 All right. Thanks very much. Well, it's my pleasure to be here this morning. I really want to thank Dr. Tykoti for inviting me. And as always, when I come to this meeting, I see a lot of familiar faces in the crowd, and I'm very happy for that. So thank you for coming this morning. What I want to talk about is what has really happened with regard to removing renal cell carcinoma in kidneys by trying to spare as much kidney tissue as possible. And what I want to do is talk about what is partial nephrectomy? Why is that important for patients with renal cell carcinoma? Why do we do partial nephrectomy? And then talk about how we're now doing it using the robotic approach and why this is better for for patients with this condition. So a little bit about myself, just so you know, actually was at the University of Washington and did my training there. And then I was on faculty for about 10 years. When I started on faculty, there was no robot. There was all laparoscopic surgery. So I went to Germany to learn how to do laparoscopic surgery, came back and brought that back to the University of Washington and did all the first laparoscopic procedure for kidney cancer. And it was head of laparoscopic robotic surgery before I left to go to Swedish in 2005, where I started their program. We've had a very robust program there, do a lot of prostatectomies, but also a lot of partial nephrectomy. And they also trained fellows in robotic surgery as well. So I want to kind of briefly talk about some of the terminology I'm going to be using today because sometimes this is not always clear, but a radical nephrectomy is removing the entire kidney. And that's a very common operation. And that's usually done for very large tumors. A partial nephrectomy though is the idea of removing the tumor and sparing the kidney. And I'm going to show you why that's important for a lot of patients. Another term that you're going to hear is something called nephron sparing surgery. And that's essentially the same thing as a partial nephrectomy. Basically, when you're sparing nephrons, you're doing a partial nephrectomy. So how do we do this? Well, here's a little cartoon. There's a tumor on the kidney. That yellow thing is a tumor. What you do is you identify the tumor. You create a margin around that tumor because the idea here is when you remove the tumor, you want to remove the tumor and a small margin of normal kidney tissue to ensure that you have removed all the kidney tumor. So you do take a small portion of normal kidney tissue when you do a partial nephrectomy. In order to do a partial nephrectomy, you actually have to control the blood flow to the kidney. The kidney is very vascular. In fact, it gets a quarter of the blood flow every minute of your body. So these are extremely vascular organs. And if you cut into them and don't control blood flow, you lose a lot of blood and you can't see. So that compromises the margin. So we clamp the blood vessels temporarily with little clamps, which are called bulldog clamps. We cut out the tumor. So there's a defect left in the kidney when we remove the tumor. And then we sew that back together. And that's essentially a partial nephrectomy. And the idea here is to save as much kidney tissue as possible, but at the same time get rid of the cancer. And when you weigh getting rid of the cancer with sparing tissue, you always want to err on the side of getting rid of the cancer. So if there's ever a question, you take more tissue to try and have a negative margin. So why do we do partial nephrectomy? That's, I think, a very important question because for a surgeon, removing the entire kidney is much easier than doing a partial nephrectomy. It's technically much easier and it actually has sometimes fewer complications than doing a radical nephrectomy because you don't have a kidney left behind which can bleed and do things that you don't want them to do. So why would we go through all the trouble of a partial nephrectomy? These are guidelines created by two bodies. The AUA is the American Neurological Association and the EAU is the European Association of Urologists. And they've come out with recent recommendations that for tumors, four centimeters or less, so the first category, what we call a T1A tumor, partial nephrectomy should be considered the standard of care. And this is because there are significant advantages for patients when you leave their remaining kidney behind. And in fact, when you look at larger tumors, tumors between four and seven centimeters, partial nephrectomy should be considered for those patients if it's technically feasible, especially in patients who only have one kidney. So obviously if you have one kidney, you don't want to remove that kidney because then the patient's on dialysis and that's an extreme change in their lifestyle. The other reason we do partial nephrectomy is that one of the major questions that was raised is if you remove the tumor and leave that kidney behind, is there a chance that the cancer can come back? And if you look at comparing partial nephrectomy to radical nephrectomy for tumors four centimeters or less, the data overwhelmingly supports doing a partial nephrectomy. There is no increase in cancer recurrence by doing a partial nephrectomy. Another important thing to consider is that 20 to 30 percent of masses that are found randomly that are four centimeters or less are going to be benign tumors. So taking out an entire kidney for a benign tumor is not a good idea. So another reason to do partial nephrectomy in those patients. And then more importantly, the recent findings have shown that maintaining as much kidney tissue later in the life is extremely important for health. This is an important study published in the New England Journal of Medicine. The first author's go was actually showed that the more kidney tissue you have later in the life, the less cardiovascular events you have, cardiovascular events being heart attack, stroke, and other conditions that shorten your life. So it clearly shows that the more kidney tissue you have, the longer you're going to live. And this has been a major driver for doing something that's more technically challenging than doing a radical nephrectomy. So when we talk about nephron spring surgery or partial nephrectomy, there's basically three ways to do that. You can do open, which is the traditional. You can do it laparoscopically, which was an attempt to decrease the pain and the recovery of open partial nephrectomy and then more recently robotic. So open partial nephrectomy is really the standard. This is where the procedure started. This is how we develop the techniques we currently use. The nice thing about open partial nephrectomy is you can cool the kidney. Now, what does that mean? Well, as I showed you, when we put a clamp on that kidney to stop blood flow to the kidney, we're also stopping oxygen flow to the kidney. And that's not good for any organ. So if you can decrease the oxygen consumption by cooling the kidney, and that's what cooling does in all organs, you can actually have a healthier kidney after partial nephrectomy. The other reason that we people do partial nephrectomies open is that for patients with solitary kidneys. It's riskier. They only have one kidney, so you want to make sure you have everything in order when you do that. So some people will choose to do that as an open procedure. But the disadvantage really with open partial nephrectomy is really what patients go through. And these are some patients of mine. These are in the incisions we do. So there's that incision in the front, which you can go underneath the rib cage. And then there's a decision through the ribs on the side. What we call a flank incision. And neither of the incisions are fun. In fact, the flank incisions, even though it looks smaller, is probably the more painful than two because every time that patient takes a breath, those ribs are moving and they feel that incision. So despite the fact that open partial nephrectomy is truly the standard, this is a significant morbidity for the patient. And this can really affect how they recover. Laparoscopic partial nephrectomy was brought on to try and decrease the morbidity of open partial nephrectomy. But what was found, this is extremely difficult. When you remove that tumor and you have that opening there, you have to suture that together. And doing that laparoscopically involves two little sticks. And it's like working in a tissue box with two little toothpicks. And it's extremely difficult to suture. So it was something that really was only done at a few places in the country where there was experience with laparoscopic surgery. And it really was not something that was going to be widely available. So a lot of patients were getting radical nephrectomies because they could do that laparoscopically. So surgeons could do laparoscopic radical nephrectomy because it was easier, but they weren't offering partial nephrectomy. So that means a lot of kidneys are being taken out that didn't need to be taken out. Here's an example of laparoscopic partial nephrectomy in the complexity. This guy named Gil is a very famous guy. He's the guy that developed laparoscopic partial nephrectomy. He was at Cleveland Clinic. He's a guy that I colleague. I worked with him for many years. And he looked at his first 800 cases with laparoscopic partial nephrectomy. And he divided them based on the time that he did them. So the first group was this first 276 cases, the second group, and then the third group. And as I say in the third group, he did something called early unclamping. So what was recognized is that because this was such a difficult procedure, the kidney had to be clamped for a very long time because it took a long time to suture, took a long time to cut the tumor out. So tumors were being clamped for 40, 50 an hour. And the ideal time is really around 30 minutes. So he developed a technique where he took the clamps off early to try and decrease the time the kidney was not getting blood flow, what we call the ischemic time, the warm ischemia time. And here's what he found. The mean warm ischemia time for his first 565 patients was about 31 minutes. That's actually quite long. If you compare an open procedure, it's around 15 minutes or so. And then with early unclamping, he clearly could decrease the warm ischemia time, but there was a cost. His transfusion rate went back up to 15 percent. So when he was coming off early, there was more blood loss. So what this demonstrated is basically the best guy in the world took 30 minutes to do this and he was losing blood when he took the clamps off early. So this was a hard operation and it really was not going anywhere. I can testify to this when I was at the University of Washington. Here's my first 91 patients. And we started this experience in 1999. And you can see my warm ischemia time was 35 minutes. And you can see what time you get better, but it's still, so my first patients were 38 minutes, so my last 10 patients were 26 minutes, but still very difficult operation. So the question was, could we make laparoscopic parfaitomy less challenging? And there was, at the time that we started asking this question, there was a fair amount of experience with the robot using it for prostatectomy. So the DaVinci robot, which is very, people are very familiar with now, is basically a surgeon tool. It doesn't do anything. It's not automated. It's just a very complex scalpel, a very complex sewing machine. And you need a surgeon to do this and you need a surgeon with experience. But this is a multi-armed robot, a surgeon sits at a console, he's not at the bedside, and this robot has more degrees of freedom, more precision, and it actually has 3D vision. So 3D vision is really important because when we did the laparoscopically, we did this with 2D vision. So when you did it in 2D, you're looking at a television monitor and you have no depth, but when you have 3D, you actually have depth. And when you have depth, you can be more precise. And that's something that was a major advantage with the robot. It allowed us to see better. But not only that, it was magnified about 10 to 15 times. So I'm looking at a magnified view in HD and it's with depth. Now, HD sounds kind of cool on your television and it's kind of neat, but when it's, when you're using it medically, it's a great thing. I mean it, that ability to see, it's much more important than watching a movie, all right? So we really enjoy that and really, it really benefits our patients. This degree of freedom concept I think is really important because degrees of freedom are what you can do with an instrument in space. So that instrument on the left is a laparoscopic instrument. That's an old instrument and basically to give you an idea, when a laparoscopic instrument goes to the body, it goes in through what we call a port. And when you put that instrument in, you can go in and out, you can go up and down, you can go side to side and you can rotate. Those are four degrees of freedom. That's what we mean by moving an instrument four degrees of freedom. With the robot, we actually have two more additional degrees of freedom. And those are called pitch and yaw. So not just going up, but then bending your wrist one more degree of freedom up and not just going to the side but bending to the side with more degree of freedom. Because of this thing called the endo wrist, it actually allows us to do more complex maneuvers in tighter spaces and therefore this really facilitated suturing. So this really changed what we did laparoscopically. And the other thing about robotic surgery which is different than laparoscopic surgery is it's intuitive and that's the name of the company that makes the robot. But here's what i'm talking about. So when you put that trocar in through a trocar, when you want to go up, you move your hand down. And when you want to go down, you move your hand up. That's opposite of what you normally do. When you use a robot, when you move your hand up, the instrument goes up. When you want to go down, you move your hand down. So this is this is easier, I think, for surgeons to grasp in doing an opposite motion. Another feature of the robot is a safety feature called scaling. Scaling means that when you move your instrument on the outside of the body, it scales it down to make it smaller on the inside of the body. And this was a safety measure because that if you weren't at the bedside, the engineers or the robot thought, well I don't want somebody making big movements and hurting something that they can't see. When you scale movement down, though, that has another side benefit. And that is it gets rid of what all surgeons have and that's called a tremor, of what we call an intention tremor. And when you get rid of your intention tremor, you're more precise, you're more fluid, you look better. And so this robot really takes your motions and makes them better. So again, another advantage, probably a probably an unsung advantage is what this means for the surgeon. So when I do a surgery, I'm not standing up at attention for four to six hours and hurting my back and my shoulders. I'm sitting down. So I'm going to operate later into my career probably and I'm also more comfortable when I'm doing surgery. I'm not stressed and strained and worried about myself and I can completely focus on the patient. So that's the robot in a nutshell. It's a great tool. There's a lot of plus plus and minus, but it's changed surgery and it's not going away and it's a huge advance. Cost, irrespective of cost, this is something that's allowed us to do things that we couldn't do before the robot. So we start using the robot in 2006 for partial nephrectomy and I do two different approaches. I'm not going to go into the details of that for this talk, but we use both the transparently and retroparently of the approach. Now this was a study from a friend of mine named Sam Bayani at Wash U in St. Louis when he first started doing robotic surgery he compared them to laparoscopic surgery and what he found was this WIT means warm ischemia time. That's how long the kidney has clamped and almost immediately when he started on the robot he dropped his warm ischemia time six minutes and again this was comparing his his early robotic experience with a very mature laparoscopic experience. We found the same thing when we compared our retro peritoneal laparoscopic partial nephrectomy to robotic we found a 10 minute decline in warm ischemia time. That's significant. That's a big deal for the kidney and if we look further in our experience when I looked at my first 120 partial nephrectomies to my 91 laps again big difference in warm ischemia time almost 20 minute difference in warm ischemia time with experience. So the thing about the robot as you do more you get better and better and better and the warm ischemia time continues to drop. It doesn't it doesn't level off like Dr. Gill did you know at 576 patients he wasn't getting any better and he had to do something to make it better you get better with more experience. Here's an example who have the robot on the left the laparoscopic on the right I'm just showing you what it looks like side by side and look there's there's quite a bit of difference here between the fluidity of the motion and and you can see it's just an easier method of suturing we're bringing a kidney together in both of these these pictures there's a defect in the kidney and we're suturing it that white thing on the right is what we call a bolster and we don't have to use bolsters anymore because with the robot we can suture more precisely and you can see it's just a better way to move and it's much easier and it's much faster it's more it's more efficient so what can we do with the robot versus lap we can do larger tumors we can do larger patients which in our culture is very important now we can do more complex tumors we can do patients with solitary kidneys which was only done open before and we can do patients with bilateral tumors so let me show you some examples so here's a laparoscopic so there's clearly a difference in what we can do with the robot this laparoscopic tumor is a very easy tumor it's basically ready to fall off the kidney and that's what we could do laparoscopically but look at the tumor on the right that tumor is deep in the kidney that is a what we call a completely endophytic tumor that's a tumor that we could not see or even try and do laparoscopically so this is something we do routinely with the robot here's another example a cystic tumor so these are both cystic tumors but the cystic tumor on the left again is very exophytic almost off the kidney the one on the right is very complex very deep and again we can do this routinely with the robot here's another completely endophytic tumor this is on the left kidney and is there a pointer? so right here you can see there's the tumor right there completely covered by kidney tissue we would never ever attempt to do that laparoscopically and this would be a hard case to do open here's that Bosniak III cyst let me show you another case this is a patient with polycystic kidney disease you can see both kidneys have significant cysts and there's a tumor right in the center of the cysts very difficult tumor to do even open but robotically very straightforward tumor location can be very important hyalur tumors the tumors that are around the blood vessels like this one these are very difficult to do and this is on the what we call a posterior hyalur tumor very large again with the robot and a retroperitone approach we can approach this without difficulty here's a very large tumor this is a tumor that's greater than six centimeters right here warm ischemic time 24 minutes four percent loss in renal function with this approach so that's a very good recovery of renal function after partial refractomy here's a completely intra renal tumor this tumor is completely in the center of the kidney and it's very large this is it's almost like somebody described it as a baseball and a catcher's net I mean this is a tumor that even open this would be a radical nephrectomy this patient was very young she was 30 years old we did it as a robotic partial nephrectomy and as I mentioned before some of these are actually benign this is not a kidney cancer this is what's called an oncocytoma if we had taken out this entire kidney for an oncocytoma and a 32 year old female she has the rest of her life with one kidney and whatever can happen to that kidney might happen to that kidney so again we can do this now with the robot another complex tumor 7.2 centimeter hyaluronic tumor and a patient who's quite large this again very complex here's a patient with bilateral renal masses this is a patient I saw about three years ago and you can see there's a large tumor here on the right but that's not her biggest problem her biggest problem is on the left here a much larger tumor and these patients you have to do in what we call a staged fashion you can't do them both at the same time because if you operate on both kidneys at once then they don't really have any renal function because both kidneys have taken are recovering so we do these we did the right one first and it's a transparent neopartic nephrectomy and then the left one is a retroperitoneopartic nephrectomy and she's done well and she has both kidneys now here's a very easy tumor we could do laparoscopically but I'm showing you this is 5 centimeters of perinephric fat that's a big deal because that's very difficult to work in in somebody like that and this is a patient's outline here you can see this is a very obese patient but again robotically this is a very straightforward case BMI is 44 here's another patient we did robotically BMI of 54 so we can do larger patients now and it allows us to do more complex tumors so I want to show you a case of a patient with kidney cancer who I actually did he's kind of a frequent flyer in my practice I saw him in 2006 for that DDP stands for Da Vinci Prostatectomy he had prostate cancer we took out his prostate we were following him and then four years later he developed a tumor on his right kidney and it was a large tumor and it was a very central location so at the time we thought we should do this as a radical nephrectomy so we took out his entire right kidney and in retrospect I was thinking well I wish I would have done that as a partial nephrectomy and this is the situation you get into if you do a radical nephrectomy in somebody you don't know when they're going to come back down the road with a tumor in their other kidney and now you're operating on a solitary kidney and the stakes are much higher when you operate on a solitary kidney so at any rate we did a radical nephrectomy just like a lot of people would do and just like we normally do and then because it was a Furman 3 over 4 a little more complex he had T3A with invasion and sinus fat we did a scan at 6 months and here's a 6 month CT scan so these are all CT scans by the way that's the tumor and this is a solitary left kidney and here's a tumor and it's in a very unfortunate location this is right in the center of the kidney that's not something hanging off the side which would be a very nice easy parts nephrectomy this is something that's quite central and here's what it looks like what we call a coronal view this is another view on CT scan so you can see very much within the what we call the hylum of the kidney so it's 2.2 centimeters in a solitary left kidney his metastatic evaluation was negative and he has a baseline creatinine of 1.2 so we do this using a transparent needle approach with the robot forearms this is just the port configuration we used just to show you so it's basically five ports we have the robotic scope here my assistant's here left arm right arm and fourth arm so five small incisions now when we take the tumor out we put it in a bag and we extract it whole we don't break it up or morsel it because we want that information for pathologic analysis so what we'll do is we'll take one of these incisions and we'll make it a little bit larger for a 2 centimeter tumor you can get it out pretty much through a trocar some of these tumors we're taking out now they're 9 centimeters we have to make them a bit larger but where you put the incision and the fact that there's no retractor on that incision during the operation makes a big difference in their pain so they patients recovery even if you take out a large tumor they recover quite quickly when you've done this robotic approach so I'm going to show you the video of this case this is kind of a full portion of rectomy this is the artery and we're putting our clamp on the artery this is the vein the vein's larger and we're putting it on the vein so this has now we have complete blood control to the kidney and here's the tumor right here right in the central portion of the kidney and we take these robotic scissors as you can see this is using the robot and this we're cutting the tumor away as I showed you here's our margin of resection it's a very small margin because there's some important structures here and you can see you can see that's the most important thing you can see and the vision is amazing and that's what is such a great thing about robotic surgery is that we can do this now there's some very large blood vessels right at the base of where I'm removing so I'm being very careful not to hit that vein there and there's an artery right next to it so there's the tumor freed up and there's a blood vessel you see a little opening right there that's a blood vessel we're going to suture that shut so when we take the clamp off it's not going to bleed so we control this these blood vessels by suture and then shut so that when we take the clamps off we don't get any bleeding afterwards so you you can tie just like you would do with open surgery and then what we're going to do is we're going to close this defect now we have this opening in the kidney there's a little chunk out of the kidney we're going to close that back together so it doesn't bleed so this is using different types of suture there's a needle with suture there and and the robot allows us to bring this together very precisely and that's really what's nice about this so this is my assistant down here that's not a robot that's my assistant there's a human being on the end of that and he's doing a great job of giving me a view of that and what I you can see is I'm bringing the suture together it's it's coming together and I put a little clip on here this little thing's called a clip and that secures the suture and keeps it from sliding and by doing that it holds the suture in place and it brings the kidney back together and then I'm going to close the outer layer of this these are this is a different type of suture but the same idea here is that we put a clip on the suture to to secure it and you can see the tissue coming together quite nicely and this allows us to bring this together and not have to worry about bleeding afterwards the whole time we're doing this the kidney is clamped so we're going to take the clamps off now and this is what it looks like after we're off so no bleeding precisely brought back together and the kidney is nice and perfused I don't usually get applause in the OR so so the kidney was clamped for 21 minutes that's not very long that's good you can see the OR time is not very long it's just about three hours blood loss 200 cc is very acceptable for a partial rectomy this turned out to be a renal cell carcinoma 2.2 centimeters again firmin 3 over 4 the firmin grade is something that we look at very closely to tell how these tumors are going to act in the future with negative margins now this is what happened to the kidney function so the creatinine is a blood test you do that measures your kidney function and his baseline creatinine was 1.2 the higher the number the worse your kidney function the lower the number the better your kidney function you probably are all familiar with that technique that term so his creatinine went up to 1.45 on day 4 but by two weeks he was back down to his baseline and now he's actually down to 1.2 again so it worked quite nicely for him Hyler tumors with the robot are something that has been looked at in the literature these were tumors as I mentioned before that were just done with open surgery but this is a review by Craig Rogers and Henry Ford 11 patients he looked at tumors that were 3.8 centimeters in size on average and the mean warm ischemia time was 28 minutes now this is a again I hate to beat up on Dr. Gill but here he is again this is his series of 25 partial nephrectomies laparoscopically and you can see this is robotic with Rogers lap with Gill 28 versus 36 warm ischemia time length of stay a full day better with the robot and I will tell you in our experience our patients go home on average 1.2 days so the majority of our patients go home on day 1 now after partial nephrectomy and it's a big difference for their recovery this is our early experience what we call imperative indications for partial nephrectomy these are patients who have either solitary kidneys or bilateral tumors they can't get a radical nephrectomy so that imperative means they must have a partial nephrectomy so if you look at this approach the mean tumor size is 3 centimeters the collecting system is a term for the inner portion of the kidney that the urine collects in what we call the plumbing of the kidney when you enter the collecting system that's a deep tumor because that's the deepest portion of the kidney is the collecting system so we were these were deep tumors 60 percent of the time so primary kidneys the mean warmest kidney time was 13 minutes which is quite low the decrease in GFR was 9 minutes and the bilateral patients the mean warmest kidney time was 23 minutes and again a modest decrease in GFR GFR stands for glomerular filtration rate it's another measure of kidney function other than carotene it's actually supposed to be more accurate than carotene because it takes into account the patient's size and men and women have different renal function there were complications we had bleeding complication in one patient in a solitary kidney she lost 1600 cc's of blood her carotene actually went up quite high because of that blood loss but eventually her carotene came back down to baseline no patient required temporary dialysis which is a great thing normally when you work on a solitary kidney those patients go on dialysis temporarily and we didn't lose any kidneys which is another great thing we've also looked at our patients with large tumors tumors greater than four centimeters and we had two conversions to radical nephrectomy the mean tumor size was five centimeters 5.3 centimeters and we used both approaches and if you look at the two groups here so comparing the tumors less than four centimeters the greater than four centimeters we added the collecting system more often with the larger tumors the OR time is larger the blood loss is greater and the wheeling or scheming time is significantly greater but again only by two minutes so again very acceptable outcomes with very large tumors we had complications we had something called pseudo aneurysms which is where a blood vessel opens up after surgery and we treat that by asking the radiology doctors to go into their groin go up to the kidney and they could stop the bleeding of the blood vessel and then we had a couple other things but we had no urine leakage urine leakage is a very common thing after partial nephrectomy because when you cut into the kidney it can leak urine and we just don't see that robotically I'm going to end with one case where I think it's interesting for this group this is the patient I saw about five years ago he's 61 years old at the time he had a 2.4 centimeter tumor found in his left kidney and he had a creatinate of 1.8 so his creatinates that's a pretty high creatinine that means his renal function was compromised he's also large and he's been treated with his HIV and the CD4 count is very stable so that means he's actually doing quite well from an HIV standpoint so he's got a good survival he's not going to go away anytime soon this tumor was found actually in June of 2009 and it was 1 centimeter and so he was followed and then in March not to next year it actually doubled in size so less than a year later it doubled in size and then an ultrasound basically three months later was 2.4 centimeters so this thing was growing faster than it should and so therefore watching this was not necessarily the best idea so here's another CT scan and the axial view you're going to see this tumor right here now what's different about this tumor is it's not nice and round it's got a little tail right here I don't even appreciate that but when I saw this tumor it doesn't have a distinct border it's not a nice tumor that we would normally see there's no nice tumors but it's not nice and round and here's again the coronal view again not a very distinct tumor so we did this as a partial refractomy again using the robot transparent needle approach here's our trail cards I showed you earlier and it took us 12 minutes to get the tumor out and the pathology was quite unusual this is something called collecting duct carcinoma and Dr. Tycote is familiar with this this histologic variant but this is a very aggressive tumor collecting duct carcinoma has a poor response to chemotherapy they're highly aggressive and the mean survival is about 11 months on average so we were concerned about this we talked about this we presented with our tumor board we had a good margin he had no sign of venus act as he's elsewhere his renal function was somewhat compromised so a radical refractomy was not a good was something we could have done but it would have been a problem for him so we actually followed him and he's almost five years out now and he's NED normal renal function HIV status is stable so again this is a rare case where we got away with it but I think if you find these tumors early and they're offered nephron sparing surgery they can do well so in summary the robotic carcinofractomy facilitates nephron sparing surgery it avoids radical nephrectomy which I think is very important for patients who potentially need to be treated for renal cell carcinoma or for any other condition and it avoids open partial refractomy and again that really improves our patients lives thank you very much for your attention