6th International Kidney Cancer Association Symposium, 6—7 May, 2011, Warsaw

Surgical options for patients with kidney cancer

Professor Peter Mulders (Nijmegen Medical Centre, Radboud University, Netherlands)

I presented data on surgical aspects of renal cell carcinoma like laparoscopy or ablative therapies. So we know that more than 60 percent of our patients have so-called incidentaloma, so they are discovered by the fact that they have an ultrasound or a CT scan for other reasons and then they have a tumour in the kidney. So they are smaller for definition, and then you have several options these days. It is not that the standard radical nephrectomy is performed any more, which was always a large scar, taking out the kidney with all the lymph nodes. But we know now that we can do other things with the laparoscopy or with ablative therapy or, especially in smaller tumours, we do nephron sparing surgery. And because we now have several options and the discussion is now what is the best for which patients. So it has changed dramatically the last, I think, ten years that we now have as a standard laparoscopy to take out kidney tumours, to do a total nephrectomy if technically feasible. And with laparoscopy, one of the techniques used there is using the robot; it is just a different way of doing surgery with laparoscopy, so we call it robotic assisted laparoscopy. And because we have the robot it is more easy to do suturing, and suturing you need for partial nephrectomy so therefore there is an increase in the usage of laparoscopic partial nephrectomy or nephron sparing nephrectomy, a tumour nephrectomy, with the robot.

So we have now, as a standard for kidney tumours, laparoscopy and we have also as a standard, if technically feasible, that if you have a chance to do a nephron sparing procedure you should do that. So apart from these surgical therapies there are also other, we call that ablative, therapies, are performed and at this moment ablative therapy, like cryotherapy or radiofrequency ablation, is used for patients who actually are unfit for surgery or even for laparoscopy. And these are patients who are mainly elderly patients, they have quite some morbidity or performance status which is not good enough to undergo surgery or anaesthesiology. With the accumulating data now, so especially with cryoablation, we have now longer term follow up that we may extend that to other patients soon, not only the elderly or the unfit patients but also younger patients because the results actually on the long run are relatively good. But still at this moment surgery for these patients is still the standard.

But ablative therapy is still invasive?

Yes, in some ways invasive, especially when you do it laparoscopically assisted because then you need anaesthesiology for that. But you can also use it percutaneously where you don’t need general anaesthesia, you can do that under local anaesthesia, so especially in these patients who will have quite some comorbidity and that’s an attractive approach. So I think the role of ablative therapies like RF and also cryo, is more to the percutaneous procedures and I think the field is moving to that. At this moment most of the cryoablative therapies are done with laparoscopy. It is only very small tumours, especially the so-called T1A tumours which are less than 4 cm.

More smaller tumours are being discovered. How do you assess malignancy?

Yes, that’s really an issue. You want to know beforehand if these tumours are malignant or not, and in general you can say that patients who have a tumour less than 4 cm that they have a chance of 20% of having a tumour that is not malignant. The problem is that you are not sure; you cannot always tell that by the CT, or MRI and by enhancement of these images, or you cannot always tell that by biopsy. So if you do a partial nephrectomy and you have a benign lesion it is a better way of doing that nephron sparing than doing a total nephrectomy, because if you end up with a total nephrectomy and a benign lesion I think that costs too many nephrons. So either with images or with biopsies we can be more accurate to define malignant or non-malignant, but on the other hand we will not have a 100% certainty in that. Even if the biopsy turns out benign in a younger patient you always have not 100%; you need a lot of follow up images there so in that case in younger patients, even for those patients, partial nephrectomy is still an option.

What are the benefits of robotic surgery for kidney cancer?

I would say the robotic is for the surgeon; it is more for the surgeon than for the patient. Because the way you sit behind the so-called console is very convenient and, on the other hand, the movements of your wrists is exactly the same as the movement of the instruments by the robots and that makes, especially when you need 3-D working access, especially with suturing, makes it far more comfortable. And that, finally, of course benefits the patient because if you can do a more comfortable suturing the complications are less. So definitely I think with the robot because it makes laparoscopy by the surgeon easier, the results are better, but if you are a very well trained laparoscopic surgeon the need for a robot is less than if you have less experience. So it helps the surgeon more than the patient but finally when the surgeon is happy, the patient is happy with the results. Especially in kidney actually laparoscopy and also with the robot the hospital stay is less. The benefit is more in kidney surgery than in prostate surgery using the robot. The robot is used in more than 90% for prostate cancer, for radical prostatectomies, but I think that laparoscopy especially benefits patients with kidney cancer.