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PHYSICIAN UPDATE
Winter 2002 Edition
PHYSICIAN UPDATE
Spring 2002 Edition
PHYSICIAN UPDATE
Winter 2001 Edition
PHYSICIAN UPDATE
Spring 2001 Edition
-Dennis L. Fowler, M.D.
Joseph J. Del Pizzo, M.D.
Director, Laparoscopic Urologic Surgery Department of Urology,
Weill Cornell Medical Center
Renal cell carcinoma originates in the renal cortex and accounts
for 80 to 85 percent of malignant kidney tumors. It accounts
for approximately 2 percent of all cancers. Its incidence
varies among countries, with the highest rates in North America
and Scandinavia. 1 It is estimated that there are 35,000 new
diagnoses of kidney cancer in the United States each year.
Renal cell carcinoma occurs twice as often in men as in women,
with an incidence equivalent in American whites and blacks.
1 It is rare in patients less than 40 years of age, and the
disease occurs predominantly in the seventh and eighth decades
of life. 1 Documented risk factors include cigarette smoking
and obesity. 1 The risk of renal cell carcinoma has also been
reported to be increased in patients with acquired renal cystic
disease associated with chronic renal insufficiency and tuberous
sclerosis. 1
Renal cell carcinoma is known as the "internist's tumor"
because of its multiple potential signs and symptoms. Small,
localized tumors rarely produce symptoms, and, as a result,
the diagnosis is often delayed until after the disease is
advanced. Historically, the most common presentations are
hematuria (50-60%), abdominal pain (40%), and a palpable mass
in the flank or abdomen (30%). These three symptoms occur
as the classic triad of symptoms in less than 10% of patients.
2 Other signs and symptoms are nonspecific and include fever,
night sweats, weight loss, and malaise.
In recent years, the widespread application of computed tomography
(CT) and magnetic resonance imaging (MRI) studies for other
indications has led to increased detection of renal cell carcinoma
as an incidental finding. 2 The "incidentaloma"
is now the most frequently diagnosed renal tumor. This has
improved patient prognosis, as tumors found incidentally are
typically smaller and those that produce symptoms and are
more likely to be cured by resection.2
Historically, 25% of patients have evidence of metastatic
disease at the time of presentation, although this number
is lower now with the substantial increase in incidental masses
discovered. Frequent sites of metastatic disease, in order
of decreasing frequency, include the lung parenchyma, bone,
liver and brain. Many paraneoplastic syndromes that are found
in less than 5% of patients have been described, including
erythrocystosis, hypercalcemia, hepatic dysfunction (Stauffer's
syndrome), and amyloidosis. 2 These syndromes are usually
transient and resolve with resection of the primary lesion.
The gold standard for evaluation and clinical preoperative
staging of solid lesions of the kidney is the CT scan. The
accuracy of CT scan in defining the extent of a renal tumor
preoperatively approaches 90%. 2 The recognized limitations
of this technique include the evaluation of minimally enlarged
retroperitoneal lymph nodes and the degree of cephalad tumor
extension into the vena cava. 2
MRI with intravenous gadolimium is superior to CT scan for
evaluation of a suspected tumor thrombus involving the renal
vein or inferior vena cava. Other indications for MRI include
detection or evaluation of renal masses in patients with contrast
allergy or renal insufficiency.
All patients with a suspected renal cell carcinoma should
be evaluated with chest roentogram and serum liver function
tests as part of their preoperative metastatic work up. Patients
with an elevated alkaline phosphatase level or who complain
of bone pain should be evaluated with a nuclear bone scan.
Appropriate treatment of renal cell carcinoma is based almost
entirely on the clinical stage of the tumor at presentation.
Radical nephrectomy has been the standard therapeutic modality
for localized renal cell carcinoma since its introduction
by Robson in 1963. 3 This technique includes en bloc removal
of the contents of Gerota's fascia, including the kidney,
ipsilateral adrenal gland, and proximal ureter, and involves
early ligation of the renal artery and vein. It necessitates
a large flank incision, resulting in significant postoperative
morbidity, including pain and extended convalescence.
The initial laparoscopic total nephrectomy was performed
at Washington University in June, 1990. 4 Since that time
the laparoscopic approach to renal surgery has been adopted
and modified in numerous centers worldwide and has been expanded
to include donor nephrectomy, radical nephrectomy, partial
nephrectomy, and nephroureterectomy. Laparoscopic surgery
for solid renal masses is now recognized as a viable minimally
invasive alternative to open extirpative renal surgery.
The perioperative benefits of the laparoscopic approach have
been well established. Several studies comparing patients
undergoing laparoscopic radical nephrectomy with a similar
cohort undergoing open radical nephrectomy demonstrated that
the laparoscopic group had less postoperative discomfort,
better cosmesis, a shorter hospital stay, and a significantly
more rapid return to regular activities. 5-9
· Solid, enhancing lesions of the kidney > 4cm
· Smaller solid, enhancing lesions of the kidney near
the renal hilum not amenable to partial nephrectomy (Figure
1).
Fig 1A and B:
Computerized tomography scans with contrast on two different
patients reveal enhancing solid lesions of the right kidney
(arrows). Each lesion originates from the parenchyma of the
kidney and are highly suspicious for a primary renal cell
carcinoma.
Laparoscopic nephrectomy may be performed via an intraperitoneal
or retroperitoneal approach. Advantages to the intraperitoneal
approach include a greater working space, easy identification
of adjacent landmarks, and use of a muscle-splitting incision
for specimen extraction. Advantages to the retroperitoneal
approach include early identification of the renal hilum and
lower incidence of post-operative ileus.
We perform laparoscopic nephrectomy via an intraperitoneal
approach. This necessitates 2 or 3 small incisions, each less
than 1cm, to place our laparoscopic trocars through which
our dissecting instruments are placed. After the kidney containing
the tumor has been released from its blood supply and attachments,
it is placed within a laparoscopic bag inside the patient
and removed through a 5 or 6 cm Pfannestial incision. At times,
this extraction incision must be made larger to remove very
large tumors.
Hand-assisted laparoscopy (HAL) is a technique that combines
the principles of laparoscopy and open surgery. It allows
the surgeon to place his/her hand in the operative field during
a sustained pneumoperitoneum. This technique allows the laparoscopic
surgeon to use the most versatile instrument available, his
or her own hand, for exposure, retraction, dissection and
maintaining hemostasis.
With the hand-assisted technique, a periumbilical incision
is made at the beginning of the case, and will be used as
(1) the site where the surgeon places his/her hand during
the case, and (2) the site of specimen extraction at the end
of the case.
The hand-assisted technique is useful in the dissection of
large renal tumors that are difficult to mobilize with the
laparoscopic instruments. In addition, it shortens the often
steep learning curve for attaining the laparoscopic skills
necessary for safely performing a laparoscopic radical nephrectomy.
Partial nephrectomy involves removal of a renal tumor along
with a rim of normal kidney parenchyma, while leaving the
remainder of the kidney intact, thus maximizing the amount
of functional nephrons left with the patient. Data from several
studies support the use of partial nephrectomy in selected
patients with small (<4cm) peripheral lesions localized
to either the upper or lower pole of the kidney who also possess
a normal contralateral kidney. These patients' overall survival
is similar to that of patients with disease of similar clinical
stage who undergo radical (complete) nephrectomy. 10
Small tumors that are located deep within the renal parenchyma,
or are centrally located near the renal hilum, are generally
not amenable to partial nephrectomy.
· Patient with bilateral renal tumors
· Patient with tumor in a solitary kidney
· Patient in whom the contralateral kidney is threatened
by an associated disease, such as hypertension or diabetes
mellitus.
Laparoscopic partial nephrectomy is performed with the hand-assisted
technique. Our incision is usually periumbilical, and our
trocar distribution is the same used for radical nephrectomy.
The hand-assisted technique is helpful in tumor palpation
and hemostasis. In most cases, the renal hilum is isolated
as in radical nephrectomy. This allows the surgeon to clamp
the artery if necessary to maintain hemostasis during tumor
resection. The tumor is resected using the harmonic hook blade,
along with a rim of normal renal parenchyma to ensure a negative
surgical margin. The surgeon can use his hand to compress
the normal renal parenchyma in order to minimize blood loss
(Figure 2).
Laparoscopic partial nephrectomy
is performed with the hand-assisted technique
helpful in tumor palpation and hemostasis.
Fig 2:
(A) Specimen is excised using the laparoscopic harmonic scalpel.
(B) The surgeon maintains hemostasis by applying pressure
to the kidney defect.
We have performed over 200 laparoscopic radical nephrectomies/partial
nephrectomies at the Cornell campus over the last two years.
The patients typically require a two- to three-day hospitalization,
with return to normal activity within 2-3 weeks. This is in
stark contrast to the morbidity of a large flank incision,
which necessitates a longer hospitalization (5-7 days) and
an extended convalescence (6-8 weeks). The patient is walking
and started on a liquid diet the morning after surgery, and
will typically be given solid food on postoperative day two,
or three, after return of bowel function. Postoperative pain
is significantly less than with the open surgery, and therefore
the patient's postoperative narcotic requirement is significantly
less than that with open surgery. The patient is seen two
weeks after surgery to check his/her incisions, which typically
heal well with good cosmesis (Figure 3).
Fig 3: Two weeks following laparoscopic
radical nephrectomy, the patient's incisions are well healed,
including the extraction site (large arrow) and the smaller
working port sites (smaller arrow).
Laparoscopic surgery for renal cell carcinoma is an advanced
minimally invasive procedure that has evolved significantly
since the first case was performed over a decade ago. In experienced
hands, it is a safe, effective and reproducible option for
treatment of patients with renal cell carcinoma. The immediate
benefits of laparoscopic nephrectomy to the patient are clearly
established, as comparisons between laparoscopic and traditional
open radical nephrectomy have consistently demonstrated the
superiority of the minimally invasive approach in all indices
of perioperative morbidity including estimated blood loss,
postoperative narcotic requirements, length of hospitalization,
and duration of convalescence. Most importantly, recent studies
have demonstrated that laparoscopic radical nephrectomy confers
long-term oncologic effectiveness equivalent to traditional
open radical nephrectomy.
- Korsay CL, McLaughlin JK. Kidney and renal pelvis.
In: Miller BA, Ries LA, Hankey BF et al., eds. SEER cancer
statistics review, 1973-1990. Bethesda, Md,: National Cancer
Institute, 1993.
- Motzer RJ, Bander NH, Nanus DM: Renal Cell Carcinoma.
New Engl J Med 1996, 335:865-875.
- Robson CJ, Churchill BM, Anderson W: The results
of radical nephrectomy for renal cell carcinoma. J Urol
1969, 101:297-301.
- Clayman R V , Kavoussi LR, Soper , NJ et al: Laparoscopic
nephrectomy: initial case report. J Urol 1990, 146:278-281.
- Dunn MD, Portis AJ, Shalhav AM et al: Laparoscopic
versus open radical nephrectomy: A 9-year experience. J
Urol 2000, 164:1153-1159.
- Ono Y , Kinukawa T , Hattori R et al: Laparoscopic
radical nephrectomy for renal cell carcinoma: A five-year
experience. Urology 1999, 52:280- 286.
- McDougall EM, Clayman R V, Elashry OM: Laparoscopic
radical nephrectomy for renal tumor: The W ashington University
experience. J Urol, 1996, 155:1180-1185.
- Eraky I, El-Kappany H, Shamaa M et al: Laparoscopic
nephrectomy: an established routine procedure. J Endourol
1994, 8:275-278.
- Kavoussi LR, Kerbl K, Capelouto CC et al: Laparoscopic
nephrectomy for renal neoplasms. Urology 1993, 42:603-606.
- Novick AC, Streem SB, Montie JE et al: Conservative
surgery for renal cell carcinoma: a single-center experience
with 100 patients. J Urol 1989, 141:835-839.
Stephen M. Cohen, M.D.
Associate Clinical Professor, Obstetrics and Gynecology
Columbia University College of Physicians & Surgeons
Gone are the days of women having to suffer with heavy menstrual
periods. New procedures and technology now allow gynecologists
to end heavy periods forever, without major surgery.
It is estimated that in the United States, approximately
700,000 hysterectomies are performed annually. Of these, 140,000
are performed for abnormal uterine bleeding. Most, if not
all, of these hysterectomies can now be eliminated with a
simple, inexpensive office procedure called "endometrial
ablation." Many more women have heavy periods, but do
not seek medical attention, as they believe that hysterectomy
is the only solution for their problem. Probably, 20% of women
suffer from abnormal bleeding sometime during their reproductive
life span.
The procedure of endometrial ablation eliminates or significantly
reduces menstrual bleeding, by permanently removing the recycling
endometrium lining the uterus. This procedure is not new,
having been first performed back in the early 1900's. What
is new is the technology that now allows the procedure to
be performed more effectively, safely, and cost efficiently.
Over the last few decades, many materials have been used
to try to eliminate menstrual periods. Crazy glue, radium,
tetracycline, and many other substances have been tried in
the past. The modern era of endometrial ablation was ushered
in the late 1980's by Dr. Milton Goldrath of Detroit. He demonstrated
that if one vaporized the endometrium using the YAG laser
through the hysteroscope that menstrual periods would be eliminated
or reduced in over 90% of patients. The YAG laser ablation
was a slow and expensive procedure, but it was effective.
During the years that followed, other technologies were developed.
In the early 1990's, most gynecologists began performing "rollerball"
ablation. In this technique, one places a hysteroscope with
an electrified metal ball on the front end into the uterus.
One then rolls the ball over the endometrial surface coagulating
the endometrium down through the basalis layer. This procedure
is also about 90% effective in reducing menstrual flow, but
requires moderate to advanced surgical skills and in addition
has the associated complications of fluid overload and hyponatremia.
In 1998, Gynecare introduced the first modern non-hysteroscopic
method of ablation called ThermaChoice. In this procedure,
a balloon is introduced through the cervical canal into the
uterus. This balloon is then filled with heated water, which
destroys the endometrium. This procedure was simple to perform
and eliminated the problems of fluid overload, but it could
not be performed in an office setting and the amenorrhea rate
was not comparable to the older methods.
The procedure of endometrial ablation eliminates or significantly
reduces menstrual bleeding, by permanently removing the recycling
endometrium lining of the uterus.
Two new methods of endometrial ablation have been introduced
into the United States within the last 6 months. One is a
non-hysteroscopic (blind or ultrasound guided) method, called
cryoablation - Her Option. The other is a hysteroscopic method
(direct visualization) called HydroThermal Ablation. The cryoablation
technique utilizes cold to destroy the endometrium. Cryoablation
is performed with 2 blind intrauterine freezing periods using
the probe provided. Hydro Thermal Ablation is a system that
destroys the endometrium with heat. The HTA system heats the
free flowing distending medium to 90¼C and the heated
saline destroys the endometrium over 10 minutes while the
surgeon observes. The complication of fluid absorption is
eliminated, as the system will notify the operator if 10cc
of fluid is missing from the closed system. This procedure
is simple to perform and can be done in an office setting.
Many other methods of endometrial ablation are currently under
study worldwide. Some of these investigative methods may result
in even safer and more effective elimination of periods.
No longer do women need to endure the hardship of excessively
heavy menstrual periods, which can affect their daily activities.
Gynecologists now have the skills and technology that can
safely and effectively cure this problem during a ten-minute
office procedure.
The Minimal
Access Surgery Center at New York-Presbyterian Hospital offers
the latest advances in minimally invasive surgical and diagnostic
techniques for a wide range of conditions. Minimally invasive
surgical services are particularly applicable in the fields
of general surgery, gynecology, urology, cardiothoracic surgery,
pediatric surgery, and colorectal surgery. Surgeons in all
of these disciplines at both campuses of the Hospital have
expertise in minimal access techniques and are available for
elective or emergent consultation.
Minimal Access Surgery Center
NewYork-Presbyterian Hospital
525 East 68th Street
New York, NY 10021
Dennis L. Fowler, M.D.
Director
(212) 746-5599
Richard L. Whelan, M.D.
Site Director
Columbia Presbyterian Medical Center
(212) 305-6136
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