The Jikei University School of Medicine urology department

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Guidance about laparoscopic kidney cryogenic surgery for narrow path renal tumor (renal cancer)

Preface

We start laparoscopic kidney cryogenic surgery for narrow path renal tumor (renal cancer) in September, 2017 in hospital attached to the Jikei University School of Medicine. We gave kidney cryogenic surgery (cryotherapy: Cryotherapy) by percutaneous approach (method to insert needle for freeze under CT, the MRI guide from outside the body) for 134 patients in The Jikei University Kashiwa Hospital attached to the Jikei University School of Medicine until now from September, 2011.
At hospital (Shimbashi) attached to the Jikei University School of Medicine, we introduce treatment device for freeze into operating room and are enforcing cryogenic surgery for recurrent prostate cancer now. We start laparoscopic kidney cryogenic surgery for narrow path renal tumor this time. We have insurance adaptation for this treatment. We explain laparoscopic kidney cryogenic surgery as follows. About consultation of treatment, please contact the following, urology department outpatient.

Contact
Hospital urology department outpatient department attached to the Jikei University School of Medicine 
03-3433-1111 (weekdays from 13:00 to 16:00)
[charge] The Hiroshi Sasaki outpatient department morning of Friday, the afternoon
[charge] The Gen Ishii outpatient department morning of Wednesday, the afternoon

With renal cell carcinoma

There is kidney in spinal right and left and, at approximately 10cm in height, approximately 5cm in width, approximately 3cm in width, is organ which filters blood, and makes urine. Renal cell carcinoma is malignant tumor occurring in this kidney. Kidney has many tumors which occurred and it is asymptomatic and, by medical examinations, is often found, but ① hematuria, ② mass touch. ③We may be discovered for symptom such as pain.

Treatment of renal cell carcinoma

As for the radical cure treatment of renal cell carcinoma (of 4 cm or less) of narrow path, surgical resection (Partial nephrectomy or nephrectomy evisceration) by operation is basic treatment. As for the operation, partial nephrectomy to remove only a part of all the kidney itself nephrectomy evisceration to remove surgically or the small cancer lesion surgically with cancer is common. In late years another method includes cryogenic surgery (Cryotherapy: cryotherapy). There are percutaneous approach to let you do stitch under the MRI guide from skin as for the freeze treatment and laparoscope approach to develop Spey - in laparoscopic surgery, and to stab with needle under the looking straight. We have insurance adaptation for both methods in Japan. At hospital attached to the Jikei University School of Medicine, we install this freeze therapeutic apparatus in operating room, and freeze treatment under the laparoscope is possible. In The Jikei University Kashiwa Hospital attached to the Jikei University School of Medicine, we give percutaneous kidney cryogenic surgery under MRI guide and the CT guide.
This brochure explains freeze treatment of renal tumor under the laparoscope. We puncture to echo guide while seeing tumor by freeze treatment under the laparoscope directly, and there is merit that we freeze up and can treat. Tumor contacting with neighborhood organ (intestinal tract and liver, pancreas) is treatable to exfoliate people. (when it is percutaneous and is difficult, we may approach laparoscopically)

With cryogenic surgery

We give cell damage by letting lesion of cancer freeze up, and cryogenic surgery of renal tumor is method that disease is treated. We insert and cool involved site by this probe rapidly, and, as for this treatment, thin pipe of approximately 1.5mm in diameter called probe is performed under the local anesthesia using freeze teletherapeutic unit to involved site by letting you freeze. Treatment is there being few simple nakoto, treatment time and recovery periods in short ikoto, bleeding, treatment that kidney is partial again, and preservation of renal function is possible and, as for the advantage of this freeze cure, includes merit that treatment of repetition allows for recurrence examples in comparison with method such as surgical resection. As cure with a few burdens for patient, we are used for treatment of small renal tumor in hospital in United States or Europe.
This cure treated freeze by percutaneous approach to 13 patients with small renal cell carcinoma as part of clinical study since before it was published insurance and has been enforced in short-term hospitalization without big complications in The Jikei University Kashiwa Hospital attached to the Jikei University School of Medicine safely. We received this result and cryogenic surgery for narrow path renal cancer established to this country in July, 2011 and was published insurance. After that it enforced cryogenic surgery in September, 2011 to 134 patients in total (147 renal tumors) in The Jikei University Kashiwa Hospital attached to the Jikei University School of Medicine during December, 2016. It is enforcing cryogenic surgery to approximately 40 a year patients now.
 Because we install instrument of freeze treatment in operating room in this hospital, freeze treatment under the laparoscope is possible. We are giving freeze treatment for recurrent prostate cancer after radiation therapy now. We explain freeze treatment under the laparoscope for narrow path renal tumor this time.

Adaptation of laparoscopic renal tumor cryogenic surgery

All narrow path renal tumors do not become adaptation of freeze treatment. In this hospital, it enforces freeze treatment for patient corresponding to all in principle following.

  • ①Being 3 cm or less in tumor diameter, and tumor being identified by MRI or CT
  • ②Solid tumor (because cyst characteristics have the risk of dissemination at the time of puncture)
  • ③We do not contact with kidney status pulse book trunk
  • ④When standard treatment notes that it is operation, and cryogenic surgery is hoped for
  • ⑤Operation by general anesthesia being possible (please consult about one with complications with the chief physician well)

Laparoscopic kidney freeze treatment takes effect under the general anesthesia. When anesthesia is difficult, this method cannot take effect. In addition, it may be difficult by part of tumor. Please consult with the chief physician well.

About laparoscopic surgery

All narrow path renal tumors do not become adaptation of freeze treatment. In this hospital, it enforces freeze treatment for patient corresponding to all in principle following.

  • ①Being 3 cm or less in tumor diameter, and tumor being identified by MRI or CT
  • ②Solid tumor (because cyst characteristics have the risk of dissemination at the time of puncture)
  • ③We do not contact with kidney status pulse book trunk
  • ④When standard treatment notes that it is operation, and cryogenic surgery is hoped for
  • ⑤Operation by general anesthesia being possible (please consult about one with complications with the chief physician well)

Laparoscopic kidney freeze treatment takes effect under the general anesthesia. When anesthesia is difficult, this method cannot take effect. In addition, it may be difficult by part of tumor. Please consult with the chief physician well.

  • [open surgery]Open surgery
  • [laparoscopic surgery]Laparoscopic surgery

About method of laparoscopic renal tumor cryogenic surgery

We take lateral decubitusposition (sokugai) like the above, figure and, after the general anesthesia, are operated on. We insert fatty car and exfoliate kidney people. We exfoliate the tumor surface while confirming in echo and are exposed. Implant (puncture) does stitch for kidney cryogenic surgery to involved site under the looking straight here. The number of needles to insert is 1-3. The number varies according to size, places of tumor. Freeze time is approximately 15 minutes, and thawing time is approximately five minutes. We perform this freeze and thawing approximately 2 cycles as 1 cycle. Treatment time is from two and a half hours to three and a half hours. When we do not perform biopsy of tumor beforehand, biopsy takes effect on the spot, too.

  • Freeze treatment imageFreeze treatment image
  • Freeze modality (kuraiohitto)Freeze modality (kuraiohitto)

(reference materials) percutaneous freeze treatment treatment image

  • MRI guide bottom percutaneous cryogenic surgeryMRI guide bottom percutaneous cryogenic surgery
  • CT guide bottom percutaneous cryogenic surgeryCT guide bottom percutaneous cryogenic surgery
  • It is before treatmentIt is before treatment
  • Treatment six months later (tumor disappears)Treatment six months later (tumor disappears)

Concrete method of cryogenic surgery

Treatment punctures thin pipe called probe of approximately 1.5mm in diameter using freeze teletherapeutic unit while monitoring tumor part directly laparoscopically. There is no pain at the time of puncture to be operated on under the general anesthesia, and to puncture. We cool involved site by this probe rapidly, and freeze treatment is provided by letting you freeze up. We observe the situation after the freeze during freeze before freeze of involved site while using echo together and, during treatment, decide freeze range.

  • We perform real method as follows.
  • We are hospitalized 1-2 days before before operation.
  • It becomes nothing by mouth in the pre-day and night. We take laxative.
  • We give an enema on the morning of the day.
  • We enter operating room on foot.
  • We perform vascular security for intravenous feeding. (we may perform beforehand in ward)
  • We perform anesthesia by basic general anesthesia. (there is not consciousness in treatment)
  • We exfoliate kidney people under the laparoscope and expose tumor to light while confirming in echo.
  • When we do not confirm composition, we perform renal tumor needle biopsy.
  • We puncture probe of approximately 1.5mm for tumor directly. We perform while using echo together. The number of the puncture performs one - several by volume of tumor. Freeze time is approximately 15 minutes, and thawing time is approximately five minutes. We perform this freeze and thawing 2 cycles as 1 cycle.
  • We confirm hemostasis and we detain drain tube and perform shut wound and finish operation. Wound becomes wound not to need suture removal.
  • Operative time is about from two and a half hours to three and a half hours. We observe vital signs (blood pressure, the pulse, temperature), electrocardiogram, subjective symptoms, objective symptom during treatment (it may take depending on the adhesion, place, volume of tumor further).
  • Please rest quietly in bed after the treatment on bed to Japan and North Korea, the following day.
  • We perform examination of drawing blood, X-ray examination on the treatment next day. We may perform computed tomography for confirmation of post-operative haemorrhage as needed.
  • We confirm that there is not bleeding, anemia and become discharge.
  • Confirmation of effect of treatment performs examination of contrasting CT or MRI in four weeks after after surgery and the 3,6, twelfth month after surgery. In addition, we may perform a biopsy by effect measurement after the operation 12 months after 6. (about flow of treatment, there is change appropriately. You explain, but please ask the chief physician a question casually appropriately each time when you worry.)

About effect and complications of cryogenic surgery

Because frozen site necrotizes by damage by freeze, general effect of treatment of cryogenic surgery may cure radically. We remove surgically in surgical Partial nephrectomy directly and are extracted, but cell which freezes up by freeze cure, and necrotized is gradually absorbed.
Merit of freeze cure having little thing (damage may become heavy depending on datashi, freeze range) bleeding than extraction with a little damage of kidney, it is put up that length of stay is short. In comparison with segmental resection, burden for patient is regarded as few cures. However, we may do volume of tumor and that staying (survival) and cancer cell which remained even if the image top can finish freezing once multiply again without tumor being able to finish completely freezing up depending on part and increase (recurrence).
It enforced percutaneous cryogenic surgery (method to sting direct thorn from skin (outside the body)) in September, 2011 to 134 (147 renal tumors) patients in total in Jikei University School of Medicine The Jikei University Kashiwa Hospital during December, 2016. Of these, in 137/147(93.1%), survival of tumor to recurrence enforce re-freeze treatment in doubted 18 of 20 cases after the treatment, and case (response rate) that contrasting effect disappeared after one freeze treatment detects disappearance of contrasting effect in contrasting CT after the treatment.

About complications

As complications of this treatment, the following thing is expected.
Slight fever may last one week by postoperative pain, freeze necrosis of lesion part. As we puncture kidney directly, lump of blood may be made around kidney. It is absorbed with nature without providing special treatment if small amount. In addition, complications that needed treatment were said to be around 5-10% in overseas report and admitted toward ten of 147 (6.8%) by freeze treatment by percutaneous approach in Jikei University School of Medicine The Jikei University Kashiwa Hospital. The breakdown was one renal haemorrhage (it enforces skill in transarterial hemostasis), cerebral embolism two, chest wall hematoma one, pneumothorax two, intestinal frostbite three, retroperitoneal abscess one after the treatment.
We freeze up and provide laparoscopic treatment this time in this hospital. We have insurance adaptation for this method. There are complications with general anesthesia, laparoscopic surgery, too. It is thought that there is merit that merit confirms tumors contacting with serious neighborhood organ by percutaneous freeze treatment directly and can puncture.

It is as follows for complications that are possible by this treatment.

①Fever, infection: We may run a fever with treatment for 1-7 days. When fever continues after it, infection is possible. Pneumonia, wound infection, perinephric abscess, peritonitis, intraabdominal abscess are possible. In that case, it enforces inspection treatment appropriately.
②Bleeding, hematuria: Slight kidney neighborhood hematoma happens with high probability after the treatment. We may need skill in hemostasis by possibility of blood transfusion and artery embolization in some cases. In this case length of stay may extend. In addition, also, nephrectomy evisceration, change to open surgery may be necessary laparoscopic Partial nephrectomy on the spot when control of bleeding is difficult. When postoperative bleeding control is difficult, we may perform nephrectomy evisceration.
③Pain: There are wounded area ache and pain with treatment after the treatment for a few days. We cope with pain-killer. We cooperate with anesthesiology and cope. Nausea with pain-killer may come out.
④Urinary leakage: When tumor is near renal pelvis, urine may begin to leak outside kidney. In that case, we may insert pipe called ureteral stent. Extension, rehospitalization of length of stay are possible. It may occur after time passed. Case, nephrectomy in improvement may be necessary.
⑤Other organs frostbite (the lungs, liver, spleen, pancreas, the duodenum, small intestine large intestine): When tumor approaches adjacent organ by part, volume of tumor, we puncture these organs and may freeze up. We may need restoration surgically in some cases. Because we can secure space between these organs in laparoscopic surgery, it is thought that the frequency lowers than percutaneous approach. But we are at risk of injury at the time of detachment when there is the adhesion.
⑥Thromboembolism: There is the risk of pulmonary embolism and myocardial infarction due to lower limbs phlebothrombosis and cerebral infarction. There are past illnesses of heart in particular and brain, and which discontinues antiplatelet drug and anticoagulant, and is treated becomes at increased risk of this. As for before and after operation, the risk increases. Preventive guidelines observe in it which there is and are operated on in this hospital. We may influence life by any chance when it occurs. We cope with specialized course.
⑦Hypothermia: By freeze treatment, we may suffer from hypothermia. Temperature-controling performs with caution.
⑧Unexpected complications: Possibility of the onset of fatal complications of freeze treatment shock and unexpected heart, lungs, brain is not zero. Freeze treatment shock is freeze treatment, and cell necrotizes, and it is said that we are angry by material and absorption of cell which necrotized released from there. It is said that acute renal failure and disseminated intravascular coagulation (DIC) are caused if we become dangerously ill. The incidence is associated with the volume of tumor, and it is said that there is freeze treatment safely to 30-40% of liver if it is liver. There is not report of freeze treatment shock with small renal cell carcinoma relating to, but performs with caution. These side effects do not necessarily appear. We perform prophylaxis for possible thing and deal with every possible treatment when side effect appears.
⑨Renal failure: Only one is freeze treatment for narrow path renal tumor in patient without kidney, and it may be for renal insufficiency under the influence. In this case dialysis may be necessary. When renal function is not improved, it is thought about dialysis being necessary throughout the life.
⑩Recurrence: When there are survival, recurrence of treatment tumor, additional treatment may be necessary. We metastasize even if we go to treatment and may recur. It is not 100% of treatment.

With cryogenic surgery

When there are not complications in particular, discharge is possible after the treatment in 3-7 days.
In addition, it is taken antiplatelet drug, anticoagulant in separate table and needs length of stay by approximately one week in before and after therapy between discontinuation more when intravenous feeding of heparin is necessary.

Necessary medicine has cancellation including some diabetes remedies. Please identify patient with internal use common use medicine to the chief physician, nurse by all means.
(when cancellation does not cancel necessary medicine, freeze treatment postpones and may become rehospitalization some other time. Please be careful.)

Length of stay

When there are not complications in particular, discharge is possible after the treatment in 3-7 days. In addition, it is taken antiplatelet drug, anticoagulant in separate table and needs length of stay by approximately one week in before and after therapy between discontinuation more when intravenous feeding of heparin is necessary.

Generic name Brand name Stopping dosage time
Aspirin Bufferin 81, bias pilin,
EAC Seven days ago
Warfarin potassium Warfarin Four days ago
Dipyridamole Persantin, anginaru One day ago
Hydrochloric acid ticlopidine panarujin Ten days ago
Cilostazol Pre-tar Seven days ago
Ethyl icosapentate Epadel, Sor Milan Seven days ago
Beraprost sodium doruna, professional rhinoceros phosphorus One day ago
Sarpogrelate hydrochloride Ann Prague One day ago
Trapidil Rocornal, beauty treatment salon re-Nord 3-4 days ago
Limaprost alfadex Opal mon, professional rhenate Two days ago
Tartaric acid ifenprodil serokuraru Two days ago
Hydrochloric acid trimetazidine basutareru F 1-2 days ago
Hydrochloric acid dilazep Comerian One day ago
Ibudilast Ketas, pinatosu Three days ago
Nicergoline saamion 2-3 days ago
Hydrochloric acid ozagrel Vega, domenan 1-2 days ago

Necessary medicine has cancellation including some diabetes remedies. Please identify patient with internal use common use medicine to the chief physician, nurse by all means.
(when cancellation does not cancel necessary medicine, freeze treatment postpones and may become rehospitalization some other time. Please be careful.)

Precaution after discharge

After the treatment, please be careful about bleeding, the following things that you may run a fever after the discharge for a while.

  • Please have alcohol on the next time (about one month after surgery) to outpatient department.
    Alcohol is able to expand blood vessel and may promote post-operative haemorrhage.
  • Please refrain from riding bicycle, motorcycle for one month after surgery.
    Driving in one, please refrain from driving of car.
  • Let's take a little a lot water. Hematuria may continue after the treatment.
    As urine may be clogged up when hematuria comes out, please take water enough.
    Please contact by all means even if you take water when hematuria is very strong.
  • Please refrain from intense sports (swimming, muscular workout) after the treatment for approximately one month.
    Momentum of walk and mild gardening degree does not have any problem, but please never overdo it.
    When you are not well-conditioned, please contact immediately.

●Result of renal tumor biopsy becomes clear in approximately two weeks. We explain in outpatient on the next time. It may not be cancer by this biopsy. Diagnosis may be difficult by diagnosis of needle biopsy. When it is not cancer, we see in progress or may perform a biopsy again. Please consult with the chief physician.

If you have any questions, please contact as follows.

Hospital urology department outpatient department attached to the Jikei University School of Medicine 
03-3433-1111
Weekday From 9:00 to 16:00 urology department loanword
[holiday, the night] (16:00 - next morning 9:00) emergency room

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