Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, our discussion is highlighting renal cell carcinoma and single-port robotic surgery.

Joining me is Dr. Goutham Vemana. He's a urologist with Allegheny Health Network. Dr. Vemana, thank you so much for joining us today. I'd like you to start by telling other providers the scope of the issue we're discussing here today. Speak a little bit about renal cell carcinoma and the prevalence that you see.

Dr. Goutham Vemana: Yeah. Renal cell carcinoma is the most common type of kidney cancer that we see. It is a solid tumor that occurs from the kidney itself. It is fairly common in the United States. It is the ninth most common type of kidney cancer among men, and the 14th most common type of cancer among women. There are about 80,000 new cases of kidney cancer being diagnosed per year, and about 14,000 people die from the disease per year. The lifetime risk of developing kidney cancer in men is around 2% and is about 1.4% in women.

Melanie Cole, MS: That's interesting. It's not something we hear as much about, right? It doesn't get as much play and airtime, which is why it's great that we're discussing this today. So, how's it identified? When does it become apparent? Speak about clinical presentation and what would even send someone to primary care or Urology? 

Dr. Goutham Vemana: Yeah. So, the thing about kidney cancer is that most of the time these are being found incidentally, meaning that somebody's going into the emergency room, they're coming in for abdominal pain, nausea. They think it's maybe a gallbladder issue or an appendix problem. They're getting CAT scans, MRIs, ultrasounds for other reasons, and you're finding these masses on the kidney that don't generate any symptoms. So, it can become somewhat difficult to diagnose these primarily. But oftentimes, primary care doctors are ordering these tests and they're seeing them pop up when they're looking at patient's results. And that's how we get most of the referrals for kidney cancer or kidney lesions or masses. And then, the primary care doctors are usually referring them to us in these situations. 

Melanie Cole, MS: Thanks for clarifying that these are very often found incidentally when checking for something else. So, let's talk about treatment options. And as we think of the evolution of robotic surgery techniques in treating many things, but renal tumors specifically, tell us a little bit about the current standard treatments for this and how robotic surgery fits into these options. 

Dr. Goutham Vemana: The treatments for kidney cancers are primarily surgical. And prior to the advent of robotic surgery, many people were getting surgery on their kidneys with larger open incisions. And this was obviously a much more difficult way to recover, but it was a fairly technically challenging process. So, the conversion to minimally invasive surgery was somewhat difficult. It was hard to do complex surgeries with just pure laparoscopic surgery, meaning that these were long sticks that you're basically operating through small trocars.

With the advent of robotic surgery, this allowed us to do much more complicated surgeries through these smaller incisions. And initially these surgeries were done with what's called a multiport robot. So, multiple small incisions made throughout the body to gain access to the kidney, and this is a predominant way of doing it even now. And this allowed us to do complex surgeries of the kidney in a very expertly done way. This has then kind of been refined where some of these surgeries are being done with something called a single-port robotic surgery platform, and these are both made by Intuitive Surgery. So, the single-port robot, basically you make like a two and a half centimeter incision, which allows us to pass this new robotic device into somebody's body. There are four arms that go through this small incision and allow us to do a fairly complex set of surgeries with one tiny incision.

Melanie Cole, MS: Isn't that interesting and what an exciting time in your field as these things really are advancing. So, speak a little bit more about the single-port partial nephrectomy and the benefits to, as you said, the multiport is still being done, but speak about the benefits not only to the patient, but also to the surgeon. 

Dr. Goutham Vemana: Yeah. So, one of the things that single-port robotic surgery has allowed is it's allowed surgeons or urologists specifically the ability to treat kidney cancer in something called the retroperitoneum. And the retroperitoneum is a space where the kidney lives, which is actually outside of where all the intestines and the other abdominal organs live.

So, this kind of replicates how urologists did these surgeries back in the day with an open incision on the side, which was called a flank incision. And this allowed you to do all these kidney surgeries without even violating the abdominal compartment. So, the nice thing about the single-port robotic platform is that it's a little bit easier to get access to this special space, the retroperitoneum. This is highly advantageous because you can do these complex surgeries without disrupting those organs or let's say somebody's had numerous previous abdominal surgeries and, traditionally, if we're going to do these surgeries, we'd go through the abdominal compartment and you'd have to worry about adhesions, risk of injury of bowel, bowel injuries. So, we can avoid all that by getting access to the retroperitoneum and we can do very complex surgeries and we don't have to worry at all about injuring those intraabdominal organs. The other thing is that you can do all of these complicated procedures with a smaller incision, and this does translate to less pain in the recovery setting, and it's a little bit easier to get patients home the same day.

Melanie Cole, MS: So as long as we're speaking about how it translates into clinical outcomes and recovery, what about follow up? What about after the fact? What have you seen, Dr. Vemana, as far as how this is translating to better outcomes for patients.

Dr. Goutham Vemana: Yeah, so what I've observed personally from doing these surgeries over the last couple years is that, one, patients do get home faster. They tend to have less pain afterwards and they also return to full activity a little bit faster as well. We tend to be conservative in surgery about what patient's activities are, but the beauty of doing a retroperitoneal surgery is that your risk for getting a hernia is extremely low. And so, patients are returning back to a more robust level of activity within just a few weeks rather than six weeks or more.

Patients are kind of doing a normal activity. They're getting back to work faster. So, the advantage is fairly significant to the patient and the provider because patients are much happier afterwards. You don't have to give them as many pain medication afterwards. It's been very, very advantageous. 

Melanie Cole, MS: What about technical considerations and learning curves for other providers? 

Dr. Goutham Vemana: It definitely is a steeper learning curve, I think, than the traditional robotic surgery. and the reasons for that is you have to think about how you do surgery a little bit differently with this platform. The movement of this robot is maybe not as wide as the other traditional multiport robot. And it requires a little bit of extra specialized training.

But with that being said, the platform is being adopted across the country a little bit more than it has been recently. So, there are now residents who are being trained on this platform. Our residents at Allegheny General are learning how to operate on the single-port robot platform. So, they're getting experience. So, they will likely be able to go and practice and use this platform as soon as they're done. 

Melanie Cole, MS: Dr. Vemana, before we get ready to wrap up, and you've given us a lot to think about and it was really an informative episode, what would you like other providers to take away, the key messages? And the future of robotic surgery heading in the direction of renal cell carcinoma, where do you see it heading? Where would you like to see it head? 

Dr. Goutham Vemana: Yeah, I see that, whether it's the single-port or the multiport, I do think that more surgeons are going to probably be picking up this technique to do treatment for kidney cancer. I think that it's important to find somebody who has good experience in doing it. I think it's great coming from a training program that has good experience doing it like our program. I think that we will be seeing more and more complex surgeries being done with a single-port robotic platform. We're already seeing that at specific centers around the country. I think we'll continue to see that.

I think the huge benefit here is that makes it more likely that patients are going to get a partial nephrectomy rather than losing their whole kidney. And this is advantageous because some patients don't tolerate that well. They may have some underlying kidney dysfunction or other risk factors that we really don't want to take their kidney out. And by doing these surgeries in the retroperitoneum and you have access to doing these complex tumors, it is going to lead to much better patient outcomes in the end. 

Melanie Cole, MS: Thank you so much, Dr. Vemana, for sharing your incredible expertise with us today. And to learn more or to refer a patient to Dr. Vemana, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.