tumor Program and director of minimally invasive urologic surgery at BIDMC. Here, he answers some of the most frequently asked questions from our patients about kidney cancer surgery.
Dr. Wagner: Once the tumor has been removed, it is placed in a laparoscopic bag, and sent to our kidney cancer pathology department. There, the pathologists evaluate the tumor to determine what category it falls into (in terms of what type of kidney cancer it is), or if it is even cancer at all. Then, looking at the cells under a microscope, the pathologists evaluate the tumor to see what grade it is by determining how chaotic the cells look. The more chaotic the cells are, the higher the grade level, which ranges from 1 to 4. They also determine the stage of the tumor by its size, as well as the degree to which the tumor is invading surrounding tissues next to the kidney.
Dr. Wagner: Laparoscopy is a surgical approach to abdominal surgery where we make several small incisions about one centimeter each. Then, we place a camera and long thin instruments through these incisions, and use those instruments to perform the operation. In our case, we perform kidney surgery and remove either the entire kidney or the cancerous parts of the kidney with these instruments. This eliminates the need for a large incision and forcing the surgeon's hands inside through which he performs the procedure.
Dr. Wagner: With laparoscopy, the incisions are smaller and the trauma to the patient is much less. Thus, patients have far less pain and can return to normal activities in three to four weeks instead of eight to 12 weeks, which is common after open kidney surgery. It is important for patients to realize that in experienced hands, the surgery on the inside of them is the same, thus the cure rate for cancer is the same in both procedures, but we're able to spare patients a lot of the post-operative pain and recovery time.
Dr. Wagner: A partial nephrectomy is the removal of part of the kidney. It is usually performed on tumors that are smaller or located towards the edge of the kidney, so that we are able to save most of the kidney but remove the tumor(s). A radical nephrectomy is performed to remove larger tumors or tumors located in the middle of the kidney. This procedure removes the entire kidney and surrounding fatty tissue. Sometimes the adrenal gland, which sits on top of each kidney, or lymph nodes in the region must be removed as well. Debulking radical nephrectomy is the removal of the tumor(s) and the entire kidney in patients who have metastatic disease — cancer that's already spread to other parts of the body. And we perform that to help patients respond better to systemic therapies after surgery.
Dr. Wagner: The way we follow patients after a nephrectomy depends on the grade and the stage of the tumor. Those patients with small tumors that are low grade are typically followed on a yearly basis with X-rays or CT scans taken of their chest and abdomen. Those patients with more aggressive kidney cancer require closer follow up to make sure that the disease does not spread. For such patients, we sometimes see them as often as every 3 months, with appropriate scans and blood work.
Dr. Wagner: If the kidney tumor is invading or starting to encroach on adjacent organs, then often we'll remove those organs as they can be affected by the cancer. For the most part, the most common organ we remove is the adrenal gland during surgery, but others can be affected, like the bowel, liver, or pancreas.
Dr. Wagner: RFA is a less invasive technique of killing cancer cells and small tumors. In a very select set of patients, whose tumors are smaller than 3 cm, we can place a probe through the patient's skin into the tumor, and this probe allows us to deliver enough heat to the tumor to kill the cancer cells. The advantages of RFA are that these patients don't require general anesthesia and can usually go home the same day with less pain than surgery. A disadvantage is that, since it's a relatively new technique, we don't have long-term data showing that its cure rate is equivalent to surgery. Another disadvantage is that we're not able to fully stage and grade the tumor with this approach since it is destroyed without going to pathology for analysis; moreover, the overall complication rate is the same for RFA and surgery.
Dr. Wagner: CyberKnife is the newest technology that we are using for patients. It allows us to ablate (destroy) tumors without any anesthesia or invasive procedures. This is called extra corporeal ablation. Currently, we're using CyberKnife on patients with smaller tumors who, for one reason or another, are not able to tolerate surgery or RFA. We were the first center in New England, and one of the only centers in the country, to use this modality to treat kidney tumors. We also perform a needle biopsy on the tumor(s) on all CyberKnife patients so that we can look at all the cells, stage them and verify that you have cancer. The advantage of this approach is that there are few, if any, side effects or complications. However, the disadvantage is that we do not know if CyberKnife completely eliminates all the cancer cells in the tumor because the tumor is not removed from the patient.
Dr. Wagner: During a two-year fellowship in laparoscopic and robotic urologic surgery at Johns Hopkins Hospital, I performed hundreds of kidney surgeries; since coming to BIDMC, I have performed more than 350 major kidney surgeries, the majority of these using minimally invasive approaches. This includes partial, radical, and debulking nephrectomies, performed using laparoscopic or robotic technology. In those patients for whom we perform minimally invasive surgery, they benefit from a less painful and faster recovery, permitting them to begin regular activity and/or other systemic treatments sooner than other traditional surgeries. Currently, I am performing three to five major kidney cancer surgeries per week.
Dr. Wagner: I believe that we stand apart particularly because of our multidisciplinary approach to kidney tumors. Patients are cared for by a team of doctors and nurses, not just a surgeon. Our team meets weekly to discuss important patient issues and therefore patients really do benefit from that team approach. Furthermore, we treat patients like we would want our family to be treated, with respect, kindness, and patience. Regarding surgical advances, we are able to offer the most recent advances in minimally invasive surgery, including advanced techniques for robot-assisted laparoscopic partial nephrectomy, performed by surgeons who are experts in kidney surgery. The breadth and volume of kidney surgery performed here at BIDMC, I believe, is second to none. Another factor that I think makes us unique is that as the lead kidney cancer center for Dana-Farber Cancer Center, we are able to combine leading-edge surgery options with leading-edge systemic therapy, including tumor vaccine trials, high-dose IL2 trials, and other novel clinical trials particularly important for metastatic kidney cancer.
Other innovative techniques we are exploring include the CyberKnife radioablation of tumors, robotic-assisted laparoscopic surgery, and "single-port" laparoscopic surgery. We are constantly studying ways to decrease pain and shorten recovery time after surgery while maintaining the highest standards for tumor removal. We continue to conduct studies that evaluate quality of life following all types of kidney surgery.