Pioneering procedures such as laparoscopic and minimally invasive applications in urology have dramatically improved the treatment of various disorders, tumors and malformations of the kidney, as well as other urologic organs. Until recently, patients with kidney cancer or obstruction would often undergo surgery with a large incision and significant post-operative recovery.
Using a miniature camera and tiny surgical instruments we can now remove a diseased or cancerous kidney without performing major surgery.
Performed through narrow tubes rather than large incisions, the laparoscopic approach benefits a patient by allowing a shorter hospital stay, less pain, a better cosmetic result and a quicker recovery compared to major surgery. Specifically this means that a kidney can be removed with three small holes, all less than a half an inch in length, and the patients can go home in one to two days and are back to work in about 10 days. For kidney-cancer patients this is all accomplished with equivalent cancer control as compared to open surgery.
The first laparoscopic nephrectomy for cancer was performed in 1991. In the past few years, dramatic improvements in instrumentation and surgical training have made the laparoscopic approach a standard of care for virtually all renal surgeries. Both Dr. Caruso and Dr. Lombardo have extensive training and experience in the following minimally invasive laparoscopic treatment approaches.
Patients with kidney cancer can be treated by either laparoscopic radical or partial nephrectomy. The word radical in this case means that the entire kidney, its surrounding fat, part of the ureter, and possibly the adjacent adrenal gland are removed. Currently, laparoscopic radical nephrectomy can be used for tumors up to about 10 cm.
This procedure is performed through three to five small holes in the abdomen and takes between two to three hours. Inside the body, the blood vessels leading to the kidney are identified, clipped and divided. The surrounding structures are dissected away and the kidney is placed inside a "sack." The neck of the sack is pulled out one of the incisions and the kidney is divided into small portions to remove it. This enables the entire surgery to be performed without any incisions larger than 2 cm. Since the sack is resistant to cells and fluid, it is safe to remove a cancer in this manner. Once the kidney is removed, all the instruments, drapes, gowns, and gloves are changed to further protect the patient from cancer spread.
Success rates for this procedure are equivalent to open radical nephrectomy and, the significant benefits to the patient are shorter hospital stays (one to two days), less pain, less blood loss, less complications such as hernia or bowel adhesions, and earlier return to work (10-14 days).
Dr. Caruso has co-authored a online book chapter on this technique of Transperitoneal Laparoscopic Radical Nephrectomy. You can see this article at Emedicine.com by clicking here.
In a partial nephrectomy, a tumor or portion of the kidney is removed rather than the entire organ. This procedure can be performed laparoscopically for the appropriate patient, usually when the tumor is less than 4 cm.
The procedure involves three to five small incisions in the abdomen and takes between two to three hours. The kidney is dissected away from surrounding structures, identifying the renal artery and vein. These vessels are clamped and the diseased portion of the kidney is removed. The remaining kidney is then sewn closed with suture.
Post-operative pain and recovery are similar to that for the laparoscopic radical nephrectomy.
One exciting new treatment for kidney cancer is ablative therapy. This involves eliminating the cancer cells in the kidney without actually surgically removing the tumor. This may represent the near future of all cancer surgery; as technology improves and the tools available to surgeons.
Two current technologies being used for kidney cancer ablation are cryotherapy (freezing) and radiofrequency (heating). We are currently performing cryotherapy for small renal tumors (2 to 3 cm) in patients who need to save as much functional kidney as possible. Cryotherapy is performed through a laparoscopic approach, with ultrasound imaging aiding in positioning the cryoprobes into the tumor. Once in place, the probes are supercooled to kill the targeted tissue. Recovery is similar to the above laparoscopic renal procedures.
Even less invasive than this is radiofrequency ablation of a small kidney cancer. This procedure is performed in the radiology suite using a CT scanner to direct a needle into the renal tumor. Once in the correct location, the needle heats the cancer tissue until it dries up and dies. The potential benefit is a cancer treatment with an even faster recovery than the laparoscopic approach. This is reserved for small posteriorly located tumors especially for elderly patients as local recurrence rates may be slightly higher than with cryoablation.