Kidney Cancer and Minimally Invasive Surgery

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Kidney Cancer and Minimally Invasive Surgery




Guest:  Dr. Stephen Savage – Urology

Host:  Dr. Linda Austin – Psychiatry


Dr. 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?


Dr. Stephen 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. 


People, 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.


Dr. 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?


Dr. 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 scenario.


Dr. 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?


Dr. 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.


Dr. 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?


Dr. Stephen Savage:  Certainly that it needs treatment surgically, and there are many things we have to offer in that circumstance. 


Dr. 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?


Dr. 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.


Dr. Linda Austin:  Who is not a candidate for that type of approach?


Dr. 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.


There 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.


Dr. Linda Austin:  So, most patients, then, are good candidates?


Dr. Stephen Savage:  We do, at MUSC, easily, over 90 percent of our kidney surgeries laparoscopically.


Dr. 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?


Dr. 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. 


Dr. 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?


Dr. 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. 


And, subsequently, 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.


Dr. Linda Austin:  This is done under general anesthesia?


Dr. Stephen Savage:  It is done with general anesthesia.


Dr. Linda Austin:  Now, where are the incisions?


Dr. 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.


Dr. Linda Austin:  So, where, then, on the torso would the incisions be?


Dr. 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 to that.


Dr. Linda Austin:  So, how many incisions, then, are there, typically?


Dr. 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.


Dr. Linda Austin:  And, how many surgeons are involved in this procedure?

Dr. Stephen Savage:  At the time of the surgery?


Dr. Linda Austin:  At the time of the surgery, yes.


Dr. Stephen Savage:  Usually, there’s a single surgeon with an assistant.


Dr. 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?


Dr. 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 the surgeon.


Dr. 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.


Dr. 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 clinical training.


Dr. Linda Austin:  How long was your training in this?


Dr. Stephen Savage:  My training was one year.  Well, I like to say, we squeezed two years into one.


Dr. 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 University?


Dr. 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.


Dr. Linda Austin:  What are some of the risks of the surgery?


Dr. 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.


Dr. Linda Austin:  Dr. Savage, thanks so much for talking with us today.


Dr. 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.

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