The Evolving Role of Minimally Invasive Surgery in Pediatric and Adolescent Urologic Oncology

Pediatric Oncology – Special Section The Evolving Role of Minimally Invasive Surgery in Pediatric and Adolescent Urologic Oncology Armando J. Lorenzo and Rodrigo L. P. Romao OBJECTIVE

METHODS

RESULTS

CONCLUSION

This review aims at evaluating the current status of minimally invasive surgery at the difficult crossroad between the attractiveness of innovation faced against the solid outcomes offered by the current gold standard, specifically concerning pediatric and adolescent urologic oncology conditions. This is a critical review of the literature and current paradigms on the use of minimally invasive surgery for pediatric and adolescent urologic oncology cancers. Focus is mainly on the use of laparoscopy for the treatment of Wilms’ tumors but other neoplasms are also discussed. We draw parallels with other similar pathologies, respecting critical lessons from international cooperative study groups. We discuss various aspects of the pros and cons of minimally invasive surgery in this patient population and make a case for the development of dedicated pediatric surgeons for urologic cancer. Herein we draft a proposal suggesting a way forward with the adoption of reasonable paradigm shifts founded on carefully conducted studies for the introduction of minimally invasive surgery in the care of pediatric and adolescent urologic cancer. UROLOGY 91: 180–189, 2016. © 2016 Elsevier Inc.

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t is hard, some may say almost impossible, to pick up a recent issue of a peer-reviewed surgical publication and avoid finding an article exploring some aspect of minimally invasive surgery. The concept—based on the promise of achieving equal or superior outcomes against benchmarked, well-established, traditional open procedures while generating less tissue trauma—has changed the way surgery is performed in many parts of the world, and has created unprecedented healthcare market and training pressures. Implementation has been further accelerated by the so-called “robotic revolution,” a technological breakthrough that is often de facto equated with better, modern care; and a tool that has clearly shaped subspecialties within our specialties. The overall appeal and real (or perceived) success with reproducing or modifying open surgery employing minimally invasive tools have generated widespread demand for them. Unfortunately, this is often supported by modest degrees of scientific rigorousness. Thus, Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Surgery, Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; the Division of Urology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada; and the Division of Pediatric General Surgery, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada Address correspondence to: Armando J. Lorenzo, M.D., M.Sc., F.R.C.S.C., F.A.A.P., F.A.C.S., Department of Surgery, Division of Urology, Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. E-mail: [email protected] Submitted: September 14, 2015, accepted (with revisions): December 14, 2015

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we often encounter a plethora of case series and small retrospective comparative analyses claiming feasibility and safety based on early, limited, clearly preliminary experiences. Rightfully so, many have raised concerns over the impact of going through a learning (or experimenting) curve, and worry about underreported suboptimal results with unacceptable complication rates. Indeed, it is reasonable to question and wonder about the seemingly arbitrary application of novel devices and equipment to conditions that can be managed expectantly or with already well-established surgical procedures. As the field of minimally invasive surgery continues to mature, we can still witness tension between the obvious extremes: indiscriminate desire to “push the envelope” vs stubborn stagnation with “true and proven.” In between, many practitioners struggle to strike a balance, being cautious while fostering innovation. Although these issues are germane to all aspects of surgical care, they are particularly sensitive in oncology (where the stakes are often high and mistakes notoriously difficult to correct) and in pediatric care (a very delicate and vulnerable patient population). This review aims at evaluating the current status of minimally invasive surgery at the difficult crossroad between these issues, addressing pediatric and adolescent urologic oncology conditions. We will attempt to draw parallels with other similar pathologies, respecting critical lessons from international cooperative study groups. Lastly, herein we also draft a proposal suggesting a way forward with the http://dx.doi.org/10.1016/j.urology.2015.12.023 0090-4295

adoption of reasonable paradigm shifts founded on carefully conducted studies.

CURRENT STATE OF AFFAIRS (IE, “STANDARD OF CARE”) Although slowly shifting, current pediatric surgical approaches (in most centers) follow open extirpative techniques. Likewise, despite tempting theoretical bases for organ-sparing interventions, radical organ removal is often favored. These statements strongly apply to renal and testicular malignant neoplasms, less so for bladder and prostate tumors. The clear improvement in prognosis introduced by standardized radical resection, complemented with protocol-driven chemotherapy and radiation, provides a solid compelling argument for resisting change in our contemporary surgical strategy. A good working example that highlights the current status can be seen in the management of Wilms’ tumors (WTs). There is little argument that cooperative study groups—such as the Children’s Oncology Group and Société Internationale d’Oncologie Pédiatrique—have set the bar high, turning a diagnosis with a dismal prognosis into one that enjoys a very high cure rate.1 Cornerstone in management has been the radical resection of tumor and kidney—largely agreed upon as the surgical strategy of choice in most situations—while differing on timing and type of adjuvant multimodal therapy. In the absence of bilateral disease, known predisposition to develop metachronous lesions, or severe functional impairment in the remaining renal unit, current data fail to show a significant increase in renal insufficiency on modest longterm monitoring of nonsyndromic patients.2-4 Conversely, there is rightful concern regarding loco-regional recurrence, as it demands intensification in therapy with a detrimental impact on survival. Some would say that based on these facts, open surgery should be the gold standard and is here to stay. Nevertheless, the perceived potential advantages of minimally invasive surgery continue to fuel growing interest in the topic!5,6

WHY CHANGE? Cure is one goal; a very important goal, yet not the only one. Although 5 and 10-year survival curves are impressive, it is critical to remember that children are expected to enjoy a dramatically longer survival period than adults, by mere fact of biological age and life expectancy. As survival rates improve and we accept many neoplasms as curable, medium and long-term morbidity introduced by aggressive treatment is being brought into the limelight. The dilemma lies in addressing this without adversely impacting cancer-specific survival or triggering subsequent therapy intensification with escalation in side effects and morbidity. Many urological conditions fit within this paradigm. Open surgical interventions are often perceived as fairly invasive. Ample, comfortable exposure demands a proporUROLOGY 91, 2016

tional disruption of the abdominal wall, which translates into prolonged convalescence, higher analgesic requirements, and undeniably noticeable scars. In addition, the impact of open surgery may very well go beyond cosmesis, recovery, and pain control. A growing body of evidence suggests that the degree of surgical trauma can modulate inflammatory and immunological pathways, a phenomenon that can have an impact on the body’s ability to eradicate the malignancy.7 Minimally invasive interventions, at least in selected circumstances, may be associated with a more robust host response against cancer. Unfortunately, there is limited information on the value of pediatric minimally invasive surgery due to difficulty measuring outcomes with changes in approach. In children and adolescents, it is hard to quantify and defend time to recovery, particularly return to activity in infants and young children. Similarly—although conceptually reasonable to assume—there is paucity of data on the cosmetic, body image and self-perception sequelae of large vs small abdominal incisions. Also, due to the rarity of these tumors, as well as the common use of multimodal therapy within protocols, it is difficult to detect small impacts (either detrimental or beneficial) on tumor control unless these translate into discernible, relatively large, evident changes in local recurrence, cancer-specific, or overall survival. This difficulty holds particularly true during analysis of protocols designed to specifically evaluate the impact of other aspects of care on mortality (such as chemotherapy regimens or radiation), and not the surgical approach per se. However, there is theoretical fear of worsening outcomes due to suboptimal surgical technique or patient selection for laparoscopic interventions,8 which may translate into tumor ruptures, positive margins, therapy intensification, substandard lymph node sampling or dissection, local disease recurrence, and mortality. Unfortunately, this highlights one of the problems with surgical management of children, as expertise for minimally invasive nephrectomy is perceived to be unevenly distributed. There is little role for ramping up a learning curve in this scenario. Providers interested in introducing this approach should have a well-founded technical background from the outset, likely only to be gained by training in high-volume referral centers or bringing skills from dealing with renal tumors in other populations, such as adults with renal cell carcinoma.

HISTORICAL PERSPECTIVE Historically, open surgery has been the default standard of care for solid tumors. These tend to be more frequent in adults than in children or adolescents, including genitourinary neoplasms. Even though the underlying pathology is different (and clearly age related), malignant renal, bladder, and testicular tumors are routinely seen in adults, and management strategies and innovation often start or mature in this patient populations. Whereas pediatric urologists and pediatric surgeons see few cases a year, management of genitourinary tumors is routine for general and oncologic urologists. Thus, surgical approaches in chil181

dren often mirror adult ones, with a delay introduced by the slower adoption of innovations in pediatrics. By default, many dictums and traditions—such as consistently removing the adrenal gland during a radical nephrectomy, approaching all testicular masses through an inguinal incision, or routinely conducting radical orchiectomy for testis tumors—are deeply ingrained in our surgical culture, passed on from generation to generation, and often unchallenged for years.9,10 Conversely, the temptation of focusing primarily on the disease rather than on the individual and caring for children as small adults is a slippery slope. As exemplified by various noncancer clinical situations, pediatric tumors are notoriously different from their adult counterparts in many aspects and simple extrapolation of principles followed in any subdiscipline of adult oncology may not necessarily apply to our young patients’ best interests. Although management principles are often extrapolated, novel procedures and treatment trends seem to lag behind compared to other patient populations. As expected, the minimally invasive controversy hit adult urology circles a lot earlier, and was initially met with some unavoidable resistance and even skepticism. Despite this, the climate at the time of introducing minimally invasive procedures fueled a perfect storm: Tumors were being diagnosed at an earlier stage, thanks to the widespread liberal use of axial imaging studies, a new “generation” of young enthusiastic surgeons was growing up exposed to minimally invasive surgery for benign conditions, many academic institutions fostered the creation of minimally invasive centers, and patients often perceived this innovation as a superior way to address problems. Since then, patients and families often equate words such as “laparoscopic” and “robotic” with better care.11 The early diagnosis of small neoplasms, way before it would represent any real threat to the patient, has been a great driver for stimulating innovations in minimally invasive approach and calling into question radical open resection. Detecting indolent tumors of questionable clinical significance was initially seen as an opportunity to be proactive and treat very early, potentially preventing advanced/ metastatic disease. Unfortunately, this was at the expense of significant morbidity. In response, minimally invasive options flourished. Currently, robotic-assisted laparoscopic partial nephrectomy and prostatectomy are well established and considered by many to be the new standards of care. Similarly, laparoscopic retroperitoneal lymph node dissection has been considered a viable option in detecting small deposits of metastatic disease in patients with testicular germ cell tumors. Favorable, comparable outcomes are also reported for procedures for nongenitourinary neoplasms.12 This mindset is commonplace in training programs in many places around the world, particularly North America and Europe. Thus, the Pediatric Urology workforce growing out of a training stream that originates in Urology training programs has rightfully led the charge questioning more and more the rationale for treating children differently.13 182

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR WILMS’ TUMOR The best example of minimally invasive surgery in pediatric and adolescent genitourinary oncology is in the management of renal masses consistent with Wilms’ tumor and, in older patients, renal cell carcinoma. Following the landmark initial experience by Duarte et al,14 a growing number of case series have been published,15-25 including children managed within geographical areas where preoperative chemotherapy is the norm,25-27 as well as comparisons with open surgery cohorts.17,20,27 Subjectively, many would argue that there are clear intraoperative advantages to minimally invasive nephrectomy, particularly in terms of visualization of key structures during dissection (Fig. 1). For the most part, the presented data fare a favorable comparison against the gold standard, with the accepted limitations imposed by information gathered in a retrospective or nonrandomized prospective fashion. Furthermore, there is a high likelihood of publication bias, whereby less than optimal outcomes may not be submitted or accepted for publication.28 Despite these shortcomings, the reality is that there is growing interest in minimally invasive options for renal tumors in children, and the expectation is that future cooperative international studies will increasingly take this trend into account.17 These publications also unveil an often-overlooked aspect of the surgical treatment of Wilms’ tumors and other pediatric abdominal malignancies regardless of modality (open or minimally invasive). For the most part, they are mostly a reflection of centers of excellence, with surgeries being done by experienced surgeons with skills that may not be representative of what can be expected in general practice. Such observation highlights the fact that treatment of pediatric cancer requires surgical subspecialists with a dedicated, all-encompassing interest in the field of oncology, irrespective of their original affiliation by training. Minimally invasive options will likely have the best opportunity to thrive in such an environment, where their true benefits are more likely to surface under the auspices of carefully designed trials conducted by cooperative groups; nonetheless, different priorities in treatment philosophy between Children’s Oncology Group and International Society of Paediatric Oncology may represent a barrier to their execution in the near future.

OTHER PEDIATRIC NEOPLASMS Interest for minimally invasive surgery is far from being solely in the radar of urologists. Aside from growing enthusiasm in gynecology, thoracic surgery, colorectal surgery, endocrine neoplasms, and many others, pediatric oncology patients are beginning to experience from similar knowledge translation and potential benefits. These include minimally invasive options for selected neuroblastoma,29-32 adrenocortical carcinoma, 29,33 pheochromocytoma, 34 hepatoblastoma,29,35 teratomas and malignant ovarian germ cell tumors,29,36,37 pulmonary metastasis from multiple primaries,38 and appendiceal neoplasm cases,39 to name a UROLOGY 91, 2016

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Figure 1. Visualization advantage of laparoscopic and robotic surgery, providing detailed view and access to the upper pole/adrenal gland (A), the hilum (B), and ureter/gonadal vessels (C), with controlled mobilization of the kidney and tumor within Gerota’s fascia (D). (Color version available online.)

few. In addition, it has become a favored approach for biopsy of lesions or suspicious nodes in anatomically challenging locations (such as the mediastinum),34 determination of resectability, and in protecting bowel and reproductive organs from the effect of high-dose pelvic radiation.40 Different degrees of apprehension and calls for caution have been part of the transition from open to minimally invasive surgery for many of these conditions. Nevertheless, the trend is gaining momentum and less invasive options are slowly becoming an accepted option.

FACTORS THAT AID IN DEFINING THE APPROACH: AGE, PREDICTED PATHOLOGY, AND EXPERIENCE Older children and adolescents closely resemble clinical situations that are encountered in adult patients, and established technological advances are easier to introduce.16,41 For renal neoplasms, the pathology spectrum shifts from Wilms’ tumor to renal cell carcinoma.42,43 Also, the working UROLOGY 91, 2016

space becomes proportionally larger and the abdominal wall more robust, strengthening the case for laparoscopic and robotic surgery.26,27,41 Although WT and congenital mesoblastic nephroma are more common in the first 3-4 years of life whereas renal cell carcinoma is the main consideration in adolescents, the incidence curves by age change progressively rather than abruptly, and many children fall outside of the more certain age-defined prediction profiles. In these patients, a strong case can be made for percutaneous biopsy to help guide management and define any role for adjuvant therapy.44-48 Patient selection is critical. It is seldom that we develop a procedure or intervention that can be equally applied to all patients irrespective of other factors or characteristics at presentation. For example, although laparoscopic or retroperitoneal lymph node dissection can be considered a reasonable option in adolescents and young adults with lowstage testicular neoplasms, it is certainly more controversial for patients with large tumor burden (particularly following chemotherapy or radiation),49 or in prepubertal 183

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Figure 2. Situations that are not suited for minimally invasive surgery are better addressed in an open fashion or with a low threshold for open conversion: presence of a large tumor thrombus despite neoadjuvant chemotherapy (A); encasement of the aorta or vena cava by tumor or large lymphadenopathy (B); signs of tumor rupture on preoperative imaging studies (C); concern for difficult dissection from surrounding structures such as liver, spleen, or pancreas (D); and very large mass displacing the aorta or compressing the vena cava, thus limiting the laparoscopic working space and jeopardizing a safe dissection of the hilum (E). (Color version available online.)

children with paratesticular rhabdomyosarcomas.50,51 Patients with renal neoplasms may not be good candidates for laparoscopic or robotic resection based on imaging characteristics (Fig. 2), lack of response to neoadjuvant therapy, or known anaplasia on preoperative percutaneous biopsy (as routinely obtained in some centers48). 184

NEOADJUVANT CHEMOTHERAPY Relatively small, well-encapsulated, and less friable tumors are more amenable to minimally invasive and organsparing procedures. This is because laparoscopic manipulation often feels less delicate than open surgery, although UROLOGY 91, 2016

this admittedly represents a subjective observation. Robotic surgery is also limited in terms of tactile feedback,52 relying on other cues for accurate dissection. Not surprisingly, this can impact the surgeon’s comfort level with minimally invasive options. There are a few pertinent clinical scenarios that underscore the benefit of preoperative chemotherapy: decrease in tumor size, development of a well-defined capsule, and change in consistency.53 For example, resection of lower urinary tract rhabdomyosarcoma is rarely considered before chemotherapy, taking into account that these lesions tend to be fairly large, in an anatomically difficult location, and obstructive at presentation. Laparoscopic radical nephrectomy for WT has been mostly conducted in the setting of preoperative neoadjuvant chemotherapy,17 although a few isolated reports describe primary resection without adverse outcomes.25 Friability and a perceived increase in rupture risk with laparoscopy have been two of the main reasons for avoiding or only selectively offering minimally invasive surgery for suspected cases of adrenocortical carcinoma.54,55 Conversely, neoadjuvant chemotherapy has been instrumental in triggering favorable changes that allow for safe preservation of normal parenchyma in cases of bilateral WTs.56,57 The opportunity to offer minimally invasive surgery in cases of unilateral renal tumors is heavily influenced by the institutional philosophy on how to initially manage these patients, as influenced by which protocols are followed.58 With an exceedingly favorable response to chemotherapy, as well as for the occasional patient that presents with a small tumor, the dilemma of minimally invasive vs organsparing surgery is likely to arise. Comfort with laparoscopic and robotic interventions is likely to gain acceptance for radical resection sooner than partial nephrectomy,59 creating a situation in which there is a trade-off between the benefits of minimally invasive surgery against the theoretical risk in removing adjacent normal renal tissue. This was the experience with adult patients during the peak of experience with laparoscopic nephrectomy and before the widespread introduction of laparoscopic and robotic partial nephrectomy.60 Although the introduction of laparoscopic and robotic surgery in pediatric oncology will probably be quicker and smoother (as the techniques are now well developed), this is an issue that should be kept in mind as a potential drawback of laparoscopic surgery. An easy minimally invasive procedure should not trump a harder open or laparoscopic one if there are clear potential longterm benefits with the latter. The implications of favoring neoadjuvant chemotherapy can be associated with important management considerations, particularly issues related to lack of pathological confirmation and loss opportunity to detect early patients at high risk who would benefit from intensified protocols. Upfront nephrectomy allows detection of anaplasia and biological characterization, which is expected to gain an increasingly important role in North American protocols.61 Based on this information, the likelihood of a large renal mass in a young child being amenable to upfront laparoscopic resection is relatively small. Clearly UROLOGY 91, 2016

a matter of debate, yet also an opportunity to revisit the need to upstage patients who undergo preoperative biopsy.48 If patients who undergo biopsy can be optimally risk stratified and then allowed to proceed to neoadjuvant chemotherapy, more children may be optimal candidates to minimally invasive surgery.

EVOLVING OUTCOMES Aside from traditional end points, such as survival (overall and disease specific), local recurrence, tumor spill or rupture, blood loss, length of stay, postoperative pain, narcotic requirements or need for neuraxial analgesia, other factors have gained notoriety with minimally invasive procedures. The popularity of laparoscopic and enthusiasm for natural orifice and single port surgery suggest that cosmesis is an important, often overlooked aspect, of surgical care.62 Although not formally explored, it is hard to deny the cosmetic benefit of procedures such as radical nephrectomy (Fig. 3). Similarly, speed of recovery is likely important. Unfortunately, it has often been considered to be a less pressing issue in pediatrics, an argument that stands on shaky ground due to the potential psychological benefit of returning home early and resuming activities sooner, as well as allowing caretakers to go back to work sooner. The decrease in analgesics (both systemic and regional)27 minimizes side effects and complications from these interventions, which impacts on the child’s well-being and need for additional medications (such as stool softeners and antiemetics). It also stands to reason that a quicker recovery may allow for earlier initiation of adjuvant therapy, such as chemotherapy and radiation. More importantly, yet equally difficult to measure, is the ultimate impact minimally invasive options can have on quality of life—both in the short and long term—and survival compared with more traditional options.

FINDING A HAPPY MEDIUM Not everything is amenable to minimally invasive interventions, nor are these procedures truly the best way forward to achieve similar, less morbid outcomes than established open counterparts. A clear example outside of the oncology arena can be seen in patients with neuropathic bladder in need for bladder augmentation and creation of a catheterizable channel. Although clearly “doable,” it is hard to accept that a very long robotic procedure, with multiple port sites and prolonged lithotomy position, is clearly better or less morbid than an equivalent, quicker open procedure done through a Pfannenstiel-type incision.63 Similarly, other interventions should be critically assessed, past the preliminary “safe and feasible” stage, and truly satisfy expected oncological outcomes while adding benefit in other areas such as recovery, cosmesis, and pain control. How to strike that balance is hard, and likely an evolving, moving target based on expectations and technological advances. It is important to acknowledge the evolving nature of novel interventions. Perhaps the most notable example to 185

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Figure 3. Comparison of healed wounds in patients following open (A) and laparoscopic (B) radical nephrectomy. (Color version available online.)

highlight this is the evolution of radical prostatectomy. Open radical prostatectomy, once the undisputed gold standard for surgical treatment of prostate cancer, was challenged by the development of a “pure” laparoscopic counterpart, a very difficult procedure with a steep learning curve, highly criticized by many during its introductory phase.64 Clearly, discouraging results and rightful challenge by many authorities could have discouraged any further development. However, evolution of the technique and introduction of robotic assistance led to excellent outcomes and a favorable learning curve, to the point that robotic radical prostatectomy has become the new gold standard in many institutions.65 We submit that in the future, the next wave of minimally invasive procedures will include the introduction of laparoscopic and robotic nephron-sparing surgery, particularly in patients with predisposition syndromes who are diagnosed with small renal masses during screening.59,66 The appealing leap to this technological advance has to take into account the implications of rupture or positive margins, which can lead to therapy intensification and local radiation. Pure laparoscopic surgery provides limited intracorporeal dexterity for complex dissection, whereas robotic surgery is limited by lack of tactile feedback, which is sometimes critical during dissection of postchemotherapy lesions. As a step toward less invasive surgery in these patients, we currently perform a laparoscopic-assisted dissection, mobilizing the affected renal unit, securing the hilum, and performing lymph node sampling laparoscopically, but performing intraoperative ultrasound and nephron-sparing surgery through a small open incision (Fig. 4). The concept follows principles previously employed in adults with small renal masses,67 and serves as a bridge to gain comfort with pure laparoscopic interventions. Adoption of scoring systems, such as the RENAL nephrometry, may be of assistance in selecting adequate candidates.68 186

Figure 4. Exposure after laparoscopic mobilization and small flank incision fashioned directly over a small intrarenal mass, further defined with intraoperative ultrasound. Note vessel loops around hilum and ureter, both placed during laparoscopic dissection. (Color version available online.)

FUTURE DIRECTIONS The exercise of exploring the topic of this paper certainly allows for some reflection on future management paradigms and directions to follow. We must first admit our bias and love for the idea of organ sparing and minimally invasive procedures, both pure laparoscopic or robotic, concepts that hold great promise in terms of adequately treating cancer while preserving function and cosmesis. With little doubt, minimally invasive surgery represents the future and next revolution in management of selected pediatric patients. However, we must also acknowledge the need to implement this very carefully. Most surgeons dealing with pediatric and adolescent genitourinary tumors on a regular basis practice surgeries that were included in the multiUROLOGY 91, 2016

disciplinary armamentarium that led to a dramatic increase in survival of many neoplasms. Open non–organsparing procedures provide good local tumor control and many have–thus far–not been associated with significant functional problems except for patients with predisposition to have metachronous tumors or involvement of paired (or solitary) organs. The question, however, should not be regarding the value of traditional approaches, but exploring the possibility or providing similar or better results with alternative, less morbid procedures. Conversely, catastrophic outcomes arising from inadequate utilization of innovative minimally invasive and organ-sparing techniques in the treatment of large WT must be kept in mind whenever these procedures are under consideration.69 If we accept the value of innovation and change, we must also take into account the training background of our surgical workforce. In North America (and likely other parts of the world), the number of fellowship-trained pediatric surgeons and urologists continues to rise. This phenomenon has led to widespread coverage of the pediatric population by properly trained individuals, with the unavoidable dilution of experience for certain cases, such as relatively rare neoplasms. This carries an unfortunate snowball effect, where proportionally lower number of cases are treated in a growing number of referral teaching centers, slowly producing young faculty with marginal exposure. More surgeons with diverse background and expertise are targeting a rather small patient population, further diluting the experience and opportunity to have true centers of excellence. In addition, although seemingly competing specialties bring valuable training and expertise to the table, management is often seen as the exclusive domain of one over the other. The surgery and urology workforce is changing. There is a growing trend for less open surgery, in some cases less surgery (and more conservative management), more minimally invasive procedures, and a tendency for percutaneous (image guided) and sometimes robotic-assisted laparoscopy. By mere exposure, work-hours restrictions and current limitations from simulation, a generation of surgeons is going into the workforce with a different skillset than prior generations. Consider, for example, that to many residents an open radical prostatectomy is a rarity worth making time to witness whereas less than a decade ago it was a routine procedure. Is it then right to question who should be offering open or minimally invasive procedures dealing with neoplasms of the genitourinary tract of children and adolescents? We propose that care should be provided based on expertise and not solely specialty training or tradition. With great exposure to minimally invasive and tissue-sparing genitourinary interventions, pediatric urologists can offer knowledge and technical skills invaluable to this patient population, whereas pediatric surgeons have in-depth understanding of solid tumor resection and management of ill pediatric patients. Thus, the ultimate answer may be collaboration between surgical specialties, approaching cases together rather than fighting over control and tradition. Again, UROLOGY 91, 2016

the development of well-rounded pediatric surgical cancer specialists with solid, yet sometimes diverse and complementary backgrounds seems like an obvious future direction.

CONCLUSION Surgical technological advances hold great promise in changing the way we deal with pediatric and adolescent genitourinary neoplasms. Changes should be carefully introduced, and studied within the confines of large cooperative groups with input and collaboration from interested specialties, such as Surgery, Oncology, Radiation Oncology, and Urology. It is critical to go through this process focused on the patient and his or her problem, rather than pushing for potentially expensive technology solely because it is available. Undoubtedly, minimally invasive interventions will have a growing role in our surgical armamentarium until we reach a point where we can question if surgery is needed at all.70 References 1. Dome JS, Graf N, Geller JI, et al. Advances in Wilms tumor treatment and biology: progress through international collaboration. J Clin Oncol. 2015; doi:10.1200/JCO.2015.62.1888. 2. Interiano RB, Delos Santos N, Huang S, et al. Renal function in survivors of nonsyndromic Wilms tumor treated with unilateral radical nephrectomy. Cancer. 2015;121:2449-2456. doi:10.1002/cncr.29373. 3. Romao RLP, Lorenzo AJ. Renal function in patients with Wilms tumor. Urol Oncol. 2015;doi:10.1016/j.urolonc.2015.07.002. 4. Lange J, Peterson SM, Takashima JR, et al. Risk factors for end stage renal disease in non-WT1-syndromic Wilms tumor. J Urol. 2011;186:378-386. doi:10.1016/j.juro.2011.03.110. 5. Cost NG, Sawicz-Birkowska K, Kajbafzadeh A-M, et al. A comparison of renal function outcomes after nephron-sparing surgery and radical nephrectomy for nonsyndromic unilateral Wilms tumor. Urology. 2014;83:1388-1393. doi:10.1016/j.urology.2014.01.051. 6. Wilde JCH, Aronson DC, Sznajder B, et al. Nephron sparing surgery (NSS) for unilateral Wilms tumor (UWT): the SIOP 2001 experience. Pediatr Blood Cancer. 2014;61:2175-2179. doi:10.1002/ pbc.25185. 7. Goldfarb M, Brower S, Schwaitzberg SD. Minimally invasive surgery and cancer: controversies part 1. Surg Endosc. 2010;24:304-334. doi:10.1007/s00464-009-0583-3. 8. Chui C-H, Lee AC-W. Peritoneal metastases after laparoscopic nephron-sparing surgery for localized Wilms tumor. J Pediatr Surg. 2011;46:e19-e21. doi:10.1016/j.jpedsurg.2010.11.024. 9. Moore K, Leslie B, Salle JLP, et al. Can we spare removing the adrenal gland at radical nephrectomy in children with Wilms tumor? J Urol. 2010;184(4 suppl):1638-1643. doi:10.1016/j.juro.2010.03.126. 10. Kieran K, Anderson JR, Dome JS, et al. Is adrenalectomy necessary during unilateral nephrectomy for Wilms tumor? A report from the Children’s Oncology Group. J Pediatr Surg. 2013;48:1598-1603. doi:10.1016/j.jpedsurg.2013.04.019. 11. Dixon PR, Grant RC, Urbach DR. The impact of marketing language on patient preference for robot-assisted surgery. Surg Innov. 2015;22:15-19. doi:10.1177/1553350614537562. 12. Sammour T, Jones IT, Gibbs P, et al. Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: analysis of a large prospective clinical database. J Surg Oncol. 2015;111:891898. doi:10.1002/jso.23893. 13. Vanden Berg RNW, Bierman EN, Noord MV, Rice HE, Routh JC. Nephron-sparing surgery for Wilms tumor: a systematic review. Urol Oncol. 2015;doi:10.1016/j.urolonc.2015.07.003.

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