James P. Wilmot Cancer Center surgeons have become the first in the nation to use a new, infrared imaging technique combined with robot-assisted surgery to remove kidney cancer. The team, led by Dragan Golijanin, M.D., has successfully performed robotic laparoscopic partial nephrectomies on patients at Strong Memorial Hospital using the new technology.
Golijanin, an assistant professor in the University of Rochester Medical Center’s Department of Urology and at the Wilmot Cancer Center, spearheaded the research behind the development of the new technique, which illuminates tissues and organs in a completely different way. He worked with experts at Intuitive Surgical, which manufacturers the da Vinci Robotic Surgery System, to adapt the da Vinci system for use in special renal cancer cases as well as other genitourinary malignancies.
Golijanin’s study found the novel technology, for which URMC has pending patent applications, to be safe and effective. The federal Food and Drug Administration (FDA) granted approval for the procedure based entirely on the work of Golijanin and fellow Urology surgeons Guan Wu, M.D., and Hani Rashid, M.D. Their preliminary study has been accepted by the Journal of Urology and is expected to be published online this summer.
Kidney cancer, or renal cell carcinoma, is diagnosed in more than 58,000 people a year in the United States and was responsible for more than 13,000 kidney cancer specific deaths in 2010. Surgery is usually the first, and in many cases, only course of treatment. For small tumors (less than 5 cm) robot-assisted laparoscopic partial nephrectomy is an emerging technique that has gained acceptance. Partial nephrectomy removes the cancer while preserving as much healthy, unaffected kidney tissue, and kidney function, as possible for the patient. However, robotic surgery carries a long learning curve for surgeons, who are challenged to remove tumors with adequate margins while preserving healthy tissue amid a complex vascular supply within the kidney.
Until now, the best existing technology required the surgeon in the operating room to toggle between two systems – a console with “arms” to control the robotic instruments, and the imaging system that provided views of the surgical site. Typically before an operation begins, the patient is injected with a dye that fluoresces green when exposed to infrared light, which defines and illuminates the operative area in detail for two to five minutes at a time. The challenge for the doctor has been to move relatively quickly between the instrument console and a projection of the images that are often displayed across the room – similar to watching two different TV screens.
“This can be cumbersome and time-consuming, especially in more challenging cases,” said Golijanin.
The new technology, developed with Intuitive, of Sunnyvale, Calif., integrates the fluorescent imaging system and the surgical console into one system. The multimodal imaging allows the surgeon to turn his or her attention back and forth from different types of images to the surgical tools, without stepping away from the console. Existing da Vinci systems can be upgraded with the new imaging technology.
“This combination of new and existing technology offers great potential and opens the door to being able to provide the option of minimally invasive surgery to a greater percentage of patients, and to preserve kidney function in a greater percentage of patients,” said Golijanin. “Through further study we’ll fine tune the process to determine the optimal dosing of the infrared dye, the exact timing of the intravenous injection, and determine whether this new imaging technology actually improves outcomes, both in terms of cancer prognosis and the preservation of kidney function. By simplifying the imaging process, it will also assist young urologists and decrease the number of cases needed to master robotic laparoscopic partial nephrectomy.
Results from Dr. Golijanin’s study showed that in 11 patients, the kidney tumors and surrounding renal arteries were clearly identified, and malignant tissue was differentiated from normal tissue. Surgeons expect the new system will serve as an adjunct to existing imaging, allowing them to achieve better resection margins around the cancer with fewer bleeding complications, Golijanin said.
Going forward, the new procedure will be utilized within the URMC Center for Robotic Surgery and Innovation, which is led by Jean Joseph, M.D., and Edward Messing, M.D., Chair of the Department of Urology at URMC.
In general, robotic surgery can be beneficial for people meeting specific criteria. The incisions are much smaller than the incisions from traditional, open surgery, often allowing for faster recoveries and fewer complications. In 2003 the Strong Memorial Hospital at URMC was the first in the Rochester region to introduce the da Vinci system. Today, specially trained surgeons use it to remove a variety of cancers (prostate, kidney, bladder) and to treat other gynecologic and pelvic issues.
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