New surgical technique provides kinder cut for kidney patient

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When Ashley Overly's surgeon asked if she would become the first patient in the region to undergo a new technique to remove her cancer-riddled kidney, she didn't know single-site nephrectomies were the subject of an international debate.

With a newborn baby and a job at Taco Bell to worry about, plus a 6-inch scar from her kidney transplant in 2003, what her surgeon at UPMC Shadyside, Benjamin Davies, told her about the advantages made sense to her.

"He said there would be just one incision instead of three. There would be a better and quicker recovery and fewer scars. That all sounded good to me," said Ms. Overly, 31, a Greensburg resident who has dealt with her kidney disease for 15 years. Besides, "I don't like being in hospitals; I've been in there too much."

She spent just four days in the hospital recovering, was able to pick up her then-5-month-old baby boy two weeks later and was back at work four weeks later, thanks to a laparoscopic technique that used just one incision above her belly button 13/8 inches long.

That's instead of three incisions for a typical laparoscopic nephrectomy -- one incision for each of two surgical tools that are inserted into the body and one more for a camera to see with.

Because studies don't show that outcomes of the surgery are any better than multi-port or open nephrectomies, some surgeons argue that then there is no reason to use a technique that takes such highly specialized skill and tools, even if you reduce pain, recovery time and the risk of infection with it.

But Dr. Davies said: "If there's no worse outcome, why not do it? Scars for many people are an important issue, and so is recovery time and time in a hospital. And for Ashley, these were important factors."

Frequently called laparo-endoscopic single-site surgery (or LESS), the technique of using a single port to enter the body and remove an organ was first done in 1997 with a gallbladder removal. Other organs have followed since, with LESS being used to remove appendixes, uteruses, the colon and other organs.

Removing kidneys using LESS didn't occur until more recently, in 2009 at the University of California San Diego Medical Center by Ithaar Derweesh, who had used the technique on other organs.

"There are skeptics out there who doubt the benefits that can be reaped," he said. "Some of the critics are the young turks who were champions of laparoscopic surgery 20 to 30 years ago when they were pushing technology then that the establishment thought was radical. So, there's a certain irony there."

But part of that debate, he said, comes down to surgeons who are only worried about outcomes, versus surgeons worried about outcomes plus tangible benefits to the patient that surgeons sometimes discount.

In an article in the Diagnostic and Therapeutic Endoscopy journal in 2010, a team of surgeons at the Medical University of Vienna, Austria, reviewed their experience using LESS. They concluded that because it didn't benefit outcomes and only helped with less scarring, pain, use of pain medication and offered a quicker recovery time, that it should only be used for a small percentage of patients.

"Do we really have to measure the clinical equivalence of surgical procedures by cosmetics, or do we actually measure and compete ourselves as surgeons," they wrote in the article. "We think that LESS will play a role, but a minor role, in laparoscopic renal surgery."

But the benefits to the surgeons employing the technique now seem as obvious as they are to kidney patients who undergo it.

Since 2009, David Leeser, a surgeon at New York Presbyterian-Weill Cornell Medical College, has been working with a team at his hospital that has been doing LESS surgeries for more than 100 live donor nephrectomies, with the kidney then going to a needy recipient.

Living donors, who are volunteers not forced to have a kidney removed, have perhaps even more reason to enjoy the benefits of LESS, Dr. Leeser said.

Their experience has shown that "the ability of people to give [a kidney] and not have a huge interruption in their lives was greatly improved. Most of them were back at work within two weeks and up and out of the hospital within 48 hours.

That might ultimately help more people agree to donate a kidney -- which is by far the organ most needed by people on the national organ transplant list.

Dr. Derweesh said last year at the end of a conference in Chicago, he and another surgeon shared a cab back to the airport to head home. On the way in the cab, they got into a spirited debate about why or why not LESS surgeries should be used and what those benefits could be.

Unbeknownst to them, their cab driver was listening the entire way to the airport. After he unloaded their luggage and placed it on the curb and was paid, "He looked at us and said: 'I think I'll take the single-port approach,' " Dr. Derweesh recalled with a laugh. "The point is, patients are going to demand not just a better cosmetic outcome but a quicker recovery and less narcotics. Doctors should want that, too."

Not every urologist is doing LESS, though.

"It's a paradigm shift," Dr. Derweesh said. "Muscle memory alone might prevent some surgeons from doing the same type of surgery."

That wasn't a problem for Dr. Davies. He was inspired to learn more about the technique last May when he saw a video presentation at a medical conference.

"We've been conservative here with new techniques, but I thought, 'That's something we can do here,' " Dr. Davies said. "Because I work with cancer, I immediately thought about my patients with cancer and how we could use it with them for partial nephrectomies and radical nephrectomies."

After training on the technique in September, he immediately thought of Ms. Overly as a candidate.

"I was a little bit leery. But [Dr. Davies] was like, 'Don't think of yourself as a guinea pig. It's just something new.' And I agreed with him," she said.

But having had her baby in August meant Dr. Davies wanted to wait at least five months to ensure she had recovered from the birth.

Finally, on Jan. 4, the two-hour surgery was completed without any problems. The entire renal cell carcinoma tumor around the kidney was removed though the single incision, and Ms. Overly's prognosis is good, he said.

Since then he has already done a second LESS radical nephrectomy and now is thinking more about the future. Dr. Davies, who already uses a robotic surgical machine to assist with other types of surgeries, said this first-in-the-region LESS radical nephrectomy is "in my view, a bridge to further robotic work."

Robotic-aided surgery uses robotically controlled tools that can rotate 360 degrees inside a patient's body, something neither laparoscopic tools nor the human hand can do.

"That's the future of advanced surgery," he said.

Sean D. Hamill: or 412-263-2579.


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