 Thank you, Sandy and thank you everybody for for coming. It's great to see everybody here the past few years We've had it up in the city, and it's nice to have everybody visit us down in our neck of the woods And thanks for braving all of our construction This looks like we've got it set up so what I hope to talk to you about today is How we try to do a better job in Surgery to remove kidney cancer and I wanted to try to set up a little bit of historical perspective of what we've done and Then what we're doing now to try to advance our surgery to be better And I hope that this talk about augmented reality in the operating room will actually also be a great setup For dr. Mitra after me as we talk about markers that we can use in imaging for kidney cancer as well So I don't know if it's a good thing or a bad thing that you all just ate If you were feeling a little tired, some of my slides are a little graphic. They may wake you up But if you're queasy, I'll try to go fast But I wanted to actually show you pictures and videos from inside the operating room to kind of get you a taste of What we actually do In addition, I have grant support from Stanford as well as from the NIH No industrial support or industry support related to what I'll be talking about today So I have this in every one of my kidney cancer talks. This is my grandma and grandpa at my wedding and Betty Is a great example of how kidney cancer has changed over the years. So she had a fall Had a fracture in her back and that prompted imaging that actually showed two renal masses one in each kidney both Impressively large and this is at 78 and This was during my training and it really shaped my interest in kidney cancer and why I wanted to be a kidney cancer surgeon Luckily, she had great care and she's now no evidence of disease almost 10 years out from her surgeries for both of her kidneys I'm sure that you guys talked about this earlier today, but kidney cancer is a common cancer and more common in men and then women But over time we've seen a steady rise in the incidence of kidney cancer. This is a growing problem And so by 2013 there were 65,000 cases and almost 14,000 deaths due to kidney cancer in the United States But things have changed in in addition to seeing more kidney cancer. We're seeing different kidney cancer So this is a chart of the size of kidney cancers when they're first diagnosed And what I want to draw your attention to is the filled-in triangles Those are small tumors. They're two to four centimeters and In the 80s, they were relatively uncommon by 2000. They were the most common size at diagnosis of kidney cancer So much like my grandma We find kidney cancers by accident and we often find them by accident while they're still small and this is a great thing but this Shrinking of the tumors when we first see the patients for many patients at least and our understanding about chronic kidney disease has really driven the field to try to do more Nefron sparing surgery in other words take the tumor out, but leave as much kidney behind as we can and Chronic kidney disease we've now come to understand Obviously everybody knows end-stage renal disease dialysis is a bad thing But what we're understanding better now is that even small reductions in your kidney function have potential impacts on your health over the long run and So we've really been motivated as a field to try to do better to save as much kidney function as we can If you look at patients that got a partial or a radical nephrectomy at single institutions I think this is data from Memorial Sloan You see that the partial nephrectomy patients live longer There's a lot of factors that go into that number one. They tend to have smaller tumors. They tend to be younger patients There's a lot of other things that drive their survival But our concern has always been that we don't want to make chronic kidney disease The reason why a patient with kidney cancer has a shorter survival So this is one of my favorite pictures people who have seen my talks know that they've seen my grandma and they've seen this But this is a picture from the Cassini spacecraft. It was released by NASA just this year So this is an actual picture from space at Saturn and that dot down at the bottom is earth So the view looking back at Cassini's travels. I Like to use this as a setup to look at our historical ways that we've approached kidney cancer surgery So this goes back to 1975 where I trained in UCLA and This was the Kauffman clamp and this was a surgical accident They were doing a kidney cancer case and they happened to be doing it with a famous liver surgeon And the liver surgeon said you should use my clamp to clamp part of the kidney So that you can cut the tumor out while the blood flow is still going to the rest of the kidney And so they published this in 1970 and as we've become more interested in ways to save kidney while still removing kidney cancer This has become kind of a stepping off point of what we do So you can use the clamp to block the blood flow Obviously the kidney's job is to filter blood and so you have to interrupt the blood flow when you cut into the kidney Otherwise, you'll have a lot of bleeding So this clamp lets you do that And there's different ways you can put the clamp on as to Remove the top half of the kidney the bottom half the lateral half all of the different areas of the kidney Well, we've moved from there to be even a little more sophisticated So I want to show you now a CAT scan and then an MRI from a patient Where we did a partial refractomy using this clamp And this gets now to the theme of us trying to use imaging to do a better job with our cancer surgery So this is a CAT scan the patient's head is behind the screen their feet Sticking out towards us and these are slices through that belly and you can see here You're starting to see A mass In the left kidney And this is a fairly impressive mass, but it also has a nice round appearance. It has a border It's distinct from the rest of the kidney And the rest of the kidney looks fine This isn't something where we're worried that there's cancer in more than one area And now I'm going to show you the MRI and so the MRI can actually show you pictures These show the blood flow in the kidney And you can see that there's not as much blood flow in the tumor compared with the rest of the kidney And as we kind of make a three-dimensional Rotation of these pictures you can see that the top Half of that left kidney There's a divot in it So our goal with this surgery was to find the tumor. Here's the tumor and here's where the graphic images start But here's the tumor we've exposed it through an incision We've been able to place our coffin clamp into the field And we can clamp underneath this tumor on the good kidney and with that clamp in place We can actually cut through and this If you haven't seen the inside of the kidney, it's awesome But this is a picture of the inside of the kidney. So our clamp we're picking up the areas of the collecting system So these are all the tubes that funnel urine down to the bladder And the yellow portion of the kidney is the normal meat of the kidney that's doing the work the filtration And so with this clamp in place, we don't have bleeding. We can cut the tumor out and we can try to preserve the rest of the kidney And here's the tumor that we removed and we've now cut it in half and you can see that it's an ugly tumor This patient did very well. He had a papillary renal cell carcinoma That's not surprising given on the MRI. We didn't see a lot of blood flow on a for a clear cell tumor We probably would have seen much more flow He had negative margins. He was discharged home his third day after surgery and he's cancer free Well, that involved a big incision that involved our big clamp What can we do in a minimally invasive approach to still do nephron sparing surgery? So this is a picture from our operating room in the va With our older generation of robot And a patient getting prepared for surgery And so what I have here now is our first introduction to fluorescence imaging so These are pictures from the camera that goes through a small incision in the patient to look inside And as we're operating we use a light. We use the camera to be able to see This is very nice because we can drive the camera right up to where we're working. We can see well But sometimes we want even more information or we want to see things behind other structures Like where is the artery behind the fat? How can we get to that area safely without injuring something else? So I'm going to show you here a video of what is called the firefly technology Mouse working if this doesn't work. I can switch to the actual video itself. I apologize guys So what you see now is you see a view from inside the patient Those are our robotic instruments and we've dissected out the artery and the vein And we give a tracer the tracer is called icg And when we turn on a certain wavelength Of fluorescence imaging we get near infrared light back So in this case what you're going to see is that pulsating structure on the left Will light up quite brightly edited version I want to give you the shorter version And when we give this tracer and switch to that fluorescence light We'll be able to see exactly where the artery is. It'll light up for a very bright green And that way we know we can put a clamp only on that artery And block the blood flow to the whole kidney or to the part of the kidney where we're going to be working So this is the fancy clamp that we use. It's basically a glorified closed pin By placing that on the artery and blocking the flow of blood to the kidney. We can then safely cut into the kidney So here's some pictures of us starting to work on the kidney But the next question is we want to know exactly where the cancer is and one nice thing with this tracer is That the normal kidney lights up green and the tumors tend to not light up at all So we know when we switch from our regular picture to Our fluorescence picture and we see green that we know we're operating a normal kidney and that we're not leaving any cancer behind And here's the kid the cancer after it's been actually physically removed and you can see there's green on the surface So in other words, you took a normal Rim of tissue a margin And the rest of the tumor was black So similar i'm going to show you another video Where we did a similar thing but using this Technology instead of clamping the main artery we clamped a branch of the artery So that we could keep blood flow going to the rest of the kidney while we were working on the upper pole of the kidney So you can see again this bright green it lights up for the artery first After it circulates through the kidney it'll start to light up the vein We can switch back and forth between our regular view and our fluorescence view And then here's the tumor up at the top part of the kidney And we can actually look and show you that the kidney not so bright in the projection I'm sorry, but the kidney is lighting up green and the tumor is black in that fluorescence imaging So again as we cut through this tumor Remember we didn't block all of the blood supply to this kidney So it's a little bloodier than the first video I showed you but here We were willing to spend blood because we wanted to protect his kidney function And we can see that we're cutting in a green area So the way that I teach my resonance is green means go, you know, you're safe If you see green you can cut in that and know that you're not cutting the the cancer And again, we see green as we keep working to cut the tumor out and at the end of the case You'll see that we have this nice green surface on the tumor as we remove it And at the end of the case just like last time I can show the green on the surface of the kidney And I can inspect the margins I can know if I need to go back and take more tissue If we have any concern about whether or not we did a good cancer operation Well, this has been really easy to apply to Robotic surgery because we have a camera in place We have a light source inside the patient, but we haven't been able to do this as easily In open surgery But that's actually Beginning to change as well So these are pictures of another patient and this patient unfortunately had a small kidney tumor He had radio frequency ablation about five years before these pictures And then on his surveillance pictures, he was found to have three recurrences In that same kidney So he's an unfortunate person who's had multiple tumors in the same kidney And we used we brought in our own camera and our own infrared light source into our surgery So that we could do an open surgery and had this and get similar information as we showed you with the robotic pictures So here's a just a plain picture in the top left of his kidney and you can see that it's quite lumpy It's not a smooth surface that we normally see with a kidney This is from his scarring from his prior procedure and from his tumors and he has a couple cysts And I'm going to show you here on the video. Hopefully this one works That in the operating room. These are my hands here holding the kidney We haven't dissected the artery out now. We wanted to know exactly where it was So we're looking through fat and because this fluorescence imaging will penetrate through tissue We can actually see the artery Here before we could see it with the naked eye because it's behind other tissue And then in the operating room We can put a clamp on the portion of the kidney that we're going to work on So the rest of the kidney is still getting blood flow And we can look the bright white Is normal kidney the darker areas are either cysts or tumors that aren't lighting up And one of the nice things with this camera system is we can actually Colorize these pictures to make it a little easier for us to interpret so that the bright red Is intense fluorescent signals. So that's normal kidney And the areas that are a light blue or a dark blue are cold areas with less fluorescent signals So we can inspect the kidney have an idea before we even start to cut into the kidney where we think these cancers are And how we're going to do a good job to remove these three tumors that were all next to each other And at the end of the surgery, I'll show you this clip We've removed the cancer and so the area where we've cut through the kidney is bright red That's normal kidney We know that we remove the tumor and the rest of the base of the kidney looks good And then in a second here, I bring the tumor specimen into the field with the camera and I'll show it to you So that's the raw surface bright red normal kidney We know there's no tumor on that surface and as I rotated around you can see on the other side where the tumors were We don't get that same signal. So here we're using fluorescence Imaging in this one tracer called icg to try to help our ability to remove tumors Whether they're larger or smaller tumors in a partial nephrectomy setting and I I hopefully have convinced you that it's helpful for us To feel confident that we've done a good cancer operation One of the challenges is for pathology if we give them a piece of tissue they can try to look at it But their ideal setting is to use special stains to look at the tissue and those stains takes time So for us to get information from the pathologist about a biopsy in the operating room may take hours Or it may even be something that we won't have that information for a couple of days And so this is our way to try to speed up that process in real time and get a better understanding of where the cancer is So looking forward. I think dr. Mitra and alice will show you some of the very impressive Work on new markers that will hopefully show where kidney tumors are on imaging like regular CAT scans MRIs PET scans As well as other things that we can do to try to make sure that we're Giving our best treatments to patients with kidney cancer. Thank you very much