Transforming Urological Care

Partial nephrectomy for kidney cancer promises to ease dialysis burden

By Dr Tushar Narain, Senior Consultant in Urologic Oncology and Robotic Surgery Max Smart Super Specialty Hospital in Saket, New Delhi

The rising prevalence of chronic kidney diseases (CKD) in India makes it the 8th leading cause of death as per the Global Burden of Diseases report. CKD deaths have surged by over 50 per cent in the last decade, accounting for over 3.04 per cent of all mortalities. The foundation of addressing this crisis lies in understanding the different urological conditions affecting renal functioning and the intricate dynamics of treatment modalities. Diseases like kidney cancer have also been on the rise in the past decade with the estimated incidence being over 100.4 per 1 lakh people in India.

One of the adjuvant therapies tied to kidney conditions is dialysis, a lifeline for individuals with compromised kidney function, providing artificial filtration to maintain internal equilibrium.

Due to these conditions rising, the demand for innovative solutions to alleviate the burden on dialysis services increases as well. The demand for dialysis is primarily driven by underlying chronic ailments such as high blood pressure, diabetes, and some autoimmune diseases, which escalate the risk of kidney failure.

Patients with these co-morbidities develop deteriorating renal function and a majority of them become dialysis dependent for life or require renal transplantation. Hence it becomes imperative to preserve as much renal function as possible by keeping these diseases in control with medications and lifestyle modifications. The development of renal tumours in such patients becomes a double whammy as the tumour eats up into functional renal parenchyma, and the surgery for this cancer, which was the removal of the whole kidney in the past, also poses a major threat to the preservation of functioning renal parenchyma.

Historically, for renal tumours, radical nephrectomy was the norm, entailing the complete removal of the affected kidney. This forces individuals to continue their life with one kidney, which often leads to them developing chronic kidney diseases in the next 10-15 years; resulting from hyperfiltration injury to the remaining solitary kidney.

With the advent of new-age technologies like robotic-assisted surgery (RAS), surgeons can now precisely target and excise tumours while preserving most of the healthy kidney tissue.

In RAS the three-dimensional stereoscopic vision, articulating tools, and scaled-down movements that minimise tremor provide a significant advantage that helps excise the tumour precisely and suture the remaining kidney to prevent haemorrhage and urinary leak. The surgeon can potentially replicate well-established open surgical manoeuvres with the help of the system, articulating instruments and enhancing their range of movement. As compared to radical nephrectomy, a popular choice in the past, partial nephrectomies avoid the removal of the entire kidney, saving as much of the healthy tissue, which could reduce the threat of CKD developing in the next 10-15 years. This paradigm shift towards better modes of treatment not only reduces the chances of recurrence after the treatment but also mitigates the risk of subsequent dialysis dependency.

Hence, the introduction of partial nephrectomies with robotic-assisted surgery with surgical systems like da Vinci as a treatment modality can positively impact the dialysis burden in the country. In addition to this, robotic-assisted surgery also provides advantages like minimal scarring, lesser blood loss and shorter hospital stays. In my experience, salvaging a significant portion of the kidney through RAS can slash dialysis dependency by an impressive 50-70 per cent. This obvious reduction in dialysis dependence following renal cancer surgery is evidence that robotic-assisted surgery can help reduce the burden of the overwhelming demand for renal replacement therapy in India. By preserving renal function and mitigating the risk of cancer progression, these advanced surgical interventions pave the way for improved outcomes and enhanced quality of life.

Here, patient education plays a crucial role in their treatment journey, especially during the consideration of partial nephrectomy with robotic-assisted surgery. Patients who are well informed about their condition, treatment options, and potential long-term effects, are empowered to make informed decisions about their health. Active participation in their treatment journey helps promote patient autonomy and ensures that their preferences are considered. In addition to this, we’ve seen that these patients tend to adhere to treatment plans and engage in self-care, which may lead to better outcomes.

In an ideal scenario, India would require an estimated 3.4 crore dialysis sessions annually. However, with only about 2600+ nephrologists and approximately 15,000 dialysis centres nationwide, the gap between demand and supply remains glaringly wide. With at least 2.2 lakh new cases of end-stage renal diseases emerging annually, the strain on dialysis services is palpable.

Despite the pressing need for renal replacement therapy, India grapples with a significant shortfall in dialysis centres and nephrology expertise. With less than 6,500 kidney transplants conducted each year and a glaring deficit of dialysis facilities, the demand far exceeds the available resources.

Addressing this disparity necessitates a multifaceted approach that prioritises preventive measures and enhanced healthcare infrastructure. A small contribution can be made by uro-oncologists treating kidney cancers to adopt partial nephrectomies as a standard of care for surgical management of stage 1 and 2 kidney cancers, to preserve maximal functioning renal parenchyma and to delay the onset of chronic kidney disease and the need for dialysis.

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