Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

So, where, where is everyone of people joined in the other, I pressed, go live and now we are live and I can't see anybody unless no one's gone, which was uh we can see you how many how have we got everyone here phil, do, we know 0 18 already here, I'll a microphone and my camera's should we just do brief introductions of the two of us charlie or exactly yeah that's that's perfect, so hello, everybody thank you so much for turning up to this first session of our new surgical oncology teaching series. Uh My name is charlie uh and adam and I, as well as our other colleague have thought basically there's a lot of things about surgery that don't get taught in medical school. There's a lot of things that cancer that don't get taught at Medical school. I personally have an interest in becoming a cancer surgeon um and as a result, we thought why don't we do a teaching series about this particular subject uh so we can a learn more ourselves about to be in part knowledge and two other people and hopefully create more keen cancer surgeons in the future. Um So I'm currently working at the Manchester Royal Infirmary um. I work as an F three doctor uh working in urology and medical education uh and so I get to combine two of my passions together uh during my uh working working life um. Adam We met Medical School. He's also an f three can introduce yourself a little bit yeah hi, hi, uh for those of you who haven't, I haven't met already uh My name's adam like charlie said we went to medical school together in birmingham, uh where I have a degree in clinical anatomy as well as uh medicine. I did f one f two in birmingham, I've stuck around in Dudley to be a clinical teaching fellow there. I spend my time in General Surgery, I'm particularly interested in pediatric surgeon embryology, but I also really like cancer surgery, which is why I joined Charlie and Antoinette in this uh this program Fantastic Thanks Adam and yeah no matter what we'll be dealing with cancer patient's during our career throughout dealing with surgical patient's that so yes let's crack into it without further a do on our first session, which is on renal cancer. Um Before we start with just going to talk through a case of a gentleman called Richard who's 67 years old and he presents with a mass in his scrotum. He says that he first noticed this about four weeks ago that did not make an appointment initially as it was not painful, exsmoker of 25 years, and he suffers from hypertension for which he takes 2.5 mg a day of ramipril. On examination, you see distended vessels on the left side and these feel like a thickening of the thematic cord. He diagnosed him with a left sided varicocele. During the abdominal examination. You feel a solid left sided mass as you palpate the kidney as well and he denies any significant lower urinary tract symptoms. Okay. Essentially, the gentleman presenting with the left side of varicocele and a mass in his, give me just going to leave you to ponder over that. Whilst we talked through the case uh think about how you might uh Obviously the diagnosis kind of given away by the subject of this talk, but how would you then go about investigating this, managing this and so on and so forth and hopefully the answers will become a bit more clear after this session. Renal cancer is actually quite common and it's incidence is rising as well and this reason for the incidental increase is because we're finding more with the more imaging that we perform, we perform ultrasound scans and ct s, a much higher rate due to uh the availability of these. Therefore, we're picking up more asymptomatic patient's with the condition. It commonly doesn't present until it's relatively late stage with symptoms and therefore previously before all of these incidental findings, many patient's presented with metastases with advanced stage disease between 80 to 90% of tumors are renal cell carcinomas, and ct and ultrasound imaging are the mainstay of our investigative diagnostics, patient's have early stage disease and the mainstay of treatment is with surgery. However, there are many other modes of treatment for renal cancer including immunotherapy, and then other treatments for metastatic and advanced stage patient's. Of course as with all surgeries, we need to take into account patient performance status and wishes as well so as I said renal cancer is common that is 3 to 5% of cancer diagnoses in total, and it's more common in men, with it being the fifth most common cancer in men and the 10th most common cancer in women. It's more common in western countries, and this is perhaps due to our superior diagnostic methods, were able to uh use imaging to a greater extent, but in addition, we have more risk factors such as smoking, obesity, uh and things like that patient has a family history of renal cancer, consider whether there may be a defect within the von hippel lindau gene, which is the most common gene to be affected in renal cancer. Other less common risk factors include hypertension, which is also more common in these western countries, end stage renal disease, expo, exposure to certain substances such as asbestos or cadmium, petroleum, and then as I said several single do mutations as well, so again it commonly doesn't present with many symptoms until it's relatively late stage is a classic triad is known, however, which includes loin pain, hematuria, and the loin mass. It should be noted this actually only occurs in 10% of patient's even though it's in all the textbooks as being the trial to look out for left sided cases, such as in our gentleman in our case may present also with a varicocele. Systemic symptoms rarely present unless associated with advanced disease as well. These include weight loss, cervical lymphadenopathy, and bony tenderness. If a patient has renal cancer as well as lower limb adina, it may suggest that there is involvement of the imperial in the carver and that of course suggests quite advanced disease, so because of it's a symptomatic nature in the early stages, it's diagnosis is very challenging, however, if patient's present with two weeks, it should be noted that if there is a suspicion of renal cancer in the patient, that you see the incidents of benign tumors is very rare, so it should be considered malignant until proven otherwise uh okay, but it should also be noted that renal cancer is one of the most common cancers too, cause paraneoplastic syndrome, which if you've not heard of that before, paraneoplastic syndrome is a condition not related directly to the cancer, but because of the body's reaction to the cancer or because of something that the cancer produces such as a hormone such as reading, which may occur because the kidneys produce renan, overproduction of certain things like aretha equate uh or parathyroid hormone related peptide. Uh There are many other types of paraneoplastic syndrome, america and renal cancer just because of their endocrine um and immune functions uh and my consultant who confirmed the slides and, and give a few pointers told me about a case that he saw the patient who was admitted with severe muscle weakness, immobility. He was a young patient. I was diagnosed with neuromyopathy and there was no clear cause until they did a ct abdomen pelvis that revealed a renal tumor and so they diagnosed the power of Neo plastic syndrome. After an effect to me. He was able to walk out of the hospital despite being completely immobile, having severe weakness, so it just goes to show that a if we treat the cancer, you can treatment of paraneoplastic syndrome that can have dramatic effects. But if someone has strains of neurological features, strange features, then consider maybe they're having a paraneoplastic syndrome and they may just have an underlying diagnosis or something like renal cancer, so it started to take in a little while to um load up yeah okay Our investigations, at the very least should include um the basic investigations that we require from most patient's teaches the u. N. N. Full blood count bone profile um lDH is useful and renal cancer as well, even though it's a bit less standard and a clotting profile should be noted that the bone profiles to look for hypercalcemia, which occurs in malignancy, uh and our clotting profile will help us decide whether the patient can have surgery or not based on their eye on our imaging as well. Of course, in any cancer case or suspected cancer case imaging is necessary that and the mainstay of diagnosis when it comes to imaging and renal cancer is a ct with contrast as well. The ct, of the thorax, abdomen, pelvis is necessary for cancer staging. They may have metastases, however, of course, not all patients can tolerate a ct, some patient's may not be able to have contrast due to their renal function until alternatives include an ultrasound scan and an MRI scan. It should be noted that mri scans are useful for investigating ivc thrombosis, which may be a complication of advanced renal cancer. When it comes to biopsy, as may know, most cancers get biopsied prostate cancer being quite a significant example. There's a major role in the diagnosis and confirmation of everything but in the case of renal cancer, it's an area of debate. There are fears that renal cancer could become seeded as a result of biopsy, but of course there are those few cases that where the Green or cancer is benign and so if we don't biopsy, we may end up causing a lot of distress and damage by taking away part of the kidney or the whole of the kidney. When in actual fact the lesion was benign, wouldn't have caused many issues if any at all modern literatures going towards uh suggesting that renal boxes aren't dangerous for the spread of cancer. However, this is an area of debate um and so you may find a lot of patient's don't ever have a biopsy, so when we do ct imaging, one of the most common things you might see is assist, so uh the bosniak one or bosniak anything from bosnia to F or 34 until proven otherwise and further investigation and or outright treatment with a nephrectomy should be performed. Sorry charlie cut out a bit at the start of that slide just to, just to let you know, we we missed kind of the first half of what you were saying there uh. Sorry. Thanks Adam uh said well essentially when we do, cts, some lesions on the kidney can appear as cysts, essentially cystic lesions, but because some cysts are basically benign, such as our bosniaks one, cyst, bosnia to cysts, these lesions should essentially just be left alone, uh whereas bosniak to f three and four should be investigated more thoroughly as these are much more likely to be cancerous, Should be noted that these bosniak to s, probably about 50% or so, are malignancy rather than benign lesions of benign cyst, so as I said before 80 to 90% of renal cancers are renal cell carcinomas and 80 to 90% of these renal cell carcinomas are clear cell carcinomas. Less common forms include prep, ilary renal renal cell carcinomas. These metastasized less frequency uh frequently, but they do have an associated worse prognosis. In addition to other rare forms include chroma, foam chromophobe, and collecting doctor in a cell carcinomas and these exist within the collect conduct. Renal medullary carcinomas are very rare, but are very aggressive and they can be seen in sickle cell disease patient's, and then there are transitional cell carcinomas as well, So transitional cell carcinomas are the most common type of bladder tumor in your it'd tumor, but in the case of renal cancer, they form only about 10% of these tumors. One interesting fact about these is that transitional cell carcinomas will tend to um spread upon lines if a patient has a nephrostomy, and so therefore this should be considered. If a patient needs a nephrostomy, will the renal cancer go from the kidney up through the line and into the skin. This may be a consideration as that will significantly affect the patient's quality of life, but of course, it may be a necessary nephrostomy in order to preserve the patient's like other benign tumours include angiomyolipoma. It's these are associated with the disease tuberous sclerosis, which is a genetic disease. There are oncocyte, oncocyte, omagh's, and there are also uh These are also fairly rare benign tumor's um that don't cause any problems unless they're going to be an extremely large size, unfortunately, like I said before without biopsying these lesion's. Many of these are still diagnosed following a nephrectomy, so these patient's will have lost part of all of the kidney uh as a result of benign tumor rather than a malignant tumor. Pediatrics, so wilms tumor's are the most common extra actual tumor in children and wilms tumor is may also be known as nephroblastoma as these patient's usually present with a unilateral flank mass as well as hypertension, which is highly abnormal in a child, many of them occurring young children, often around the age of three to age 3 to 5, uh and there are very few other causes of these issues in children. So if you see a child with the flank mass or with hypertension, one of the differential diagnosis that should definitely think about is a wilms tumor. These patient's usually do very well after surgery. It should be said because children are very good at recovering post operatively. So like with all tumor's, we use the t. N. M. Staging system, Tea depends on the tumor size, n the presence or absence of nodal disease, and m, for the presence or absence of distant metastases, not going to go through the whole thing just because it's quite long, however, essentially with m and m, it is just the presence or absence of these futures of disease, whereas when it comes to t as you can see, there are many different stages of the tumor size uh depending on the size and the level of extension of the tumor. So yes as I'll say, again using TNM system for the staging of the tube and that's why we also need to have a ct thorax, anthem and pelvis after we have suspected or diagnosed renal cancer and onto our treatment as well, so we've discussed our diagnosis, investigations, onto our treatment. When it comes to surgery, we've got laproscopic methods, robotic methods, and open techniques, and each of these can be used. The management really depends on tumor staging and we're going to go into that in a little bit, but it is important to remember that partial effect to me, which you can see an example of in the schematic below is an established treatment for t one disease, so that is early stage small sizes of tumor want to take only a section of the kidney and there are a number of techniques that we'll talk about in a little bit this image. I just want to highlight the fact that these dots represent where you would put your ports in and that will allow you laproscopic access or robotic access to your patient for the operation, So when patients have slightly larger humans, which are 22 These may also be treated with a partial nephrectomy. These may also be treated with a radical nephrectomy, which is where you take the whole kidney and associated structures out. I remember being an effective uh effect of the operation with the surgeon. Patient had t two disease genuinely didn't decide on whether to do a partial or a radical nephrectomy until he was inside the patient in the operation, he could see the tumor for himself, so sometimes these decisions are very hard to make just with radiology and we need to get into the patient and see what we're dealing with in real life. Other consideration, uh things like catheterization preop that's so that the bladder is as small as possible, so it doesn't get into in the way of our operation uh and antibiotics as well because we're going into the genital urinary tract by incising the kidney. Of course, there could be urine contamination. Therefore, we want to make sure that our patient's have antibiotics. It should be noted that the role of partial effectively exists because it's never unsparing you want to preserve as much renal function as possible. That's going to serve the patient well going forward in life. If they ever have a decline in kidney function, and they only have one kidney, this can cause quite a lot of complications, particularly they're young during the nephrectomy, and there are very few country indications for surgery as well, other than the standard bonds that exists for all surgeries such as bleeding disorders, the patient feels too many comorbidities, we're not going to survive the operation, or if there's widespread malignancy so open versus laproscopic surgery, so what does open surgery actually involve well. It can involve either a sub costal, which is transperitoneal remember sub costal costal is the ribs, so going through that section of the abdomen or flank incision, so that's retroperitoneal this patient here on the bottom is in the lateral decubitus position and that is what we use for flank incisions. When we do open surgery, my consultant told me that very large tumours may even require rooftop incision as well, so that's normally how we access the upper abdominal organs, the liver, the pancreas, in very large kidneys as well, this may be required laproscopic surgery. Generally, it's minimally invasive as I said it's where it's essentially keyhole surgery you purport in rather than making a large cut into the patient's use the cameras of the laparoscope in order to view the abdomen, inflate the abdomen with carbon dioxide and use probes to handle the organs, separate the kidney and manoeuvre tissue as well, and robotic surgery, So I imagine a lot of you won't have actually seen some robotic surgery. Many hospitals don't yet have a robot my hospital that I work on working, doesn't have a robot yet even though we're a large city center, tertiary center, um so all of the surgeons that do the robotic procedures have to go somewhere else, um but basically it's a little bit like laproscopic surgery, however, instead of using our arms in order to manipulate the uh scope in order to manipulate the tools. Actually the robot does all of the physical movements and it's controlled by the surgeon away from the patient's, so it's a bit hard to sort of conceptualize, but there there is a computer system that the surgeon operates that mimics the arms of the robot that you can see here and that instead of directly moving the arms, the computer system controls it digitally and the robots able to move and that allows for much smaller, much easier and much more precise movements and this happens in real time as well for going back to partial nephrectomy. This balance is the benefits of uh complete excision marking margins and parenchymal preservation. There's very little point in preserving tissue if you're just going to preserve tumor, so therefore you need to make sure that your excision margins are as tight as possible in order to preserve as much good tissue and take out all of the bad tissue. The kidney is manipulated without removing the perinephric fact and most uh partial nephrectomies have now performed either laparoscopically or robotically. The reason why i'm t one patient will use partial effectively because actually the outcomes are equal, there is no difference between them and partial effectively, has a lot fewer complications. I still have most of that kidney after all, in addition one thing to consider is that you may insert a urata extent after in order to facilitate draining from the collecting system down into the bladder as well, that's something that can be considered perhaps at a later date, perhaps not during this operation, flank incisions are the most commonly news that's when the patient is in that lateral decubital position and you have to clamp the kidney off for no more than 30 minutes, and that's because we want to make sure that this kidney doesn't become ischemic, uh nonfunctional. As a result of our surgery, we usually don't actually clapped the renal vein, and this is because if we do that, then the kidney is going to swell full of arterial blood potentially and then that can cause either rupture of the kidney or spread of the tumor itself. The kidney is a highly vascular organ as we know, it receives one kid that received about 10% of all the cardiac output, so be aware of a lot of bleeding using that diet family to prevent bleeding and stop any bleeding at as precise points as possible, uh and being aware that with severe bleeding will necessitate resuscitation of the patient maybe converting a procedure to an open procedure, so this image I really like actually because it shows roughly what the steps are you can see here. There's a normal kidney and then protruding out is our tumor, you can see the line drawn around the margins and you can see the surgeon slowly but surely removing this tumor, which actually looks very large um away from the kidney, exercising it and then removing it from the body. Snitching the kidney backup is a very complicated process due to that bleeding, but because it's also such a soft and sensitive organ, however, uh this is achieved uh with care uh through suturing using a, either through direct featuring of the, of the kidney or using a patch, there are a number of ways of performing a partial effectively as well. So this was actually what kind of sparked my interest in uh doing this series because I what I saw when I was in my first partial effectively was an inn nucleation of the tumor, and I always thought it was actually done through wedge reception. This is just what I presumed but I saw in nucleation uh and that is how we uh that is, if you're confident about getting all of those margins. If you're less confident, perhaps a more complicated tumor make performance a you nuclear reception which is a combination of slight reception of normal tissue with the tumor or a wedge reception, where you remove a whole wedge of a wedge of kidney that includes the tumor and therefore removing of both a decent amount of normal tissue, sacrificing that for the sake of removing all of the tumor, perhaps it's very complicated or indeed very large. So, onto our radical nephrectomy, I'm happy to take any questions if there are any um at this moment, I appreciate that's a lot of information um do please use that chat function, I can see it um and I'll try and get to those asap, uh but if there are no questions, we can move on to radical nephrectomy, so principal in cancer surgery. If something's radical, we're trying to move all of the tumour and much of the surrounding structures, So in the case of nephrectomy, we not only remove the tumor, but we remove the entire kidney and this involves removing the renal artery, the renal vein, and the proximal urata. In addition that we remove the derogatis fascia, the perinephric fat as well what we do not usually remove is the adrenal gland, and we usually keep the local lymph nodes in situ as well, so there's no need to remove that and that obviously is good for the patient, preserve. The adrenal gland is there less likely to get things like Addison's disease and the lymph nodes as well, which allows for our lymph drainage to be intact. It should be noted that again as a general principle laproscopic surgery, yes, it's it's better for the patient's and it's the fewer complications. The scar is much much better. Patient's are usually in hospital for less a less long period of time, but it's more technically demanding uh laproscopic surgery, doesn't allow you to have as free and movement as open surgery, so as a general principle open surgeries quicker, it's less complicated, but often it needs the patient having more need of blood transfusions and needing to stay in hospital for longer as well, and the case of radical nephrectomy or partial effective is no different to that. Normally. This is achieved through the transparent a meal approach. That's when the patient is lying supine, but you can also use the flank position when they're in that lateral position, I should say, I'm just the other day with some of the people who I know and so essentially if you have someone who is quite a large body habitus that might allow you to do it by the transperitoneal approach, those with quite small body habit, This will allow the flank position much more easily as well. Another thing that we haven't spoken about just yet um is the ivc from by so as I said before the patient has uh bilateral lower lymphedema, They may have a IBc from bus. If this is the case in our patient's that we've got on the table, we remove that at the same time because we're removing the renal vein and so we don't want this patient to have a pulmonary embolism or anything like that until we remove any from by that are caused by our tumor, and there are other surgical management options as well, so what we've got. If someone has a very small tumor, perhaps isn't fit for a whole partial nephrectomy. One thing that we can do is percutaneously, ablation therapy that includes cryer ablation or radio frequency ablation now appreciate, I've used quite a lot of big words so percutaneously, that's through the skin, an ablation, I like to think of as just zapping, so in cryo ablation, we use very cold temperatures to obliterate any tumor that we can find or, c, and in radio frequency ablation, we use radiated waves in order to essentially zap any tumor fry it and hopefully get rid of it now These this is reserved for patients who are considered not fit for surgery because the outcomes are inferior, so you're more likely to have tumor recurrence or you're more likely to have missed a bit of tumor. Things like that survival is less, but of course, it's better for patient's, if they aren't fit for surgery because it's better than nothing if a patient is fit for surgery. This isn't an option for them go for a partial nephrectomy and I do think partial because this is only for small tubers, uh sorry, that's like delay onto metastatic disease now, you might think oh okay, so the majority of metastatic disease. Surgery is not an option for these patient's um So effectively their options may include things like chemotherapy or radiotherapy. Things like that or in the palliation. Renal cancer is like a few of the things I've said today, just slightly different because actually a lot of these metastatic patient's may benefit from surgery, so what kind of surgery could we do well, we can do cytoreductive surgery that's basically where we d, bulk in the areas that are affected by the mass effect of a large tumour. It may even involve a radical nephrectomy, and patient's usually receive immunotherapy after this as well. This has been not only gent, improves survival outcomes, but of course symptoms as well as that as well, and then there's something called metastatic to me, which I personally hadn't heard of until I started looking into renal cancer a bit more as one of the few examples where we can surgically remove bits of tumor from the brain and from bony lesions. Now. Obviously that has a lot of benefits for patient's a lot of these brain metastases can cause major complications such as epilepsy, it can cause major headaches and they can cause race intracranial pressure, and then the bony lesions can lead to a lot of bone pain and fragility fractures as well, So this is a possibility for patient's okay j f receptor inhibitors, sorry, charlie you cut out for a bit, then you were just at the start to protect to me. Uh You talking only lesion's a little bit so we lost you between then and now oh thanks adam sorry about that just to go back to medicine effectively, then essentially the removal of the uh metastases from the, from the brain or bones, or both why is this necessary well. Actually, it's been shown to prevent um complications obviously from these metastases such as epilepsy such as race, intracranial pressure. They significantly improve quality of life and can improve survival as well. It's one of the few cancers where you can actually remove metastases and lead to benefits from patient's. If they are fit enough for this, many other cancers don't have this and I uh to be honest, I haven't really heard of another type of cancer where you can perform uh metastatic tech to me um sorry. If you heard this a little bit again, but I'm not sure when a cut out but effectively uh nowadays we have a lot of targeted molecular treatments. These effect, single molecules um and these include things like anti vascular endothelial growth factor or platelet derived growth factor inhibitors. What these do is. They prevent the blood vessels from forming around tumor's and if they don't and have blood vessels, they're not going to grow and that's why they work. There's things like nivolumab, which is a type of immunotherapy, effex, the pd L1 receptor, uh and this effectively allows tubes to hide away from the immune system, and so effectively, this nivolumab agent enhances our immune system's ability to see cancers and therefore destroy them on its own and then there's anti ctla four ctla four is another key agent in the immune system, allows the activation of the adaptive immune system, are T, cells, are the cells, and, and our regulation as well, and so ctla four leads to regulation of the in fact of the immune system, it downplays the immune system, so if you block ctla four, you enhance the immune system and then for hopefully improve our ability to detect cancers, so it's a very complicated, but actually very effective as well, and then there are other methods are conservative methods to this includes active surveillance uh Consider this in our more fail elderly patient, very morbid patient's uh and then there's palliative treatments that's where the focus is making the patient as comfortable as possible, reducing united symptoms that they have um and ensuring that they have a peaceful end to their life if they are approaching the end of their life. Should also note actually decided to go back that chemotherapy generally is an ineffective farina cell carcinomas um So that's one of the few areas where cytotoxic agents uh that make you lose your hair and things like that aren't used. One exception to this is our collecting duct and medullary cell cancers, which may be treated with chemotherapy, so what about prognosis how long our our patient's going to live well. Uh Many studies regarding this in a few key factors uh that we use in order to figure out how likely and how long the patient is to survive over a period of time and there are different sort of tools that we use for post nephrectomy patient's and for patients with metastatic disease as well, so I'm not going to go through all of this. It's quite complicated, but essentially Henkes criteria is used for our metastatic patient's why do we use the listed agents here well. The reason is is because they've done survival analysis, and they've shown that the following factors, anemia, hypercalcemia, performance status, uh and the rest of them are the most associated things with a poor prognosis, and so if you have one or many of these, your prognosis is poorer, and so therefore we use these in order to gauge our patient's length of life. In addition, as a result of the effectiveness of these tools, we can stratify our metastatic patient's into low intermediate and high risk group and then when we have our post operative patient, so those who have had an effect on me. We instead use the Leibovich score and that depends when our patient's are followed up, and this depends on the tumor size and the stage, presence of lymph nodes, and particular histological features that we can gain Again. These are going to post nephrectomy after we take uh specimens and put them in the lab for the histology ist to analyze. We again can use this to risk stratify our patient's there's a schedule based on the data that we can garner from all of these investigations to determine at what point and how frequently patient's are followed up. So in summary, renal cancer commonly has no presenting symptoms. We commonly nowadays, especially, are finding incidental diagnoses and this is becoming more and more common as time goes on. Our treatment depends on the cancer stage, and there are many surgical and medical options that exist. There are many options for local disease patient's, and there are many options for metastatic patient's. As well. Our surgical methods include partial and radical nephrectomy, and these can be done through open methods, laproscopic methods or robotic methods, and we've touched on what those actually mean today, laproscopic methods overall are used. Most often remember are targeted molecular therapy, so all of those molecules that we may have learnt about in our first years of medical school. These are really important for metastatic patient's uh should say actually I didn't mention that submitted is the most commonly used of these agents um and follow up is based on data driven scoring systems um that show that have been shown to uh to risk stratify patient's into low intermediate and high risk groups, so I said at the beginning of our talk that we would discuss a case uh and our cases Richard who is 67 year old gentleman who presents with a massive his scrotum. He says that he first noticed this four weeks ago, uh but he did not make an appointment originally. Uh He's a smoker uh ex smoker. I should say he's got hypertension an examination you feel what looks to be a varicocele and during the abdominal examination, you feel a left sided masses, you palpate his kidney. He denies any low urinary tract symptoms and I should say other symptoms too, um so what I hope at the end of this talk. What what you can realize is. You could recognize that this is a patient who has a few risk factors for renal cancer such is his smoking gender, his age, he has hypertension well. I hope is that he may well have had this for a little while but his presenting future is a left side of varicocele. You also noticed a left side of mass, but he did not notice this himself and um you didn't present with any clear frankie materia, uh or anything like that either, so again noticing that left sided cancers can present the varicocele uh as well, so what I'd hope if you saw this patient, for example in a any or in g. P, or perhaps incidentally on the ward that you would consider that this is a high risk of renal cancer. You know that ct with contrast and the on, main imaging investigation as well as basic blood tests you want to look out for many paraneoplastic symptoms um and then following the ct, you can get an idea of the size of the tumor, perhaps the lymph node involvement, and potentially metastases as well. And then following that you can decide whether this patient is a good candidate for surgery, I would suggest that because he only has hypertension with a low dose of ramipril and and he's only 67 he may well be a good candidate for surgery can consider, does he need a partial nephrectomy, which you spoke to about that because you've spoken about or radical nephrectomy, or if there are metastases could he have one of the many treatment options that we discussed um. And that's the end of our talk, thank you very much. I'm happy to take any questions that you have um Please let me know um. And we do have a content that you can take home, so I've made a flat shoot earlier in the week. Um That summarizes all of the things that we've spoken about today, thank you very much for coming to this uh session, so there are a little bit where the sound wasn't so good, but I hope it was good for the rest of the talk and I hope to see you in our session next week, which will be at 6 13. That session will also be delivered by myself. It will be on prostate cancer and then in sessions after that, which will be delivered by my uh my colleagues and friends adam and antoinette on various other cancers as well um yes, So thank you very much, I'm going to stop presenting um and yeah happy to take any questions if not have a pleasant evening, I'm happy to break the silence for the first one, thanks so much I that was such an interesting talk, I think renal cancer is probably one that we encounter a bit less in our medical education. I don't remember ever specifically covering it during um during, during my studies, I know I did the four most common ones, but I think renal is probably number five or six. I think so it doesn't doesn't really get a lot of coverage, but thanks, thanks so much for that that was really really interesting. I wanted to ask you little bit about the robotic side of things. I think it's probably something a lot of us haven't actually seen any of, but you you've obviously got got a bit of wisdom to share on that. Um specifically comparing it to laproscopic surgery. In terms of the advantages of robotics, there was something about how the movements are more dynamic, is it that your hand is less likely to slip, if there's a robot controlling it or is it just just the dynamics of the movement and the challenges of laproscopic surgery are removed, is there anything you could say to that. Yeah Definitely, so my experience with with both laproscopic surgery and with robotic surgery comes from having used one of the robots, so I use the robot conference, I didn't wasn't on a patient, but you do various exercises and it does allow it, uh like large movements that you perform very small in real life, and because there's that sort of the magnification actually that means that your movements are much more precise than if you were you were to do them, So that allows you to perform smaller sutures, allows you to diathermy smaller areas and as a result do more precise movements as well. In addition, um if you get yourself into a sort of uncomfortable position on the robot, I'm not sure if you guys can see my hand, um you can put on a setting readjust without actually moving the hands of the robot, so you can put yourself in a much more comfortable position. If you get yourself a little bit skew with it, is a bit strange looking through sort of a headset uh and moving your hands kind of in the air rather than in a person in real life, that's something to get used to and there are certain techniques to get used to as well, but because of this patient's have been shown to, for example need if your blood transfusions, I think the length of stay in the hospital is better. I think long term, there may be fewer complications as well. Um The downside is that there's less availability because not all hospitals have a robot um So my hospital for example doesn't have a robot um expense. These robots are very expensive, so when I was at the christie hospital, I was told that they have two robots and they both cost a million pounds each. Um So if your your trust has a spare million pounds lying around they may by a robot, but they may decide to spend it on something else um and actually something that I found a conference is um just the use of things like plastics, so there's a lot of additional plastic materials that need to get used, and so it's not particularly green um as an option uh downside particularly this day and age, but perhaps with disposable plastics or uh things like that might change in the future, any additional questions happy to answer anything with the best of my abilities. Um Again, thank you so much for coming. I'd also, if you, if you're up for it in the chat, happy to take suggestions from you. Guys. Of course you our audience, we want you guys to to an extent the the producers as well of the teaching series. So if you have any suggestions uh that we haven't thought of uh again happy to do those. I know, I think you uh feel that a feedback form service uh any suggestions can go there as well, uh but we're coming up to 7 30 which is when we were due to uh finish, um so I'll wait around for a minute or so that if there are no further questions, do you have a very good evening, I can see there's something in the chat okay. I can distribute the feet platform in the chat uh hang on. So thank you again, I really appreciate the feedback form. Um I posted it in the chat. I will also um email you guys just with the feedback from just in case uh. Super important to us again, this is this is a brand new teaching series that was the first ever event um uh of our new teaching series uh something that I know I'm very passionate about I know adam and anton that are very passionate about it um and um so yeah we want to get better and we want to continue, so your feedback very much um appreciate it. Thank you so much guys um yeah, Thanks so much for attending everyone uh we'll see you we'll see you all next week at the same time uh for the prostate cancer, cheers guys.