Cancer and Minimally Invasive Surgery
Guest: Dr. Stephen Savage – Urology
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Stephen Savage who is
Associate Professor of Urology here at MUSC and Director of Minimally Invasive
Urology. Dr. Savage, I’m aware that you
can do minimally invasive surgery at many points in the urologic system, but
let’s start with the kidneys. What are
the sorts of kidney diseases that you might use these techniques for?
Savage: There are a number of different
types of procedures that could be performed laparoscopically in the kidney,
first and foremost, treating kidney cancer.
Virtually any surgery that can be done with open surgery can now be done
laparoscopically in the kidney. And
that’s a big advantage because the kidney is in an anatomically unfavorable
place, where it’s tucked up underneath the ribcage towards the back. Historically people have required long
recoveries and have had issues related to those recoveries
postoperatively. Laparoscopic surgery
allows an approach in which people can recover quickly and also do very well
with the treatment.
certainly, who require removal of their kidney, even very large kidneys, can
have it done laparoscopically. Many
times those people can be discharged from the hospital the following day when
previously it had been a three to five-day hospital stay. Also, increasingly, as we became more
comfortable in doing more advanced procedures laparoscopically, we can remove
part of the kidney laparoscopically, where we just remove a smaller tumor
rather than the entire kidney and actually do reconstruction within the kidney
to maintain the rest of the kidney, to allow for kidney function down the road
for that patient.
Linda Austin: So, let’s walk through the
experience, starting from the beginning of first symptoms of someone, let’s
say, who has kidney cancer that might end up coming to you for evaluation and
then a surgical removal. What might be
the first symptoms of that person?
Stephen Savage: Well, it’s
interesting. Now that many people get
CAT scans for a variety of reasons, the overwhelming majority of people who
have kidney cancer have no symptoms whatsoever, and it’s simply a diagnosis
that is made when someone has an imaging study done for some other reason. So, they’ll have a CT scan or an ultrasound
that will show a mass within the kidney, so then they’ll be exploring treatment
options in order to treat these tumors.
And it’s important for them to know that this is an option in that
Linda Austin: Now, if something shows up
incidentally, are you able to look at those images and have an idea as to
whether that is benign or malignant, or do you do a biopsy? How do you proceed?
Stephen Savage: There are certain
imaging characteristics that we see on standard imaging, whether that’s a CT
scan or an MRI, or ultrasound, that will make you think, perhaps it’s a benign
tumor, but the overwhelming majority of these lesions that are of a significant
size, meaning, over two centimeters, will be malignant. But that’s something we discuss on an
individual basis with the patients when they come in. Typically, they do not get biopsies unless
there’s something unusual about the appearance of that lesion prior to any type
of treatment, the reason being, we get very good information based on the
imaging, and biopsies are often not as good as the actual imaging study.
Linda Austin: So, it sounds like you
have a pretty good feeling just looking at it.
And if it’s a large size, over two centimeters, you’re pretty sure that
it’s probably malignant?
Stephen Savage: Certainly that it needs
treatment surgically, and there are many things we have to offer in that
Linda Austin: Now, what kind of advice
would you give a patient, or how would you walk a patient through the decision
as to whether to have an open surgical procedure, with a large incision, the
sort of classic technique, versus a minimally invasive procedure?
Stephen Savage: One concern that many
people have when they come in to consider a minimally invasive technique is, is
it equivalent to the open surgery?
There’s, understandably, the concern that, well, can somebody see as
well when they’re doing surgery through just keyhole incisions? The truth of the matter is that with
laparoscopy, you have a camera that goes in closer than you can see with the
naked eye, with magnification up to 10-15 times. So, as long as the surgeon is comfortable and
qualified to do the surgery laparoscopically, overwhelmingly we do that
laparoscopically, certainly, here at MUSC.
Linda Austin: Who is not a candidate for
that type of approach?
Stephen Savage: There are certain
conditions that may make somebody less favorable to have laparoscopic surgery,
certainly, extremely large masses where there’s not enough room in the abdomen
to do laparoscopic surgery. To take a
step backwards, when you do laparoscopic surgery, you need to put gas, carbon
dioxide, into a cavity and to expand that cavity so you have space to work,
since you’re not opening up with a surgical incision. And, if the mass takes up all that space,
then there’s no room to work laparoscopically.
are other medical conditions, such as severe chronic obstructive pulmonary
disease, where someone cannot take insufflation with carbon dioxide gas. It’s important that an expert looks at that
and evaluates and says whether or not a person is a candidate for that. Otherwise, locally advanced disease, where it
may be actually difficult to resect the mass completely, again, increasingly,
that’s an exceedingly rare circumstance.
Linda Austin: So, most patients, then,
are good candidates?
Stephen Savage: We do, at MUSC, easily,
over 90 percent of our kidney surgeries laparoscopically.
Linda Austin: Wow. That’s impressive. From the time a patient first gets referred
to you to when they can have their mass excised laparoscopically, how much time
is there, usually?
Stephen Savage: One of the good things
about tumors of the kidney and treatment for tumors of the kidney is they tend
to be slow-growing, so the patient can make an educated decision and feel
comfortable in what they’re doing in making that decision. Typically, from the time someone’s seen and
had their full evaluation, it’s four to six weeks.
Linda Austin: So, let’s walk through the
procedure itself. What can a patient
expect when they come to the hospital on the day of their procedure?
Stephen Savage: Well, somebody comes in
to be readied for surgery. There’s no
preparation or admission prior to surgery.
They come in the day of surgery and get prepared for surgery just as anybody
else would, with an intravenous line for anesthesia. Surgery, typically, takes between two and
three hours, which is equal, essentially, to the open surgery. That’s another concern that some people may
have, if laparoscopic surgery can take longer.
However, that has not been the case in laparoscopic kidney surgery.
there certainly is discomfort related to the surgery, since we are still doing
a major surgery, although it’s through small incisions. That discomfort improves dramatically over a
short period of time so that 90 percent of our patients are home within two
days. And, increasingly, many patients
are home even the following day after surgery.
Linda Austin: This is done under general
Stephen Savage: It is done with general
Linda Austin: Now, where are the
Stephen Savage: It depends on the
approach. There are two different ways
to do laparoscopic surgery on the kidney.
The kidney is located in a separate section of the abdominal cavity,
called the retroperitoneum. So, you can
go directly to that and do laparoscopic surgery, or you could go into the
peritoneal cavity where the intra-abdominal organs are. So, those are two different approaches and
there are different reasons to do both of those approaches. Again, not every urologist does laparoscopic
surgery both ways since there are reasons to do both of them, but we’re able to
do both of them here.
Linda Austin: So, where, then, on the
torso would the incisions be?
Stephen Savage: Typically, the advantage
for laparoscopic surgery is you can make the incisions in favorable locations,
either they’ll be on the side, just underneath the ribcage, or you may have
incisions around the bellybutton, and just underneath the ribcage, and then
just above the hip area. You do need to
make an incision to take the kidney out so the pathologist can evaluate it and
give us important information about the tumor and what the prognosis is related
Linda Austin: So, how many incisions,
then, are there, typically?
Stephen Savage: Typically, there are
three incisions, all less than half an inch, and there’s one extraction
incision, which may be up to three to four inches.
Linda Austin: And, how many surgeons are
involved in this procedure?
Stephen Savage: At the time of the
Linda Austin: At the time of the
Stephen Savage: Usually, there’s a
single surgeon with an assistant.
Linda Austin: Just one, and somebody
watching. I think it’s fascinating to
understand exactly how the surgery happens.
Those three incisions, then, what is each one of them for?
Stephen Savage: Well, you need to be
able to see what you’re doing, so there’s a camera port where we put a camera
lens, and we use lenses of various angles to facilitate the surgery the best
way possible, so there’s one for that, and the surgeon has a left-handed
instrument and a right-handed instrument to do the surgery. Occasionally, we’ll need one other keyhole
incision where we can have an assistant retracting to help create the
space. So, most commonly, we only use
the three incisions, where it’s a camera and the two working instruments with
Linda Austin: It’s a very remarkable
thing. Actually, my mother had
laparoscopic surgery for a different kind of urologic condition, and it was
extraordinary to see this 85-year-old woman have a major procedure and be up
and walking in two days and completely comfortable. It’s really very astounding. Tell me, now, what sort of training you had
personally in order to learn how to do this procedure.
Stephen Savage: Well, every urologist
has a certain training period, but in order to do advanced laparoscopic
surgery, I completed a fellowship in minimally invasive surgery at the
Cleveland Clinic and went into practice, subsequently, after that. Most of the people that do the more advanced
laparoscopic surgery do complete a fellowship of one to two years with advanced
Linda Austin: How long was your training
Stephen Savage: My training was one
year. Well, I like to say, we squeezed
two years into one.
Linda Austin: Well, the Cleveland Clinic
would do that. That’s an excellent place
to train. And, how long have you been
doing these procedures here at Medical
Stephen Savage: I’ve been at the medical
university since 2004. I was in practice
in New York
for four and a half years prior to that.
Linda Austin: What are some of the risks
of the surgery?
Stephen Savage: The risks of the surgery
are identical to risks for open surgery, as far as injury to contiguous organs
while doing the surgery. There are very
few risks that are unique to laparoscopic surgery versus open surgery. The good thing is that you eliminate some of
the risks that are associated with the open surgery when you do the
laparoscopic surgery. As you mentioned,
it is particularly helpful in patients who are more infirm and who require
surgeries, because the benefit is that much greater for them.
Linda Austin: Dr. Savage, thanks so much
for talking with us today.
Stephen Savage: Thank you.
If you have any questions about the services
or programs offered at the Medical University of South
Carolina or if you would like to schedule an
appointment with one of our physicians, please call MUSC Health
Connection: (843) 792-1414.