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0:00so we're gonna talk about preventing
0:02positive margin to two techniques that
0:05you can use to do so reminder of the
0:07annual nurse in Vegas February tonight
0:09hopefully your calendars are all marked
0:11you're planning to come look forward to
0:13seeing you there so one of the items you
0:19know from having certains come and visit
0:21and talking about partial nephrectomy is
0:22one of the things that i found from
0:25discussions that prevents people from
0:27taking on more and more challenging
0:29partial nephrectomies is the fear of a
0:31positive margin a tumor that's so big or
0:33so deep and they're afraid of getting
0:35into it meaning that there are people
0:37who are just not comfortable that they
0:38can identify where the tumor is before
0:42they start cutting into the kidney and
0:43in the complication session i'll show
0:46you a nice example of that later but I
0:51think being more confident about your
0:53ability to localize the tumor before you
0:55start cutting it out is gonna help you
0:57and make you feel more confident taking
0:59on challenging and more complex partials
1:01so that's why this this topic is
1:04important it's not just for the purposes
1:06of getting a negative margin it's for
1:07the purposes of being more confident and
1:09taking on more challenging cases and
1:12there's two different ways that that you
1:14can do this number one and probably the
1:16most important thing that I can tell you
1:17is that this is something that you need
1:19to do before you start cutting into the
1:20kidney meaning that there are some
1:22people who kind of wing it they're just
1:23like ultrasound okay good enough mark it
1:25all right here let's go and then they
1:27just kind of wing it figure it out as
1:29they go oh I think I got into the tumor
1:31I'm gonna change no look look before you
1:33start cutting the kidney make sure you
1:35know where that tumor is is I was saying
1:36during the live case you know I think
1:38those of us who have done a bunch of
1:39these and for you probably the same case
1:41if you've done a bunch of these you're
1:43trying to make a 3d picture in your mind
1:45where that tumor is before you start
1:47cutting the portion of the tumor that's
1:48in the kidney that you can't see you
1:50have to visualize in your head where it
1:52is so that you know the direction that
1:54you need to cut the stay out of it and
1:55the way you do that predominantly is
1:57with ultrasound and I'll show you
1:59because we don't have good education on
2:02how to use laparoscopic ultrasound I'll
2:03show you my tips and tricks for how to
2:06do so so all of us do this all of us use
2:11the ultrasound
2:12to identify the edges of the tumor
2:14that's what Jim was showing with the
2:15tumor that he did basically we place the
2:18ultrasound we move it around until we
2:19find the edge of the tumor and then we
2:21mark the capsule the kidney and
2:23typically this is something that you'll
2:27do obviously on every tumor and
2:28everybody does this routinely but the
2:30question that is sometimes asked is do
2:33you have to do altar sound on every
2:34tumor do you have to do elder sound
2:35every time you do a partial nephrectomy
2:36and again I've had visiting surgeons who
2:38have told me that look our Hospital
2:40doesn't own the ultrasound we have to
2:41rent it it costs us $2,000 or whatever
2:43so sometimes I'll do a partial and I
2:46won't get the ultrasound just save the
2:47money for the hospital I say don't like
2:49that don't do that do the ultrasound in
2:51every single case to me it's not a
2:53luxury item it's a necessity and even if
2:56you think you have the easiest partial
2:57in the world and that there's no reason
2:59to need an ultrasound for this still do
3:01it because every time you use the
3:03ultrasound you get better at doing
3:05ultrasound and sometimes you'll be
3:07fooled you'll think it's a very easy
3:09tumor and from the outside you think
3:11it's gonna be straightforward then you
3:12do the ultrasound and you're surprised
3:13so I'll give you an example so here's a
3:15tumor that I think most people would
3:17look at and they say okay this is gonna
3:18be like an easy chip shot tumor I don't
3:21need to do ultrasound here I can see
3:23where the tumor is I'm gonna cut it out
3:24no problem and if you were estimating
3:27where you needed to cut to get to the
3:29deep portion of the tumor you would say
3:30well it's probably right about here
3:32because this is how much is sticking out
3:33I look at my CT it's about 50% exofit
3:36'ok so if i just mark it around here and
3:38i cut here i'll be fine but then look
3:41what happened when we did the ultrasound
3:42and we saw something very different so
3:48here you see the tip of the probe so
3:49I've cleaned off this much fat thinking
3:51that I was going to cut where I put the
3:52arrow but then look I'm putting the
3:54ultrasound there's a projection of tumor
3:55out here that goes beyond where I
3:57thought so here's the tip of the probe
3:59at the edge of the tumor and it's way
4:01out here beyond where I had cleaned off
4:03the fat so I was actually much further
4:05out than I originally expected from the
4:06outside of the kidney so the ultrasound
4:09saved my booty in this case because I
4:11would have cut in the wrong place and I
4:12would have ended up in the tumor so I
4:14ended up having to clean off more fat
4:16off the kidney here so that I could cut
4:17out here rather than where I originally
4:19intended to cut much closer and there
4:22right there is the edge of the tumor so
4:23the edge that's where I need to cut
4:25to get around the tumor in fact you have
4:26to cut a little bit further to get a
4:27negative margin much further than I
4:29thought so this is an example of where
4:31the ultrasound can save you even though
4:34you think you might have an easy tumor
4:37so use the ultrasound in every case you
4:40use it like we saw here to find the edge
4:42of the tumor mark the capsule but
4:45there's another move that you should be
4:46doing with the ultrasound that isn't
4:48really talked about very much and in
4:50fact I've heard people like very
4:52prominent surgeons at big meetings who
4:55have said the opposite who have said
4:57that look when you do the ultrasound you
4:59always want to keep the tip of the probe
5:00perpendicular the kidney and you want to
5:02sweep with the probe perpendicular does
5:03anybody ever heard that before that's
5:05what they tell you it's not true don't
5:07listen I wanna tell you something very
5:09different
5:10so yes you want to start that way so
5:12you're gonna do that sweep with the
5:14probe perpendicular to the surface of
5:16the kidney to identify the edge of the
5:19tumor and mark your capsule once you've
5:21done that now take the probe and put it
5:23at the edge and rotate the head what
5:26does that do that tells you the
5:27direction that you need to cut so the
5:29ultrasound is not just to tell you where
5:31the edge of the tumor is the ultrasound
5:32can also tell you the direction that you
5:34need to cut to get around the tumor so
5:36for example we marked here on the
5:37capsule we were sweeping we marked here
5:39but then do I need to cut down this way
5:41to get around the tumor or do I need to
5:42cut out this way which direction I need
5:44to go by rotating the head until I see
5:47the edge of the tumor I can tell that I
5:48need to cut this way and not this way
5:50and this way would be very bad so when
5:55you combine those two you get a much
5:57better idea again about that deep
5:59surface of the tumor which direction you
6:01need to to cut to get around it so
6:03here's a video example of that this is a
6:06left upper Pole medial tumor and you'll
6:09see that we're gonna do this experiment
6:11with the ultrasound probe we're gonna
6:13lay the ultrasound probe at the edge of
6:15the tumor and then we're gonna rotate
6:17the head as you can see here we're
6:18rotating the head there's tumor tumor
6:20tumor tumor tumor or no tumor that's the
6:23direction I need to cut so no tumor or
6:28no tumor no tumor or no tumor will
6:30rotate until we see the tumor and that's
6:33the direction that we need to cut so
6:34you'll see here the tumor will come into
6:35view right here so
6:37that's the direction that we need to go
6:39on that topside we don't need to go out
6:41but we also can go in we'll get into the
6:43tumor and now on the bottom side same
6:45thing
6:45where's the tumor here's the tumor now
6:47we'll rotate until the tumors gone boom
6:49that's the direction I need to go so on
6:51that bottom side I have to cut pretty
6:53much straight perpendicular into the
6:54kidney I don't have to cut down to get
6:56around the tumor but I also can go up at
6:58all I got to go straight across on this
7:00bottom side and then up here I'm gonna
7:02make the wedge basically down like this
7:04this way and I got a negative margin
7:06make sense so again this is something
7:08that nobody teaches you because nobody
7:09really taught us how to do laparoscopic
7:10ultrasound we just had to kind of figure
7:12it out on our own but this is a critical
7:14thing and it becomes even more critical
7:16when you have a completely under fitting
7:17to mer when you have a completely
7:19undefended tumor you don't have any
7:20external cues whatsoever so this is just
7:23a video you can't see the tumor
7:24obviously but basically what I'm gonna
7:25show you here in this pretty old video
7:27is that I'm using ultrasound probe and
7:29this is the laparoscopic my assistant is
7:31rotating it and I'm looking to see where
7:33the tumor goes away and then in my
7:34mind's eye you're gonna see what I do
7:36here I'm pointing I'm saying okay I got
7:37to cut this way here I got to cut that
7:39way there so this is just illustrating
7:40that in my mind's eye I've done this
7:42ultrasound and I'm figuring out the
7:44direction I need to cut from both
7:45directions from above and below the
7:47tumor to get a negative margin so this
7:50is critical so again before you ever
7:52start cutting the kidney do this so that
7:54you know where to go and so you don't
7:56get lost so that's one thing the other
7:58thing too for reducing your positive
8:01margin rate is using the Firefly anyone
8:05in the room here using Firefly to assess
8:07their margins nobody that's exactly
8:12yesterday roomful of about 50 urologist
8:14nobody was using it for that purpose
8:17intuitive what's going on man nobody's
8:19using all right that's okay I'm gonna
8:20help you out let me ask this question
8:23because there's another question I
8:24always pull the audience on so this is
8:27what Firefly this is what I call
8:28differential fluorescence the idea that
8:30the tumor does not fluoresce and the
8:31kidney fluoresce is green so this is
8:34what it looks like an white light here
8:35it is with the Firefly view here's the
8:38tumor it's non green here's the kidney
8:40it's green if I could give you this 90%
8:44of the time 90% of the time I can
8:46provide you this property where the
8:49tumors not floor
8:50singing the kidney is so as you cut into
8:51the kidney you see green you know you
8:53have a negative margin how many of you
8:55would use Firefly for this purpose and
8:57would feel that it could help you with
8:58your positive margin rate several people
9:01so I'm going to show you how this works
9:03how to do it and then I want you to go
9:04home and try it now I'll tell you that
9:06the vast majority of surgeons don't use
9:09this and I'll tell you why now the
9:12really high-volume highly experienced
9:14surgeons will tell you what we just
9:15don't need it our positive margin rates
9:16really low and that's true but honestly
9:19a lot of them tried it early on and
9:21couldn't get it to work and so they gave
9:22up so when Firefly first came out I was
9:26asking around and everybody was tell me
9:28yeah we we don't use it anymore we
9:29couldn't get it to work the reason why
9:32they weren't able to get at work I'll
9:33show it to you here in a second but if
9:34you look in the literature you'll find
9:36you know several papers that saying that
9:39it doesn't work for this purpose you
9:40know show camels done a lot of papers a
9:42lot of cases with the Firefly didn't
9:45find any difference in the positive
9:46margin rate but honestly they weren't
9:48getting it to work they were getting
9:49hypo fluorescents but they weren't
9:50getting that a fluorescence which is
9:53what we want so this is how it's
9:55supposed to work but I'm gonna show you
9:56an example of it working and then what
9:59people do wrong that can make it not
10:01work so here's an example on the SI
10:04robot so this is the older robot and
10:06you'll see here we give the green the
10:08green is coming in and then we look at
10:11the kidney and then here's the tumor not
10:13green and here's the kidney green that's
10:15exactly what we want here's an example
10:19on the next iRobot the Firefly was much
10:22improved on the X iRobot as is the HD so
10:25that's why it looks so much better but
10:27you'll see here we give the ICG and
10:32obviously here's the tumor now here
10:34comes the green so the green now the
10:37kidney is going to turn green the tumor
10:38doesn't turn green so this is the
10:44property we want now watch how it
10:45functionally works as we do the
10:47resection watch how I use this to do the
10:49resection so now here I am cutting I'm
10:51getting to the deepest portion of the
10:53tumor and now I want to check my margin
10:55and if it's green then I keep going
10:57green means go so I'll just be flipping
11:00in and out of the fire
11:01it's all green look at the tumor tumor
11:03not green margin green that's a negative
11:07margin now I checked my specimen before
11:08I'm done all green that's a negative
11:11margin so again if you could have that
11:1490% of the time how many people would
11:16want to have that property it's a
11:19no-brainer it's a no-brainer
11:21but you got to get it to work now here's
11:23why yes you can no no you can do it you
11:34can do it I'll explain that at the end
11:36I'll explain how you can do both all
11:38right so here's why it doesn't work
11:40here's why a lot of people gave up on it
11:41it's because this happened and so they
11:44said I'll forget it I'm not going to use
11:45this thing so here's a tumor again this
11:48is the SI robot visit before we figured
11:50it out so it's an old case and you'll
11:53see her here to the tumor and then now
11:54we give the green here's the green look
11:56kidneys green tumors not green awesome
11:58we're in great shape right but now
12:00what's happening oh oh wait a minute no
12:02what's going on
12:03the tumors turning green oh no it's
12:05useless there's no differential
12:07fluorescence anymore now everything is
12:08green so any guesses why that happened
12:12too much the dose exactly it was the
12:15dose we overdosed the ICG and that's why
12:18the tumor turned green and that's the
12:20key issue here is the dose of the ICG
12:24when the Firefly first came out there
12:27was no recommendation on how much I CT
12:30to give because it wasn't FDA approved
12:32for this purpose it's still not so the
12:33intuitive guys won't people be able to
12:35really give you much direction on this
12:36because it's only FDA approved for
12:38perfusion assessment when you do
12:40perfusion assessment it doesn't matter
12:41how much you give you can give one CC to
12:43CC makes no difference
12:44the early papers that were looking this
12:46for example a chokes paper they were
12:48using two to three CCS of ICG two to
12:53three CCS the correct dose you may be
12:55surprised to hear is a half a CC so two
12:59to three CCS is way too much way too
13:02much so this dose is way too high even
13:04if you look at the insert that comes
13:06with the ICG from intuitive again
13:08they're talking about perfusion so
13:09they're telling you one CC to CC still
13:12way too much so
13:13use that dose you're gonna overdose and
13:15you're gonna get green tumors and it's
13:16useless to you so there's a sweet spot
13:19if you give too much the tumor turns
13:21green it's useless if you give too
13:23little the kidneys not green enough it's
13:25useless
13:25there's a sweet spot in between but the
13:27dose is critical so we published this a
13:30while ago I'm gonna tell you how we
13:32dosed this but we published this on the
13:33SI robot back in 2013 Journal of Urology
13:37you can look up the paper for the
13:38details but the long and the short of it
13:40the summer is that if you use a half a
13:43CC of ICG on the SI robot 90% of the
13:46time you'll get differential
13:47fluorescence half a CC on the SI robot
13:52what we found is on the x irobot we had
13:56to adjust the dose because the firefly
13:58got better so when we first got the X I
14:00robot a few years ago I started using
14:03the same dose half a CC and all of a
14:05sudden all the tumors are turning green
14:07and I said hey what's going on here so
14:09what we figured out is that you actually
14:10have to cut the dose by half it's a
14:12quarter of a CC on the X I robot one
14:15quarter of one cc 90% of the time we'll
14:18give you differential fluorescence so if
14:19you're using one CC to CC I guarantee
14:22you you're overdosing every time your
14:23tumors are all gonna be green but with a
14:25quarter CC 90% of the time you'll be
14:29able to get this property we published
14:31this we presented this at the AOA last
14:33year our updated series when we
14:36published the paper was all si cases I
14:38think it was 79 cases now we've done
14:40over 250 and again about 90% of the time
14:43we're able to get it to work and my
14:46positive margin rate is well below 1%
14:48it's the lowest positive margin rate
14:50that I've seen anywhere in the
14:51literature if you can find me a paper
14:52that shows less than point three point
14:54four percent positive Martin rate I
14:56don't think you'll find it but it's
14:58because I use this and because I can see
15:00grossly negative margin before I go home
15:02I sleep very well at night knowing that
15:04I have a negative margin without any
15:07pathologist or anyone else so here are
15:08some examples so here's my tumor that
15:11I've cut out so here's the tumor surface
15:13this is the kidney surface I flip it
15:15over and this is what I'm looking at any
15:17guesses on whether this is a negative
15:18margin or not sometimes when you cut
15:20deep into the kidney you got these weird
15:22things and collecting system here and
15:24there and
15:24pyramid you don't even know what the
15:25hell you're looking at but with the
15:27Firefly I know exactly what I'm looking
15:29at the tumor wasn't green when I flip it
15:31over it's all green it's a grossly
15:34negative margin I know for sure that I'm
15:36going home with a negative margin here's
15:39another example so here's the flipside
15:41the underside of the tumor and I'm
15:43looking over here I'm saying is this the
15:44pseudo capsule of the tumor did I get
15:46too close to it nope because it's green
15:48this was just a renal pyramid that was
15:50projecting into the collecting system
15:52its parenchyma it's a negative margin
15:54here's another example so in this
15:57example you can see this is the pseudo
15:59capsule of the tumor this is what it
16:00looks like when you get too close it's
16:02not green anymore so I'll show you how
16:04you use this to adjust your margin as
16:06you're going so here's the tumor is not
16:09green here's the kidneys green and then
16:11as I'm cutting this out I got too close
16:14so what did it look like that told me
16:16hey something's not right
16:17green green green green I lost the green
16:19so what did I do I backed up I made a
16:22new resection angle a new plane of
16:24resection so I ended up with this extra
16:25flap of kidney here that's the new
16:27margin so basically I'm cutting here I
16:29said nope I don't like it I backed up I
16:31went deeper into the kidney here's my
16:33final margin I'm going home knowing that
16:35it's a negative margin here's another
16:38example same thing I was cutting in this
16:39plane I lost the green so I backed up
16:41all the way until the green and then I
16:44started going deeper I got this extra
16:45piece of kidney here there's the final
16:48flap of tissue I have a grossly negative
16:50margin I know I'm going home safe here's
16:53another one here's the external surface
16:54of the tumor not green the kidneys green
16:57as I was cutting I lost the green so I
17:00said oh I don't like it I backed up all
17:02the way till I saw green I made a new
17:04flap deeper resection plane and this is
17:07my final margin all green so I'm leaving
17:10with a negative margin I'm sleeping very
17:12well that night and that's why I
17:14attribute my negative margin rate or my
17:16positive margin rate is so exceedingly
17:17low it's because I don't need a
17:19pathologist to tell me that this is a
17:20negative margin I'm knowing ahead of
17:22time that it's a negative margin so I'll
17:25stop there reminder of the nurse and
17:26then I think we have a couple of minutes
17:27for questions
17:29oh okay great so that yeah let's go back
17:31to that question that was asked before
17:32and then I think Jonathan has a comment
17:34ooh
17:34so the question about using it for
17:37perfusion assessment if you want to do
17:38this so the thing is that once you give
17:41the ICG you have to wait about 10 15
17:44minutes for it to wash out sometimes
17:45longer so what you wouldn't want to do
17:47is you wouldn't want to do your
17:48perfusion assessment and then have to
17:50sit there and wait for it to wash out to
17:52then reduce it to look at the
17:53differential fluorescence so here's what
17:55I do now I use the ICG for differential
17:58fluorescence on every case every partial
18:00I don't do perfusion assessment on every
18:03case you know I'll do the Doppler
18:05ultrasound like I showed you before but
18:06I won't use the Firefly every time it's
18:08more selectively but you can do both and
18:10here's what I do if I want to do both
18:11what I'll do is I'll clamp the artery
18:14that I'm planning to clamp I'll give the
18:16dose of ICG the half CC or quarter CC
18:18depending on the robot then I'll wait
18:20and I'll see the kidney turn green and
18:22the area of the tumor doesn't turn green
18:24then I'll take the clamp off there's
18:27enough ICG still in the circulation that
18:29then the area that didn't turn green is
18:31now going to turn green and I get the
18:32differential fluorescence because I
18:34picked the right dose to begin with so
18:35now I combine the two make sense same
18:39dose because if you give too much if you
18:41give too much for the perfusion
18:42assessment then then when you take the
18:43clamp off now you overdose the tumor so
18:46still use a half a CC or a quarter of a
18:48CC you've got the clamp on once the
18:50kidney starts turning green you've
18:51confirmed that the area of the tumor is
18:53not turning green then take the clamp
18:54off quickly so that the ICG gets into
18:56the entire kidney and then that area of
18:58the kidney around the tumor turns green
19:00so you can still accomplish both goals
19:01Jonathan you had a common absolutely no
19:12that's the pseudo capsule yeah so this
19:15would still be most likely a negative
19:17margin microscopically but if the pseudo
19:19capsules not attacked if the tumors
19:20ruptured through the pseudo capsule
19:22there was a nice paper from Indy Gill
19:23actually where they looked at this
19:24specifically the microscopic t-38 tumors
19:27and they found that there's actually a
19:28pretty good proportion about 15 percent
19:29of tumors where the tumor will actually
19:31grow through the pseudo capsule rupture
19:33into the pseudo castle so grossly you'll
19:36see pseudo capsule but then
19:37microscopically it's a positive margin I
19:38never want that to happen
19:40again I want my patients to have a
19:41negative
19:41every time so that's why when I even get
19:43to close like this I'm gonna take a
19:45little extra print c'mon now is it gonna
19:47affect the patient's long-term renal
19:48function it's not it's not clinically
19:50relevant parenchymal that they need so
19:53my one comment I mean this is great and
19:56that's a good example and I think you
19:58have a nice clean field and you can see
19:59that maybe there's lack of perfusion
20:01there well to be interesting to see if
20:03that was cancer or not in the end the
20:05problem I've always had with this is and
20:07we have engineer here so maybe the
20:08engineer can help answer this is the
20:11deepest part of the tumor where are you
20:12really worried about it is where the
20:14bottom of the two mermaids in this build
20:16ICG right and so what happens is it
20:19coats the surface I mean it turns green
20:21so if you have a tumor and then you are
20:24dipping it as you're cutting it out and
20:25the renewer fee bed which is icy green
20:28blood it turns green this washes right
20:32off so you're constantly irrigating it
20:34yeah yeah I mean like the video that I
20:37showed you obviously wasn't a bloody
20:38case yes it's not bloody it's not gonna
20:40shoes yeah they're coding it but if
20:41that's a concern yes as you're cutting
20:43if you're getting you know kind of ICD
20:46green blood that's back bleeding from
20:47the kidney then you just irrigate it as
20:49you're going and you can still assess
20:51your margin as you're cutting because
20:52it's not gonna stain it's not going to
20:54die the tissue right but it's gonna wash
20:57right off yeah now if you do this and
21:00you have to adjust
21:01that's that flap that you have there for
21:03example how do you communicate that with
21:05your pathologist to capture that well
21:07usually I don't have to because usually
21:09this is what I'm giving them so they
21:11know this is the deepest margin that's
21:13what they Inc but if there's any
21:15confusion about it I'll actually take it
21:17to the gross remand I'll show it to them
21:18I'll say okay look here this is this and
21:19this is this alright so I think we can
21:24move on
21:32what's the next one we don't ask biopsy
21:36strategies all right
22:01so real mass biopsy is a little bit of a
22:05controversial topic so I can't claim to
22:10be an expert on this topic and my
22:13opinion is gospel and not at all there's
22:16plenty of room for discussion
22:19criticism debate on this topic but I'm
22:23just gonna give you my take on this just
22:25a more practical approach to renal mass
22:28by op C and then you can take it or
22:30leave it it's up to you I would
22:32certainly say though that within the
22:34last few years there's been a lot of
22:35talk about renal mass biopsy a lot of
22:38people who have been really championing
22:41it trying to push for it telling us that
22:43we should be biasing all these tumors so
22:45to a degree that I think it's kind of
22:46like a fad that you know people were
22:48saying that renal mass biopsy you know a
22:50new standard of care you know renal mass
22:52biopsy just do it in Journal of Urology
22:54I think you have some people like Jamie
22:57Landman and Stewart Wolfe you know
22:59you've got several of these you know
23:01big-name guys very smart guys much
23:03smarter than me certainly who have
23:06really been telling us that we should
23:07buy of see a lot of these tumors in fact
23:09this is a quote from from Jamie Landman
23:11who I have a lot of respect for and his
23:15suggestion was that in the US only 6% of
23:18patients are getting renal mass biopsy
23:20but probably 94% should get renal mass
23:22biopsy so is that really true do ninety
23:25four percent of patients with a renal
23:26mass need a biopsy of their tumor I'm
23:29gonna argue no but again there's plenty
23:31of room for discussion and debate so
23:34let's talk about what are we trying to
23:36achieve with a renal mass biopsy so
23:39let's start and say okay what would be
23:40the perfect ideal if we had a perfect
23:42renal mass biopsy what would it provide
23:44for us well number one it would tell us
23:46whether it's cancer or benign it would
23:48tell us whether it's aggressive cancer
23:50or a more indolent cancer which is
23:52really your grade
23:53it would have minimal or no
23:54complications and it would be low cost
23:56and easy to do if all of these things
23:58were true then we would probably say
24:00yeah we probably should do biopsies in
24:02the majority of patients so let's look
24:05and see if that's true so I'm gonna show
24:06you a couple large studies this was one
24:09that was published in April
24:10sixteen in European urology it was a
24:12meta-analysis of 57 papers with a total
24:16of 5000 plus patients who had renal mass
24:19biopsy now only seven of these 57
24:22studies specifically looked at small
24:24renal masses which means that there were
24:26majority of the series where including
24:2810 centimeter tumors 13 centimeter
24:31tumors 18 centimeter tumors 20:32
24:33centimeter why would you biopsy at 32
24:35centimeter renal mass well people are
24:37doing it and so a lot of these patients
24:39were those what you need to keep in mind
24:42though is that the smaller the tumor the
24:44less diagnostic the biopsy so if you
24:46have a 30 centimeter mass then yeah
24:48you're probably gonna have a diagnostic
24:49biopsy but the smaller the tumor the
24:51less your differentiation so according
24:53to this paper the sensitivity of a
24:56biopsy for a smaller renal mass is lower
24:58so if it's a four to six centimeter
25:00renal mass your sensitivity is only 84
25:02percent versus ninety seven percent for
25:04all comers well really the small real
25:06mass is the one that we care about we
25:08don't need a biopsy for a 15 centimeter
25:10tumor so if the small renal mass it's
25:12gonna be less diagnostic than obviously
25:15we can't go off of these papers that are
25:16telling us the sensitivity of renal mass
25:18biopsies 94% well yeah but that's not
25:20really true those aren't the ones
25:22reacting in a biopsy so the smaller the
25:24biopsy the less diagnostic but those are
25:26the ones that we care about so that's
25:28the take-home message from that paper
25:30well here's another one so this one was
25:32from May of 16 this was meta-analysis of
25:3520 studies of almost 3,000 patients who
25:37had a renal mass biopsy but 11 of these
25:40studies included tumors that were less
25:44than 5 centimeters that were t1a and
25:46then three of them were less than 5
25:48centimeters so the others there were 6
25:50studies in other words that were
25:52including larger tumors so the same
25:54problem with the other papers that
25:55they're still by seeing some big tumors
25:57that we really probably wouldn't biopsy
25:58but at least 14 of the papers in these
26:0120 were 41a or less than 5 centimeter
26:04tumors which are the ones we care about
26:05again so how likely were they to
26:08differentiate cancer from benign so
26:10again our ideal biopsy is going to tell
26:12us as a cancer or not it's got to tell
26:14us that at least 14 percent of these
26:16were non diagnostic which I'm sure if
26:19you've sent patients
26:20renal mass biopsy you've seen this over
26:22and over again nine diagnostic 4% work
26:24false positive meaning that it told them
26:26that it was cancer but it turned out it
26:28was benign when they took it out the
26:30negative predictive value in this
26:32meta-analysis the negative predictive
26:34value was sixty three point three
26:36percent which means that over a third of
26:39patients that the biopsy said were
26:43benign actually turned out to be cancer
26:45if they had the tumor removed so can you
26:48imagine that a third of the time the
26:50biopsy tells you it's benign but it's
26:51actually cancer that makes me nervous I
26:53don't like that so is the biopsy really
26:56as sensitive as people are telling us
26:59also we said that the ideal biopsy would
27:01differentiate between high grade and low
27:03grade because if we're considering doing
27:05surveillance on somebody we want to know
27:06is it high grade or low grade right well
27:09in only two-thirds of the cases was a
27:11great even given so many times the
27:13pathologist will say well we can't grade
27:14it we don't have enough tissue or we
27:16just can't tell so many times they won't
27:18even give you a grade low grade high
27:19grade 1 2 3 4 in 16% of cases it was
27:23upgraded so they said it was low grade
27:24it turned out to be high grade
27:25concordance concordance studies so
27:28people have looked at concordance of
27:29grade on biopsy versus grade on final
27:31pathology if you look at it there's a
27:33wide range but it goes somewhere between
27:3550 and 75 percent which means that it
27:38could be as often as one and two that it
27:40tells you it's low grade but it's really
27:41high or it tells you it's high but it's
27:43really low so it's a crapshoot in other
27:45words so the biopsy telling us what we
27:48need to know to make treatment decisions
27:50how confident are you in your biopsy so
27:55essentially the grade on the biopsy is
27:57pretty useless is what I'm saying so if
27:59it tells you it's low grade you can't
28:00trust it if it tells you it's high grade
28:02you can't trust it so again from this
28:04meta-analysis looking at even including
28:07large tumors the grade concordance was
28:09sixty-two point five percent if you use
28:11Fortier meaning grade one two three four
28:13if you use just high grade low grade
28:15it's much better it's 87% but still are
28:18you gonna be being able to make
28:19treatment decisions on those patients if
28:21that's your concordance and again for
28:24small renal masses your ability to
28:25diagnose it as cancer or not and your
28:27ability to give a grade it's gonna be
28:29harder for a small renal mass it was
28:32only two-thirds of the time
28:33that there was great concordance if it
28:35was a small renal mass so how confident
28:37again are you to take this to the bank
28:38and make a treatment decision are you
28:40gonna trust it and then we said the
28:42ideal biopsy would have low or no
28:44complications these are the
28:47complications of rates again in these
28:48two thousand or so biopsies hematoma
28:51rates about five percent significant
28:54pain meaning that they needed to be
28:55admitted to hospital for pain one point
28:57two percent hematuria one one percent
28:59pneumothorax i mean that's a pretty
29:01awful complication significant
29:04hemorrhage and then on rare occasions
29:06you have things like AVM or tumor
29:08seating but honestly these are so rare
29:10that we really shouldn't use them to
29:12argue against biopsy so if somebody
29:13tells you well I don't do renal mass
29:15biopsies because of tumor seating I
29:16would say that's not a good argument
29:17it's really really rare but one of the
29:22arguments I would make is that for those
29:23of us who are doing robotic parts for
29:25effect amis how does the complication
29:27rate of the biopsy compared with the
29:28complication rate of robotic partial
29:31nephrectomy my own personal experience
29:33my transfusion rate is less than 1% so
29:35the bleed rate is the same or better
29:37than renal mass biopsy urine leak rate
29:39is well below 1% again I've not had any
29:41patients who have had AVM pseudoaneurysm
29:44or bleeding to need to go to i are most
29:46of these are an overnight stay and the
29:50complication rate including medical
29:52complications is about 5% so it's very
29:55similar to a biopsy so why not just cut
29:57it out and then what about cost so again
30:01the argument is by many people they say
30:03well do the biopsy because it might save
30:05you from spending the money on the
30:07partial nephrectomy if it's a benign
30:09tumor you don't have to take it out you
30:10saved a lot of money
30:11okay let's analyze that and see if it's
30:12true how much does a renal mass biopsy
30:14cost so in this paper in Journal of
30:18endor urology they compared the cost of
30:21renal mass biopsy by ir versus doing it
30:24in the office if ir does the biopsy it's
30:264500 bucks so if it's ctrl' strong
30:29guided by IR it's 4500 bucks which is a
30:31lot if you do it in the office they
30:34could do it for 2,100 bucks which is
30:36obviously a lot cheaper but they didn't
30:38count the complications they're just
30:39looking at the cost of the biopsy so if
30:41there was a complication the patient had
30:42to be admitted or transfused or whatever
30:44they didn't count that so we're just
30:45talking about the cost
30:46actual biopsy so the cost is certainly
30:49much less in the office but in the
30:51office you're gonna only be doing the
30:52easier tumors so even somebody who's an
30:55expert at this Jamie Lanvin whose paper
30:57this is even somebody like him was an
30:59expert at doing office based renal mass
31:01biopsies they're still cherry-picking
31:03the tumors they're doing the less
31:04complex the more EXA FIDIC posterior
31:06tumors so even with these cherry-picked
31:11tumors still twenty one percent were non
31:13diagnostic so that means one in five
31:15biopsies that Jamie did in the office
31:17didn't give a diagnosis it was a waste
31:21so again we said these are the ideal
31:24characteristics that we would want in
31:25renal mass biopsy but are we getting
31:28this out of renal mass biopsy as we do
31:30it today but the main problem again from
31:32a practical point of view the main
31:34problem that I would tell you with renal
31:35mass biopsy is that rarely do I find
31:37that it changes my management and that's
31:39the biggest argument why not to do a
31:41renal mask biopsies very rarely does it
31:43change your management because the
31:44pretest probability of cancer is high
31:46most renal masses are cancer we know
31:48that grading is poor on the biopsy
31:51anyway so it's not going to help me
31:52decide because I'm not going to trust
31:53the grade and in most cases the
31:55treatment decision is pretty obvious
31:57without a biopsy and I'll show you some
31:59examples of that in a minute so
32:01ultimately what I would say is that we
32:03should only do procedures that are
32:05diagnostic if they're gonna change our
32:06management so don't do a CT or an MRI or
32:08renal scan or whatever genomic testing
32:11for prostate cancer don't do these
32:13things unless it's going to change your
32:14management one way or the other don't
32:15just do it cuz you want to so there are
32:17certain cases where I would say just
32:19don't do a biopsy for example this large
32:21renal mass that's in the caiva don't do
32:23a biopsy it's not going to change your
32:24management it's ridiculous to do a
32:26biopsy in that case don't do a biopsy if
32:28you're already planning surveillance on
32:30that patient so if I have an 80 year old
32:32patient with a one centimeter renal mass
32:33on this patient there's no way she could
32:35tolerate surgery anyway why would i
32:37biopsy that tumor if anything it's gonna
32:39make her nervous because it's gonna come
32:41back cancer and now she's gonna say well
32:42you know what do you mean you're gonna
32:43do surveillance I have cancer I'm better
32:45off not doing a biopsy in that patient
32:47tell your look it's most likely cancer
32:48it may not be but we're just gonna watch
32:50it don't do a biopsy if you wouldn't
32:54trust a negative biopsy or if you're
32:57planning to intervene anyway meaning
32:58if the risk of a false negative is too
33:01high then don't biopsy it just take it
33:03out so for example if I have a 40 year
33:05old patient very healthy long life
33:07expectancy and I said to myself okay so
33:09there's maybe a 20% chance that this
33:11thing is gonna say benign but it's
33:13cancer am I gonna trust it no not in
33:16this patient she's 40 years old I'm
33:17taking it out then one get a biopsy so
33:22I'm gonna show you my real-world
33:23experience and make an argument against
33:28renal mass biopsy so this is a series
33:31over the course of three years I did one
33:33hundred and sixty-one robotic partial
33:34nephrectomies of which 87% were
33:36malignant now this is higher than what
33:38you'll find in the literature for
33:39smaller renal masses in particular but
33:42the reason why is because I do active
33:43surveillance so if you do active
33:45surveillance then a higher proportion of
33:47the patients you operate on are gonna be
33:48cancers so eighty seven percent in my
33:50hands are cancer so I do active
33:53surveillance but I almost never biopsy
33:54I'd say less than ten percent of the
33:56time i biopsy so we're gonna look at the
33:57cost in this population of patients if
34:00we did ninety four percent of patients
34:02of ifsc like Jamie recommended so this
34:05is the real world
34:05welcome to the real world population
34:08everyone but you
34:09it's just funny what you can find on
34:11Google all right
34:12so one hundred and sixty one renal
34:14masses and now this is a busy slide but
34:16I'm gonna walk you through it and I'll
34:17kind of you know if anything is
34:19confusing let me know so if one hundred
34:21and sixty one renal masses based on the
34:23meta-analysis the papers that I showed
34:25you
34:25reliable papers European urology Journal
34:27of Urology fifteen percent of your
34:29patients are going to be non diagnostic
34:31which is twenty four so 24 of my 161 if
34:34I buy seed all of these patients twenty
34:36four would be non diagnostic so I might
34:39send them for a rebuy op see because I
34:40really really want to know well on REE
34:42biopsy actually the success rates eighty
34:45three percent according to the
34:46literature so I would still have four
34:48nine diagnostic now I did two biopsies
34:50still have four people non-diagnostic
34:52seventeen of these would be cancer based
34:55on the pretest probability because again
34:56in my hands eighty seven percent end up
34:57being cancer so 17 of these have cancer
35:00they're still having surgery anyway
35:01three of these would say benign but
35:04because of the negative predictive value
35:05of 68 percent one out of every three is
35:08going to really be a cancer so they're
35:09going to keep growing their cancers
35:11I might do another biopsy down the road
35:12Oh actually turned out to be cancer or
35:13it's growing too fast it's still a
35:15cancer we're still gonna do a partial so
35:17that guy's gonna eventually maybe a
35:19couple years down the road is gonna end
35:20up over here all right let's look at the
35:22rest 137 of the 161 are gonna be
35:25diagnostic if their cancer so again 87%
35:28are gonna be cancers so these people are
35:30gonna go to a partial nephrectomy 18 are
35:32gonna be benign and you would say oh
35:33wait now I don't have to do surgery on
35:35these 18 people I just saved 18 people
35:37from surgery out of these 161 but one of
35:39those is a false positive and so they're
35:41gonna have a surgery anyway so one of
35:43them is going to end up being a cancer
35:44and they're gonna go to have a partial
35:46and then you're gonna have again these
35:48false negatives because the negative
35:49predictive value of 68% six of these are
35:51still gonna be cancerous and eventually
35:53are gonna have surgery so of these 18
35:57patients one of them was a false
35:59positive they didn't have cancer but the
36:01biopsy said cancer so I took out that
36:02tumor and of the other 17 there were six
36:06that actually had cancer for the Bible
36:07said benign I'm gonna want to take those
36:09out anyway so how many patients did I
36:11actually save well we did 185 biopsies
36:14because some we had to do more than once
36:15for being non diagnostic we still ended
36:18up treating 148 out of 161 so we avoided
36:2113 surgeries but we did 185 biopsies to
36:24achieve that so what's the cost if we
36:27sent him to IR which I do I don't do
36:28biopsies in the office so if I send IR
36:30for the biopsy I'm spending 4500 bucks a
36:33piece so that's eight hundred and
36:34thirty-two thousand dollars you know but
36:37again if I said ninety-four percent of
36:39patients need biopsy not a hundred
36:40percent then I can cut that down to
36:41seven hundred and eighty two thousand
36:43five hundred fifty dollars what that
36:45translates into is $60,000 per avoided
36:48robotic partial nephrectomy so for every
36:50patient that I saved from a partial
36:52nephrectomy I spent $60,000 what's the
36:54cost of a robotic partial nephrectomy
36:55it's about ten to twelve thousand
36:57dollars so I'm actually spending five to
37:00six times the amount of money to avoid
37:02that surgery compared to doing a partial
37:04and then hey guess what it turned out to
37:06be benign your complication rate was 1%
37:08and you know patients happy doesn't have
37:11to have surveillance scans so I think
37:14this fad is changing I think this this
37:17push to tell us that we need to be
37:18biasing everybody
37:19I think this pressure is now starting to
37:22abate because the recommendations are
37:24now backing us up so this was a nice
37:28paper that came out in European urology
37:30it was a nice kind of consensus
37:33statement from some big-time experts in
37:35kidney cancer who are giving us this
37:37flowchart for when we should do a renal
37:40mass biopsy and this really makes great
37:41sense it's telling us that if lymphoma
37:44abscess or metastasis is suspected then
37:46do a biopsy but how often does that
37:48happen
37:48extremely rare is the patient an active
37:50surveillance candidate yes is there a
37:52clinical benefit to histologic risk
37:54assessment in most cases no in most
37:56cases one of the patients a canister for
37:57surveillance you don't need a biopsy to
37:59tell you that you can just put them on
38:01surveillance without a biopsy
38:02so still most of these patients are not
38:04going to get a biopsy is ablation
38:06planned well if it is then you're going
38:07to do a biopsy at the time of ablation
38:09but again that's the minority of
38:10patients and is the patient treatment
38:13team willing to observe benign lesions
38:15if the answer is yes then do a biopsy
38:17this also includes being willing to
38:19accept the false negative rate so again
38:22if the biopsy tells you benign you have
38:25to be willing to accept that it might be
38:26wrong and that it could be a cancer if
38:28you're willing to accept that then do
38:30the biopsy and follow those patients if
38:32you're not willing to accept that risk
38:33again 40 year old patient for example
38:34then just take it out and most of these
38:37cases though the answers going to be no
38:39no no no no so the vast majority of
38:41patients are gonna be no biopsy and
38:43fortunately the aua came out with
38:45guidelines on this last year you can go
38:48and look at this all of the AOA
38:49guidelines are online at hey you a
38:51network and this is what they're
38:53recommending now is renal mass by
38:55chickens be considered when mes is
38:57suspected to be hematologic metastatic
38:59inflammatory or infectious again that's
39:00rare
39:01renal mass biopsy is not required for
39:03young healthy patients who are unwilling
39:05to accept the uncertainties associated
39:06with renal mass biopsy so again 40 year
39:09old patient with a real mess I'm not
39:10willing to take a one-in-three
39:12you know false negative rate older frail
39:15patients who will be managed
39:16conservatively independent of renal mass
39:18biopsy patients that you're not gonna
39:20operate on anyway even if the biopsy
39:21says cancer don't do a biopsy you just
39:23put them on surveillance and then
39:25counsel regarding rationale positive
39:27negative predictive values potential
39:28risks and not non-diagnostic rates a
39:30renal mass biopsy and then multiple
39:32cores are preferred over f na f na is
39:34useless if your radiologists want to do
39:36an F
39:37don't even bother something to tell you
39:38anything which also counts for cystic
39:42lesions so cystic lesions the diagnostic
39:45rate on a cystic renal mass a complex
39:47cyst is terrible so I don't even bother
39:49I don't even consider it on a cystic
39:51renal mass so I mentioned before that if
39:55you're gonna put a patient on
39:56surveillance you don't need a renal mass
39:57biopsy for that why because when you put
39:59them on surveillance we know from the
40:01natural history of untreated renal
40:03masses on surveillance what their growth
40:07kinetics are and typically the growth
40:09kinetics of our renal mass are about are
40:12going to be less than three millimeters
40:13a year if it's less than three
40:14millimeters a year you can pretty much
40:16take it to the bank that that is
40:17something that you're not gonna have to
40:18operate on so this was one paper that
40:21was published in journal in the gold
40:23journal in 2016 where they looked at a
40:25group of patients that they just
40:27followed and then eventually ended up
40:29doing surgery on them so they took those
40:31tumors out or could it could tell if
40:32they were cancerous or not what they
40:35found was about 60% were grade 1 2 to 40
40:37percent were grade 3 to 3 to 4 so it's a
40:39pretty representative sample and they
40:41found again that about 3 millimeters a
40:43year was the median growth rate 3
40:45millimeters a year is kind of a
40:46reasonable cutoff it was low grade 75%
40:49of the time I figure less than 3
40:50millimeters if it grew more than 3
40:52millimeters a year then the odds ratio
40:54was almost 4 times that it was grade 3
40:56or 4 all right so that's the argument
40:59against real nasty now I'm gonna share
41:00with you some real-world cases so these
41:02are examples from my own personal
41:04practice these are not like you know
41:05cherry picked from you know the internet
41:08or something these are literally my own
41:10my own patients so this is a 45 year old
41:13male with a 5 centimeter right upper
41:14pull mass before he was sent to me he
41:16was sent to IR for a biopsy I would say
41:18why he's 45 he's got a five centimeter
41:21mass why are you by seeing this I'm
41:23doing a partial but guess what happened
41:25afterwards he ended up getting a urine
41:28leak from the biopsy isn't that a
41:31tragedy he didn't need a biopsy in the
41:33first place he got a urine leak from the
41:34biopsy here's a 72 year old woman with a
41:373 point 2 centimeter renal mass she
41:39comes with the biopsy the biopsy says
41:41papillary RCC so now she wants a partial
41:43now honestly if she had come to me
41:45without a biopsy I probably could have
41:46convinced her to do surveillance
41:48now she's coming to me with a biopsy and
41:49it's cancer I've got to have this out
41:51doctor said all right we'll take it out
41:53what did we find at the time of surgery
41:55this is the picture of the ultrasound
41:57intraoperative ultrasound can anybody
41:59tell me what we're looking at this is a
42:03complication of biopsy that will drive
42:05you crazy
42:07this is the tumor right here and this is
42:10all perinephric hematoma it was a
42:14disaster I've had several of these one
42:16of my referring urologist literally
42:17biopsies every single renal mass and
42:19there I are guys I don't know why but
42:21every so often they create these huge
42:23hematomas for me to have to dig through
42:25to try to do the partial so that was
42:30just a video showing how ugly it was but
42:32we'll skip it all right
42:34here's a 45 year old with a two
42:36centimeter renal mass does this patient
42:37need a biopsy well the primary care
42:39physician thought so because the
42:40radiologist recommended a biopsy in his
42:42CT scan so the CT scan report said two
42:45centimeter renal mass recommend biopsy
42:47so the primary care doctor didn't know
42:48better sent the guy for a biopsy what
42:52did the biopsy say benign renal cortex
42:54no neoplasm identified anybody else had
42:56one of these benign kidney on biopsy
42:59yeah because there's a non diagnostic
43:01rate they're not gonna hit it every time
43:03so we still did a partial on him I said
43:06look I don't need another biopsy I'm not
43:07gonna send this guy for a second biopsy
43:09I'm gonna do a partial on him he's 45 to
43:11semi-real mass we took it out it was
43:13cancer we didn't need the bio scene
43:14here's a 33 year old with a two
43:16centimeter renal mass somebody sent her
43:18for a biopsy vibes he said renal cell
43:21carcinoma but unable to determine
43:22subtype did we need a biopsy on this
43:24patient 33 year old with a 2-centimeter
43:26illness I'm gonna take it out either way
43:28I'm not willing to accept the 1 in 3
43:29chance that the Bible would say benign
43:31but it really ends up being cancer 45
43:34year old with a 6 centimeter real mass
43:36also sent for a biopsy why I don't know
43:38I'm gonna take it out biopsy said unko
43:40siddik neoplasm consistent with onco
43:42site Tomah vs. chromophobe RCC
43:44absolutely useless anyone else has had
43:47this before all the time right
43:49chromophobe versus onco site oma they
43:52can't tell you useless 79 year old with
43:55two renal masses in this case again 79
43:58years old two small renal masses I would
44:01just
44:01surveillance in fact I would avoid a
44:03biopsy in this patient because I want
44:04them to be less nervous not more nervous
44:06what did the biopsy say honk Oh site
44:08Tomah vs. chromophobe vs. clear cell
44:10versus papillary RCC absolutely he was
44:13listen these are real-world cases
44:16patients sent to me here's a 72 year old
44:19with a 1.7 centimeter renal mass the
44:23urologist referred him to me did a
44:25biopsy but it was non-diagnostic they
44:26weren't able to get enough tissue to
44:28make a diagnosis so he comes to see me
44:30and I said you know what you don't need
44:32another biopsy but you also don't need
44:34surgery you're 72 you've got this little
44:36tumor we're just gonna watch you what
44:38ended up happening on surveillance the
44:40tumor got smaller
44:41there's the tumor before six months
44:43later I said go away you don't need
44:46anything
44:46so avoided a biopsy here's a five
44:49centimeter complex cystic mass in a 78
44:53year old this person had not one but two
44:56non diagnostic biopsies why why this
45:00doesn't need a biopsy we just put him on
45:02surveillance six months later it hadn't
45:03changed the guy's gonna be on
45:05surveillance for the rest of his life
45:06doesn't need a biopsy here's an eighty
45:09four-year-old with a four centimeter o
45:11mass the referring urologist Senate for
45:12a biopsy and the result was UNK acidic
45:16renal neoplasm the findings could
45:18represent an oncostatin although certain
45:20types of renal cell carcinoma with Anka
45:22set of features ie chromophobe carcinoma
45:23cannot be excluded so again how did this
45:26biopsy help me I could have made the
45:28treatment decisions based on this 84
45:30year old look we're gonna do
45:31surveillance we're just gonna watch it
45:32don't worry don't do a biopsy
45:34so again if you're planning to do active
45:37surveillance on somebody you don't need
45:38a biopsy you just do growth kinetics and
45:40you follow them with scans so that's my
45:43argument against real nice biopsy again
45:45it's not Dogma it's not you know set in
45:49stone it's open to criticism debate you
45:54know alternative opinions again there
45:55are very smart people much smarter than
45:56me who feel the opposite on this but
45:58this is just my own personal
45:59recommendation my own personal opinion a
46:01reminder again about the nerves beating
46:03Las Vegas I'm gonna keep reminding you
46:04because I want to see you guys there and
46:06also for the people online who are
46:07joining us throughout the day and I'll
46:10stop there any questions
46:14everybody agrees I convinced you all
46:17that was easy
46:18man you guys are easy all right thanks
46:20guys

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