 So next up, we have Dr. Riggs from Levine down in Charlotte. He is the associate professor and the residency director of the urology program there. And he'll be giving a talk on the updates and advances in surgical management of kidney cancer. Good morning. It was a very nice drive here today from Charlotte. And I also have the distinct pleasure of bringing my daughter. So that's made it an enjoyable day. And she quickly realized whatever she wants on this trip she gets. So I think she's enjoying being here. Thanks to Ray for inviting me, Tracy, for putting this together. Having been in this space before, it's a lot of work. And it's a pleasure and a privilege to be on a panel with a lot of impressive people. And just following Mary, I've been fortunate to work with Mary in several forums. And it always highlights, we work with a lot of advanced care providers where I am. And this, the evolution, how important they are into the care of patients, no matter what disease state they are in, whether primary care or oncology. So it's an exciting time for us and patients. So I'm going to talk a little bit about surgical techniques. I put a question mark beside this because this is really a story of evolution. And where a lot of people with a lot of interest in trying to advance the field and multiple areas have contributed and continue to contribute. And what I tend to tell all the residents and tend to tell myself is you're on this trajectory. And what you need to be very cognizant of is that everything begets something else. And so the innovations in surgery really isn't just limited to what we do in the operating room. It's really a look on all fronts, how we can prepare people before surgery, what we can do on a very granular and repetitive basis during the surgery. And then how we think of it after. How do we return you to your life after? And this is just going to be a narrow window in this. And this is really going to be a story of laparoscopy that I'm going to talk about one specific aspect. So I'm going to go over some anatomy to orient you today. And then I'm going to talk about robotics and laparoscopy, which really is, comes down to really two things. Robotic parts don't affect to me. Robotics has been around for the last 15 plus years. It really made its name in surgery for the prostate and it has to do with your ability to access areas. And then I think you'll see on some of the videos it just has enhanced our ability to be fair and to maneuver in these tight spaces. I'm going to briefly finish towards the end on the concept of metastatectomy. And that really is wrapped up in a story of really good systemic therapies. They're therapies we deliver to patients at certain times they're a disease. And then we had this opportunity and this evolving concept of can we come back and remove certain sites? And that's a very delicate space. But what it makes you appreciate is the multidisciplinary framework of any cancer and kidney cancer certainly in that. And that is it's a yin and yang of surgeons, of medical oncologist, of radiation oncologist, of a multitude of people kind of thinking through the continuum. And as we hopefully live longer, that comes into more play new opportunities, new things we think about. And then I'll just hit on a little bit about future direction. So you've heard some of this 67,000 new cases about 15,000 deaths. And the way I tell people and the way I think about it, kidney cancer starts out in three forms when you show up. One, it's only confined to the kidney. Most of those patients will be cured or a lot of them will be. Two, it's advanced. It's kind of crawling right outside the kidney or it's extending to a significant location somewhere close to it. And then three or stage four, it is called metastatic. And then if you look at new cases, a lot of this is dictated by imaging and that is we now find the kidney cancer a lot easier. I always relate to people in terms of this. We are in the age of what I call radiographic medicine, meaning we do not teach physicians very well how to do physical exam anymore. And because we are in a period of time where when you have a complaint, you get a CT scan or some type of imaging. And I can't tell you how many times people show up into my office. They had complaints of something on the right side of their body. They found a kidney tumor on the left. It was completely unrelated. But the scan is what prompted the, excuse me, the pain is what prompted the scan and they found something incidentally. So we touch on this briefly. So I'll leave that. All right, so options for surgical treatment and this evolution. And these are all still applicable today. And I'm not here to argue whether one is better than the other. But we started out historically in what's called open surgery. We went from a period of time where we would make very large incisions. And then we said, you know what, can we pair this down? Can we make smaller incisions? And how did that happen? Well, number one, people tried it. And number two, we started to make instruments and technology to deal with that to get into tighter spaces. And then the third thing we started doing is what's called laparoscopy. And that's really based on a technology where you can inflate the abdomen with carbon dioxide, basically like walking into a tent so it doesn't collapse. And then you can go through smaller incisions and work in that space. And then what robotics has done is taken laparoscopy and afforded us the opportunity to be more nimble in that space. I.e. with a robot, you can move your wrist. We still do a lot of traditional laparoscopy, but think of it as holding two pairs of scissors. You can move this way, but you cannot move with your wrist. And I would suggest to you that improvement in all these areas really has two things in common. The first, though, is the imaging is so much better. The imaging allows us to plan for the surgery. And because of that, we can think in the background about what we want to do. And we already have a really good roadmap. And I'm going to allude to that in kind of future directions towards the end of the talk. And the other thing is just the technology has increased with us. As we get onto the frontier, companies are very vested in improving the technology, proving instrumentation. It's like having a car that you bought in 2000. It was awesome in 2000. It is not, the technology is not great in 2016. So it's, and you can imagine how, and you can see how fast that's changing. A car in 1990, the difference between 1990 and 2000, I would argue is not near what it is in 2000 to 2016. All right, I got to admit, every time I do a talk, I like to play around with some function in PowerPoint or Prezi. So I drew the heart up top and then I scribbled. I couldn't figure out how to correctly do that, but that's the right and left kidney there. This is the big blood pipe, the vena cava. Now this delivers all the blood that is shunted into your body back to the heart. And then the vessel that brings the blood all the way away is the aorta. So you can see the kidneys sit in the space. They're very big places. They're like rest stops on major interstates, and they take about 20% of your blood volume at any one point of time. So if you're going to operate on the kidney and you're going to do something in the kidney, either A, have to accept the fact that it's going to bleed, or you have to block the flow in temporarily. And then the other important structures that we try to stay away from or people are worried about are called the ureters. And those are the tubes that take the urine, kidneys make urine. They're the factories down to the bladder. So what about the staging? This just is a little highlight to staging. We talk in staging in what's called TNM. That is based on the primary tumor, whether you have nodal involvement and whether the cancer spread outside the kidney. And then we turn around and we stage those. So a lot of people are easier to frame than staging, but it's just putting, mixing these together and putting them in various buckets. So this is just looking at the staging. So, again, as you go higher in the number, your stage is greater everywhere from stage four, which means the disease has left the organ to stage three. It hasn't left yet, but it certainly appears that it wants to do that. So this is back to a little bit about minimally invasive surgery. So far left of the screen, open surgery, not perfect example. You could go down the middle. You could go on the side. A lot of people historically went on the side. What's called flank surgery. And people say, oh, that's really uncomfortable. And I tell you, well, think about it. If you ever box, the one thing they tell you to do is hit the patient in the side. It's very uncomfortable. You have a lot of nerves. Then we went to smaller surgeries, so laparoscopy. And you can see that robotics looks very similar on the outside to laparoscopy. And then down here, I'm sure a lot of you are familiar with, but down at the bottom is the robot's, by definition, a master-slave orientation. But realistically, if I'm operating on you at the robot, I am a distance away. So I would be about this far from Tracy if she was the patient and I was a surgeon. One of the drivers to robotics, notwithstanding a lot of different concerns slash interest in the space, is it is probably fundamentally easier on the surgeon? It is more ergonomic. It is less physiologically taxing, physically taxing, I should say. And I think there's an argument and suggestion that this may increase life expectancy of surgeons, which actually is a really big deal for people. And also, in all fairness, if you are leaning over your spine, that's a lot of stress, just like if you sat down a desk, typed all the time, et cetera. This is a little bit of going to be the evolution that's in process. This is approved in different states, spaces, but not yet renal surgery. It's just single ports. So now you take four or five little holes. You put them in one minimally big hole, I should say. And then you put all the ports there. This is strictly driven by two things, excuse me, about two things, one, the imaging to the technology. This is an earlier rendition of it. The current renditions, the reason it works better is because the instruments in the arms coming in are much smaller. They're not a lot of collision. And the technology of the cameras, the way they work, it's pretty fascinating. All right, so I'm going to just show you a little bit of video. I hope no one gets sick or doesn't mind seeing this, but this is going to be a little bit about the evolution of the technology. And so again, this has been around, but every time we do one thing, we're looking to do something else. Can we replicate the surgery? Can we do it in a right to cancer from a cancer outcome standpoint? But then can we minimize the risk to the patient? So this shows the level of the cavel thrombus. Just to kind of highlight, you basically go from one to three, the further you get towards the heart. The big issues, as I showed you before, and I don't know that, let me see if I can point here. It's really the fact that, so kidney cancer is a little bit unique in that it puts tumor into the blood vessel. All right, and so that not for a large number of patients, but for a few that we see. And especially if you live in a position where you get referred a lot of patients, you find patients that have tumors that also go into the blood pipe. Now, as we showed you from the beginning, that is the major flow back to the heart. So that creates a little bit of an issue from a technical standpoint. So I'm going to go through a couple of pictures before I get to the video. So that's the tumor thrombus. So basically this would overlay the liver in blue. So the liver is in front of the heart. So when your blood volume goes back to the heart, the liver filters it out. That's a very important process that your body needs to do. So if the tumor thrombus goes in just a little, this is you could clamp the side of it, block the side, but the blood could still sneak by the traffic here, go all the way back to the heart up here. Not a big issue. You then take it to the next level. Excuse me. All my cool animation may or may not work. There it goes. So same idea here. So this time the tumor thrombus is going a little bit higher. The liver's overlaid. And now because the tumor goes higher, you have to block the blood flow from the left kidney because it can't come this way anymore, going back to the heart and coming back. Now let's think about that. If you don't have blood come back to the heart, you have nothing to pump out. All right? So that creates another little bit of a challenge. And the higher you, so the blood can't get back. So again, as you go up, basically what we do is block the blood flow at all positions or else it would just bleed continuously and then we open up this blood vessel. This is historically all done through very large incisions that create quite a bit of morbidity or complications for the patient. Having said that, it's a very complex state. So then if you take it a step further, if the blood is going all the way back, excuse me, the thrombus is going all the way back to the heart, which is in there, then what you have to do with the liver is move the liver to the side in order to access the vena cava or the blood pipe that's going back up. When that happens, you can go in what's called circulatory arrest, meaning you cannot get any flow back to the heart. And then if you can't do that, you can't sustain life. So the way we get around that is that we take the blood flow coming back from the legs and we just bring it outside the body for a hot second, take it back into the heart and then pump it back down. So this just talks a little bit about before I get into some video here about robotic versus open and this just came out in the journal Urology. It's a smattering of a couple reports and I don't want to over undersell this, but I think what the data will suggest to you is it's probably not inferior and it may give you an opportunity to return back to your normal life and reduce your blood loss, all of which we think are important outcomes. And this just so there's probably not any difference in, excuse me, in survival. All right. So I'm just going to orient you to the video. So that's going to be the kidney. That's going to be the liver. All right. That's going to be the inferior vena cava. So that's going to be this right here is the big blood pipe that's going to take the blood back to the heart. What's already going to have occurred in here is that I've gotten the liver, moved it slightly to the side to access that space. And hope it works. Can I get it? Yeah. Sorry. You're just a little bit into it. All right. So basically what's going to occur here? So just again, we've kind of already oriented here. These are just some of this highlight some of the technology. So I'm actually under the big blood pipe that goes back to the heart right here. I'm just just seals kind of some of the blood flow that's coming in. I'll tell you, when you do any surgery, it's a team sport. This is the assistant over here that's putting his instrument in to help out. So basically I'm just kind of getting the kidney free. The liver is to the screen right. Again, you can start to appreciate kind of how nimble the instruments are. So this is just me putting a clip on. These are blood vessels that will come into that big blood pipe that if you do not secure and then you cut it open would bleed. And to me, they're just a headache. So here I'm going to and so here that's that big blood pipe again. So what I'm going to do is just to isolate it for myself. I'm going to put a little what I call a vessel, what we call is a vessel loop. And I'm going to put that around the part going to the liver. And again, you can appreciate kind of, I mean, you can really move the arms just like you're putting your hands are in there. And that's again, it's been a big advancement. The other thing you'll hear me talk, I'll mention a little bit at the end is for me, what I so appreciate about this and what I think is driven improvement in technology is this right here. This is one of the first one I did. This is two years ago. I get people to look at this. I look at this. I critique everything and this iterative process, this ability to translate that to other people for me to look at their videos for us to train people is an immense improvement just from this. So this is just some technology that I thought would be interesting. So this is the artery coming over. I'm way meet what I call media or more towards the main blood pipe, the Aorta. But basically, wow, you don't have to sew it. You just put this instrument and it's going to cut it. And it's going to, after a while it cuts it, it's going to seal it on both sides. So basically, this is that instrument coming in and then they're going to show you and I watch, he's going to squeeze it down. It's going to cut it on both sides. And then it's going to, excuse me, it's going to cut in the center. It's going to seal it on both sides. Once you do that, you've taken the blood flow that goes to the kidney away. And so that I always tell people that diffuses the bomb. That takes a lot of pressure off right there. And so then, so a lot of it is not only what I do, but some of the instruments and the technology that's increased. And so here we're going to go below, I believe, and then we're going to find the best. So this is actually the tube going to the left kidney to the left right here. Then we're going to get around. So that's what the patient is laying on their side. So that's actually the tube going to the left kidney. So you don't want to mess with that, but I don't want to, I don't want it to flow and just be coming out of the main blood pipe when I cut it open in a second or remove the thrombus and you'll see that what you're trying out to do is knock a bunch in your bunch of stuff here because that gets a little unenjoyable. That's that vessel coming across. And then again, this is, I'm just going to show you ultrasound. You'll see in another quick video about a partial nephrectomy, but basically I'm just without showing you too much here, I'm just ultrasound exactly where the thrombus is going. So I can see inside the vena cava here. I'm going to look at the left renal vein because I don't know if I have to pull it out of that as well. I'm controlling this with myself. I'm looking at it in real time. And then basically now here's where I got to get down to business. So I'm going to block the blood flow going back to the heart. And again, you need a good assistant here. If you don't put them on yourself, I'm going to block the blood flow going to the left kidney. Again, these clamps are an improvement in techno. I mean, all of this stuff is kind of come with this as we figured out stuff. That is a clip of a little vessel coming up into the big blood pipe. I mean, they're going to put a clamp on here and then we're going to start cutting this out. But you're not seeing it back in a lot of people. A lot of people in the room, anesthesiologists, people up at the table, people that do this all the time and know your next instrument. And that's never lost on me. I mean, this is a team sport. And so here you go. So that's actually the kidney's out to the top of the screen and now I'm going to start cutting this out. And what you got to do is you got to really kind of figure out where it's going and you got to open up the blood pipe and then let this thing come out to you. And a lot of the way I know if it's appropriate for me to do this or not is patient selection, but a lot of that is just driven by the imaging that I can kind of tell is this a good person to do this on or is this too much to do it this way? And then I'm going to keep doing this. I'm going to keep opening up the blood pipe here. The white in the background there is the inside of the blood pipe that goes back to the heart. And I'm going to keep walking it up and just keep getting. That's the drum that tumor right there is in my left hand. The left side of the screen. I'm going to keep walking it up and just keep walking towards the liver until I can get it all out, open it up. And then after I get it out, I'll cut the backs out of the vessel. And a lot of that has to do with I just can't cut the entire pipe unless you're going to put a little piece of graph or something in that to make it bigger. I might at this point be yelling why my scissors aren't cutting very well. And then basically I'll just sew it back. And then in a second here, you're going to restore the blood flow. And then what we have to do is just open things back up. And then you'll see just one quick second here. I'll kind of show you. So you can see how it's a little bit smaller there, but that's the blood flow going back to the. Yeah, so I'm going to show you one other quick bit. It's a lot shorter. It's it's not that's an extension. You don't have to do all that work that you just did on the tumor thrombus or the blood pipe. I'm sorry. I heard that, but I don't know exactly who was asking. Yeah. Yeah, that's a fair assessment. I'm just going to get back to. I mean, easy is a relative term like that. Not sure what do you know how to get back? What am I doing here to not kick out? Yeah, I do. Sorry about this. Yep. Of course. Yep. I go on. So I don't know. I'll just give you one other way. Hit right there. Yeah, it's doing. They get I'll just have to kick. I hope I don't mess this up either. I'm having to bring this in for another presentation. So what I one of the reasons I put this in is a just to show you a little bit different look. This is just taking a tumor off the kidney. So I won't be I won't be taking out an entire kidney here, but also a little bit of I mean, this is only like a couple of years that you can just I think you just look at this and say, hey, the other one looks a little bit more Gucci. It's a little bit better. You can see better the instruments look a little bit cooler and you can see actually that my assistance putting on the clamps here. He did on the last one, but you can you can actually put them on yourselves now and but you'll see him ultrasounding in a second or you may have already seen him do that and here I'm just cutting out the tumor. The kidneys remaining on the floor there. And then you basically just cut out that leave most of the kidney as much of the kidneys you can behind. And then you will a lot of people have figured out a lot of cool techniques and this is just you slide. You use these clips to slide against the suture. So the kidney in order to repair the kidney and liver, which are very similar. You want to you basically create compression. You show the vessels, but it's like a delicate sponge. And then you can basically create people do various maneuvers. This is one I did this way. I've done it in multiple different ways where you just basically squeeze the kidney like you're squeezing your hands together in that area. And that reduces the risk of bleeding. So I kind of repairs that. So just I'm going to move on for just one second. And then just again, I touched on this before. I think this is an evolving kind of concept. People will hear and talk to patients about the concept of metastatectomy. I think there's I'll just make a couple of general comments. One in general it appears improved survival, but it's very selection biased. And what I mean by that listen, you're not going to have this offer to you unless you're presumably in a state where a we think it'll help and you've had some response most likely to your therapy. It's usually driven by feasibility and surgeon experience and oligometastatic disease really defines one site. So listen, if you have 15 or 18 sites of disease, that's going to be hard to search, render that or add, have surgery add value in that space because in general in surgery, we're not taking out five, six, seven spots at the same time. It does appear to be you should enter this space with caution. Certainly when you talk about the liver and that makes sense just from this fact, you are most that when you talk about metastatectomy, you've already probably had primary renal surgery. You've already had therapy. You're further in your disease state. You're not a strong initially. And so anytime you operate on that type of patient, it does increase the risk. Other reasons I always tell people that we might do some type of surgical intervention may not be to improve your disease state, but it may be to manage your symptoms in your quality life. Whether that be a fracture of a bone, whether that be a GI bleed or something that is life threatening to you in its current state, secondary, the disease. So the things we do may not improve your overall survive or how long you live, but they make severely improve your current quality of life. And then these are just other kind of scenarios we've talked about and the idea that some patients can have a mixed response. That means you can have five sites of disease, four of them go away with therapy, but one of them done, does not. So maybe they behave differently and maybe since everything else is doing well from the therapy you're being delivered, that if you cut out or remove or ablate that by freezing it or radio frequency or sterotactic radio surgery, then you can then augment or change the course of that disease. So just a couple of quick slides. These are from Duke Carol. He's a friend of mine at Vanderbilt. He's done some really awesome stuff. He's got a background and people he works with in engineering. And so this is a lot of his plight in life. And so this concept of we do as surgeons of active imaging as urologists we do this, but certainly of in the moment we're doing some type of imaging and we're looking, whether it be ultrasound or CT that's in the operating room. But what you really have in 2017 and going into 18 is passive imaging. That means you came into the surgeon's office and you had a CT scan and we were looking at that and we were disconnect in a disconnected way saying we see your image and this is what we're going to do. And he's really taken this to true interoperative kind of real time meaning can you overlay this and for people who are in the medical field we understand that this is really current. And the reason it's current is it's easily represented in what we call MRI for prostate cancer. And it's a basically you get an MRI for prostate cancer and you overlay it on the ultrasound and really in 2017 much more biopsies are done that way. And it's this concept of three-dimensionally overlaying. So it can be quite beneficial or the perception that can be beneficial and also kind of get surgeons on a faster platform and curve to really understand three-dimensionally what's going on. So this is his example, but it makes sense to me. You would look at your phone and you would say, hey, this is where I'm going. But in return this would be you looking out the window and it's kind of overlaying that in your visual field. So this you saw some of this already. So doing some ultrasound and that's kind of there's a slight disconnect between, hey, I see what I see but then what am I going to do with it? I mean, I'm going to just this is kind of the basics of it. I'm going to skip these two just to go to this. So this is a 3D reconstruction and so you can take a picture like this that not only shows you that there's a tumor in green but that says what's going on around there. So let's because let's think about that. We are always trying to remove cancer, do the surgery and leave everything else alone. And so I just thought that was cool. I'm not even sure what he was doing here. To be honest with you. I'm not going to lie. So anyways, he had a great video here and what I'll just show you I believe is on the next slide. Let's see is this and I think this will hire. He will actually take his cursor. I've seen him do this a couple of times. So what you can see is the blood flow coming in. You can see this which is where the urine collects. So you kind of have a 3D now. If he takes his instrument in screen 2 here moves it around. That green dot will move it where he is. So he can start planning ahead of time. You already know what you're going to get into. You already kind of know where you need to go. And if you think about that from a surgeon perspective that's immensely helpful. You are planning for everybody in the operating. What's getting ready to occur? Are you already predicting that in time? So he's doing a lot of this already and I do believe this will become a lot more mainstream in our lifetime. So what does the future hold? I think it holds precise surgery but I also think that precision is really driven by an iterative process of feeding back. Of talking to each other, showing each other videos that we can share and learn from each other. And I think that's really important and that's never lost to me in the evolution of what's called laparoscopy. People can come in and learn and we can continue to share that. I will make one other comment after this but on better surgery, we now track outcomes. Aggressive, we've always done that. We can track things very granular. Your cost in the operating room, every movement you made with your right and left hand feed that back to people. Video review and get feedback. And I always say to our residents, listen, you never see Tiger Woods. He may not be the best example anymore but he still relates to me without a coach on the driving range. He is a professional. There's nobody in this room that he can't beat in golf but he's always looking for an advantage and it's imperative that we do the same, that we continually demand of ourselves to be fed back. And then also it's not lost on me this concept. That's one part. Being in the operating room, doing the surgery is one part. How we prepare for surgery. How we think about it after. How we reduce the chance that you're going to come back. How we deal with everything is very important. And that's, a lot of that is a term called enhanced recovery after surgery. And it's really important in this space. I appreciate your time and attention. And again, thank you for the opportunity.