Surgeons: Ravi Munver and Ronald Boris

Moderator/Discussant: Ketan Badani


Dr. Ravi Munver

Dr. Munver is Vice Chair and Chief of Minimally Invasive and Robotic Urologic Surgery in the Department of Urology at Hackensack University Medical Center and is Professor of Urology at Hackensack Meridian School of Medicine. He is the founding Director of the Hackensack University Medical Center Robotic and MIS Fellowship Program.

Dr. Munver received his medical education at Cornell University Medical College and completed residency training at Duke University Medical Center. He received advanced fellowship training in robotic, laparoscopic, and endoscopic surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center.

Dr. Munver is a passionate academician and educator. He has been teaching medical students and residents for more than 18 years and received and the Golden Apple Award for excellence in teaching.

Dr. Munver is known for his compassionate care with patients and received the Gold DOC Award for Humanism in Medicine.

Dr. Ronald S. Boris, M.D.

Dr. Boris is board certified in urology and an Associate Professor of Urology at Indiana University School of Medicine. He received his Bachelor of Science from the University of Michigan and his masters in Biotechnology from Northwestern University. Dr. Boris graduated with high honors from medical school at Wayne State University and was awarded membership to the Alpha Omega Alpha honor society. He completed his urology residency at Henry Ford Hospital’s Vattikuti Urology Institute. He completed his urologic oncology fellowship at the National Cancer Institute at the National Institutes of Health where he performed complex kidney and adrenal-sparing surgery using both open and minimally invasive techniques.

Dr. Boris specializes in urologic oncology focusing on prostate, kidney, adrenal, and bladder cancer utilizing minimally invasive techniques whenever feasible. He has special interest in hereditary kidney cancer and multifocal renal masses and runs the genetic kidney cancer program at IU Simon Cancer Center. Dr. Boris has published extensively in the fields of kidney, prostate, and minimally invasive urologic surgery.

Dr. Ketan K. Badani

Dr. Ketan K. Badani is the Vice Chair of Urology and Robotic Operations at Mount Sinai Health System in New York. Dr. Badani has performed nearly 4,000 robotic procedures in his career, placing him in the top 1% of urologists worldwide for kidney and prostate surgery. He is one of the preeminent practitioners in the world for robotic partial nephrectomy for complex kidney tumors.

Dr. Badani is the author of over 150 peer reviewed publications and has presented more than 400 abstracts at national and international meetings. He leads innovative clinical trials, feasibility and safety studies of new technology, and health related quality of life outcomes research. He has pioneered the field of robotic urologic surgery with several of the early, fundamental publications on robotic surgery for prostate, kidney and bladder cancer. Analysis of robotic techniques during surgery to improve patient outcome has been a paramount focus in my recent work and efforts to improve surgical and oncologic outcome. Specifically, Dr. Badani has developed the First Assistant Sparing Technique (F.A.S.T.) which is utilized during robotic partial nephrectomy which specifically involves intracorporeal placement of sutures and bulldog clamps prior to clamping and tumor. This technique is published in the Journal of Endourology and reduces reliance on the first assistant and has been shown to lead to a shorter operation and shorter ischemia time for patients undergoing nephron sparing surgery. Dr. Badani is also an editor and/or reviewer for numerous academic journals including Cancer, Journal of Urology, Urologic Oncology, Journal of Endourology, among others.

In addition to surgery, Dr. Badani leads innovative research projects in the field of kidney cancer. He currently studies the optimization of MRI imaging data to predict long-term outcomes after treatment. Dr. Badani is also studying the role of recent advanced technology such as virtual reality and 3D modelling to help better understand the specific anatomy of each patient and apply that to planning the surgery to optimize the outcome. Another area of research focus is a clinical trial to study a novel medication for advanced and metastatic kidney cancer.

 

Webinar Transcript 

Dr. Ketan Badani:

I want to welcome you all to the endourology and SURS Masterclass in robotics surgery. We're very happy to be here. My name is Ketan Badani, I'm your moderator for this session. We're going to have a great session. But before we get into it, I am going to speak on behalf of Dr. Ash Tewari, who is the president of SURS. He unfortunately had a conflict he couldn't get out of at the moment. He wanted to be here to greet everybody. But I will speak on his behalf and welcome you all. We're very excited to launch this series again. For those of you that attended last year, you know how valuable and the high quality of content that was part of this Masterclass.

Dr. Ketan Badani:

So we hope that we're going to provide the same, if not even better educational experience for you all. And Dr. Tewari hopes that this forum will create a platform for exchange of ideas and collaboration. So again, regret that he can't be here to welcome you, but on his behalf, welcome. I want to do a few housekeeping things as is important for any CME activity, and so before we do that, I just want to thank, on behalf of The Endourology Society, our two sponsors for this educational series. Intuitive Surgical, who has been a tremendous partner in putting this together, and CONMED, who also has been a really supportive partner, and many of you who do Da Vinci robotics know about CONMED and AirSeal, and both of them we appreciate your partnership in this and the grant support for being able to allow us to do this.

Dr. Ketan Badani:

Today's session, for those of you who didn't get the emails, we're going to talk about robotic partial nephrectomy, and I'll talk a little bit more specifically about what we're going to speak. And we have two really good friends of mine, and very accomplished robotic surgeons, Dr. Ravi Munver and Ronald Boris, who I'll introduce momentarily to you. So again, this is a CME event, read this real quick and memorize it and we'll move on. But you will receive a survey from Michelle Paoli, who is the organizer at this event, and usually at the last day of every month, last Wednesday of every month, which I think is today, you'll get another email for a survey you need to fill out to get your CME.

Dr. Ketan Badani:

So fill out the survey, it's very easy. I wouldn't say it's fun, but it's easy. And you'll be granted your CME credit for attending this event. And then the other thing I want to make sure everyone knows is that we have a chat function. Please use the chat function to ask questions or even interact with each other, and ask our speakers are speaking, I can also moderate some of that and answer some things along the way. So, please feel free to make your comments in the chat box. We'd love to have some exchange of ideas and interaction.

Dr. Ketan Badani:

So the format for today, we're going to have the two speakers, and we're going to talk about specifically the role of enucleation in robotic partial nephrectomy and hilar tumors. The other thing that's really exciting is we're going to have a additional session that we didn't do last year, which is the SURS spotlight series. We're going to host a informal discussion Wednesday, March 3rd. So the Wednesday after each of these Masterclass events on the Facebook group RUC, Robotic Urology Collaboration with Dr. Boris, Dr. Munver, myself and some other guests will be there, to answer questions and go through some highlights in a more informal setting where we can interact with you all, and even more informal way.

Dr. Ketan Badani:

So I encourage you to join RUC at that link below and be there on Wednesday at eight o'clock. It's going to be a lot of fun. If you're not a member of the endo society or SURS, which is the Society of Urologic Robotic Surgeons, please, we'd love to have you as members. There's a lot of benefits to that, check out the website, www.endourology.org. All right. And then finally and hopefully, we'll have an in-person meeting in September. Let's see. I'm optimistic some days, most days I think. In Hamburg, Germany, September 23rd to 25th, let's hope we can all meet in person and see each other again.

Dr. Ketan Badani:

All right, so the role of enucleation and hilar tumors, and again there is some parallels to this as we go through and you'll get an understanding but, let me introduce our speakers. Again, I've known both of our speakers for a long time, and they've really done a lot of work in robotic surgery and specifically kidney surgery. So the first presenter, is Dr. Ronald Boris who is currently an Assistant Professor of Urology at Indiana University School of Medicine. He did graduate from my alma mater, University of Michigan, in college although we weren't friends back then and perhaps we're not friends now either.

Dr. Ketan Badani:

But in the middle we were friends Ronnie, because we were in residency together. And Ryan I trained at The Vattikuti Urology Institute at Henry Ford. And so I got to know all Ronnie's deep dark secrets, and really got to know him very well. But Dr. Boris has done a lot in terms of the role of enucleation, he spent time at the NCI and did a lot of hereditary renal cell carcinoma. So I'm really looking forward to hearing your perspective on enucleation and different ways of approaching partial nephrectomy.

Dr. Ketan Badani:

Our next speaker is Dr. Ravi Munver, who also as I said, I've known a long time and has been doing robotics for ... I don't know 18, 16 so a lot of years and been teaching and educating residents and fellows. Dr. Munver is currently the Vice Chairman of Urology and the Chief of Minimally Invasive and Robotic Surgery at Hackensack Meridian or Hackensack University Medical Center, which is just across the river from where I'm at, in New York City. He's Professor of Urology there, and also the director of the fellowship.

Dr. Ketan Badani:

So, Dr. Munver spent a lot of time in New York, went to college at Cornell, did his residency at Cornell, and he went to Duke for medical school. So you've been around a bit, but have spent a lot of time in the area. So again, it's nice to have these two speakers here who have really a wealth of experience to teach us today. And then again, I want to encourage you to join RUC because we're going to have a live session on Wednesday at eight o'clock, and it'll be fun and informal, and we'll be able to dive deeper into some topics we may not have been able to get into today.

Dr. Ketan Badani:

Again, we encourage you all to post your own videos, your own partial nephrectomy content, we'd love to see what you all are up to in different countries or different areas of the US and your thoughts and opinions on this. So I think without further ado, I'm going to turn the microphone over to Dr. Boris, who's going to present first.

Dr. Ronald Boris:

Briefly, I wanted to thank Ketan, Dr. Tewari. I think Chandru Sundram probably snuck my name in here to give me an opportunity to come out here and present to everybody, it's really very fortunate to be able to do it. I'm not an IT guy, so actually sitting down with some of these videos, and trying to put them together and not screw them up was one of my biggest challenges. But I feel very lucky to be here, so thank you for having me. I'm going to talk hopefully in a complementary way to Dr. Munver's presentation on hilar tumors, because there's certainly a lot of overlap.

Dr. Ronald Boris:

And we'll focus a little bit my talk on the techniques of resection, especially variations of tumor enucleation. So, I'm going to start with four cases, and we're going to move from more traditional partial nephrectomies to what is known as hybrid enucleation or enucleo-resection. There's a lot of different nomenclature for this type of resection and then focus on a couple of different tumor enucleation cases. As I went through these cases, initially I was looking at some of the bigger and badder tumors and I realized that the videos often are made with some of the simpler cases where you can really appreciate the plains and some of the nuances for these various techniques.

Dr. Ronald Boris:

So it's not always the largest partial nephrectomy that can illustrate the strongest point and then we'll talk a little bit about the enucleation data that is out there. So the first case is a 42 year old, young black male, normal kidney function. This was a really straightforward, standard partial nephrectomy, 90 minutes in the operating room, minimal clamp time and blood loss. He did well, he had a Type 1 papillary RCC, which we see frequently in our African American population.

Dr. Ronald Boris:

So, I just want to set the stage a little bit as the caseloads for what I mean by standard partial nephrectomy or margin partial nephrectomy. You can see the small tumor in the lower portion of the left kidney. And when I typically do these with the idea of trying to create a margin, it's really the idea of creating this sphere of tissue that coats over the kidney circumferentially. So, what I'll try to do here is broadly cut down, at this point the kidney's tumor has already been clamped. So I'm cutting down and widely down until I get into the collecting system or the sinuses.

Dr. Ronald Boris:

And you'll see my assistant here pulling, and that's really important with the assistant who's giving you that counter-traction so that I can see down into the base. And now as the blood is escaping the kidney and will get essentially drier and drier as some of it drains out, I'm trying to create a little bit of coverage around the tumor. And you can see that you don't necessarily see the glistening pseudocapsule, you're actually looking at what looks like the meat of the kidney.

Dr. Ronald Boris:

Now you can see me cutting down into the deeper recesses of the kidney. And once I get down into the sinus or the collecting system, I'll start to curve my scissors and try to create that same amount of coverage along the entirety of the kidney. So this is a little bit sped up. But again, as you use your left hand, or I use my left hand to lift this out of the base, you can see that consistent coverage of normal kidney around it.

Dr. Ronald Boris:

So, you don't have to have a huge margin when you do these partials. But if you're going to do a more standard partial, you want to have a consistent margin around the tumor. And that's just an example of that type of standard case. So the next case as we go through these techniques, is going to be this is what I call one of my Hoosier thin patients in Indiana, this is a female weighing over 300 pounds, we get a lot of these in our Hoosier State. So it teaches you a little bit about working on obesity and renal cell cancer.

Dr. Ronald Boris:

This is a larger mass, it's a little bit longer, operative time and clamp time. And this was a 3.7 centimeter cystic clear cell kidney with negative margin. So, when I think about hybrid resection, the goal is for me to start, like I typically do with a traditional margin partial nephrectomy, and we'll go wider on the kidney. So this is a hilar mass in the upper portion of the right kidney, which drops down pretty deeply onto the renal vein.

Dr. Ronald Boris:

So I'm starting similarly as I do with my other ... with the last case that I presented, but you can see here, now after I get on a wider base, I'm trying to find the tumor pseudocapsule. So, you can see a nice example here of the renal parenchyma. And then here is the tumor pseudocapsule. So, I've now fall back on the pseudocapsule, and now I'm creating essentially this enucleation, after starting out wider and then coning in. And you can see here, I'm stripping down the tumor pseudocapsule, as I roll or mobilize the tumor out.

Dr. Ronald Boris:

So what you wind up with is on the top and the sides of the kidney, you have this nice parenchymal coverage. And on the base of the tumor, you have this bare area where the pseudocapsule is visible. And then I'm using that pseudocapsule to guide me as I roll it out of the tumor bed. And a lot of times that pseudocapsule will just push off, and it really allows you to take on very deep and challenging tumors and preserve a lot of the critical deep structures, by rolling the tumor out of its bed.

Dr. Ronald Boris:

So you start in wider, and then you get on to the tumor pseudocapsule and then you use that plane to continue finishing the resection. And that's exactly what you'll see here. And then, as I get more circumferential or wider out, I will use more heat on the capsule of the kidney, to ultimately free up the tumor. And you can see just a nice depiction here of the basically bare area of pseudocapsule. So now I want to talk a little bit about tumor enucleation itself. This is a small mass again, 58 year old male.

Dr. Ronald Boris:

And this is an example of, I think one of the benefits of tumor enucleation which is the off clamp partial nephrectomy. So this was a case that we were able to do without tumor clamping, and it was another good illustration of some of the differences in papillary renal cell cancer as this was a very thick pseudocapsule which allows for a very nice enucleation. We'll talk a little bit about that also, once I get through the next case when we look at some of the slides depicting pseudocapsule differences between renal tumor subtype.

Dr. Ronald Boris:

So, this is an example of tumor enucleation. And the biggest difference here compared to the last two illustrations is that instead of doing that wider, more broad base, cutting through the capsule, you're going to actually now try to strip the layers of the capsule, and peel it back to get on to the pseudocapsule. So, here again is a smaller tumor in the lower part of the right kidney, and we'll see this quickly again, not a big tumor but I think it illustrates the point and you can see here, I use my left hand like a right angle.

Dr. Ronald Boris:

And I'll actually cut down the capsule of the kidney. Then I continue to go ... if I can, all the way around the tumor until the capsule is broken. And now I'm going to use my partner in crime, the bedside assistant to push down on the renal bed, as I try to get onto that capsule and sweep it out of the base. One of the tricks that I don't do here but you can do if you're not able to get safely down to the base of the tumor is you can cruciate the kidney parenchyma. So you can split the parenchyma here.

Dr. Ronald Boris:

Which gives you a little crack down to the base, and what you'll see whether you're doing this open or robotically is these tumors have little tiny feeding vessels, if you're doing it open, you'll use little metal mini clips. A lot of times robotically, you can just use your bipolar, and what I try to do is just roll that kidney out and try to free up those little tiny vessels that are feeding the base, and then you'll see me go bipolar, cut it bipolar, cut it and then continue to release and roll on the back out.

Dr. Ronald Boris:

And you can see me do that four or five times. You're off clamp, so you're [inaudible 00:16:10] here, you can work as long as you need to, as long as the bloodletting is reasonable to free it up, and eventually you get it up and running, and it rolls right out. And oftentimes you don't have to clamp ... the masses, especially for the smaller tumors. So, again I'm using more heat because that's the kidney pseudocapsule and the tumor is released. So this is an example of a thinner pseudocapsule, it's another papillary tumor, but this one has a thin capsule.

Dr. Ronald Boris:

This is a 50 year old male, with a little bit of an elevated creatinine, and a four centimeter papillary tumor. So I want to illustrate this. Now, this is another tumor enucleation. And the same type of concept. So you can see here a bigger mass over on the right side, very classic for papillary in terms of its enhancement. So again, the same type of move where I'm trying to use my left hand and strip down the capsule and fall right onto the pseudocapsule of the tumor.

Dr. Ronald Boris:

Some tumors are easier than others. At this point, I've actually already clamped the kidney, this is a mass that I'd be a little uncomfortable trying to do off clamp, especially a solitary mass. So, one of the interesting things about papillary, you can see here that yellowish papillary look, you always want to be a little careful with papillary because the pseudocapsule can be very thin, and you can easily break it and get into the tumor.

Dr. Ronald Boris:

So it's one of the things that I get a little nervous about with tumor enucleation for papillary renal cell cancer specifically. But you can see here, the tumor, and again, I'm finding that perfect pseudocapsule plane. And the other thing is not to get stuck in one spot, but to really work broadly. So once I find the right plane, I'll try to widen that out all the way to the right, and then all the way to the left, once that plane is accessed. And then I'll go a little deeper, go wide, go deeper, go wide until ultimately I get on the base of the kidney.

Dr. Ronald Boris:

Again, the same concept, you want to find your little mini vessels, you bipolar them and release them, and then sweep them down. Then I'll try to again go out wide because you don't want to get too combed in and break the tumor capsule. And ultimately, once you get on the base of the tumor, then you really or have the thing on the run. And then a lot of times just your left hand broadly pushing up will give you all the exposure that you need. Your assistant which is bedside is always giving you counter-traction and pulling away.

Dr. Ronald Boris:

Then eventually you see the heat here that I'm using on the kidney pseudocapsule, which I can freely fulgurate, and ultimately release the tumor. And you can see this big tumor, big papillary tumor here that now essentially has been enucleated. So I think when you talk a little bit about tumor enucleation, and I see some of the questions guys, I just want to get maybe through the talk, and then we can address them.

Dr. Ronald Boris:

I think historically, tumor enucleation was created for hereditary renal cell cancer. These initial tenants were essentially tumor removal, at that time little regard for tumor margin, renal parenchyma preservation and limiting hilar ischemia. You can see some examples up here of some VHL tumors, and this is hereditary papillary renal cell cancer. We also know that partial nephrectomy is evolving and we're learning that ischemia and renal parenchymal volume preservation are both very key components to preserving function and that ipsilateral are operated on renal unit.

Dr. Ronald Boris:

So both of these things can contribute to salvage of that kidney function. And this was some work that we did earlier looking at specific pseudocapsule characteristics as they pertain to certain renal tumor subtypes. So clear cell which you can see here is very consistent tumor subtype capsule, thick fibers capsules. Papillary which you can see up here, tends to have this very wide breadth of pseudocapsule, you can have a very thick pseudocapsule like I illustrated in the first enucleation case.

Dr. Ronald Boris:

Sometimes that capsule falls out completely and it can be very thin and you have to be careful when you enucleate the papillary renal cell cancer, and interestingly, the oncocytic tumors and the chromophobe tumors have essentially no pseudocapsule at all. So again, these are interesting observations when you look at these tumors specifically. Its pseudocapsule is a thick rim of tissue that separates normal parenchyma from the tumor. This is an example of a perfectly enucleated tumor from the Italian series.

Dr. Ronald Boris:

This is an example of one of my hybrid tumors. Again, you can see the stripped capsule, you can see the renal parenchyma, and then you can see the exposed bare area of the base of the tumor pseudocapsule on the hybrid tumor. So can we judge quality of tumor enucleation? And I would argue that it seems like we're getting towards that. So there's some nice work on what's called the SIB score or the Surface-Intermediate-Base score from the Italian group and the Fox Chase group.

Dr. Ronald Boris:

Which is a way that surgeons can assess the quality of their enucleation resection. And this was some work we did with the Loyola Group looking at the penetration or involvement of the tumor pseudocapsule by the tumor, which may be able to correlate with overall oncologic outcome and local recurrence. So when you look at most of the data on sporadic tumor enucleation, it comes from Italy. And there's been a lot of fairly extensive publications looking at improve urine leak and bleed rates, very minimal differences in complications, the ability to take on more complex tumors.

Dr. Ronald Boris:

And it's suggested that enucleation not only is safe, but potentially can widen the indication for nephron sparing surgery. When you look at functional outcomes, this was some nice work from the Loyola Group, showing almost 50% rates of being able to do off-clamp partial nephrectomy with tumor enucleation. And you can see consistently that tumor enucleation can preserve more parenchyma, than standard partial nephrectomy. And this can translate to more preserved EGFR. What about oncologic outcomes?

Dr. Ronald Boris:

So this is some more Italian data looking at comparisons with whole kidney removal and standard partial nephrectomy, and in each case, the technique itself did not predict progression for your cancer-specific survival. What about the positive margins? Is the enucleation positive margin better or in this case, less worse? And I would argue that it is. So if you look at an example of an enucleated tumor, you see the pseudocapsule, the pseudocapsule falls off, and now the tumor is a budding, the inked margin and this could be considered a positive margin.

Dr. Ronald Boris:

But when you look at a standard partial nephrectomy and you have normal kidney and tumor, this is an example of a gross positive margin. And this is a little bit more worrisome. So I would argue that the tumor enucleation is not a zero margin, but rather a microscopic margin technique. And the idea of keeping the enemy closer by staying on the tumor itself is beneficial. So the reality check is are you really going to enucleate everything? So here's what I do, I really don't perform enucleation on most renal masses.

Dr. Ronald Boris:

Why? Because most renal masses are a single tumor in someone who's never had surgery. And most of these patients are going to receive a standard partial nephrectomy. But, I do try to consider enucleation in these scenarios, multi-focal disease with or without poor renal function, solitary kidney, patients with poor renal function. And then I cherry pick tumors like we all do. A tumor that I know is going to have a good capsule, like a clear cell renal cell cancer or a very exophytic tumor, these are good candidates for tumor enucleation.

Dr. Ronald Boris:

And I would argue that I commonly default to hybrid enucleation, which allows you to take out bigger, more challenging tumors. So that's really my summary on tumor enucleation. I do briefly want to thank Mohammad Mahmoud, our fellow who helped me a lot with the video editing for which I would not have been able to present today. So, that's what I have for today Ketan.

Dr. Ketan Badani:

Ronnie, thank you very much. That was awesome. I think that last slide is very helpful because I think I feel the same way as you do. I [inaudible 00:24:19] put it down on a slide and had my thoughts organized that way. So that was really nice. While we load up, we'll have time at the end to have questions. But while we load up, Dr. Munver's slide I'll ask you one that the audience has been asking. What do you do in the case of a tumor rupture or a spillage in these enucleations? How do you damage control that situation?

Dr. Ronald Boris:

Yeah, so I would say two things with that. Sometimes, the more common scenario is actually that you just can't find the plane, and you struggle and struggle and struggle and that's really an easy fix. I think the nice thing about tumor enucleation is that, you just say, "Screw it." And you move further away and then you essentially convert to more a standard partial nephrectomy and take a wider base. If I'm doing enucleation, or for that matter any standard partial nephrectomy and I get into the capsule, it really depends how that happens.

Dr. Ronald Boris:

Aa lot of times the tumor's already mostly out, and you get into the capsule, and at that point I wouldn't change anything other than I would essentially immediately bag the specimen. And then wash out the base a little bit more aggressively. If it happens while I'm getting the tumor out and it's still in the bed, I think at that point I would just do a wider resection in that area and try to include more coverage with that tumor as it comes out. Hopefully that's helpful.

Dr. Ketan Badani:

Yeah, no, thank you. Dr. Munver. The spotlight is yours.

Dr. Ravi Munver:

Thank you Ketan. I want to echo Dr. Boris's appreciation for you Ketan and [inaudible 00:25:53] as well as Chandru and the entire and the entire endourological side and SURS for allowing me to present today. So the topic you've given me is Robotic Partial Nephrectomy for Hilar Tumors. And I'd like to share some interesting cases as we move through the presentation. So, just like Dr. Boris who gave an excellent presentation, you want to think about, "Well, who are the patients who are adequate patients for identifying and treating these renal hilar tumors with partial nephrectomy?"

Dr. Ravi Munver:

So, the things that I think about, are obviously size, everyone thinks about the size of the tumor, but the location is also equally important, especially whether it's anterior or posterior, endophytic or exophytic, and the spatial relation to the surrounding vasculature. And then intra operatively, you want to think about whether you're going to approach this transperitoneal or retroperitoneal, how you're going to place your trocars, whether you're going to clamp the artery, the artery and the vein, or do selective clamping.

Dr. Ravi Munver:

In terms of reception, whether you're going to do enucleation, which Dr. Boris eloquently and elegantly presented or excise the tumor. Then in terms of the reconstruction, how best to reconstruct the parenchyma, when you've excised these tumors. So surgeons, it's very important to mentally reconstruct these images into a three dimensional image from the 2D CT and MRI images. So in terms of trocar placements, essentially no different over a transperitoneal approaches, you're looking at a right sided approach, whether I do it for a hilar tumor or for an anterior or a posterior tumor, upper or lower pole.

Dr. Ravi Munver:

Let's see, so this first case is a patient who had a posterior hilar tumor. So said interferometry score of 9ph, so his posterior and hilar. So if you look at the images, you can see that it's a posterior tumor, it's completely endophytic, and it's hilar in nature. So, I approach most of these tumors transperitoneally. I feel it gives me more space, and allows me to mobilize the kidney. And as you can see in this video, we first start by identifying the hilum, isolating the artery and the vein.

Dr. Ravi Munver:

In this case, the patient had three renal arteries, and one renal vein. And then after that, you would proceed by flipping the kidney, so freeing the lateral attachments, and then isolating the area of the hilum and intra renal ultrasonography is of extreme importance. So, the first thing when you identify the tumor, you want to remove the perinephric adipose tissue. So, free the tissue, and it gives you an access to the renal parenchyma. And again, placing the ultrasound probe you can see at the bottom of the screen, is the tumor itself.

Dr. Ravi Munver:

And the excision is essentially facilitated with the assistant, to score the capsule. In this case, the patient had three renal arteries, and I ligated all three of the arteries. This is ligation of the main renal artery. And the surgeon can do this himself or herself or can use the assistant to place Bulldog clamps. This is placing a clamp on the second artery. And then you'll see there's a third artery, he's applying the lower portion of the kidney.

Dr. Ravi Munver:

I didn't want to take my chances in this case to identify which of the arteries was actually supplying the area of the tumor, so I felt that a bloodless field in this scenario is going to be most helpful for me. So you can see that the arteries are clamped and now we're flipping the kidney and looking at the posterior aspect, and I injected ICG in this patient. I wanted to make sure that there is no blood flow to the area of the tumor, as you can see, there is no blood flow in this area. The renal caps has already been scored.

Dr. Ravi Munver:

I like to use [inaudible 00:30:01] just to get through that initial portion of the capsule, and then I essentially use cold scissors to excise. I want to make sure that I'm not getting into the tumor itself. I start in an area where I can see some parenchyma. And as you take this dissection deeper and deeper, it's a combination of excision as well as sweeping the tissue off. So it is of this partial enucleation technique. And you can see the renal sinus fat right here in the center.

Dr. Ravi Munver:

But because we clamped all three vessels, there is no bleeding identified at all. And this allows me to verify that I had a good adequate margin visually. And I first start by sewing the base. I like using V-Loc sutures for the base. So this is a 3/0 V-Loc suture that I used. This is the renal sinus fat, and this is a portion of the parenchyma here. Obviously these hilar tumors do originate from the parenchyma, even though they invade the hilum, so not the entire base is secured to parenchyma.

Dr. Ravi Munver:

And once I've sutured the base, then I'll proceed with the [inaudible 00:31:05] runner fee. And this is one of the more complicated parts because you have to think about how to bring the capsule back together, whether you bring it from lateral to medial, or from cephalad to Caudad. In this case, we had parenchyma in the most caudad portion of the excision, and at the most cephalad portion.

Dr. Ravi Munver:

And you can see in this area on the right, this is all renal sinus fat, so you don't want to be bringing any sutures through the renal sinus fat. So in this case, I like using interrupted sutures, I use a 0 Vicryl suture on a CT-1 needle, and place them in an interrupted fashion, so I can bring them together. The reason why I don't do this in a running fashion is because I feel that if any of these sutures break, you still have the other sutures that are still there securing the capsule, and when you unclamp, if there is bleeding, it still allows you to place additional sutures in between to allow you to secure your [inaudible 00:31:57] ) runner fee "renal fee"

Dr. Ravi Munver:

And I know a lot of surgeons have gotten away from using hemostatic agents in these cases, I'm still a big fan of Floseal, it's gotten me out of trouble on many occasion. So after I placed my [inaudible 00:32:13] renewal sutures, I will place some Floseal in the center of the defect and then I will unclamp at that point. And if there's no bleeding at that point, I will place LAPRA-TY clips over the Hem-o-loks to make sure there's additional security and the procedure is completed at that point.

Dr. Ravi Munver:

So I want to talk a little bit of 3D anatomical modeling. Intuitive Surgical has an application called Iris. And this allows a 3D modeling of the kidney from 2D 3 CT scan images with a maximum slice width of three millimeters. So you have to have fine cuts on the CT scan. These images are delivered to an iOS device either an iPad or an iPhone. So you can preoperatively analyze and assess the tumor, and then intraoperatively using Tile Pro, these images can be inputted into the robotic console.

Dr. Ravi Munver:

So this is an illustration of a patient that had a hilar tumor. You can see the CT images on the left and the MRI images on the right. The MRI was obtained because the CT wasn't clear in terms of whether this tumor was originating from the kidney itself, or from or whether it was extra renal in origin. So, using the Iris system, you can remove different planes, in this case, you can see the tumor with this vasculature.

Dr. Ravi Munver:

And by looking and orienting yourself, you can see that the tumor clearly is hilar, it is originating from the renal parenchyma itself, it is pushing against the collecting system. And by these images on the left, you can see by removing different planes, you can have a better identification in terms of preoperative planning and what you're going to expect intraoperatively. So this next case is an anterior hilar tumor with a renal score of 10ah. And you can see in 2018 this patient was a 76 year old female with diabetes and hypertension, who was really advised by her urologist to watch this 1.8 centimeter tumor in 2018.

Dr. Ravi Munver:

Well, over the course of time, the tumor grew to 2.9 centimeters, and it was still hilar in nature. And the patient decided at this point even though she was in her 70s, because she had some compromised renal function, did not want to lose that kidney and [inaudible 00:34:36] to undergo partial nephrectomy. And in this instance, I was able to use the Iris imaging. The tumor looks a lot smaller than it did and actually was because, this tumor was based on the 2018 CT scan images.

Dr. Ravi Munver:

As I said, at present, you can only use CT scan for the Iris 3D reconstruction. So, this shows the hilar location of the tumor, but this was when it was 1.8 centimeters, the tumor was actually 2.8 centimeters at the time of the resection. And this is what it looked like intraoperatively. Once again we use renal ultrasonography to identify the location of the tumor. But using the Iris technology, we were able to have an idea about where the tumor was, you can see the tumor in the lower portion of the screen with the ultrasound.

Dr. Ravi Munver:

And it's really important to have a good identification with intraoperative ultrasonography. So, those of us who are not comfortable with renal ultrasonography, it's important to get a good grasp of that technology because, in order to score the parenchyma, you need to really make sure you have an adequate resection. I used to do these cases laparoscopically before 2006, and these hilar tumors were very complicated. And I remember a saying or someone saying that, "You only have one chance for an adequate resection."

Dr. Ravi Munver:

I think with robotics, it gives us the opportunity to resect these tumors, and even if you get into the capsule as Dr. Boris mentioned, you can still go out and get that better plane of resection. So in this case, I chose to ligate the renal vein as well with a Bulldog clamp. And because I knew how deep this tumor was, how endophytic it was, I really needed [inaudible 00:36:24] as possible. So, using a partially enucleation fashion, especially when you get down to the renal sinus fat, I wasn't sure whether this was tumor or not.

Dr. Ravi Munver:

So I took an additional margin at the base. And that margin came back negative unfrozen section, got into the collecting system here, which I closed individually with the figure of eight, using the 3-0 Vicryl suture. And once the collecting system was closed, then performed a [inaudible 00:36:51]. You can see that there was a pretty big cavity within the kidney, and it was important for me to create a nice watertight clamshell closure for this patient.

Dr. Ravi Munver:

Once again, I used interrupted 3/0 Vicryl sutures. And in terms of closing the defect, you can see in this case I went from cephalad, to caudad upper pole of the kidney is here, lower pole of the kidney is right here. And once I was able to do the closure, I used Floseal again, I felt much comfortable, it really does penetrate into the parenchymal tissues. And it gives me that little extra security when I can sleep at night and all of us have been in the situation of these difficult cases and making sure these patients don't bleed and don't have leaks afterwards.

Dr. Ravi Munver:

And this is just an example of the [inaudible 00:37:46] coming with my 0 Vicryl sutures. And once the defect was closed ... The number of sutures you place is really dependent on how comfortable you feel, in terms of how the kidney parenchyma is coming together. Some people will choose to place maybe three sutures in this defect, I'll place maybe four sutures. But the key is once I've placed my parenchymal sutures, I will come off clamp at that point.

Dr. Ravi Munver:

And I will see if there's any bleeding. If there is any bleeding at that point, I can place additional sutures and still while it's unclamped and then make sure you have that security. So I think that's a real benefit of coming off. I wouldn't say it's coming off early but, this warm ischemia time for this case was about 23 minutes and a little bit longer, I had to take my time really getting that deep margin because it was completely endophytic, and I also wanted to make sure I had a positive margin.

Dr. Ravi Munver:

So I waited for that pathologist to give me that go-ahead before I was able to close that collecting system and the parenchyma. So I'm going to move on to the next case. This was also an anterior hilar tumor. This was a 4.8 centimeter tumor in a gentleman who did not have any renal insufficiency. So again, you might think, "Well, why didn't I do this case as a radical nephrectomy?" But the patient was very adamant. And he was young, he was 42 years old, he really wanted to preserve renal function.

Dr. Ravi Munver:

And you can see the location on the left of the renal mass and the coronal images on the right. Again, using Iris, I was able to identify this patient had two renal arteries and the upper pole or the main renal artery, branched significantly in the area of the tumor. You can see the branches of the renal vein also surrounding the tumor. This is just an intraoperative image. This is some fat overlying the tumor, and this is the Iris image on the right, showing the same representative image.

Dr. Ravi Munver:

As I mentioned, this patient had complex vasculature. This was a branch of the main renal artery as you can see through the tumor, you can see that this branch was primarily supplying the tumor, using the Iris imaging, and this is the case you can see the tumor in the lower ultrasound portion. It's an anterior hilar tumor as I mentioned. And as we progressed through the case, we were able to first clean off the hilum, we identified the vein which you'll see very shortly.

Dr. Ravi Munver:

And my thought process in this case was, since I had this imaging, I knew that I was going to be finding two arteries. And in this case, I chose to do selective clamping. I did not clamp the lower pull artery, and I didn't even clamp the main renal artery, I actually clamped that branch of the artery that supplied the tumor. And you'll see that very shortly. So here's identification of the vein. Very fortunate I had a good assistant. In this case, one of my fellows was assisting me as I did this operation.

Dr. Ravi Munver:

To give you an idea of the Iris technology, it was launched last year, at least we were the second institution to my knowledge to acquire the Iris technology. And we've been using it for almost all of our partial nephrectomies. And, this is really helpful in this case. You can see branching of the vein here, which allowed me to really peel the tumor off of the renal veins. And this is something for these hilar tumors, sometimes it seems that the mass is on the vessels, and you're thinking, "Well, if I have to cut, I'm going to have to cut into the vessels."

Dr. Ravi Munver:

But you'd be surprised at how well you can peel these tumors off of the vessels. The tumors generally do not invade the vessels from the outside, they invade the vessels from the inside. So in peeling this tumor off, I was able to locate the branch of the artery that actually supplied the tumor. So this is just continuing the dissection process. And I was able to place the ultrasound probe, you can see the tumor in the bottom of the screen. And then right here where I'm pointing, I'm looking at the main artery right here.

Dr. Ravi Munver:

What I did was, I placed a Bulldog clamp on the arterial branch that supplied the tumor. I also placed another Bulldog clamp across a venous branch, as you saw the complex venous vasculature that supplied the tumor. And then once I had my Bulldog clamps, we injected ICG. And you can see that the kidney's lighting up, but the portion where the renal mass did not receive any blood supply. So it gave me some confidence in being able to perform this procedure with selective clamping. And this is where I think the Iris technology as well as the Firefly technology was beneficial in this case.

Dr. Ravi Munver:

So what I did at this point was I said, let me just take that renal artery branch that supplied the tumor because, the rest of the kidney, as you saw was vascularized. So we choose the vascular stapler, we came across that arterial branch and the venous branch to the mass itself. And once we ligated and transected those branches, we were able to proceed with the partial nephrectomy. And I wasn't as concerned with time here because, I cut off the blood supply to the tumor, knowing that the rest of the kidney was receiving vasculature.

Dr. Ravi Munver:

So then as we proceeded in the dissection, you'll be able to see the portion of the mass that was attached to the kidney, which is right here, this is the portion attached to the parenchyma. And this portion of the mass was actually the hilar portion. And you can see we essentially have a nice plane, there's a little bit of bleeding because there are probably some accessory vessels that are supplying some of the watershed area. But in general, I was able to do this without having to clamp the main artery or the main arteries in this case, and the main renal vein.

Dr. Ravi Munver:

And once the mass was excised, similarly, as you can see a little bit more bleeding because this was selective arterial clamping, but I took my time in resection, I wasn't pressured in terms of resecting this mass. And similarly to the other cases, we were able to do our [inaudible 00:44:23]. And again, this is one of the more challenging aspects because you can see a parenchyma here, and there's also parenchyma right out here, but in this portion at the bottom of the screen, that's where the hilar portion really is.

Dr. Ravi Munver:

And there's no parenchyma where you can really so to definitively. And once again, I applied my ... I guess my pillow that allows me to sleep at night, I applied the Floseal and then was able to get control and came off clamp at this point and saw that there was no bleeding. So, as technology emerges, we're really able to offer our patients with latest advances in surgical innovation, and the Firefly technology is instrumental for these hilar cases. The Iris technology, I think is amazing.

Dr. Ravi Munver:

And it really allows us to have a three dimensional perspective of these tumors before we go in, and allows us to plan and then intraoperatively furthermore, it allows us to really have some more confidence in doing these cases where we otherwise may have jumped to offering patients a radical nephrectomy. So I want to thank you for letting me share some of this technology, as well as these interesting cases.

Dr. Ketan Badani:

Thank you, Robbie. That was great. And again, I want to thank both of you for giving excellent presentations on the topics you were assigned. And the quality of your videos, I think the cases were really nice, you were able to pick out good examples for what you were both trying to show and the quality was good. So, we just have 10 minutes or so, 11 minutes left. So I'm going to go through some of the questions that the audience has asked. And then if we have time, we can ask our own. But I'd like to give the audience a chance to get an answer.

Dr. Ketan Badani:

So I'll ask the first one, maybe since you've been quiet for a little while Ronnie, let me ask you the first one. How important in terms of local recurrence is rupture of a thin pseudocapsule on a papillary tumor? Do you worry about that? Do you survey them differently? Is there something different you do if you cause a rupture at the time?

Dr. Ronald Boris:

Yes, I don't know that I ... first of all, I do worry about it. I think that one of the basic tenets of tumor resection is to not rupture anything. And I think one of the concerns with the papillary tumors just with how somewhat soft they are in their nature is, unlike a clear cell, if you get into it, you might just make a little defect in the capsule, with a papillary tumor, if you get into it, you can literally look like you're squeezing a toothpaste tube and you can see the tumor coming out.

Dr. Ronald Boris:

And it's pretty scary, and it all happens pretty quickly. So, I would basically tell you intraoperatively, don't panic, get it out quickly, get it into a bag. Then, I don't really follow them any differently. I really feel like most of the time, it's the biology that will drive recurrence. It's leaving gross tumor behind but it isn't necessarily a ruptured capsule. At least I haven't found that in my own personal experience.

Dr. Ketan Badani:

Yeah, that's fair. Dr. Munver, some people talk about just doing a completion nephrectomy, if you cut into a tumor or you have a margin or you have a tumor rupture. I think that given today's talk, I feel like that's not what Ronnie does based on what he said, it's not really what I do. But, do you do that or is it wrong to do that? What's the philosophy on just doing the nephrectomy if you rupture a tumor?

Dr. Ravi Munver:

Right. Absolutely. I think there's a lot of literature that shows that even when you cut into the tumor, if you correct while you're doing that case, you can effectively get that tumor out. And the chance of recurrence is really minuscule. We're talking less than 1% chance. Now, if you have gross tumor, you've ruptured that tumor, you've got spillage everywhere, I think at that point, you may want to consider doing a completion nephrectomy.

Dr. Ravi Munver:

But even then, if you spill tumor cells all over the place, you're trying to suction all of the visible tumor up in that case, you may be more likely to have no advanced disease. But I think for the take home point is that, if you get in, you need to recognize that immediately, and I think all of us have done that at some point in our careers, where we immediately recognize it and we correct, and if you correct and you can get that tumor out and get a negative margin.

Dr. Ravi Munver:

A famous surgeon once told me, you only have one chance for a negative margin, and I think we probably all know who that is. But, regardless, I think robotics allows us more than one chance. Laparoscopically once you got in that was it, you're doing a nephrectomy, robotically you cut in you recognize it, you can correct right then in there and get a clean margin.

Dr. Ketan Badani:

Yeah, thank you. Thank you. Next question, quick answers to this one. Dr. Boris first, what do you think about fulgurating the tumor bed once the tumor is out, not necessary for bleeding but micro positive margin if you're enucleating or if you rupture?

Dr. Ronald Boris:

So, I do it. I think there's a distinction between fulgurating the open sinuses and collecting system, I do not do that. But I do usually fulgurate the exposed the peripheral rim of the parenchyma that I see on the bed. Easy to do. I don't think you lose anything by doing it.

Dr. Ketan Badani:

Then you use ... Ravi, I'll ask you techniques of fulgurating if you're going to fulgurate. Any tips or tricks on how to do that?

Dr. Ravi Munver:

Yeah, absolutely. I'll do the same thing sometimes, but it's really for the parenchyma. I flip the scissors upside down, so you get the greatest surface area of the scissors to touch the parenchyma. I'll turn the [inaudible 00:50:14] up really as high as possible because you really want to get as much thermal energy as possible. And just like Ron said, you want to stay away from the collecting system. And from the deep portion.

Dr. Ketan Badani:

Yeah, absolutely. Next question. Do you have to bring the cortex together? Re perfusion makes the kidney turgid, so you get some rigidity of the kidney and causes more ischemia. And again, there's some interesting work out there where people are not, doing the second layer [inaudible 00:50:47] there was a video actually on the RUC Facebook group of somebody who routinely is not doing it. What do you guys think? Do you have to bring the capsule together? And does that compromise renal parenchymal volume and function?

Dr. Ronald Boris:

I can answer this. I don't think you have to bring it together. There actually is some data from some of my partners at IU that have looked at this, there probably is some preserved parenchyma by not bringing it together. Maybe there's somewhat of an ischemic effect when you do bring things together. The issue is for me again, it's a lot of this, like Ravi suggested early, it's sleeping at night, it's safety, it's the ease of closing the parenchyma robotically and then electing not to do it.

Dr. Ronald Boris:

It's probably not for me. And that's just how I would leave it. I don't know what how Ravi feels about it.

Dr. Ravi Munver:

Right. I think for the superficial tumors, people have done it where they've just cauterized, but there is a risk of bleeding. When we were doing these laparoscopically, we did this one case where we just excised superficial tumor, we put some Floseal and some Gelfoam right on the tumor, patient came back to the OR 3:00 in the morning, had three liters of blood in the abdomen. And the Gelfoam that we had placed actually was just floating around in this area.

Dr. Ravi Munver:

So, you just need to use the technique judiciously. If it's very superficial, I think it's fine not to close. For the deeper tumors, I really feel you have to get that closure, otherwise you will risk bleeding.

Dr. Ketan Badani:

Yeah, and I'll just add one thing we just published a paper looking at parenchymal volume preservation. And just real quickly, and this goes back to what Dr. Boris was saying, there's a direct relationship between how much normal kidney is excised during the partial and ischemia time, and there's actually a very volumetric relationship between ischemia time and parenchymal volume excision, and it has less to do with that second layer.

Dr. Ketan Badani:

So short of a randomized study to actually look at that, I think this was for me good data to suggest that, I don't feel like I'm compromising kidney function by doing a second layer. All right so, what is the issue? Okay, reasonable question. What's the issue in correcting the problem in laparoscopy? I think that's referring to the one time you get to get a positive margin Ravi that you were saying. I guess that more has to do with just the mechanics of being able to do the micro dissections and do the small maneuvers, right?

Dr. Ketan Badani:

Is that what you were referring to?

Dr. Ravi Munver:

Exactly. I think because you don't have the dexterity of the robotic instruments, that once you get that positive margin, it's much more difficult to be able to correct and move your instruments around the area to get underneath, for example, and for example, if you've come to that positive margin at the base, and you have to get a thin sliver of tissue to get an adequate parenchymal margin, it's much easier to do it robotically to be able to lift up with one instrument and be able to cut.

Dr. Ravi Munver:

You just don't have the dexterity laparoscopically that you do robotically.

Dr. Ketan Badani:

Yeah. And not to say that there aren't really tremendously skilled laparoscopic surgeons that do it. That's for sure a fact and no one's saying it can't be done. But I think it's reasonable to say that, by and large, it is far more difficult for a urologist as a whole to do that, that we're not trying to say it's not possible. Dr. Boris, Dr. Chin is asking, how do you pre judge from the scans if the pseudocapsule is thick enough for enucleation? You had mentioned that was one of your criteria. How do you do that?

Dr. Ronald Boris:

So, [inaudible 00:54:28] biopsy obviously that would answer those questions for you and I don't routinely do biopsies in all of my partials. I do rely on the CT scan. We did look at this several years ago about the ability to actually predict histology from looking at the scan. There are some consistent characteristics with clear cell renal cell cancer with how they enhance, with how the capsule thickness looks. And there's also some distinction with papillary, especially non clear cell renal cell cancer.

Dr. Ronald Boris:

There's been some work looking at the capsule on MRI, that can actually show you if there's suggestion of T3 disease. So you can use MRI to look at the integrity of the capsule. But it's not a perfect science, but I do use that CT scan to help gauge the safety of at least considering tumor enucleation.

Dr. Ketan Badani:

Great, thank you. And I just want to make sure the audience knows if we didn't get to your question, or if you think of a question, you should really plan on joining us on Wednesday, this coming Wednesday at eight o'clock on the Facebook group RUC, and we'll be able to talk more with Dr. Boris and Munver and one of Dr. Boris's mentors, right? Is going to join us-

Dr. Ronald Boris:

[crosstalk 00:55:45].

Dr. Ketan Badani:

... from Syracuse. And he's done a lot of this work. So, we're going to have a chance to talk more, and honestly if you have questions, post them in the feed now. And so when we get to the show, we can start answering your questions right away, and it'll be first on the docket. So you'll get an answer from the experts. So I really encourage you to join, post your questions, post your videos, and we'll give you a chance to talk about them at the next visit on Wednesday. So, with that, Dr. Boris Dr. Munver, tremendous job.

Dr. Ketan Badani:

Thanks for putting relatively tough topic to find the right cases to demonstrate what you want to say. But you guys were able to pull it off in a very nice and elegant way. I hope the audience found it as interesting as I did, and we'll talk some more next week?

Dr. Ronald Boris:

Yeah. Thanks so much for having us on Ketan, it's been a lot of fun.

Dr. Ketan Badani:

All right-

Dr. Ravi Munver:

Thank you so much. It's a pleasure.

Dr. Ketan Badani:

All right. Bye-bye.