 Thank you for the introduction. It's a small group, so feel free to ask at any time if you have any questions. We're going to switch gears a little bit from metastatic disease and therapeutics to surgery, which is a kind of a linchpin to treating kidney cancer as well, especially in the localized fashion. I have no disclosures to reveal. So kidney cancer surgery has gone, undergone a pretty major evolution through time through the decades. And initially it was something that was I would call maximally invasive. And now there are great strides that are accomplishing equal efficacy from a cancer control standpoint and safety, but doing it through much smaller incisions, which is better for everyone involved, especially the patient. So modern radical nephrectomy, meaning removing the entire kidney, was described about five decades ago, plus by Dr. Robson in Toronto. As you can see, the access to the kidney does require a pretty large incision. You can see right here. And that incision carries through the rib cage. The reason the kidney is where it is is because it's protected by those ribs. The problem is from a surgical standpoint, getting through to that can be extremely painful for the patient, for those of you who've ever broken a rib. So that's how things started back then. Unfortunately, we're not we're not there at this point in 2017, but the principles involved are really controlling the blood supply early to prevent any further tumor spread through the blood system and moving the entire kidney along with the adrenal gland. That's kind of what was proposed and practiced at that time with Androides fascia, which is the envelope of fat that surrounds everyone's kidney. You know, back then survival wasn't great. Five-year overall survival was in the 50% range. It's really because we didn't have a, we had no essentially diagnostic imaging modalities. There were no CT scans and ultrasounds, no nothing. So basically finding cancers like this, what they were usually found at very late stages, which is not the case today, luckily. So that was the gold standard treatment for renal masses for quite a long time, probably for 30 years, until more minimally invasive approaches came along. Just because we are talking more about kidney cancer and how it can run the gamut, occasionally kidney cancer can involve spread into the vena cava, into the main renal vein up the vena cava, which happens about four to ten percent of the time. So I don't know if you can see the scan right here, but basically here's the right kidney. Here's this tumor thrombus essentially going up the vena cava. This is the main vein that drains into the heart. So kidney cancer does have a predisposition to do this more so than a lot of other cancers out there. And basically the staging which I'll go through depends on how high the tumor thrombus can extend. So I think long and short of the talk also is that kidney cancer can be a disease that can be treated with minimally invasive means, but because of the nature of kidney cancer and the nature of where the kidney is, it can do some damage with regards to things like this and cause the necessity to do much much bigger procedure no matter what. And again the thrombus can stay within the renal vein like this where these can usually be managed through minimally invasive means like laparoscopy or robotics. Once they get into the vena cava or up into the heart even then that becomes a much bigger surgical deal. Luckily these patients actually do fairly well as long as there's no evidence of spread into the lymph nodes. And this is actually data that precedes what Dr. Schoenervos alluded to in the first talk, you know with these newer medications they're not so new anymore actually. TKI's that can control kidney cancer from spreading. Even back then the overall survival for situations like this was quite good despite not having the the therapeutics that we have today. Again the reason why doing surgery in the kidney can be more difficult is that it basically, the kidneys basically lie very very close to the main blood supply for your whole body. So if you look at this, here's your right kidney and this is the right renal vein. It drains directly into the inferior vena cava which goes up to the heart. So any sort of kidney surgery can be fairly hazardous from a blood loss standpoint and we'll get into that. But that's why that's why doing surgeries like this can require a great deal of surgical skill and technology to make sure you have the best available capability to make sure you control bleeding and any sort of post-operative complications regarding that. Again when tumor thrombosis is involved with the vena cava, what you need to do is actually stop the blood flow of the vena cava temporarily. So you're cinching down these vessels, this is the renal vein, this is the vena cava to prevent massive blood loss. When you open this up to pull this tumor thrombus out and in another diagram again, these types of surgeries can be very technically challenging for the reasons just described. So I mean this is kind of what it looks like when you take a kidney out. There's this envelope of just for the people who don't see it. Yeah, I know some grimaces and stuff. Luckily there's no blood and guts yet. Those will be, those will come up in videos later on. But you know you try to clean these things off so you know for for photographic purposes but here's the kidney. You can't, you know patients always ask me, did you see the tumor and I said if it's a big tumor you don't really want to see it because it's encased in this envelope of fat. You don't really want to disrupt that. So what you're seeing here is there's a kidney here underneath this fat but you want to leave that envelope of fat intact in larger tumors. You really don't want to disrupt that and over here peeking out and I'll think of a yeah a little bit slightly close close-up view of it is the renal vein and the tumor thrombus. And this is kind of what kidney renal cell, clear cell renal cell carcinoma looks like. It's kind of this bright yellow looking mass. So it's very diagnostic and you know when we, we'll go into that later but when I take out smaller tumors I'll make sure that the entire small tumor has been removed and when we cut into it this is kind of what it looks like. If it doesn't look like this bright yellow thing then it's maybe not cancerous, it might be something else. Yes this was, oh yeah we'll get into that but right. You have to make a, you have to make a slightly larger incision to get it out but you don't have to make it in a place that's really, really painful. In other words you know back in the day you have to slice the ribs and stuff that's really painful. Probably the least painful part portion of your body to remove something is kind of where women would have like a C-section like below the belly button. So you try to move it through there because it's less painful and it's cosmetically less, less difficult for the patient. I'll show you a picture that will illustrate that. It's a good question you know I kind of joke at the patients and say yeah just leave it in there. You know you may roll around a bed and I feel like a bump bump it's okay it'll go away. No it's kidding no. You have to pull it down. We kind of make, we put into a bag and then make the bag with just large enough to accommodate essentially the smallest, the width essentially the smallest proportion or smallest dimension and pull it out. And as the trend goes we're always talking about doing things less invasively from a surgical standpoint and a situation like this is no different. So instead of making an incision you know way up and down here like a sternotomy you know there are other ways to to improve the cosmesis and the pain involved with surgeries like this. So again the trend has been towards in surgery in general doing things less invasively and you know for a variety of reasons the most obvious one is obviously for the patient's sake. So Dr. Klayman who's now at UC Irvine I think at that time he was at St. Washi in St. Louis. He described the first laparoscopic to Frackman in 1990 so we're talking 20 plus years, almost 30 years. And then Dr. Winfield who's he used to be here at Stanford I think at this time he was that point in time he was at also Washi described the first laparoscopic portion of Frackman. And you know others did hand assisted laparoscopy where you put your hand in there to help you know manipulate the the kidney and the tumors. And finally in the 2000s we're talking about robotic surgery. Now we'll get into robotic surgery a little bit more in detail a lot more in detail but basically is there a big difference in cancer outcomes between doing it open versus laparoscopic and what this table shows that there is not. Of course if there was then you wouldn't be doing it this way it wouldn't be worth it. It wouldn't be worth the even the you know the recovery time and all if it wasn't cancer from a cancer standpoint wasn't viable but it is and that's good for everyone involved. And the major difference when we talk about minimally invasive approaches or laparoscopic approaches is like unlike that big incision you saw and are seeing here again with laparoscopy we're making small incisions usually the you know the width of the tip of your finger your thumb. So obviously that's going to impart a great deal less pain and suffering to the patients afterwards and reduce their hospital stay. So to your question how do we get it out of there? Well so there are there are entrapment bags and we can unfurl inside the body and then kind of stuff it in there and then there's a drawstring to pull it out of the body. So yes the skin is elastic and you know again because you have a bag there you just really have to get it the incision just wide enough through this through the smallest dimension of the kidney and just pull it out and you know and that's even that's actually better than even trying to put your hand in there and pull it out because your hand is a certain dimension to it as well and you can't actually exert as much force because you could disrupt the tumor so this is actually the ideal way to do it and if the tumor disrupts it's in a bag so it's kind of contained. Yeah I mean again to disrupt it would take a great deal of force. It would almost take you to intentionally try to disrupt it rather than pulling out of the you know out of the body so this in and of itself is usually not enough to disrupt it but even if it did it's in a bag and it's not going to jeopardize the pathologic analysis but but to your to your question also you know there are certain I don't think they do any more but there are certain specialties even certain surgeons who would opt to morselate something like this and morselation means like putting a essentially like a food processor a quesanard into this bag and just kind of homogenizing it which is really not a great idea for a couple reasons first of all is that you know to your point you don't have a lot of it basically you basically homogenize the entire specimen so you don't have a great pathologic ability to analyze it number two is if you puncture the bag then you're in trouble right because now you spill that entire milkshake in the body you don't want to do that so so I mean in the name of cosmesis you don't want to you don't want to jeopardize cancer control for cosmesis I mean who cares if you have a tiny incision right I mean not going to wear your speedo anyway so well you might but so tumor size is an important criteria but there really is no true limitation to what can be handled through mainly invasive approaches as long as it's feasible there are challenges though and unlike an open surgery when you do these things mainly basically you're not actually opening a big incision so you know you do have the limitation of the actual body cavity with which you're in which you're working nonetheless still despite that things are usually feasible up to a certain size even more challenging cases like this where there are tumors in the liver and the reason is is because trying to get to the vessels laparoscopically or robotically is a lot easier than doing an open because you don't have to like try to fight your way through here and look around here you can actually put this camera which is very low profile directly into this space and be able to control the blood vessels Dr. Srinivas showed you that molecular pathway of kidney cancer and and basically what most well not the immunotherapy treatments but with the tyrosine kinase inhibitors what we're trying to do is stop the process of recruitment of blood flow to the kidney tumor that's essentially what kidney cancer is doing it's actually trying to recruit blood flow to itself from a surgical standpoint what we see is these things here these are like like channels of blood that have been pulled in from other parts of the body adjacent parts to feed this thing it's like the aqueduct right they want to build from the delta to southern california not that I'm saying anything politically here but you know you're diverting water away to a distant area this is kind of what's happening and actually doing these laparoscopically is actually a little bit easier to control these things because you can actually see them better and when you perform a laparoscopic robotic surgery you're actually insufflating the belly with gas to a certain pressure and that usually exceeds the pressure of the venous return of the vein pressure in these small vessels so it actually decreases blood loss which is a good thing so what I tell patients or attendees to conferences like this is me just talking to you can be really boring I might show you some real life videos all right I mean and it's you know I mean it's nine whatever third in the morning you know if you need a cup of coffee I mean you know this is something that'll actually keep you awake so anyway so so basically the idea with any kidney surgery is to find the blood supply to the kidney and this is a robotic robotic case and you'll kind of see that because these instruments are a lot more versatile but basically you're trying to find the blood flow blood supply so here's the artery this is the right kidney I know because this is the vena cava here here's the artery you can see it pulsating you want to kind of get that freed up from the strong attachments so here again here's the artery and the vein is right next to it and the vena cava is right below here so again the goal is to find the vessels you know this thing looks huge but in reality it's probably less than the width of this cord which is an advantage to these minimally invasive procedures because everything's so magnified you can see a lot better when we talked about this okay so remember those cases of tumor thrombus how do we deal with that now what that first video didn't show you was how we deal with blood vessels you know from a minimally invasive approach what this thing here is actually is a it's a vascular stapler now I mean when I say the word stapler you're thinking I'm like you know stapling pieces of paper together well yeah I guess that's kind of the the crude concept but that's not really what happens here so what the stapler does it's going to fire I don't know if you can see this but there's rows of indentations here and all those rows represent a row of staples so this thing is going to fire six rows of staples titanium staples and then cut in between and actually that's a very very secure way of dealing with blood vessels in the body probably much more secure than clips if you can do it this way so so that's I'm going to show you how this how this works again because you know me talking about you know survival and stuff can be quite boring this will actually give you a little more real-life insight to what actually happened so so this stapler is going to fire on the renal artery and it's as simple as that and then you can see kind of the stapline and the pulsation and I can I can re show this to you now there's a tumor thrombus in that vein you can kind of see that yellowish thing here remember that yellow thing I showed you there's a tumor thrombus in this vein but because of that because the tumor thrombus is kind of not into the vena cava because the vena cava is below here we're actually able to deal with it in a fashion like this whereas in open surgery you need pretty much a decision incision from your chest down to your pelvis to take care of this now again I mean you know one size does not fit all but when we can do this way it does greatly improve the recovery time and pain and of the patients involved and again I'm trying to you know limit the amount of blood and guts not that we're going to show a lot of that but you know it's just to show it illustrates to you that you know the way these things are done are done a certain way I can be done in very exact ways and magnified again the even the renal vein is no wider than my I don't know my my third finger here so fourth finger sorry not my third finger and you know again there are other ways like putting a hand in there and milking back the thrombus unfortunately when the thrombus gets way high like this you're going to need to as seen in those previous illustrations and slides to basically put the patient on bypass stop the heart because otherwise you won't be able to get that thing out without the patient bleeding to death now what about so any questions about that all right so Dr. Schoenervals touched on what do we do when there's metastatic disease you know do we still take the kidney out so the guidelines are that we should if the kidney is removable if the kidney and tumor are removable and if there's you know if there's a solitary area of spread we should try to move that as well if there's multiple areas you know if they're usually not completely respectable in the same setting but there's something that is respectable that's close by that you can get at you should take out take it out as well too now this is data from 12 13 years ago and this data precedes and Dr. Schoenervals alluded to this this data precedes the medications we have now the tyrosine kinase inhibitors like seraph nib and synidinib back then what they found was that removing the kidney did impart a survival benefit not a lot probably about four or five months but but not nothing and that was the era where we're using interferon and this was what they're testing up against so patients who got interferon and nephrectomy did better from a survival standpoint that those who did not now at that time you know what did they say well the patients do benefit from removing the kidney the ones who do the best actually have better performance status they're overall healthier if they have spread it's only to the lungs and that's more favorable and their tumors have good prognostic features so that that's what we know that's what we knew back in 2004 from them doing the journal paper since then you know we talked about TKI's but can we do it should we do it be doing it minimally basically and the answer is we should because it can basically put the patients back on treatment faster because the recovery time is faster so if you can remove it through minimally invasive means you should because it's better for the patients and they can get back on treatment faster which is what they really need to keep things at bay now what about doing nephrectomy and patients who have spread in the era of triosin kinase inhibitors which is where we are now we don't really know that yet so there's this trial and Dr. Srinivas and I were talking about this there's this trial that started back in 2011 trying to answer that question so you know do patients do better they're randomized do they do so to randomize into two arms whether they start with their kidney removal and then starting on synedinid or synedinid alone and there's another trial which I think is called SIR time which is testing something similar but along the same lines which is do they do better patients do better if they have their kidney out first or they have treatment first so I think this trial was started in 2011 and 2012 as well so what's going on with these do we have any information well I actually recently came upon this question or this manuscript in european neurology which says cytoreductive nephrectomy the tyrosine kinase inhibitor error a question that may never be answered okay why is that you know we do have data out there that's not randomized like those trials that suggests that it is beneficial to get the kidney out but we don't have randomized trial level data I think the reason why they're having trouble answering this question is because trying to get patients enrolled in this trial has been very difficult and I think it has to do with patients we see in our clinic and this trial mind is being conducted in Europe so let's say you have a patient that comes in your clinic and their kidney looks and they have metastatic disease but a kidney looks eminently removable you're going to kind of want to remove it and if you you know you might the surgeon or even the medical oncologist may feel a little bit uncomfortable about the prospect of saying okay why don't we put in your trial and see what happens knowing that if you put them on trial and they get on going medication that their kidney may eventually become unrespectable not removable so I think those are the kind of the issues that have come up that have made it hard for people to get recruited into a trial like this so nonetheless I think the preliminary data there are some preliminary data that's not necessarily great because it's not powered to answer the question but that suggests that if you can't again if you can't remove the kidney you should do so if you can't then put them on trial and see what happens and if they have a response then try to remove it later but again if you can remove it then move it up front and not wait and that's the that's the to the best of our ability to know at this point what we should be doing in today's era of tyrosine kinase inhibitors yeah so we talked about this now I'm going to shift more towards what is I guess more commonly found these days with kidney cancer and actually the number of cases in kidney cancer have been going up until recently I think the number has started to slide back down which is encouraging but most of what we find are actually small four centimeters or less and the reason we're finding those tumors at smaller sizes is because we're scanning people they're getting scans because they have belly pain they're getting ultrasound they're getting scanned for other reasons then we stumble upon it unlike what it was like before what I mentioned back in the 50s where didn't have any imaging so basically if you're going to stumble upon it you're going to stumble upon it because the patient has real symptoms and they have blood in the urine and their pain and whatnot so for these smaller tumors what should we do should we take the whole kidney out the answer is no we should try to save the kidney if at all possible if at all possible and we have lots of data to suggest that moving part of the kidney is just as effective as moving the whole kidney so we shouldn't really be moving the whole kidney because there's no cancer there's no cancer reason to do that but also well also there's a when tumors are smaller they can be more likely benign in certain series we found that but also moving the whole kidney is not necessarily great for the patient overall and that doesn't that's not doesn't take a huge stretch a leap of faith to understand that but you know it does make them closer put them closer to dialysis it also does have which I don't touch on here but also have can have negative effects on cardiovascular health and and things like that so if we can save the kidney we should and this is where robotic surgery comes in now you know when I talk to patients at robotic surgery they're like well I don't want some robot operating on me well you know I mean I'd be I'd be thrilled if I could push a button and leave the room you know like you know like some Ford assembly line you know there's a car at the end of the line and I've just had a couple cups of coffee or you know like a Roomba right some things vacuuming your house you know I mean that would be great of course you know the thing gets stuck under under the couch and not move the whole day that's not great either which is why which is why I mean basically the robot robotic surgery means that we're using a very sophisticated instrument that has articulating instruments that has magnified image capabilities and 3d optics to do high level surgery and that's what we're talking about with a robotic partial refractomy and these things have arms and hooks and instruments you know but I mean these are greatly magnified I mean the real size of these instruments is really like about that big so so for doing surgery like this it's actually very helpful and here's some more videos that will show you that but basically the the goal of a the goal of a kidney tumor partial refractomy and saving the kidney is to find first the blood supply just like that other video and but instead instead of dividing and stopping the blood supply we're going to stop it temporarily so this is the right side here's the vena cava here here's the renal artery and here and here's the renal vein you don't hold your breath it's not there's no surprises here no no no that's for a different talk for a different time but again the the goal is to find the blood supply and control it that's kind of the goal with all kidney surgeries because the what I tell patients is that kidney surgery can be very unforgiving you saw those pictures where the blood supply you know runs directly to the heart I mean there's just a lot of flow into the kidney and unlike whether organs to control it I mean there are like organs like the livery can just like electrocoagulated and will stop not with a kidney gotta do more than that what do you mean you mean as far as instrumentation because we don't have fully automated instrumentation oh yes oh yes claws probably not the right term but yeah yeah I mean the the surgeon is controlling every single thing that occurs there's no autonomy whatsoever someday but there's zero autonomy I mean this is whatever you do is directly translated into the into the movements that are happening inside the body with these instruments yeah that's because so it's kind of a misnomer robotics really in this context means I mean the the robotics the roboticist out there call it a master slave relationship so the surgeon's the master and the robotic the robot is the slave but basically it really is just a way for you to approach this in the most in the most technologically advanced and only invasive way possible there's no autonomy yes why why why India that would be wonderful I mean that would be I mean I could get through my day so much faster well that's why I try to in forums like this try to you know try to set it the record straight you know again yep and I'll show you this part here which is so again you need to control the blood flow yes yes yeah in 30 minutes that's correct because if it's going to take you a lot longer than that then maybe you should think about doing them a different way like open where you can actually put ice in the kidney and kind of decrease the metabolic demands and the time constraints but you know be that as a may I would say that the vast majority of these things can't be handled in 30 minutes or less and what you're seeing here is removing the tumor robotically so that tumors kind of this kind of this ball sticking out from the surface here and that again the goal is to remove the tumor cleanly and completely but not you know not take so much normal kidney tissue that you've compromised the overall kidney function more than you need to and you know there are some bleeding here I would say this is less on the on the lesser side there can be much more than this so it's important that you have kind of a a very experienced team working on things like this because again with the kidney there can be a lot of a lot of variability to how complicated and how much blood loss that can occur this is actually not that much if it's much more than this then again you need to make sure that your team is prepared to handle that and you know my personal opinion is that if you're going to be doing something like this you probably shouldn't be doing it once a year you know more like once a week just so you don't just like anything the more you do the more frequently do with the better you're going to be at it you know if I were going to try to drive an 18 wheel or a guy only knows what could happen you know I don't drive an 18 wheel for that reason and for that same reason you know this is this can be a very complicated thing but again the goal is to remove the kidney as move the tumor as cleanly as possible and as quick a time as possible there is some bleeding here and we'll see how we have to deal with that so we tuck that over there get over here having some issues then we have two sutured all back together so again the suturing is the most difficult part of this and it requires instruments at the robot to take platform allows you to use that can do things very precisely and accurately so again there's some bleeding there that can only be controlled with some suturing that has to be very precise and in nature and you'll see after this suture is thrown that it'll basically stop the bleeding so again there is no autonomy I wish there was that'd be great you know it's not like again you push up you leave this thing Roomba it's vacuum your floor and it's all done at the end of the day of course you know the reason you don't do that is because the capability of what can be done through autonomous machine learning I don't know what you want to call it I'm not a engineer it's just not we're just not there yet yep what brings about the decision to make it radical as opposed to a posture of that yeah luckily we have imaging studies that are very accurate that we can determine that preoperably but not always but again it's really the location and the size the location the size generally speaking if the size is below four centimeters it's much easier to save the kidney once it gets above that it can be much more difficult just from sheer size alone and the closer the tumor is to the um and here are those clips we used to control the blood flow uh what that tumor is much closer to the blood supply that runs to the center of the kidney it also makes it harder to save the kidney because that blood supply is going to be more easily compromised than if it's kind of hanging off on the edge I do we can talk about that as well all right so let me make this work I think we're running out of time but uh you know when we talk about robotic versus laparoscopic partial nephrectomy um that actually slightly favors robotic I think and we used to do these laparoscopically but it was very difficult for the reasons we just discussed just try to do those difficult maneuvers uh laparoscopically took a lot of really um specialized people who not everyone who could um this is a paper that came out last month that shows that um nowadays if you look at robotic partial nephrectomy about 64 or partial nephrectomy about 64 percent that orange line are done robotically as opposed to laparoscopically which is single digits or even open so I think again technological advances have helped us um improve or increase the ability to do things like this we can move on to that so that's robotic partial nephrectomy I'm gonna this isn't really surgery per se but I'm gonna talk briefly about ablation and actor surveillance so ablation means you're freezing or you're burning it and this is an example of freezing the tumor not cutting it out not cutting it out and that can be done via putting a needle directly through the skin into it or laparoscopically again cryotherapy is freezing it and rfa is burning it and the other things like microwave ablation hyphoo so there are a bunch of ways that this can be handled you know why isn't everything handled this way well I mean not every tumor can be handled in this fashion but basically what we know I mean we don't have a lot of long term data with regards to the how effective these things are but basically they are going to be inferior to cutting it out as far as recurrence of cancer they whether you freeze it or you burn it it's going to be inferior to surgery so it is appropriate in certain cases but not all especially not in younger patients probably should try to do whatever you can to eradicate the cancer in the best way possible and you know we don't have a lot of data but when we look at meta-analysis this is the most recent one I could find basically what they say is the review shows that both cryoblation and radiofrequency ablation are promising in patients with small renal tumors who are considering who are considered poor candidates in more involved surgery so again it's a it's a good option for patients who are probably not great surgical candidates long-term data is lacking longer follow-up and more rigorous head-to-head trials are really needed so I think and it says at the bottom they're giving the natural history of small renal masses a probably designed trial would follow these patients for at least five years in the absence of such data a portion of rectum remains the standard of care for small renal masses so we do have other ways other things that we can recommend and I do frequently for patients who I think fit the bill better with something like this because as you can see doing a surgery can be very invasive and and time-consuming and can impart a greater hit on the patient it just depends on making sure you choose the patients correctly finally as far you know we can just choose non-surgical options altogether and just just kind of watch and wait and why would we do that well I mean we know that these things don't grow all that fast and small tumors do not have a great propensity to spread and we have very good imaging modalities to follow these patients so I think if patients are older and they're not great surgical candidates and we don't think that their tumor will affect their lifespan in any way then we can just sit down sit back and watch carefully and again these are the best candidates and what we do know again through worldwide literature is that when you see these graphs like this basically what this is measuring is tumor growth over time and this is like going on for years so we know they don't grow more usually more than a few millimeters a year these renal masses even if malignant so that's kind of the basis of watching these things carefully if you know if we feel that the patient's life expectancy does not support doing something invasive so to conclude surgical options continue to evolve into less invasive techniques and we're continually advancing safety from a cancer control and from a surgical standpoint and again from non-surgical standpoint we'll continue to examine how effective or how safe that is to do with future studies as well thank you very much for your attention