Surgery Options

Minimally Invasive Kidney and Partial Kidney Removal

Unlike other urological cancers, such as those of the bladder or prostate, the main treatment for kidney cancer is surgery. These two factors – the rarity of kidney cancer’s occurrence combined with its smaller treatment options – means advanced expertise in treating this cancer can be as uncommon as the disease itself. Fortunately, that experience is available at the Siteman Cancer Center where our team of urologic surgeons is leading the way in kidney cancer care.

The laparoscopic urologic surgery program at Siteman treats more than 200 patients with kidney cancer each year, making it one of the largest kidney cancer practices in the world. These patients benefit not only from the expertise passed down from the pioneers in the field but also from the ongoing refinements and discoveries made by current leaders in laparoscopic urologic surgery. In fact, the world’s first kidney removal using laparoscopic surgery was performed in 1991 by a team of urologic surgeons at Washington University School of Medicine. Since that time, this minimally invasive technique has become the surgery of choice for kidney cancer treatment. The three small incisions needed to complete the procedure substantially reduce patients’ pain and discomfort and hasten their recoveries. The procedure is a vast improvement over the large incision and rib removal required during traditional surgery.

In addition to being pioneers in laparoscopic kidney surgery, clinicians continue to integrate into the program the most advanced techniques and instrumentation available for this procedure, steadily decreasing surgical time, and increasing safety and efficacy. Laparoscopic nephrectomies (kidney removal) and partial nephrectomies are now routinely performed in two to three hours, rather than the usual three- to five-hour time span, without compromising safety.

This is important since the number of partial nephrectomies is increasing as tumors continue to be identified at earlier stages, well before symptoms develop, usually by a CT scan done for another reason. A study completed at Barnes-Jewish Hospital during 2004-2005 showed that the average size of a kidney tumor at diagnosis today is 4 centimeters, compared to 8 or 9 centimeters in the 1970s. Patients with these smaller tumors are ideal candidates for partial nephrectomy. With high blood pressure and diabetes increasingly common diseases, the ability to remove a tumor while saving half or two-thirds of a patient’s kidney is an important goal. But the innovations in partial kidney removal have kept coming.

Robotic Cancer Surgery: Surgery to remove certain tricky tumors is no longer a hands-on operation. Many Siteman cancer surgeons, instead of standing for hours with arms raised above the patient, are at a nearby computer console maneuvering joystick-like controls that guide robotic scalpels, scissors and high-resolution cameras. Introduced to Siteman Cancer Center in 2008, the da Vinci Surgical System allows surgeons to operate through just a few small incisions, using a magnified 3D high-definition vision system and tiny wristed instruments that bend and rotate far greater than the human wrist. This enables your surgeon to operate with enhanced vision, precision, dexterity and control. Using the remote controls, the surgeon is able to turn his or her hand movements into smaller, more precise movements of tiny instruments inside your body.

The computer-controlled system also eliminates surgeons’ hand tremors, however minute. And the robot provides an exceptional view of the surgical field. The surgeon sees the tumor and surrounding structures in high magnification. Dual miniature cameras restore the depth perception of an “open” surgery, which is lost in standard laparoscopy. Because surgeons remove the entire tumor using robotic surgery, there’s no need for further chemotherapy or radiation treatments. Surgical applications for robotic surgery at Siteman Cancer Center include colorectal cancer, gynecologic cancers, kidney cancer, prostate cancer, and certain head and neck cancers. Robotic surgery means less pain, smaller scars, minimal blood loss and a faster return to normal activities.

In the case of kidney surgery, robotic surgery is more efficient and precise than either open or laparoscopic surgery for tumors confined to the kidney, and has gotten considerable usage.

Siteman surgeons have become adept at removing kidney tumors laparoscopically with long slender instruments inserted through small incisions. Robotic surgery to remove only the tumor and surrounding tissue also dramatically decreases the likelihood that the patient eventually will develop renal failure.

Percutaneous Cryoablation: Even with advances in laparoscopic nephrectomy, some patients are not candidates for any surgery due to failing health or age. Siteman Cancer Center is one of only two major centers in the Midwest offering percutaneous cryoablation, a procedure that involves inserting probes through the skin to freeze tumors in the kidney. Currently this procedure is appropriate only for small tumors or for patients who have no other alternative. But because the technique holds promise for being the least debilitating kidney cancer treatment with the fewest side effects, Siteman’s laboratory research is focused on expanding its application for the future.

Laparoscopic Colectomy

Siteman surgeons were the first in the area to perform laparoscopic colectomy for cancer. These surgeons were part of an international team that determined the minimally invasive procedure is as safe and effective as standard open surgery for most patients with cancer confined to the colon. They are leading a similar multicenter study of laparoscopic approaches to rectal cancer through the American College of Surgeons Oncology Group (ACOSOG). More than 60 percent

of our colorectal surgeons’ clinical volume involves laparoscopy. If your cancer is confined to the colon, your surgery will be less invasive and your recovery time shorter.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgical (TEM) excision, a surgery initially only offered at Siteman, allows for the removal of benign polyps and early cancers from the rectum. The approach is minimally invasive and allows better visualization and access to nearby lesions than traditional methods. It is also being used in appropriate patients to remove more advanced cancers in conjunction with radiation therapy. TEM was developed to avoid the effects of radical surgery for adenomas and early-stage rectal cancer, while still allowing for complete removal of the lesion. TEM requires specialized instrumentation that uses the natural opening of the anus to reach the tumor, and is a valuable surgical technique with a low complication rate for patients with appropriate rectal lesions. The main advantages of TEM are preservation of normal function for bowel movements, low complication rates, short operation times, lower blood loss, shorter hospital stays, and shorter recover times. Advantages for the surgeons include better exposure, magnified stereoscopic view, and greater reach into the middle and upper rectum.

TEM can be used as a curative operation for rectal polyps that can’t be removed during colonoscopy. It has become accepted as a procedure for benign adenomas and potentially for early cancers of the rectum. Low recurrence rates have been reported for adenomas treated with TEM.

Finding and Removing Small Primary Head and Neck Tumors

Often patients who are diagnosed with a head or neck cancer come in with a swollen lymph node that turns out to be metastasized from an unknown primary tumor. Surgeons at Siteman utilize a grid-search approach to finding small primary head and neck tumors. Human papillomavirus tumors can be only one to three millimeters, below the resolution of PET or anatomic imaging, yet still metastasize to adjacent lymph nodes. The grid-search technique examines tissue in the tonsils and tongue with a powerful endoscope and telescope, and finds the tiny primary tumor 90 percent of the time. With such tiny tumors, the surgeon can use the laser right then to remove it with transoral laser microsurgery, without external incisions, lessening the chances of further spread. This approach has dramatically reduced the need to do follow-up radiation on the throat, avoiding long-term radiation problems.

Transoral Laser Microsurgery: A diagnosis of cancer of the mouth or throat can be especially devastating. Chemotherapy, radiotherapy and surgery to treat the condition can dramatically alter facial appearance and threaten the ability to swallow, talk, eat, smell, taste, hear and even to breathe normally. These effects can be significantly reduced through the use of an operating microscope. It affords a close-up view of the tumor site, allowing pinpoint accuracy while removing the diseased tissue. New surgical techniques that don’t require cutting through the skin and muscle of the neck, giving access through-the-mouth, are getting patients out of the hospital faster, controlling the cancer better, and preserving mouth and throat function more effectively.

So when a patient’s circumstances permit, Siteman surgeons remove throat and mouth tumors transorally, using instruments specifically designed for insertion through the open mouth. With this technique, a lot of the guesswork is eliminated as the tumor is cut out piece by piece with the laser until all traces are gone. Nearby tissue is disrupted to a lesser degree. The microscope increases the certainty that the doctors have eliminated all cancerous tissue. A recent study in patients treated by transoral laser surgery showed that after two years, none of the patients in the study have had a primary tumor recurrence.

Head and neck surgeons at Siteman have helped manufacturers create many of the original instruments, and later, to develop one that would allow viewing and performing laser surgery around a corner, enabling removal of even more types of cancer. With the ongoing improvements in the surgical technology for transoral laser microsurgery and the compelling data suggesting this is an effective cancer-curing procedure, it is available to any patient who is suitable for the technique.

Sleeve Resection for Lung Cancers

Surgeons remove lung tissue based on the extent of the cancer. A wedge resection is the smallest, taking only the tumor and a clear margin around it. A lobectomy is used to remove one lobe of a lung where the cancer is larger or centrally located. A pneumonectomy removes a whole lung. Specialized techniques such as sleeve resection and segmentectomy are aimed at removing the tumor in a way that spares as much lung tissue as possible.

Siteman Cancer Center has one of the busiest dedicated chest surgery units in the country. They remove an entire lung only when absolutely necessary. Instead, they are adept at the sleeve resection in which cancer in the main bronchus (or wind pipe) is removed and the ends reconnected to salvage healthy parts of the lung, saving more lung tissue and preserving normal function. This procedure requires much more skill and experience than a pneumonectomy, but the benefits to patients’ quality of life following surgery are usually significant.

Anesthesiologists who assist the surgeons specialize in heart and chest surgical anesthesia. A full-time pain management team monitors and manages post-operative discomfort. Complementing these surgical services are anesthesiologists and nurses who specialize in thoracic surgery as well as a nursing unit specifically designed for the care of these patients.

Video-Assisted Thoracoscopic Surgery for Lung Cancer

Washington University’s thoracic surgery program is known worldwide as a leader in lung transplantation, lung volume reduction surgery, lung cancer surgery and other thoracic procedures. The department was the first in the St. Louis area to perform minimally invasive video-assisted thorascopic surgery (VATS). Siteman surgeons are adept at VATS, a type of thoracic surgery performed using a small video camera that is introduced into the patient’s chest via a scope. The camera and instruments are inserted through separate small holes in the chest wall, greatly reducing the chance for infection and healing problems from a large incision. Many lung cancer procedures are done this way.

Some patients are good candidates for a video-assisted lobectomy, which involves the removal of part of a lung. In traditional lobectomies, incisions can be 6 to 10 inches long, and surgeons sometimes need to saw through the sternum and spread the ribs. For a VATS lobectomy, small 1- to 2-inch incisions in the right flank allow the insertion of a state-of-the art camera and instruments to carefully remove the portion of the lung that contains the tumor. The video equipment provides optimal light and magnification to allow the delicate surgery to be completed through the tiny incisions without removing or breaking ribs or cutting any muscles. In addition, nearby lymph nodes are removed to ensure that the cancer has not spread to the rest of the lung.

Mohs Micrographic Surgery for Skin Cancers

New treatments for skin cancer have been appearing and evolving rapidly in recent years. However, one surgical technique has more than stood the test of time. Developed by Dr. Frederick Mohs in the 1930s, Mohs micrographic surgery has, with a few refinements, come to be embraced by an increasing number of surgeons for an ever-widening variety of skin cancers. Today, Mohs surgery has come to be accepted as the single most effective technique for removing Basal Cell Carcinomas and Squamous Cell Carcinomas (BCCs and SCCs), the two most common skin cancers, especially for tumors on the face or other areas where disfiguration could be an issue. It spares the greatest amount of healthy tissue while also most completely removing cancer cells. Cure rates for BCC and SCC are 98 percent or higher with Mohs, significantly better than the rates for standard excision or any other accepted method.

Mohs differs from other techniques in that microscopic examination of all excised tissues occurs during rather than after the surgery, thereby eliminating the need to “estimate” how far out or deep the roots of the skin cancer go. Used at Siteman mostly for tumors on the face, Mohs surgery involves cutting the tumor from the skin in thin layers. During surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible.