HJAR Mar/Apr 2022

HEALTHCARE JOURNAL OF ARKANSAS I  MAR / APR 2022 51 Gerald “Jay” Heulitt, MD Arkansas Urology Treatment The treatment of renal cell carcinoma has advanced over the years, becoming less in- vasive and focusing on nephron sparing. While an open nephrectomy may still be needed for very large renal masses, the days of this being the common procedure are behind us. Currently, after careful re- view of the cross-sectional imaging, we are able to develop a personalized approach for the treatment of a patient’s renal mass. For most renal masses, this would be a robotic- assisted laparoscopic partial nephrectomy. This procedure is both diagnostic and thera- peutic as we can confirm a tissue diagnosis and remove the entire mass. Given the tu- mor’s location on the kidney, this may be approached either via a transperitoneal or retroperitoneal approach. During surgery, the mass is identified, and using a robotically controlled ultrasound, the mass is inspected. This ultrasound allows for precise location of the extent of the tumor and ensures a nega- tive margin. The vasculature to the kidney is isolated, and a clamp is placed temporar- ily on the renal artery. Indocyanine green is given intravenously, confirming ischemia to the mass. The mass is excised, and the renal defect is inspected. Any sites of bleed- ing or entry into the collecting system can be closed with sutures. The defect in the kidney is then closed, and the clamp on the renal artery is removed. The kidney is without per- fusion for less than 25 minutes. The mass is removed and inspected with the pathologist confirming a negative margin. The patient usually only spends one night in the hospi- tal and follows up to review the pathology results in a week. For a mass that is felt to be too large or invasive for partial nephrectomy, a robotic- assisted laparoscopic nephrectomy can be performed which offers several advantages over an open approach, including less post- operative pain, decreased rates of hernia for- mations, and quicker recovery. Now, even some renal masses with tumor thrombus invading into the inferior vena cava can be performed robotically given advancements in technique. The advancements in the surgical treat- ment of renal cell carcinoma have been re- markable, and Arkansas Urology is happy to be at the forefront of this. n REFERENCES 1 Kane, C.J., Mallin, K., Ritchey, J., Cooperberg, M.R., Carroll, P.R. “Renal cell cancer stage migra- tion: analysis of the National Cancer Data Base”. Cancer. 113:78–83. July 2008. 2 Cumberbatch, M.G., Rota, M., Catto, J.W., La Vec- chia, C. “The Role of Tobacco Smoke in Bladder and Kidney Carcinogenesis: A Comparison of Ex- posures and Meta-analysis of Incidence and Mor- tality Risks.” Eur Urol. 70(3):458-66. Sept. 2016. 3 Hidayat, K., Du, X., Zou, S.Y., Shi, B.M. “Blood pressure and kidney cancer risk: meta-analysis of prospective studies.” J Hypertens. 35(7):1333- 1344. July 2017. 4 Adams, K.F., Leitzmann, M.F., Albanes, D., Kipnis, V., Moore, S.C., Schatzkin, A., Chow, W.H. Body size and renal cell cancer incidence in a large US cohort study. Am J Epidemiol. 168(3):268-77. Aug. 2008. Gerald “Jay” Heulitt, MD, is a board-certified and fel- lowship-trained urologist who specializes in urologic oncology and complex kidney stone treatment. He graduated summa cum laude from Syracuse Uni- versity with a bachelor’s degree in biology prior to obtaining a medical degree from the University of Arkansas for Medical Sciences. He completed urol- ogy residency training at the University of Mississippi Medical Center in Jackson. After residency, Heulitt completed a one-year robotic and laparoscopic sur- gery fellowship at SwedishMedical Center in Seattle, Washington withJames Porter, MD. He joinedArkan- sas Urology in August 2017. The widespread use of imaging tests has led to a steady decrease in the size of the tumors at presentation. 1 Fortunately, at these smaller sizes, the tumors are often treatable with a nephron sparing approach. Risk Factors Many of the risk factors for renal cell carcinoma are unfortunately common in our patient population: smoking, hyperten- sion, and obesity. The relative risk for renal cell carcinoma for current smokers is 1.35 and 1.16 for former smokers. 2 Hypertension predisposes to renal cell carcinoma devel- opment independent of antihypertension medications or obesity. 3 The relative risk of renal cell carcinoma increases progres- sively with baseline body mass index. 4 Less common reasons for renal cell carcinoma include ESRD on long-term dialysis, occu- pation exposures to toxic compounds, and genetic factors. The American Urologic As- sociation recommends genetic counseling for all patients ≤ 46 years old with renal malignancy. Work-Up A renal mass that shows contrast en- hancement on CT or MRI imaging has an 80-90% probability of being a renal cell car- cinoma. For some renal masses, a biopsy of the mass may be appropriate to help deter- mine if it is a malignancy. Biopsies, however, can be inconclusive approximately 15% of the time and are not without risk. Most of the time, the treatment is planned without a tissue diagnosis. Staging for a small renal mass includes a comprehensive metabolic panel and two-view chest X-ray.