 I'll go through in the next 20 minutes, hopefully a little bit less, over the really revolution that's occurred in our field, which has really been very exciting. Even about 14 years ago, we really only had two treatment options to offer, and of those two we really were not keen on offering partial removal of the kidney because we were concerned that maybe it wasn't as good of a cancer operation, and most of what we did was open removal of entire kidneys even for small tumors. But things have changed a lot, and we've learned a lot over the past several years, and while I don't have really the time to go over all of the information for you, what I'd like to do is give you a summary of where we stand now with some of these options. So they range from things such as active surveillance, which is completely non-invasive, probably the most kidney-sparing option there is, to ablative therapies, to partial removal by either open or robotic means, and robotic just being a way of doing it laparoscopically. And of course, there's still complete removal, which we can do either open or laparoscopically. I won't really talk about this, but I'll kind of start from here and then work our way through this series of options that are now available. So the question you might be asking is why do we want to go about saving kidneys? And the first concern really is one of a cancer one. And as it turns out for tumors less than four centimeters and probably for some up to even seven centimeters, the cancer outcomes are the same. It really makes no difference in terms of recurrence, whether you take out part of the kidney where the tumor is or take out the whole thing. The other fact is that there's a pretty good chance that it may be a benign tumor we're looking at. As many of you know, some of you may not, but scans really do not tell us if a tumor in the kidney is benign or malignant in most cases, not without getting some tissue. And what we've learned, for example, is that women in the 40th decade are twice as likely to have a benign diagnosis. So we were taking out all these kidneys for a long period of time to find a small benign tumor and we really didn't help that patient. More importantly, however, in relation to taking out entire kidneys when we don't need to, is this what we're learning about development of chronic kidney disease. And what we mean by kidney disease is not the cancer, but basically the kidney is not functioning well. And as it turns out there's this interplay between our hearts and our kidneys. If the heart doesn't function well, the kidneys don't function well, and if the kidney isn't functioning well, the heart may not function so well. So one can accelerate the other when they're diseased. And by taking out kidneys unnecessarily, those conditions can be worsened globally for the whole patient. These are some of the largest studies done in terms of just kidney disease. And what I want to highlight for you is this part of the graph, the purple and the green here. So age is down here and the percent of patients with chronic kidney disease. And one thing you can see is that as we get older, our risk of chronic kidney disease goes up pretty quickly in some cases. And especially if you add high blood pressure, diabetes, very common conditions these days, then that loss is actually even accelerated. Gender doesn't really make a difference, ethnicity doesn't make too much of a difference. And so now if we can combine those two, and we're just starting to be able to do that a little bit, this is one of our colleagues at Fox Chase Cancer Center. And what they did was they took a large population-based database and looked at the comorbidity. And this Charleston score is a way for us to measure how sick a patient is basically. A zero is they're not very sick. One or two means they have one or two medical conditions that are significant, high blood pressure, heart disease, for example, diabetes, or three or more. And then here is the size of their kidney tumor. The blue areas indicate the likelihood of death from any other cause but kidney cancer. And the red indicates the likelihood of death from kidney cancer. And you don't really have to be in medicine to see that there's a lot of blue. And so particularly when we look at the small renal tumors in those with high comorbidities, you can see that this red part is a fraction of the entire risk of death. Now obviously the ratio changes as the tumors get bigger and also for those who are much healthier. So we have to think about that. And one of the things that we talk about when we're trying to, when we're wringing our hands trying to decide what's the best option for a patient is, is this concept of competing risks. On one hand you have the tumor that's growing. We worry about it becoming incurable, metastasizing. And we also worry about it to a lesser degree but to some whether it's going to continue growing and destroying the kidney and losing function that way. And on the other hand you have the comorbidities, the medical conditions that the patient carries. And that bring a baseline risk to the patient which we cannot change much in terms of if we have to perform surgery and changing those risks of surgery. Those patients may be at risk of dying from those medical conditions like the graph I just showed you. And we may not alter that by removing something in the kidney. And also every time we touch the kidney whether we burn it, cut it, whatever, it's going to lose some function. So these are some of the competing risks that we have to consider. So that's just to kind of give you some baseline as we go about these options. So for a lot of these reasons, and the other one that I've essentially left out but fairly important is that what we've learned is that when tumors are small, particularly less than three centimeters, the likelihood of metastasis developing is exceedingly low. They also tend to grow very slowly. Now most of that information comes from the older population. And so we just have to be a little bit careful translating that to the younger population. But in general, that's a pattern that we see displayed and I'm going to show you some of that information a little bit later. But again, putting all that information together, what we've now have learned over many years and long follow-up on many, many patients is that partial removal really is the gold standard for small tumors. And even long-term, it's got 98% efficacy. So it's an excellent option and we can do it open or robotically, laparoscopically. Doing it laparoscopically is basically, we're doing the same operation but we can do it less invasively. So this is a somewhat older slide that shows all the different techniques we can use to remove part of the kidney. These days we don't even take out this much normal kidney. We cut it much closer to the tumor because we've also learned that size of the margin doesn't really make much difference. So I'll show you a couple of examples. This is a patient I treated many years ago, a poorly functioning left kidney. For reasons we don't understand why, you can see this right kidney is very big. It's compensated for the other one not working well. But there's also a big tumor right where all the vessels come into the kidney. So obviously this is their solitary functioning kidney and the question was what could we do with this? Can we preserve the kidney? And this is where open partial nephrectomy has a great role. We can do very precise dissection. Here's the tumor. Here's the margin. Here is the ureter, the tube carrying urine down and a lot of the blood vessels which we've already divided. And that's what the tumor removed. And we could do all this with the blood vessels clamped so that it doesn't bleed because the kidney gets a tremendous amount of blood from the heart. And as it turns out that tumor was benign. So imagine if someone had decided to remove that kidney and that patient was on dialysis. So and the kidney function was unchanged actually. So here's another case just to take it to another extreme of a 47-year-old with a 3.5 centimeter mass that was highly suspicious for renal cell carcinoma. This is considered by most to be not preservable. If you look at the scans very carefully sometimes you realize that it can be as long as you follow very precise anatomic boundaries. So what I have here in blue is showing you the outlines of the tumor inside the kidney. The yellow highlights where the urine is collecting which is where the contrast is concentrated now. There's another view tumor surrounded by the urinary collecting system. And this view shows the tumor with the arterial and venous anatomy. So fairly complex resection. This is what the kidney looks like. This is part of the tumor bulging through the fat that's inside the kidney. We've done an ultrasound so we can see inside really well during the ultrasound and see exactly where we want to resect. And this is where we start that very fine dissection. We've clamped the kidney now, you notice it looks pale compared to up here. We've clamped it and it's actually under ice. And then what we can do with very precise dissection is remove the entire tumor with essentially minimal to no margin in this case. Here we see blood vessels that we've tied off. And then after the kidney reperfuses nice and pink not bleeding functioning very well. And this is a classic renal cell carcinoma that was removed with negative margins. This is the CT scan six years later of that kidney, no recurrence. So some of these cases we can do robotically. And robotic again is a way of trying to do it laparoscopically. I used to do laparoscopic partial removal, very difficult to do, and physically quite honestly fairly exhausting. So this allows us to do it in a bit more easy fashion for the surgeon. I think it's probably somewhat of a better operation in that we can do that suturing of those fine structures much more quickly and much more precisely. And for those of you who aren't familiar, basically it's two parts. There's the surgeon console. So the surgeon is sitting slightly away from the patient. There's an assistant by the bedside and this is what does the work. This is the actual robot. But the surgeon basically is looking in these binoculars that gives him or her a 3D view and by putting the fingers in these master controls can manipulate the tips of the instruments attached to this machine. So just to kind of give you an idea of a fairly straightforward partial removal. Here what we're doing is clamping the artery to the left kidney. Here's the vein, we're going to put a clamp on that. This instrument right here is controlled by my assistant. Everything else that you see is controlled by the surgeon sitting at the console. Now here what I've done is left the fat on top of the tumor. You don't even really see the tumor. This is the fat that normally covers the kidney. We've left it on top of the tumor. We've stripped it off the rest of the kidney. I've already marked out where I want to cut. And now we're going to start cutting exactly in that area. And because there's no bleeding, every time I cut, I can make sure that I have normal tissue on both sides. And this is the foundation of this operation, is being able to ensure that we remove the entire tumor in a bloodless field. So I'm going to look at it, make sure it looks good, that looks great. And now what we've done though is cut across a bunch of blood vessels. And we're going to suture them. So this is the assistant suction. But these instruments and also the camera are controlled by the surgeon sitting at the console. And this type of suturing is what is fairly difficult to do laparoscopically, at least in terms of at least doing many and doing it quickly. And with experience, we've found that we can even approach very difficult tumors, what we call the hyalur tumors, like the other one I showed you that we did open several years ago. But ones that are in very difficult locations. And all of these we've been able to do robotically with the technique that we call micro dissection and for being able to preserve the kidneys. Here's another example of these. Actually, I'm going to stop it just to show you. Here's the tumor in the upper part of the left kidney. And this is the vein to the kidney. So the tumor is right below it. Here's an artery going up to immediately adjacent to the tumor. And then the tumors here and immediately adjacent to where the urine is collecting inside the kidney. Now, this video is sped up twice as fast so that it was minimally edited. So I apologize if it looks like it's all super fast, it's not. But basically what we have here, here's that vein. The branch of this vein that's going up to the tumor, the tumor is covered by the fat here. And by basically dividing these, we can continue to separate the tumor and at the same time start cutting off the blood supply to it. Once we've done enough of that, what we'll then do is again put a clamp on the artery, sometimes on the vein also. And then the rest of it, we'll just cut the rest of it by going through the rest of the parts of the normal kidney. So again, that's a big vein that we just went through. This is all normal kidney and some of the fat back there. So minimal blood loss, two-day hospitalization, fairly aggressive tumor actually, a type two papillary. The patient's done well at about a year and a half out. Here's another example just to show you something slightly different. Also left side, hyalur tumor. We're gonna do that dissection, go through these areas as much as we can. And then at some point we'll encounter some bleeding, stop what we're doing. Stop the, clamp the blood supply and do the rest of it with the blood supply clamped. But right now there's good profusion of the kidney as we do all this. Let's speed it up a little bit. Yeah, here we go. Gonna clamp the artery and resect the rest of it. The confidence in being able to know where to cut a lot of times is based on that ultrasound that we do, I haven't showed you. So that encompasses the options of a partial removal. The other option we have is a blade of therapy. We were really hot on this long time ago, not so much anymore. I'll tell you why in a minute. The idea with ablation is that you're gonna use energy to kill the tumor and not really do surgery to remove anything. Basically, every type of energy's been tried. Electrical, sound, lights. Lights and photodynamic therapy, radiation therapy. Really the two that are established and used are cryoblation, cold or radiofrequency ablation, which creates heat. So cryoblation is the oldest that's been around. It essentially freezes the tumor and the surrounding normal margin. And we can do that percutaneously right through the skin under CT scan or do it laparoscopically. And we can monitor the treatment really well, actually. So here's a case showing a tumor in the left kidney. One month after cryoblation, what we see is there's no perfusion at all. All the white stuff is where blood is flowing. There's no blood flowing to it. But it looks bigger. But that's because we treat a margin of tissue around it. And there's also some swelling. And at three and six months, you see continued shrinkage of the area. Radiofrequency ablation uses heat, electricity that generates radiofrequencies. And they heat the water in a particular geometry determined by the type of probe that's used. And here's some various ones. Here's an example showing a percutaneous treatment, patient under CT scan, has that treated. And again, we follow it with scans over time. Looks bigger at one month, but there's no blood supply to it. And then it shrinks over time. Now the downside with these, as I mentioned, is that they don't appear to be quite as good as surgery. So I showed you with partial removal, it's about 98% or better at greater than five years. At less than five years, these are about 88 to 90% efficacy, okay? So not bad, but not as good as surgery. And so what that means is that we reserve it for very specific types of populations. Patients who are elderly, high surgical risk. Because really, we do see very few complications with it. We do see some complications, but really very few and not major ones. So it's reserved for that type of population. And there's also, it's all, but my patients, it's a little bit like having a ball and chain a little bit. Because we have to do a biopsy beforehand, otherwise we'll never know what it was. We do have to do all the imaging at our center. Because it gets to be a little bit complicated if we try to do it elsewhere. And then sometimes we have to do biopsies afterward. Because we found out that the scans aren't perfect at being able to tell us with confidence whether there's residual cancer or not, as it turns out. So with surgery to remove a partial kidney, you don't really need to have all that intensity of follow-up. Now I want to spend a couple of minutes talking about biopsy, because there's always concerns and questions that come up with that. There's, you may read still on the internet and still even some textbooks about the results not being always reliable. That's actually changed a lot with modern techniques. And with the, but people who do the biopsy, the interventional radiologists, working much more closely with the pathologists. So we can actually get fairly reliable results in most cases these days. The other criticism of this is that it may not change the plan. And that's true, but actually now that we have more reliable results, sometimes it does change the plan. And I'll show you an example of that. Complication rate is very low. There is a bleeding risk, but if it happens, it's usually minor. Severe ones are really rare. One of the questions we get asked all the time is that we're going to spread cancer by putting a needle in it. This doesn't really seem to happen, again, because of the modern techniques that are employed. It adds cost. There's no question. It's a procedure. And it's about half a day to a day of your life. So in terms of these days, why do we do a biopsy traditionally and to this day, we do it whenever we're concerned that there's another cancer that may have spread to the kidney? Fairly uncommon. Dr. Wood actually has done some really nice work showing when we should be considering that. And there's also cases where lymphoma can occur. So there's no question about doing it in those cases. But anytime we're not removing the tumor, I recommend a biopsy when we do active surveillance, ablation, or as I mentioned, after ablation. Or whenever we think there's a suspicion of a benign mass and maybe that'll change the plan. I'll give you an example of that. Here's a 76-year-old patient, multiple medical comorbidities. Charleston score a 4, so fairly severe. Kidney function is terrible. It's not really a percent, but we could think of it as a percent if you want to. When you get to 15, you get to the risk of hemodialysis basically. And that just comes from heart disease and vascular disease. And this patient has a three-centimeter renal mass. So it's not a size we're completely comfortable watching over a period of time. So there are lots of competing risks here. Here's this MRI showing the tumor. I recommended a biopsy. It's done under MRI. Metal doesn't show under MRI, so you see a shadow. And as it turns out, the biopsy showed an oncocytoma, completely benign tumor. There's really no risk of this spreading and becoming curable. And what we decided to do was just surveillance so that we don't unnecessarily risk the patient's life with intervention that's not gonna change his life. So that brings us to this concept of active surveillance for my last couple of slides. Bottom line is that the majority of tumors under surveillance that are less than three centimeters in the elderly population grow very little. This is what's called a waterfall graft. Graph. And what it shows here is the change in tumor size over 30 months. Some tumors shrink. Most of them stay completely unchanged. And some grow, but very minimally. There's a few that act mischievously and those are the ones we need to watch for and that's why we need to keep doing scans on these and we can't just tell patients to forget about it. And there's other multiple studies over probably 1,000 now that show that overall it's a very slow growth rate in most of these. So to summarize a lot of the data that I haven't really shown you, just because a tumor grows doesn't tell you that it's cancer. Actually a lot of the benign ones can grow. The risk of metastatic disease is very low as I mentioned. People worry about losing an opportunity for intervention and that doesn't seem to be the case because usually they grow slowly enough that we can catch it and still do kidney sparing procedures. And it's a reasonable option for those who are elderly as I mentioned before. So to summarize, all of these options what they've brought us to today is the ability to really individualize patient care to a level and degree that we really weren't able to do that before. And a lot of this also applies actually to patients with metastatic disease. We don't really have time to get into that except maybe during the panel discussion. Thank you all.