Approximately one out of 10 children die each year from nephroblastoma (Wilms' tumor), the most common cause of pediatric kidney cancer. To decrease surgical morbidity when treating all types of pediatric kidney cancer, Duke’s Urology Division scales back the impact of treatments in children, using minimally invasive procedures when possible and implementing new surgical approaches to ensure the highest quality care.
One new approach involves an unusual surgical model: both a urologist and a pediatric surgeon attend every surgery. Jonathan Routh, MD, MPH, a pediatric urologist, says it’s rare to have both specialties represented during surgery. “Duke is one of the only places that does this,” he says. “Usually there’s a pediatric urologist or a pediatric surgeon in the operating room, but we have two fellowship-trained board-certified surgeons attend every surgery.” The team of pediatric surgeons includes Routh’s colleagues Henry Rice, MD, Elisabeth Tracy, MD, and Tamara Fitzgerald, MD, PhD. “This collaboration helps us focus completely on the child in front of us and it works out very well,” Routh adds.
Rice agrees: “At Duke, we are strong advocates for team-based approaches to surgical care,” he says. “This is particularly helpful for complicated renal procedures such as advanced tumors or partial nephrectomy, as there are many great advantages to having shared expertise from pediatric urologists and general surgeons. Collectively, these teams can bring together varied experiences and views that enhance decision-making and technical expertise. The main beneficiaries are the children, who are cared for by a comprehensive team that works together to provide the safest care and best outcomes.”
Routh says that Duke’s program is highly ranked nationally and has an excellent track record of successful patient outcomes, exceeding national averages for overall survival rates and tumor rupture rates. “We’ve taken an aggressive approach to not being aggressive,” he says. “We’re a highly experienced team of clinicians that tackle patient care with one goal: every child gets the treatment they need to survive and thrive. No more and no less.”
To reduce the impact of treatments, robotic-assisted procedures and minimally invasive surgeries are used when possible, Routh says, but there is no one-size-fits-all solution and the surgical team collaborates with pediatric oncologists and nephrologists to decide on the best approach for each patient. For example, using robotics is good for partial removal of a kidney but it doesn’t give added benefit when removing the entire kidney, so in those cases laparoscopy or combined open surgery and laparoscopy are used.
“With these minimally invasive procedures we do everything the patient needs—sample lymph nodes, remove tumors, and give the appropriate surgical care to keep them alive—but at the same time we minimize the size and placement of incisions to help them recover faster, have less pain and less need for medications. And if you don’t absolutely have to make a big ugly scar, why do it?” he says.
Because kidney cancer surgeries typically result in the loss of a kidney, one of the significant predictors of morbidity and mortality is renal failure in the remaining whole or partial kidney. As a member of Duke Urology’s long-term patient follow-up committee, Routh says that one of the things the committee does is determine the risk of renal failure for patients. “Anything we can do to knock down that risk a bit can make a big difference. So we are very aggressive in performing partial nephrectomies whenever feasible.”
Current research is focused on biomarkers to find disease-specific ways to reduce the body’s immune response to nephroblastoma. “We’re asking ‘are there markers that are indicative of more or less aggressive cancer so we can ratchet the amount of radiation up or down to match a patient’s tumor?’ Of course, aggressive tumors mean aggressive treatments, but many children would benefit from less aggressive treatment to treat a less aggressive tumor and thereby reduce the risk for death from drug toxicities and other complications.”