Knowing When Minimally Invasive Cancer Surgery is the Best Treatment Option Can Saves Lives
Four of our expert surgeons evaluated the pros and cons of minimally invasive surgery for genitourinary cancers, brain and spine tumors, sarcomas, GISTs, adrenal tumors and gynecologic cancers:
- Wade Sexton, MD, a surgeon in the Department of Genitourinary Oncology
- James Liu, MD, a neurosurgeon in the Department of Neuro-Oncology
- Rachel Voss, MD, MPH, a surgical oncologist in the Department of Sarcoma
- Robert Wenham, MD, MS, FACOG, FACS, a gynecologic oncologist and Chair of the Department of Gynecologic Oncology
Genitourinary Cancers
Q: Dr. Sexton, what do you think are the advantages of minimally invasive surgery?
Dr. Sexton: For many patients and some tumor types, minimally invasive surgical approaches, including the use of robotic technology, can result in shorter recovery times, lower wound-related complications, and smaller scars, as well as higher satisfaction rates.
However, minimally invasive surgery is not the best nor the correct approach for every cancer patient who requires surgery as a component of their cancer treatment.
When it is, robotic systems and minimally invasive techniques are only as good as the surgeons who use them. Moffitt surgeons are intimately familiar with the most effective ways to use precision technology at the right time, and for the right patient, to optimize cancer care.
Q: You perform minimally invasive, kidney-sparing procedures and have seen remarkable benefits to patients. Can you tell us who is a candidate for this and how you work with patients to decide whether or not to remove a kidney or spare it?
Dr. Sexton: Our very strong preference is for kidney-sparing surgery when possible, and minimally invasive techniques, such as transperitoneal and posterior retroperitoneal robotic surgical approaches, have tremendously enhanced the patient experience compared to traditional open surgery. Data reveal excellent oncologic outcomes and comparable postoperative complications, while significantly diminishing hospitalization and time to recovery.
Yet, there are many factors to consider when deciding whether a patient should undergo kidney-sparing surgery, as well as the surgical approach that would afford the patient the best overall outcome.
Some of these factors include patient age, overall kidney function at baseline, the status of the opposite kidney (if present), tumor size and tumor location within the kidney, whether there are multiple tumors in the involved kidney or tumors in both kidneys, genetic predisposition to kidney cancer, and whether a patient has other medical conditions that might place their overall kidney function at risk. A thorough understanding of the patient’s medical history, a complete physical examination and a careful review of laboratory and radiographic studies will permit the patient and the surgeon to confidently decide upon the best plan of care.
Q: Can you describe minimally invasive robotic cystectomy and bladder reconstruction surgery? When is it the best option?
Dr. Sexton: Like minimally invasive approaches for other benign or malignant conditions, the operating team utilizes small incisions and passageways for instruments to be inserted into the abdominal and pelvic cavities, in this case, to remove the bladder, the pelvic lymph nodes, and other relevant or affected organs involved by bladder cancer.
Generally, there are three methods for a surgeon to construct a urinary diversion which most always incorporates portions of the small intestine, and less commonly the large intestine:
- Constructing a "conduit" for the urine to flow from the abdominal cavity into an ostomy appliance which is a device for collecting the urine that adheres to the abdominal wall
- Reconstructing a bladder substitute (called a neobladder) that is connected to the remaining urethra which permits the flow of urine and voiding through a normal urethral channel
- Construction of an internal “reservoir” or “pouch” for the urine with the ability to empty the reservoir by the passage of a catheter through the abdominal wall via a segment of the intestine between the reservoir and the skin of the abdominal surface.
Many times, after removing the bladder and lymph nodes using multiple small incisions, surgeons will make a small open incision to complete the urinary diversion portion of the operation. Increasingly, surgeons are constructing urinary diversions using minimally invasive techniques. There are many factors that a surgeon and a patient must consider in choosing the urinary diversion that would be best for the patient and their clinical circumstances.
Current results comparing traditional open surgery to robotic surgery for cystectomy reveal that robotic cystectomy could be associated with less blood loss, but a longer operative time. However, hospital length of stay, post-operative recovery, readmissions, and complications of open and minimally invasive procedures are essentially the same. Thus, specialty organizations do not favor one approach over the other. There are clinical and pathologic factors that would support a traditional open approach over a minimally invasive technique. Still, such decisions require careful counseling and decision-making between the patient and the surgical team.
Brain and Spine Tumors
Q: Dr. Liu, how is minimally invasive surgery used in your overall approach to spinal tumors? When would an open surgical procedure be safer and more effective?
Dr. Liu: Minimally invasive spine surgery techniques can be very effective in the spinal oncology setting because it allows for stabilization of the spine while circumventing large open procedures which may result in greater pain and morbidity.
Cement augmentation can be very effective in relieving mechanical pain for certain types of pathologic compression fractures. For more extensive fractures, percutaneous pedicle screw fixation can achieve stabilization through small incisions, preserving the posterior spinal muscles. The smaller incisions allow less postoperative morbidity and allow for the resumption of systemic therapies or adjuvant radiation with minimal delay. In addition, percutaneous pedicle screw fixation can be combined with ‘mini-open’ decompression to relieve neural compression from tumors when necessary.
When there is a need to achieve a complete resection or remove a significant amount of tumor, or a need to perform extensive reconstruction of the spine, an open approach may be necessary.
Q: When would you use minimally invasive endoscopic surgery to treat brain cancer? When would a keyhole craniotomy be the right choice? Or laser ablation?
Dr. Liu: Minimally invasive endoscopic surgery can be used to access deep areas with the brain or skull base, such as during surgery for pituitary tumors, or intraventricular tumors. Endoscopic intracranial surgery allows for access to difficult-to-reach locations without the need for a large opening or significant retraction of the brain. The operative corridor is smaller with endoscopic procedures compared to open procedures therefore careful patient selection is key to success in these procedures.
Keyhole craniotomies are a type of open surgery which employ pinpoint openings in the skull to achieve tumor resection. These can be effective depending on the location of the tumor that is being resected.
Laser ablation therapy involves stereotactically placed electrodes for the thermal ablation of brain lesions. This technique can be effective for certain types of primary or metastatic brain tumors that may not be amenable to open surgical resection.
Q: In the Liu Laboratory at Moffitt, you are exploring peptide screening technology to allow tumor detection at a cellular level. This will allow earlier diagnosis of primary and metastatic brain tumors. Will it also open the door to more—and safer—minimally-invasive treatments?
Dr. Liu: Targeting tumors at a molecular level will be the future of therapeutics against brain and spine tumors. By developing therapies that are specific for tumor cells, we can develop targeted strategies that can achieve higher efficiency with fewer side effects. By being able to achieve better tumor control with systemic or radiation therapies, there may be less need for open decompression of neural elements providing more opportunities for minimally invasive stabilizations strategies to be effective.
Sarcomas, GISTs, and Adrenal Tumors
Q: Dr. Voss, you are the only surgeon at Moffitt and one of only a few in the Tampa area who perform a minimally invasive posterior retroperitoneoscopic adrenalectomy (PRA) for patients with adrenal tumors. Can you describe the procedure and its advantages?
Dr. Voss: The PRA technique allows for the removal of the adrenal gland through the most direct approach—the patient’s back. Traditionally, adrenalectomy has been performed through the abdomen, which works well for most patients, but has additional risks and is not a good option for everyone.
PRA done through the back allows the surgeon to stay out of the abdomen, avoiding injury to organs that live in the abdomen such as the spleen, liver, intestine, colon, and stomach.
PRA is often the best option for patients who have had several prior abdominal surgeries and might have scar tissue internally that makes surgery in the abdomen more risky or difficult. PRA is performed with three-four small incisions, each about 1-inch in length, placed either on the left or right back below the ribs. Patients can go home the next day in most cases and pain is minimal. PRA has the added benefit of allowing the surgeon to operate on both the left and right adrenal glands while the patient remains in 1 position; this is very useful for patients who have bilateral adrenal tumors, as is seen in some genetic syndromes.
Q: Is minimally invasive surgery for adrenocortical carcinoma (ACC) still controversial? If so, why?
Dr. Voss: Yes. Minimally invasive surgery is still not usually recommended for ACC, which is a cancer of the adrenal glands that are generally quite aggressive. Most major surgical societies and guidelines still recommend open surgery if adrenalectomy is being done for ACC or suspected ACC.
This is because, in ACC, the initial surgery is extremely important to perform correctly. Fracturing the tumor or breaching the tumor capsule can increase the risk of recurrence, the spread of the tumor within the abdomen, poor outcomes, and mortality. The risk of capsule rupture or tumor fracture is generally felt to be higher with minimally invasive techniques. So, for this reason, I advocate for open surgery for patients with ACC.
Q: While sarcomas in the extremities may present earlier, diagnosis of sarcomas involving the pelvic cavity may be delayed because of their location deep within the body. Are minimally invasive procedures appropriate for either or both?
Dr. Voss: The appropriateness of minimally invasive surgery for sarcoma is taken on a case-by-case basis. For most moderate to large tumors, open surgery is the best and safest option to ensure that the entirety of the tumor is removed in a complete and oncologically sound manner. Exceptions to this might be small tumors located intraluminally (eg a 2 cm small bowel GIST). I certainly consider minimally invasive techniques for certain small sarcomas, but any large tumor in the pelvis or a primary tumor of the retroperitoneum is usually best addressed with an open procedure.
Q: Are there any instances when you would almost always opt for an open surgical procedure for a patient with extremity sarcomas, complex retroperitoneal and abdominal sarcomas, GISTs, or adrenal tumors (both benign and malignant)?
Dr. Voss: I always perform open procedures for extremity sarcomas, retroperitoneal sarcomas, most abdominal sarcomas, adrenocortical carcinoma (ACC), and larger, complex GISTs. I consider minimally invasive surgery for certain gastric or intestinal GISTs and for benign adrenal tumors. Minimally invasive techniques are great for those applications where margins can be assured (small intraluminal tumors) or are not as critical (such as for benign adrenal tumors).
Gynecologic Cancers
Q: Dr. Wenham, which gynecological cancers, at what stages, do you feel benefit equally—or even more—from minimally-invasive surgery compared to open surgery?
Dr. Wenham: Endometrial cancer has been one of the best reproductive tract cancers for MIS. It is ideal because it accommodates and overcomes some of the challenges and morbidities of open surgery in patients who, on average, carry greater body mass.
The pathways of possible anatomic metastatic spread also make it a good choice, and we can use a special dye and camera to do sentinel lymph node mapping.
MIS is also excellent when trying to figure out if there is cancer or not. It is not uncommon to at least try to start with MIS for diagnostic purposes.
Q: Which gynecological cancers do you feel minimally invasive surgery may not be as good as compared to open surgery?
Dr. Wenham: I don’t think it should have widespread use in the majority of ovarian cancers, although there has been an increasing trend to do so. Recovery is indeed easier for the patient. But we know our existing data show that it is critical to accurately stage AND remove all visible and palpable cancer if possible because patients live longer.
For patients with a disease that is already metastatic, some studies to date claim to show no significant differences in outcome, but I feel the numbers of patients are too few to conclude that. I have done thousands of MIS and open cases, and I know that it is impossible to use MIS and see some of the areas that cancer can hide or to see tumors that may be hidden deeper in tissues and may only be palpated. We just need better data.
I also want my patients to have the smallest scars, the shortest hospital stays, and the shortest recoveries – but not at the expense of worse cancer survival outcomes. I think it is hard to be a believer in our data for debulking surgery and also accept this tradeoff.
On the other hand, many women with an adnexal mass are often referred to a gynecologic oncologist. After an assessment, when such a mass appears isolated and likely removable without rupture (by placement in a containment bag), then a minimally invasive approach is appropriate.
We lack quality prospective data on the management of early ovarian cancer by minimally invasive surgery. There are retrospective data supporting no difference between minimally invasive and open surgery. When an adnexal mass is suspicious for ovarian cancer and there are no other signs of spread, an effort should be made to avoid rupture during removal, if possible. Assessment for malignancy should occur intraoperatively and, if confirmed, followed immediately by staging.
Staging of a clinically confined cancer to an ovary may be accomplished by minimally invasive surgery, based on feasibility and patient and tumor characteristics.
In our practice at Moffitt Cancer Center, we utilize minimally invasive surgery for many benign adnexal masses and certain cancer masses that appear confined and meet criteria making it reasonable to do so.
Q: So, have you used minimally invasive surgery for cervical cancer?
Dr. Wenham: I did in the past. Then two large studies came out showing a negative effect on survival for women operated on by MIS. A randomized controlled study reported in 2018 study demonstrate that the rate of being alive without cancer recurrence was nearly 4-fold worse, and death from any cause was 6-fold worse, after laparoscopic or robot-assisted surgery compared to open surgery. And a second epidemiologic study found an almost 50% relative higher risk of dying within four years of MIS compared to open surgery.
I had personally switched back to open radical hysterectomies for cervical cancer before these data came out. Just as I intuitively sense it is not equivalent to detecting all the metastases in advanced ovarian cancer, I personally felt that I was getting a better radical surgery for cervical cancer through an open incision.
This was not due to discomfort or lack of proficiency with MIS, as I commonly use minimally invasive surgery for other cancers and difficult surgeries. I have some colleagues in our field who continue to do MIS and they have many guesses on things they are doing that make it safer. But until I see the data for that, I will continue to offer the surgical approach that has the best-reported data to support a cure. Of course, in any particular patient certain surgical considerations may change the risk-benefit ratio for MIS versus open surgery.
I am hoping, however, that some carefully done studies will demonstrate how we can return to MIS in these cancers in the future. Even more, I am hoping that we have fewer of these cancers through widespread utilization of the HPV vaccine and screening!
Q: Can you discuss the use of open surgery versus minimally invasive techniques for endometrial cancer?
Dr. Wenham: For endometrial cancer, MIS is the current standard for the vast majority. It is equivalent to open surgery, has shorter hospital stays, and allows the easiest recovery, However, sometimes it makes sense to do an "even more minimally invasive surgery," or vaginal hysterectomy. Some patients cannot tolerate the necessary positioning for MIS or be too obese to do MIS or open surgery, and their only option is a vaginal hysterectomy. Unfortunately, fewer surgeons can offer this and are forced to either try MIS or open or forgo surgery altogether.
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