The Use of Robotics/Minimally Invasive Surgery for Urologic Cancers

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features the
00:11 --> 00:13latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation about
00:21 --> 00:23the use of robotics and minimally
00:23 --> 00:24invasive surgery for urologic
00:24 --> 00:27cancers with Doctor Joseph Brito.
00:27 --> 00:29Dr. Brito is an assistant professor
00:29 --> 00:30of medicine and urology at the
00:30 --> 00:33Yale School of Medicine, where Dr.
00:33 --> 00:36Chagpar is a professor of surgical oncology.
00:37 --> 00:39Let's start off by you telling us
00:39 --> 00:41a little bit more about yourself
00:41 --> 00:43and what it is you do.
00:44 --> 00:47I'm a urologist and urologic oncologist
00:47 --> 00:48focusing on the treatment
00:48 --> 00:50of cancers of the kidney,
00:50 --> 00:51bladder, and prostate.
00:51 --> 00:54We also take care of testicular
00:54 --> 00:57cancer and this is
00:57 --> 00:58kidney cancer awareness month,
00:58 --> 01:01so I am happy to be here and discuss
01:01 --> 01:02kidney cancer specifically today.
01:03 --> 01:06So you know, when we think about
01:06 --> 01:07minimally invasive surgery,
01:07 --> 01:10I think a lot of people by now have gotten
01:10 --> 01:13used to the concept of laparoscopic surgery,
01:13 --> 01:17the concept of taking out gallbladders
01:17 --> 01:21and appendixes through little tiny incisions.
01:21 --> 01:24The concept of robotic surgery
01:24 --> 01:27has now taken off as well,
01:27 --> 01:31in large part in urology.
01:31 --> 01:34But can you tell our audience a little
01:34 --> 01:37bit more about what robotic surgery is,
01:37 --> 01:40how it's the same or different
01:40 --> 01:42from laparoscopic surgery and
01:42 --> 01:45what exactly you use it for,
01:45 --> 01:47particularly in urology?
01:47 --> 01:49Sure. I'm actually really glad
01:49 --> 01:51you asked this question because
01:51 --> 01:53I feel like I spend a decent amount
01:53 --> 01:54of my day explaining to patients
01:54 --> 01:57what the robot does and doesn't do.
01:57 --> 01:59So laparoscopy, as you said,
01:59 --> 02:00is essentially making small
02:00 --> 02:03incisions in the abdomen and then
02:03 --> 02:04through those incisions filling
02:04 --> 02:07the abdominal cavity with air.
02:07 --> 02:09So essentially you're creating a Dome,
02:09 --> 02:11and that allows us to do surgery
02:11 --> 02:12inside the abdominal cavity
02:12 --> 02:14without making a big incision,
02:14 --> 02:16which is how things used to be done.
02:16 --> 02:19The robot is laparoscopic surgery.
02:19 --> 02:21It's just a tool,
02:21 --> 02:24so it holds the instruments for us.
02:24 --> 02:26It allows us to make fine movements,
02:26 --> 02:28it allows us to work in spaces that
02:28 --> 02:30would otherwise be difficult for human
02:30 --> 02:33hands or in some cases even laparoscopic
02:33 --> 02:35instruments to gain access to.
02:35 --> 02:37I think sometimes there's a common
02:37 --> 02:39misconception that the robot does the
02:39 --> 02:41surgery and we just kind of
02:41 --> 02:43turn it on and go have coffee or something.
02:44 --> 02:45That's not the way it works.
02:46 --> 02:49It's a two-part operation basically.
02:49 --> 02:50So you have a patient of course
02:50 --> 02:52on the operating room table,
02:52 --> 02:53there's the robot which is
02:53 --> 02:54holding the instruments.
02:54 --> 02:57There's an assistant at the bedside
02:57 --> 02:59who's putting the instruments in and out
02:59 --> 03:02and maybe running a suction device
03:02 --> 03:03or helping
03:03 --> 03:05with various aspects of the case at
03:05 --> 03:07the bedside and then the surgeon is
03:07 --> 03:09in the same room generally,
03:09 --> 03:11maybe four or five feet off to the side,
03:11 --> 03:13there's a second console that
03:13 --> 03:15the surgeon sits at and we're
03:15 --> 03:17operating those robotic arms.
03:17 --> 03:19So that's sort of the nuts
03:19 --> 03:21and bolts of robotic surgery.
03:21 --> 03:23In terms of the benefits,
03:23 --> 03:24I mean many of the benefits we
03:24 --> 03:25saw with laparoscopy are what
03:25 --> 03:27we're seeing with robotics.
03:27 --> 03:29Generally you're talking about less
03:29 --> 03:31operative pain, faster recovery,
03:31 --> 03:35less blood loss, shorter hospital stays.
03:35 --> 03:37And in cancer specifically,
03:37 --> 03:38generally we're preserving
03:38 --> 03:40the oncologic benefits,
03:40 --> 03:41the cancer benefits of the
03:41 --> 03:43operation with those additional
03:43 --> 03:45benefits of laparoscopic approach.
03:46 --> 03:49And so when we think about
03:49 --> 03:51robotics versus laparoscopic surgery,
03:51 --> 03:53some of the advantages that you mentioned,
03:53 --> 03:57I mean you get a little bit more dexterity
03:57 --> 03:59with using the robot arms instead
03:59 --> 04:02of the the standard laparoscopic
04:02 --> 04:06instruments.
04:06 --> 04:08Have there been studies that have really
04:08 --> 04:11looked at tangible differences in terms
04:11 --> 04:13of all of the things you mentioned,
04:13 --> 04:16blood loss, hospital length of stay,
04:16 --> 04:19operative, time cost comparing
04:19 --> 04:22laparoscopic versus robotic surgery?
04:23 --> 04:24Yeah. So it's a great question.
04:24 --> 04:27I mean, most of the studies that are done
04:27 --> 04:30are comparing robotic to open.
04:30 --> 04:33So what I was just mentioning in terms
04:33 --> 04:35of blood loss, hospital stay, pain,
04:35 --> 04:37I mean there's no question that
04:37 --> 04:39those are generally much better for
04:39 --> 04:41a laparoscopic or robotic approach.
04:41 --> 04:43When you're comparing laparoscopic and
04:43 --> 04:46robotic directly, for the most part,
04:46 --> 04:48it depends on the operation,
04:48 --> 04:51so for instance in prostatectomy.
04:51 --> 04:53I think most people would agree
04:53 --> 04:54that a robotic prostatectomy is
04:54 --> 04:56really the gold standard and that's
04:56 --> 04:58even over laparoscopy now.
04:58 --> 04:59There's probably several reasons for that.
04:59 --> 05:01Some of its training,
05:01 --> 05:02some of it's just learning curve,
05:02 --> 05:05which tends to be a little
05:05 --> 05:06better with the robot.
05:06 --> 05:08Cost is generally higher when you're
05:08 --> 05:10comparing laparoscopy to robotics,
05:10 --> 05:12although you know it depends on if
05:12 --> 05:14you're looking at direct operative costs,
05:14 --> 05:16if you're looking at longer term costs,
05:16 --> 05:19like how the impact is on things like
05:19 --> 05:22urinary function, return to continent,
05:22 --> 05:24sexual function specific to prostate,
05:24 --> 05:27some of that cost might wash
05:27 --> 05:29out in the kidney specifically.
05:29 --> 05:31Generally we're using the robot
05:31 --> 05:33for either radical nephrectomy,
05:33 --> 05:35which is removal of the whole
05:35 --> 05:36kidney or partial nephrectomy,
05:36 --> 05:39which is removal of a portion,
05:39 --> 05:41specifically the tumor usually.
05:41 --> 05:43The real benefit there, robotically,
05:43 --> 05:44at least in my opinion,
05:44 --> 05:45is again that dexterity.
05:45 --> 05:47So for instance,
05:47 --> 05:48when you're doing a partial nephrectomy
05:48 --> 05:51and we're removing a tumor off the kidney,
05:51 --> 05:53we then have to close that defect up,
05:53 --> 05:55and that's generally done with
05:55 --> 05:57stitches and stitching with the robot
05:57 --> 06:00I think most would agree is easier,
06:00 --> 06:02perhaps finer,
06:02 --> 06:04and I would say probably a shorter
06:04 --> 06:06learning curve in terms of mastery
06:06 --> 06:08than it would be with a
06:08 --> 06:09laparoscopic approach alone.
06:11 --> 06:13And so you know, I think many
06:13 --> 06:16people have heard about the
06:16 --> 06:18robotic approach for prostate,
06:18 --> 06:20less so for kidney.
06:24 --> 06:27I mean is it something that people
06:27 --> 06:29are being offered as standard
06:29 --> 06:31practice in terms of having a
06:31 --> 06:35robotic nephrectomy?
06:35 --> 06:37Absolutely, when it comes to radical nephrectomy,
06:37 --> 06:40robotic and laparoscopic approaches,
06:40 --> 06:42are basically equivalent in
06:42 --> 06:45terms of cancer control and the actual
06:45 --> 06:48outcome you're getting from the surgery.
06:48 --> 06:50There are plenty of surgeons out
06:50 --> 06:51there that are doing laparoscopic
06:51 --> 06:53partial nephrectomy as well.
06:53 --> 06:55But again, the robot makes that
06:55 --> 06:57approach I think a lot more palatable.
06:57 --> 06:59There are benefits at the
06:59 --> 07:01surgeon level to robotics as well,
07:01 --> 07:02things like
07:02 --> 07:04when you're standing there at the
07:04 --> 07:06bedside doing laparoscopic surgery
07:06 --> 07:07it can be straining on the neck,
07:07 --> 07:08and it can be straining on the back.
07:08 --> 07:09The robot takes a lot of that
07:09 --> 07:11out of it for the surgeon.
07:13 --> 07:15When it comes to availability,
07:15 --> 07:17I think robotics in general has
07:17 --> 07:19really permeated into the community,
07:19 --> 07:21so I spend the majority of my
07:21 --> 07:23clinical time out in New London
07:23 --> 07:24at Lawrence Memorial Hospital.
07:24 --> 07:26We've had a robot here
07:26 --> 07:27ever since I've been here,
07:27 --> 07:29and I think many community sites are similar.
07:29 --> 07:32So patients are certainly being offered
07:32 --> 07:35robotic approaches for kidney surgery.
07:35 --> 07:37Probably in many instances more than
07:37 --> 07:39they're being operated or offered
07:39 --> 07:41a laparoscopic only approach.
07:42 --> 07:45And so that brings me to the
07:45 --> 07:47next question which is you did mention
07:47 --> 07:49that there's a difference in cost.
07:49 --> 07:53Is that difference passed on to the patients,
07:53 --> 07:55I mean when they get their
07:55 --> 07:59bill for their copay or
07:59 --> 08:02whatever it is, is it higher?
08:02 --> 08:04Are they paying
08:04 --> 08:06for the robotic approach and is that
08:06 --> 08:08something that many patients are
08:08 --> 08:10taking into consideration when choosing
08:10 --> 08:13whether to go laparoscopic or robotic
08:13 --> 08:15or are patients even given the choice?
08:16 --> 08:18That's a really good question.
08:18 --> 08:19You know, I don't know the
08:19 --> 08:20answer to tell you the truth.
08:20 --> 08:23I think that it depends on a lot
08:23 --> 08:26of factors which I don't have
08:26 --> 08:28granular data on. Things like
08:28 --> 08:29the various insurance company,
08:29 --> 08:32how the hospital manages various
08:32 --> 08:35costs and passes that on to the patient.
08:35 --> 08:37There is probably no question
08:37 --> 08:40that a laparoscopic only radical
08:40 --> 08:42nephrectomy for instance may be
08:42 --> 08:45cheaper at the surgical level
08:45 --> 08:48than it is for a robotic approach.
08:49 --> 08:51But again, I can't tell you specifically how
08:51 --> 08:53that gets passed on to the patient.
08:53 --> 08:55Like many things in medicine,
08:55 --> 08:57it probably depends on your surgeon's
08:57 --> 08:59level of comfort with the various
08:59 --> 09:00approach or various surgery,
09:00 --> 09:03what technology they have available.
09:03 --> 09:04You know some of this is patient
09:04 --> 09:05driven as well.
09:05 --> 09:07I think a lot of patients come to
09:07 --> 09:09see me and I think a lot of surgeons
09:09 --> 09:11because they're facile with the
09:11 --> 09:12robot and they've heard about the
09:12 --> 09:14benefits of robotics and so they're
09:14 --> 09:16really looking for that approach.
09:17 --> 09:21You mentioned when we were talking
09:21 --> 09:24earlier about prostate cancer that
09:24 --> 09:27while there may be an increased cost
09:27 --> 09:29to the operation itself that there
09:29 --> 09:32may be a reduced cost long term in
09:32 --> 09:36terms of a reduction in side effects.
09:36 --> 09:39So you know issues with urinary incontinence
09:39 --> 09:43or stream or sexual function etcetera.
09:43 --> 09:47Are there data to to support the idea that
09:47 --> 09:51outcomes are better with robotic surgery
09:51 --> 09:53versus laparoscopic surgery in terms of
09:53 --> 09:55preserving nerve function, for example?
09:56 --> 09:59So for prostate certainly comparing
09:59 --> 10:02open and robotic absolutely,
10:02 --> 10:07I mean very clear benefits in terms of
10:07 --> 10:10sexual function probably as well.
10:10 --> 10:12You know it's a little
10:12 --> 10:13difficult to interpret
10:13 --> 10:16the laparoscopic versus robotic data for prostate,
10:16 --> 10:18because not a lot of people
10:18 --> 10:19are doing laparoscopic,
10:19 --> 10:22pure laparoscopic prostatectomy.
10:22 --> 10:24It's just something that's very
10:24 --> 10:25technically challenging and
10:25 --> 10:28the robot takes a lot of those
10:28 --> 10:30technical challenges out of the way.
10:30 --> 10:32But absolutely comparing urinary
10:32 --> 10:34function and probably sexual
10:34 --> 10:36function in terms of our ability
10:36 --> 10:38to accurately spare nerves
10:38 --> 10:40and really do the finer
10:40 --> 10:41aspects of that operation,
10:41 --> 10:43which really is a delicate surgery,
10:43 --> 10:45especially when it comes to the
10:45 --> 10:46reconstruction portion of it.
10:47 --> 10:49That really is where the robot shines
10:49 --> 10:52in such a sort of narrow anatomic space.
10:53 --> 10:55And what about for kidney cancers?
10:55 --> 10:57Do we see the same kinds of things there?
10:58 --> 10:59Yeah. So I mean,
10:59 --> 11:01certainly different concerns, right?
11:01 --> 11:03When you're talking about kidney surgery,
11:03 --> 11:05we're not talking about urinary
11:05 --> 11:07continence or sexual function.
11:07 --> 11:09But I can say certainly in my hands
11:09 --> 11:12and I think in a lot of surgeons hands
11:12 --> 11:15specifically for a partial nephrectomy,
11:15 --> 11:17doing that reconstruction especially
11:17 --> 11:21if it's in a difficult part of the kidney,
11:21 --> 11:23it's very challenging to do some of
11:23 --> 11:25the finer aspects of that operation,
11:25 --> 11:26pure laparoscopic.
11:26 --> 11:29It can certainly be done open and
11:29 --> 11:31probably with the same efficacy open,
11:31 --> 11:33but then you're talking about
11:33 --> 11:34a fairly large incision,
11:34 --> 11:36which for the kidney is either a
11:36 --> 11:37big incision under the rib cage,
11:37 --> 11:39which can be fairly painful
11:39 --> 11:40during the recovery process,
11:40 --> 11:42or a big incision in the midline.
11:42 --> 11:45So again, in those cases you're looking at,
11:45 --> 11:47especially if you're doing that surgery,
11:47 --> 11:49open, a longer hospital
11:49 --> 11:51stay, more postoperative
11:51 --> 11:52pain medication requirements,
11:52 --> 11:53narcotic use,
11:53 --> 11:55and then you're dealing with things like
11:55 --> 11:57constipation and wound infection issues.
11:57 --> 11:59Socwhen it comes to some
11:59 --> 12:01of those more complex cases,
12:01 --> 12:02the robot is a major help.
12:04 --> 12:06Talk a little bit about training.
12:06 --> 12:09I mean when you were describing
12:09 --> 12:12how a robotic case occurs earlier
12:12 --> 12:17you mentioned that the patient
12:17 --> 12:19is on the operating room table.
12:19 --> 12:21There might be an assistant
12:21 --> 12:23at the bedside who's kind of
12:23 --> 12:24changing instruments in and out,
12:24 --> 12:27but the surgeon really sits at a console and
12:27 --> 12:30manages the arms of the robot.
12:30 --> 12:32So if you're a trainee,
12:32 --> 12:35an up and coming surgeon,
12:35 --> 12:38how do you learn how to work the robot?
12:38 --> 12:40It's a great question and
12:40 --> 12:43actually it's somewhat hotly debated
12:43 --> 12:45and there's a lot of interest
12:45 --> 12:47in how residents and
12:47 --> 12:49future surgeons should be trained.
12:49 --> 12:51Different institutions do it different ways.
12:51 --> 12:54I can tell you when I was a resident we
12:54 --> 12:57had a protocol where as the resident,
12:57 --> 12:58your job for
12:58 --> 13:02X number of cases was to be at the bedside,
13:02 --> 13:03being that bedside assistant.
13:03 --> 13:05So you knew the steps of the case,
13:05 --> 13:06you knew what instruments to put in and out,
13:07 --> 13:09at which times and you really learned
13:09 --> 13:10the operation.
13:10 --> 13:11And of course you were watching
13:11 --> 13:12the whole surgery as well.
13:14 --> 13:16There's no real standardized way
13:16 --> 13:18that residencies are doing it
13:18 --> 13:19across the United States for instance.
13:19 --> 13:22But again, there is a lot of
13:22 --> 13:25exposure to that I think broadly
13:25 --> 13:27in urology residency these days.
13:27 --> 13:30And as the robot permeates more
13:30 --> 13:32out into these community
13:32 --> 13:34hospitals and you have more robots
13:34 --> 13:35at the major medical centers,
13:35 --> 13:37there's just a lot more exposure to it.
13:37 --> 13:40So when residents are graduating now,
13:40 --> 13:42for the most part, they've seen
13:42 --> 13:43hundreds probably of
13:43 --> 13:45robotic procedures and many will
13:45 --> 13:47then go on to do if they want to
13:47 --> 13:49focus in oncology or in robotics,
13:49 --> 13:52they'll go on to do a specific fellowship
13:52 --> 13:54in minimally invasive surgery,
13:54 --> 13:54robotic surgery.
13:56 --> 13:58We'll pick up the
13:58 --> 14:01conversation with that right after we
14:01 --> 14:03take a short break for a medical minute.
14:03 --> 14:05Please stay tuned to learn more about
14:05 --> 14:07the use of robotics and minimally
14:07 --> 14:09invasive surgery for urologic cancers
14:09 --> 14:12with my guest, Dr. Joseph Brito.
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14:30 --> 14:32Genetic testing can be useful for people
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14:36 --> 14:38Genetic counseling is a process
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15:28 --> 15:31You're listening to Connecticut Public Radio.
15:32 --> 15:34Welcome back to Yale Cancer Answers.
15:34 --> 15:35This is Doctor Anees Chagpar,
15:35 --> 15:37and I'm joined tonight by my guest,
15:37 --> 15:39Doctor Joseph Brito.
15:39 --> 15:41We're talking about the use of
15:41 --> 15:43robotics and minimally invasive
15:43 --> 15:44surgery for urologic cancers.
15:44 --> 15:47And Joseph, right before the break
15:47 --> 15:51you were talking about training
15:51 --> 15:54of residents and fellows and
15:54 --> 15:56you had mentioned that
15:56 --> 15:58while there is no standardization
15:58 --> 16:00for this training, frequently
16:00 --> 16:03the resident will be at the
16:03 --> 16:05bedside putting instruments in and out.
16:05 --> 16:08They'll get to watch the the robotic surgery,
16:08 --> 16:11but there's a big difference between
16:11 --> 16:13watching the surgery and actually
16:13 --> 16:15doing the surgery at the console.
16:15 --> 16:19So can you talk a little bit about how
16:19 --> 16:21trainees actually gain that facility
16:21 --> 16:25with using the robot at the console?
16:25 --> 16:28Because it would seem that that's really
16:28 --> 16:30a major advantage of robotic
16:30 --> 16:33surgery is the facility that the
16:33 --> 16:35surgeon has with using the robot
16:35 --> 16:37and the dexterity of its arms.
16:37 --> 16:38Yeah, of course.
16:38 --> 16:41I mean, with any surgical approach,
16:41 --> 16:42surgical instrument, the surgeon
16:42 --> 16:44needs to have familiarity with it,
16:44 --> 16:47be able to use it safely and
16:47 --> 16:49with the robot at most
16:49 --> 16:50teaching institutions, there is
16:50 --> 16:52basically a trainer console.
16:52 --> 16:55So it's almost in some ways like a
16:55 --> 16:58driver's Ed setup where you have the
16:58 --> 17:00surgeon that has ultimate control over
17:00 --> 17:02the robot and then you have a trainee
17:02 --> 17:04who's sitting at another console,
17:04 --> 17:05usually next to or directly
17:05 --> 17:07across from the surgeon.
17:07 --> 17:09So you know the surgeon can
17:09 --> 17:11essentially control the robot
17:11 --> 17:13over to the resident or trainee.
17:13 --> 17:16They can operate for a minute
17:16 --> 17:17or a few minutes,
17:17 --> 17:18the surgeon can sort of watch
17:18 --> 17:20what they're doing and then if
17:20 --> 17:21something is happening that
17:21 --> 17:22they don't like or the surgeons
17:22 --> 17:24ready to take control back,
17:24 --> 17:25they can just go ahead and do that.
17:25 --> 17:28So it gives the resident
17:28 --> 17:30an opportunity to gain some skill,
17:30 --> 17:35learn the robot while under a pretty
17:35 --> 17:37closely supervised environment.
17:37 --> 17:39The other thing I think is important
17:39 --> 17:41to note is just that whenever you're
17:41 --> 17:43doing a laparoscopic or robotic surgery,
17:43 --> 17:45everything that's happening is being
17:45 --> 17:48broadcast onto essentially a big TV
17:48 --> 17:50screen in the operating room and so
17:51 --> 17:52not just the surgeon and the
17:52 --> 17:53assistant can see what's happening,
17:53 --> 17:54but really everyone in the
17:54 --> 17:56operating room can see, scrub nurses,
17:56 --> 17:59the scrub tech, the anesthesia team.
17:59 --> 18:01So in a lot of ways the resident
18:01 --> 18:03and the surgeon really are more
18:03 --> 18:05closely watched and observed than
18:05 --> 18:07they would be in an open surgery.
18:08 --> 18:10Let's take a step back for a moment
18:10 --> 18:12as you had mentioned earlier,
18:12 --> 18:15this is kidney cancer
18:15 --> 18:17awareness month, so let's talk a
18:17 --> 18:19little bit about kidney cancer.
18:19 --> 18:23We had talked a little bit about
18:23 --> 18:25surgery and you had mentioned
18:25 --> 18:27that for some patients they
18:27 --> 18:30require a total nephrectomy,
18:30 --> 18:33others a partial nephrectomy.
18:33 --> 18:35Talk a little bit about how those
18:35 --> 18:39decisions are made and kind of situate
18:39 --> 18:42the treatment of kidney cancer in
18:42 --> 18:43a multidisciplinary context,
18:44 --> 18:47Probably first it is important to
18:47 --> 18:49differentiate between cancers of the
18:49 --> 18:52cortex or outer portion of the kidney,
18:52 --> 18:54the sort of meaty part of the
18:54 --> 18:56kidney and cancers of the lining
18:56 --> 18:58or central part of the kidney.
19:01 --> 19:03So this is really the urinary
19:03 --> 19:05drainage part of the kidney.
19:05 --> 19:07There are tumors that are
19:07 --> 19:08both types of cancer,
19:08 --> 19:09but different types and really
19:09 --> 19:11managed in very different ways.
19:11 --> 19:13So when we're talking about
19:13 --> 19:14removing just the kidney or
19:14 --> 19:16removing just a part of the kidney,
19:16 --> 19:18usually we're talking
19:18 --> 19:20about those cortical renal,
19:20 --> 19:22usually renal cell carcinoma being
19:22 --> 19:25the most common type renal tumors.
19:25 --> 19:26When we're talking about the
19:26 --> 19:27lining of the kidney,
19:28 --> 19:30that's a different type of
19:30 --> 19:31kidney cancer altogether,
19:31 --> 19:33what we call urothelial carcinoma
19:33 --> 19:35or it used to be referred to as
19:35 --> 19:36transitional cell carcinoma.
19:36 --> 19:38It's much more akin to bladder cancer
19:38 --> 19:39really than it is to kidney cancer
19:39 --> 19:41because the cell type that lines the
19:41 --> 19:43renal pelvis and the ureter is the
19:43 --> 19:46same type of cell that lines the bladder.
19:46 --> 19:48And so our approach to those
19:48 --> 19:50cancers is generally different.
19:50 --> 19:52Now sometimes we're still removing the
19:52 --> 19:55kidney for those renal pelvis tumors.
19:55 --> 19:56But usually if we're doing that,
19:56 --> 19:58we're also removing the
19:58 --> 19:59entire ureter on that side.
19:59 --> 20:01So taking that kidney tube that drains
20:01 --> 20:04all the way down into the bladder and
20:04 --> 20:06removing the entire thing and usually
20:06 --> 20:09with a small portion of the bladder as well.
20:09 --> 20:10So you know,
20:10 --> 20:13again very different types of
20:13 --> 20:16cancer managed in different ways.
20:16 --> 20:18One thing I think probably
20:18 --> 20:21bears bringing up is
20:21 --> 20:22there are significant efforts afoot
20:22 --> 20:25to try to spare removing the entire
20:25 --> 20:27kidney and spare removing the entire
20:27 --> 20:29kidney and ureter for some of
20:29 --> 20:31these upper tract types of cancer.
20:31 --> 20:33We didn't really have a lot of
20:33 --> 20:34options until somewhat recently.
20:34 --> 20:37Really in the past couple of years
20:37 --> 20:39we were basically either doing that
20:39 --> 20:42radical surgery or we were trying to
20:42 --> 20:44manage what we could endoscopically,
20:44 --> 20:47you know putting a camera up from below.
20:47 --> 20:48Maybe doing biopsies,
20:48 --> 20:50maybe using a laser to try to ablate
20:50 --> 20:52some of those tumors endoscopically,
20:52 --> 20:54but really only so much we could
20:54 --> 20:54do and again,
20:54 --> 20:57only treating what we could see.
20:57 --> 21:00We've just recently started
21:00 --> 21:02using a type of chemotherapeutic
21:02 --> 21:03agent called mitomycin,
21:03 --> 21:05which has been used in the
21:05 --> 21:06bladder for many years,
21:06 --> 21:08but it's been reformulated
21:08 --> 21:11into a gel type of format.
21:11 --> 21:13So the same medication but
21:13 --> 21:15sort of suspended in a gel.
21:15 --> 21:17And this has been approved since 2021,
21:17 --> 21:19but this is can now be instilled
21:19 --> 21:21directly into the kidney and for
21:21 --> 21:23some patients offer them basically a
21:23 --> 21:26nonsurgical option to try to treat
21:26 --> 21:28and really ablate some of these lower
21:28 --> 21:30grade tumors and save the kidney.
21:30 --> 21:34Wow. I mean that sounds really remarkable.
21:34 --> 21:37So because as you described,
21:37 --> 21:39the surgery itself,
21:39 --> 21:41nobody first of all would
21:41 --> 21:43necessarily want to undergo a surgery period,
21:43 --> 21:46even if it can be done with small little
21:46 --> 21:49incisions using a laparoscope or a robot.
21:49 --> 21:51But when you think about removing the kidney,
21:51 --> 21:52removing the ureter,
21:52 --> 21:55removing part of the bladder,
21:55 --> 21:57you know that sounds rather extensive.
21:57 --> 22:00If this can be treated with installation
22:00 --> 22:03of a gel in the kidney that
22:03 --> 22:05seems much more palatable.
22:05 --> 22:08Talk a little bit about which patients
22:08 --> 22:11are eligible for this and how exactly
22:11 --> 22:14do we get the gel into the kidney?
22:15 --> 22:17It is important to note,
22:17 --> 22:20not every patient would be a candidate for
22:20 --> 22:24this mitomycin gel installation.
22:24 --> 22:26Really we're talking about patients
22:26 --> 22:30with low grade tumors of the renal
22:30 --> 22:32pelvis and in some cases ureter.
22:32 --> 22:34Generally speaking those are patients that
22:34 --> 22:36have already had an endoscopic procedure,
22:36 --> 22:37they've had a biopsy,
22:37 --> 22:39they've had pathology
22:39 --> 22:41proving that diagnosis.
22:41 --> 22:44So what's done is usually it's
22:44 --> 22:47either instilled by looking into a
22:47 --> 22:49patient's bladder with the camera
22:49 --> 22:51cystoscope and then putting a small
22:51 --> 22:53open-ended catheter or tube up
22:53 --> 22:56into the ureter up into the renal
22:56 --> 22:58pelvis and then basically injecting
22:58 --> 23:00this gel material up directly
23:00 --> 23:02through that catheter can also be
23:02 --> 23:04placed through a nephrostomy tube,
23:04 --> 23:07which is a drain that goes directly
23:07 --> 23:09into the kidney through a patient's
23:09 --> 23:11back usually and sort of instilled
23:11 --> 23:13in an antigrade fashion that way.
23:13 --> 23:16It's given as a series of 6 treatments
23:16 --> 23:19once a week as sort of an induction phase
23:19 --> 23:22and then if patients have a good response,
23:22 --> 23:24which is generally judged by another
23:24 --> 23:27endoscopic look up into the kidney,
23:27 --> 23:29they might be a candidate
23:29 --> 23:30for maintenance treatments,
23:30 --> 23:32which would be once monthly for up to a year.
23:32 --> 23:35That doesn't sound too bad.
23:35 --> 23:36It doesn't sound perfect.
23:36 --> 23:39It's not like it's a pill that
23:39 --> 23:42you can take and be done with it.
23:42 --> 23:43It's still somewhat invasive,
23:43 --> 23:44but certainly not a surgery.
23:44 --> 23:48It sounds like both the cystoscopic
23:48 --> 23:51procedure or the installation through
23:51 --> 23:54a nephrostomy tube would be done as
23:54 --> 23:56an outpatient basis, like a quick
23:56 --> 23:59pop in and get your installation and leave.
23:59 --> 24:01Is that kind of how that works?
24:01 --> 24:03Yep, absolutely.
24:03 --> 24:05You know, it has to be done,
24:05 --> 24:07at least initially, in an environment
24:07 --> 24:09where you can take some X-rays.
24:09 --> 24:11We do fluoroscopic images to measure the
24:11 --> 24:14size of the renal pelvis so we can calculate
24:14 --> 24:17how much medicine we have to put in.
24:17 --> 24:19And once you have that calculation,
24:19 --> 24:20you can do it in the clinic.
24:20 --> 24:23If you have fluoroscopic capabilities,
24:23 --> 24:26you could do it in a radiology suite.
24:26 --> 24:28In a patient with a nephrostomy tube,
24:28 --> 24:32once you have the volume of the renal pelvis,
24:32 --> 24:34you could do it in the clinic
24:34 --> 24:35even without fluoroscopy.
24:35 --> 24:38So yeah, I think to your point,
24:38 --> 24:39it is definitely not perfect,
24:39 --> 24:40but it is a better option.
24:40 --> 24:42I'll give you a great example actually.
24:42 --> 24:43So I have a patient,
24:43 --> 24:44the solitary kidney,
24:44 --> 24:47so he doesn't have an option.
24:47 --> 24:49He's actually already had his other kidney
24:49 --> 24:51removed for the same disease.
24:51 --> 24:52So we can't take his kidney out.
24:52 --> 24:54I mean we could,
24:54 --> 24:57but he'd be on dialysis probably for life.
24:57 --> 25:00So kind of a perfect patient to
25:00 --> 25:02to offer something like this who
25:02 --> 25:04really has no other options.
25:05 --> 25:07And so how effective is it?
25:07 --> 25:09I mean you mentioned that it was
25:09 --> 25:10approved just in the last year or two.
25:10 --> 25:13Do we have data that after
25:13 --> 25:15a year of this maintenance therapy
25:15 --> 25:18if you've had a good response and
25:18 --> 25:19maybe that's the first question,
25:19 --> 25:20what proportion of people
25:20 --> 25:21actually have a good response?
25:21 --> 25:24And then second after you've
25:24 --> 25:26had this year of maintenance,
25:26 --> 25:28are we expecting this to be
25:28 --> 25:30durable long term so that you
25:30 --> 25:33know that's kind of one and done?
25:33 --> 25:36Yeah. So like any other medication
25:36 --> 25:38that gets approved by the FDA,
25:38 --> 25:41this had to essentially prove
25:41 --> 25:43its efficacy before that.
25:43 --> 25:45So there are trials,
25:45 --> 25:47basically two major trials
25:47 --> 25:48we actually are
25:48 --> 25:50seeing complete response in a
25:50 --> 25:51fair number of these patients,
25:51 --> 25:53I mean upwards of 50-60,
25:53 --> 25:57even 70% which is remarkable actually.
25:57 --> 26:00Again, I think we don't really have
26:00 --> 26:02101-5 year data because it's only
26:02 --> 26:05been out for a few years and it's
26:05 --> 26:07not a common disease so to speak.
26:07 --> 26:10I mean statistically there are
26:10 --> 26:13about 80,000 new kidney cancers per year,
26:13 --> 26:16about 5% of those are these particular
26:16 --> 26:18upper tract urothelial types, so
26:18 --> 26:21not a huge number of patients,
26:21 --> 26:22but you know, again,
26:22 --> 26:25when you're talking about the option of
26:25 --> 26:27complete removal of the kidney and ureter,
26:27 --> 26:29which is not just surgery
26:29 --> 26:31and recovery from surgery,
26:31 --> 26:33but is also the impact on
26:33 --> 26:34kidney function long term,
26:34 --> 26:35you know, renal insufficiency,
26:35 --> 26:36chronic kidney disease,
26:36 --> 26:39possibly even dialysis,
26:39 --> 26:41I think this is a good option
26:41 --> 26:42for the right patient.
26:42 --> 26:45Yeah, and regardless of whether
26:45 --> 26:47you go the surgical route
26:47 --> 26:51or the installation route,
26:51 --> 26:53I mean certainly some people aren't
26:53 --> 26:55going to have the option of the latter
26:55 --> 26:57if they have a higher grade tumor.
26:59 --> 27:01Can you talk a little bit about other
27:01 --> 27:03therapies that these patients might require?
27:03 --> 27:06I mean how often do these patients also
27:06 --> 27:08need systemic therapies or radiation?
27:09 --> 27:12Yeah, so radiation is not commonly used
27:12 --> 27:16really for either type of kidney cancer.
27:16 --> 27:18For those cortical tumors or for
27:18 --> 27:19the upper tract urothelial tumors,
27:19 --> 27:22chemotherapy, it's interesting really
27:22 --> 27:27has gained well I should say in the two
27:27 --> 27:29different disease settings some footing.
27:29 --> 27:32So for the cortical tumors of the kidney,
27:32 --> 27:34like those solid renal tumors
27:34 --> 27:35we discussed earlier on,
27:35 --> 27:38there's been a lot of interest
27:38 --> 27:40in using immunotherapy.
27:40 --> 27:42So people might be familiar with
27:42 --> 27:45that for things like lung cancer.
27:45 --> 27:47And that's being used for metastatic
27:47 --> 27:49disease for some time and now is gaining
27:49 --> 27:51some use in patients with higher risk
27:51 --> 27:54tumors that are completely removed for
27:54 --> 27:56patients with that upper tract urothelial,
27:56 --> 27:57the more bladder cancer
27:57 --> 28:00type of tumor if you will.
28:00 --> 28:01Those patients are sometimes treated with
28:01 --> 28:03what we call neoadjuvant chemotherapy.
28:03 --> 28:07So they may get chemo before their treatment.
28:07 --> 28:09There's a lot of debate about that,
28:09 --> 28:11some of that's extrapolated
28:11 --> 28:13from bladder cancer data, but
28:13 --> 28:14the challenge, of course,
28:14 --> 28:15is once the kidney is removed,
28:15 --> 28:17those patients may not be able
28:17 --> 28:18to tolerate systemic chemotherapy
28:19 --> 28:20because of the kidney function issues.
28:20 --> 28:24So often they will be seen by a
28:24 --> 28:26medical oncologist in concurrence
28:26 --> 28:27with radiation perhaps,
28:29 --> 28:31but usually it's urology and possibly
28:31 --> 28:31medical oncology.
28:32 --> 28:34Doctor Joseph Brito is an assistant
28:34 --> 28:36professor of medicine and urology
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions, the address
28:40 --> 28:43is cancer Answers at Yale dot Edu.
28:43 --> 28:45And past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:52learn more about the fight against
28:52 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

The Use of Robotics/Minimally Invasive Surgery for Urologic Cancers with guest Dr. Joseph Brito May 7, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095