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Minimal Invasive Renal Surgery

Minimal Invasive Renal Surgery. Dr Dennis Gyomber MB BS, FRACS (Urol) Urological Surgeon University of Melbourne, Department of Surgery, Austin Hospital Austin Hospital , Urology Unit MELBOURNE AUSTRALIA. Overview. Justification for partial nephrectomy Organ preservation

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Minimal Invasive Renal Surgery

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  1. Minimal Invasive Renal Surgery Dr Dennis Gyomber MB BS, FRACS (Urol) Urological Surgeon University of Melbourne, Department of Surgery, Austin Hospital Austin Hospital , Urology Unit MELBOURNE AUSTRALIA

  2. Overview • Justification for partial nephrectomy • Organ preservation • Overview of minimal invasive surgery

  3. Evolution of renal tumours • Physician tumour • Triad of pain, palpable mass and haematuria • Increased use of imaging • 70% of tumours are Asx and less than 4cm

  4. Organ preservation in oncolcogical surgery • Organ Preservation • Breast Cancer evolved from Radical Mastectomy to Lumpectomy • Has this concept been embraced for renal surgery ??

  5. Radical Nephrectomy vs Partial Nephrectomy • SEER database on renal surgery (24,535) • 16, 495 (67%) tumours were < 7cm • 90.3% were treated by Radical nephrectomy Adapted from Cloutier et al EAU 2009 • South Korean data • 252 (84.3%) were < 7cm • 89.3% underwent Radical Nephrectomy Adapted from Cho et al EAU 2009

  6. pT1a < 4cm pT1b > 4 < 7cm

  7. pT1a < 4cm

  8. pT1a < 4cm 51.8% treated with Radical Nephrectomy (Metro) and in Regional area 68.9%

  9. Myth • “Doctor, can I live with one Kidney?” • “Sure you can there are plenty of people who have donated a kidney and they are fine”. BUT Donor Nephrectomy does not equal Radical Nephrectomy

  10. Renal cancer patients have lower eGFR than doners Adapted from Paul Russo ASCO 2010 Paul Russo slide from ASCO 2010 Paul Russo slide from ASCO 2010 Paul Russo slide from ASCO 2010

  11. Donor

  12. Nephrectomy for cancer

  13. eGFR are independent risk factors for • Cardiovascular events • Increased frailty through bone and muscle disease • Decreased physical and cognitive function • Higher hospitalisation rates • Increased vulnerability to Hospital related complications i.e. infections, drugs, therapeutic and diagnostic procedures • Overall decreased quality of life.

  14. Importance of eGFR Thompson J Urol 2008

  15. MSKCC 2008 2991 patients <4cm in size (pT1a) • 81% - Radical Nephrectomy 19% - Partial Nephrectomy • Outcomes measures • cardiovascular events and death • 4 year follow up on multivariate analysis • RN associated with • 1.38 x increased overall mortality • 1.4 x greater number of cardiovascular events

  16. MSKCC data 3 year probability of developing CRI based on the type of surgery performed Huang et al Lancet Onol 2006

  17. PN preserves eGFR

  18. Treatment • Open Surgery

  19. Complications of Treatment Incisional hernia post Left Radical Nephrectomy

  20. Minimal Invasive Treatments • Cryoablation • Radiofrequency • Radiosurgery (Cyberknife) • Laparoscopic & Robotic

  21. Cryoablation • Technique • Probes inserted into tumour • Liquid argon or nitrogen • Creates an ice ball • Cytocidal effect • coagulative necrosis and fibrosis • Membrane destruction • Intracellular dehydration • Reperfusion injury on thawing caused by free radicals

  22. Radiofrequency • Technique • Probes (needle electrodes) inserted into tumour • Cytocidal affect • Radio waves converted to heat causing coagulative necrosis & fibrosis • Aiming for temperatures 50-100 deg • Heat sink • Large vessels draw the heat away means inefficient cell kill • Collecting system can be damaged

  23. Radiosurgery: Cyberknife • CyberKnife radiosurgery device using a linear accelerator mounted on a robotic arm. • Delivers high-dose radiation into up to 1200 beams. • Beams are focused onto the lesion, sparing surrounding tissue • 16 pig kidneys treated single doses of 24–40 Gy • 8 wk after treatment lesions showed complete fibrosis.

  24. Indications • Cryoablation and Radiofrequency ablation • Ideal for small < 3cm, solid lesions in high operative risk patients • Multiple, bilateral RCC or solitary kidney Not for • Central or hilar tumours • Tumours > 5cm • Radiosurgery – Experimental Inconsistent tumour destruction

  25. Laparoscopic vs Open Benefits include • Less blood loss • Shorter length of stay • Quicker recovery • Similar oncological outcomes to open J Urol 174 Oct 2005

  26. Glubran

  27. Glubran

  28. Glubran

  29. Summary • Most tumours are Asx and small (4cm or less) • Ideal for renal preservation surgery • Maintaining eGFR is important for cardiovascular health • We now have the skills to offer organ preservation using minimal invasive techniques

  30. Thank You Dr Dennis Gyomber MB BS, FRACS (Urol) Urological Surgeon University of Melbourne, Department of Surgery, Austin Hospital Austin Hospital , Urology Unit MELBOURNE AUSTRALIA

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