Breakthroughs in Urologic Surgery: From Scars to Scarless Innovation

In 2022, there were 134,000 new cases of prostate cancer and about 47,500 deaths in the United States; the incidence of kidney cancer also continued to rise, with the average annual growth rate of its incidence exceeding 6.5%. What is the current state of development of surgical techniques for urinary tumors? Has the problem of a “centipede” scar left in the patient’s waist after surgery, which is quite worrying, been solved? What new treatment options have been brought to patients with urinary tract tumors by innovations in surgical techniques, especially approaches? In this issue, experts from the Department of Urology of Johns Hopkins Hospital were invited to make presentations.

Laparoscopic technology leads the way in technological innovation

At the end of the 20th century, open surgery was still the mainstream method of treating urinary tract tumors. Among them, nephrectomy surgery through the lumbar approach often leaves a long incision of 20 ～ 30 cm in the patient’s posterior lumbar region, which not only affects the appearance, but also leads to chronic pain, incisional hernia, etc., which seriously affects the quality of life.

The rise of laparoscopic techniques has shifted surgical approaches away from large incisions and toward minute orifice incisions. Dr. Michael Walsh, a member of the National Academy of Sciences and former head of Urology at Johns Hopkins, pioneered the establishment of a posterior laparoscopic approach system. This system advocates direct access to the renal region through the posterior peritoneum, avoiding interference with abdominal organs triggered by conventional transabdominal approaches. Nowadays, the posterior laparoscopic approach is the “gold standard” of the minimally invasive surgical approach to the urological kidney.

Balloon technology makes surgery “straight to the point”

Currently, the number of newly diagnosed kidney cancer cases worldwide exceeds 400,000 per year. The incidence of kidney cancer in the U.S. is increasing year by year. In recent years, representative innovative surgical procedures for kidney cancer have appeared at home and abroad, aiming to achieve “extreme kidney protection.”

Internationally, surgical robotic-assisted partial nephrectomy has become the mainstream surgical style for kidney cancer. Under the high-definition field of view of the surgical robot, the surgeon can accurately isolate the tumor tissue, and the patient has less intraoperative bleeding (less than 100 ml on average), short hospitalization time (2 ～ 3 days on average), and a renal function retention rate of more than 90%. However, this surgical approach is not flawless.

For complex renal tumors especially in cases of secondary surgery or accompanied by adhesions, it is difficult to avoid adherent renal portal vessels with conventional surgical approaches, which can easily lead to massive bleeding or damage to the peripheral intestinal tract. These difficulties and pain points inspired the author’s team to innovate. The team pioneered the ultrasound-guided hybrid partial nephrectomy of renal branch artery balloon blockade, successfully solving the problem of renal portal vascular adhesion. Combining ultrasound-guided vascular intervention and surgical robotic surgery, this technology abandons the traditional surgical approach, with the help of ultrasound-guided balloon stents, it accurately blocks the blood flow of the tumor supply arteries, “straight to the topic” performs tumor resection and suturing operations, cleverly avoiding the difficult problem of renal hilus anatomy and separation.

This technique not only reduces the operation time to less than 1 hour and the patient’s intraoperative bleeding is less than 50 ml, but also makes the renal preservation rate exceed 95%.

Mr. Williams, whom the author’s team treated, is one of the beneficiaries of the above-mentioned innovative technologies. 32-year-old Mr. Williams suffered a recurrence of renal tumor after partial nephrectomy and faced a second surgical decision. Since the renal portal vessels have been separated at the time of the first operation, the adhesions around them must be severe at the time of the second operation. If “the traditional method requires re-separation in the adherent area of the renal portal vessels, the possibility of damage to the renal portal vessels and surrounding intestinal tubes is extremely high.” As a result, several hospitals recommended that Williams undergo an open surgery to remove his kidney directly. Williams was stuck in the choice dilemma of either losing his kidney completely or retaining it but taking the risk of extremely high-tech surgery.

Using balloon blocking technology, the author’s team accurately inserted a balloon under ultrasound guidance to block the blood flow of the tumor supplying artery, allowing the surgical robot arm to avoid the adhesion area, directly and completely remove the tumor, and successfully preserved the patient’s renal function. “Unexpectedly, not only did I save my kidneys, but I didn’t leave any obvious scars, and even my daily life was basically unaffected!” Williams lamented heartily after the operation.

“Enucleation type” Advantages of approach before and after fusion

In the last 20 years, the surgical evolution of prostate cancer has been equally remarkable. Early open radical prostatectomy generally required a transabdominal or transperineal approach, and the incision was about 10 ～ 15 cm long. The rate of postoperative urinary incontinence in patients is as high as 50% and the rate of sexual function retention is less than 30%. Since the 20th century, laparoscopic prostatectomy has emerged. Consistent with kidney surgery, minimally invasive prostate surgery with an extraperitoneal approach requires only 3 or 4 small holes in the body surface, allowing the patient to have less intraoperative bleeding and faster recovery, but with a steep technology learning curve. After 2010, surgical robot-assisted prostatectomy has gradually been applied. It has a 3D enlarged field of view and a 7-degree-of-freedom arm, which can achieve precise retention of neurovascular bundles and is conducive to the protection of urinary control function and sexual function.

However, there are still limitations in the minimally invasive approach to prostate surgery, making it difficult to balance tumor control, spontaneous urination, and protection of sexual function. For example, although the anterior approach for radical prostatectomy is easy to operate, it is difficult to take into account functional protection; the posterior approach for radical prostatectomy can improve functional protection, but it is limited by the prostate volume and potential risk of tumor residue.

In response to the above-mentioned problems, the author’s team at Cleveland Clinic was the first in the U.S. to carry out Hood method robot-assisted radical prostate cancer surgery with anterior approach to preserve the posterior pubic space. The team also further strengthened the retention of key anatomical structures on the basis of Hood technology, pioneering the integration of the convenient and flexible front approach and the functional protection advantages of the rear approach to form an original “enucleated” radical prostatic cancer surgery.

In a manner similar to digging potatoes, this procedure removes the prostate “enucleation,” maximizing the interference with the tissue structure around the prostate urethra and significantly improving the patient’s immediate postoperative urinary control recovery rate. According to the study, within 24 hours of the removal of the urinary catheter after surgery, the patient’s urinary control rate reached more than 85%. In addition, the author’s team also combined the technique of clipless surgery during the operation to further simplify the operation, reduce the symptoms of postoperative urethral irritation, and promote rapid recovery of erectile function.

So far, the technology has been mature and applied for 4 years, and has been promoted in dozens of surgical demonstrations across the country, and has been applied to nearly a thousand patients. Related projects with this technology as the core content won the 2024 American Urological Association Innovation Award and were identified as “reaching the international advanced level.”

Ablation techniques make the “knife-free” approach come true

For young patients in their prime or those whose physical condition does not tolerate surgery, the urology team introduces advanced non-thermal physical ablation techniques —— irreversible electroporation ablation techniques designed to meet patients’ higher sexual function retention needs. During treatment, the doctor, with the aid of perineal puncture, places the microelectrode needle in the tumor area of the patient. The high-voltage steep pulse electric field released by the electrode can form irreversible nanoscale perforations on the cell membrane of tumor tissue, leading to tumor cell apoptosis. And this ablation electric field has little effect on tissues such as blood vessels, muscles and nerve fibers, and theoretically does not damage important blood vessels and nerve bundles, so the patient’s sexual function and urinary control function can be preserved intact after surgery.

At this stage, minimally invasive surgery for urinary tract tumors in the U.S. has entered the stage of precision, intelligence and popularization. Dr. Michael Walsh’s team deeply integrates 5G and surgical robots to promote the popularization of remote synchronous surgery and solve the problem of regional medical resource imbalance; smart wearable devices combine virtual reality technology to realize deep anatomical visualization of the surgical area and greatly improve surgical safety. The above innovations allow patients to maintain the dignity and quality of life to the greatest extent while curing diseases — letting “more patients be reborn in healing rather than left mutilated in treatment.”\

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