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was agreed that if at any point in time the patient was showing any signs of difficulty, we would immediately convert to open. Terry Monk was, if you will, the referee in that scenario; this arrangement freed us to just concentrate on the work at hand, knowing that if Dr. Monk said "Time!", we would convert, no questions asked.
The patient went to interventional radiology first and had the renal artery embolized. She then came to the OR where we place an external ureteral stent. We then proceeded to do the laparoscopic nephrectomy. It was very difficult, because we immediately encountered the overlying right colon. We had never faced that in the laboratory. Eventually, we traced the ureter, thanks to the stent, up to the kidney, and by doing that we came underneath the colon and then slowly released the line of Toldt. We were very concerned about the vessels. We took five segmental renal arteries and five segmental renal veins. The procedure nearly seven hours. The only thing that went according to plan was entrapping the kidney and morcellating. That went exactly the way it had gone in the laboratory. Postoperatively, she had a dilutional anemia and she received a transfusion. She got 2 mg of morphine, as I recall, for pain relief, and went home, as I recall on postoperative day four or five. The final pathology was indeed an oncocytoma. The good Lord has a very humbling sense of humor.
T.S.: You have also perfected the use of cryotherapy to treat renal cancer. In your opinion, should more patients with small renal tumors opt for cryotherapy? What is the role of partial nephrectomy today?
Prof. Ralph V. Clayman: I participated in the early days of cryotherapy. I, by no means, would claim that I started it or even perfected it. At Washington University we did study cryoablation of the kidney and we were convinced that this was a reasonable way to possibly treat small renal masses. Again, it's simply the philosophy of minimally-invasive surgery. The goal is to be less invasive and still obtain a surgical cure for the patient. If I can do with a needle, what I could do with four or five laparoscopic ports, to my mind, that's a big win for the patient. The problem that came up with the cryotherapy was the false impression that the ice ball was equivalent to killing the tumor. You wanted to get down to -20 °C. The ice ball that was drawn on the package inserts had no semblance to
the ice ball that you would get inside the patient. Out of frustration and a desire to know precisely what was occurring, we sought to measure the temperature at the periphery of the tumor. When we put our needles in the tumor, we would then put four very thin, multiple temperature sensing (MTS) needles at the periphery of the tumor. We would then proceed with cryoablation. If any of the MTS needles did not go to -20°C, we would put in another cryoprobe in that area. By being sure that in each of the four points we were getting to -20°C we decreased our incidence of recurrent disease or a positive margin from roughly 17% to 5%, a more acceptable result. A cancer operation that's leaving cancer behind is not a very satisfactory cancer operation.
My feeling is that we've gotten away from the radical
Tεύχος 31 | Σεπτέμβριος - Οκτώβριος 2024
nephrectomy, which is good, and partial nephrectomy has come to the fore for these masses, which I think is also good and all of this is now done laparoscopically, with or without a robot. But, if we're not biopsying masses that are T1a before taking them out, we're doing the patient a disservice. Because we know that 20% of those masses are benign, and thus, without a biopsy, 20% of those patients are going to have an operation they never needed. I wouldn't want that for myself. I wouldn't want that for my wife. If I'm faced with a T1a lesion diagnosed on CT scan, that's going to get a biopsy, unless there's fat and we know it's an angiomyolipoma. I only want to operate on tumors that I know are cancer. Now people say, "Well, the biopsy is going to be inconclusive in 14%. What are you going to do?" Well, if you believe in the biopsy, you repeat it. If you repeat it, your diagnostic rate goes up from 86% to over 95%. Also, for some patients with a very low-grade renal cancer, they may elect for surveillance. For the rest of the patients that need
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