Doctor Ahmed Mansour, MD, Surgeon & Urologist at UT Health San Antonio, Mays Cancer Center talks about Testicular Cancer.
Interview conducted by Ivanhoe Broadcast News in 2022.
Testicular cancer is most prevalent in young men?
DR MANSOUR: Yeah, it’s a disease of younger men. Most patients present between the age of 15 to 30 years. Good thing is it’s almost always curable. So that’s why it’s a very kind of rare, complex in terms of treatment, but it’s quite rewarding as most of the patients are achieving full cure.
What are the first symptoms that you would experience?
DR MANSOUR: In most patients would present with a lump on the testicles and that’s very, very important. That’s why promoting self-checking in younger men is very important. The sooner they present, the better the outcomes. It’s a disease which is almost always curable.
I’ve been doing these stories for almost 20 years, and I’ve never heard of men having to check.
DR MANSOUR: It’s not that common disease. It’s quite rare. Testicular cancer awareness is something that we should all be working on because presentation makes a whole lot of difference. The earlier the presentation makes, the more likely the cure rates are.
How is it traditionally treated?
DR MANSOUR: Yes, a very good question. Basically, the initial treatment is taking, of course, the testicle out. Based on that type of the cancer in the testicles, further treatments are recommended. In most cases, chemotherapy would be the first treatment plan in patients who have disease that has spread beyond the testicles. Usually, the disease has tendency to spread to the lymph nodes, which are in the back of the body just next to the major vessels in the body. When these lymph nodes are affected, chemotherapy would be the first treatment plan. After that initial phase of chemotherapy, we assess by scanning. And if we find that there is residual disease and, in the body, we recommend surgery to remove these residual lymph nodes.
Prior to this robotic surgery, the surgery was intense?
DR MANSOUR: Exactly. So, the traditional surgery, which is almost always surgery, which is performed all over the country, is quite complex procedure. Remember, these lymph nodes are quite next to the major vessels which are supplying the blood to the whole body. When attempting to remove these lymph nodes, there is always the risk of injuring these vessels. That’s why this procedure, the traditional open procedure even, is only performed in major academic centers and with urologic oncologists who have significant experience with the disease and the procedure.
Now, not just recently, you’ve been able to use robotic surgery to help, but you couldn’t do that before?
DR MANSOUR: I mean, there have been attempts in the past. These attempts in the past were performing the robotic surgery in patients who have not had chemotherapy before the surgery, because chemotherapy makes the lymph nodes more stuck to the vessels and more difficult to remove. So, the procedure was reserved for these patients and the procedure focused on just one side of their body rather than doing both sides of the body to try to, you know, fit the robot in the right space. However, with some technical modifications, we can provide the procedure with the exact same quality of the open surgical procedure treating patients who have undergone chemotherapy in the past and treating both sides of the body, what we call a full template, and in one setting at the same time.
Go back for a second. If you do this during surgery, if you would happen to hit one of those vessels, what happens?
DR MANSOUR: So, we have many tools and we have many instruments. Exactly what we would do in open surgery, what we would do in robotic surgery, luckily this has not happened to us, but conversion to open surgery is always something that we discuss with the patients before the procedure if we need to or might need to go to the traditional pathway.
What’s the risk even in traditional surgery, not even robotic, of hitting one of the vessels when you’re removing a lymph node?
DR MANSOUR: So, it depends roughly how big is the mass? Where are the masses located? How challenging the procedure are? That’s why patient selection is always an important factor. That’s why experience is very important because you go to an experienced surgeon who would look at your case and he would recommend the best type of treatment for you. That’s why patient selection is also important. So, we offer robotic surgery for select patients who would benefit most from that procedure.
So, with the robotic surgery, what did you do differently that allows it to be on both sides and more precise?
DR MANSOUR: So, it’s mainly some technical modifications in the port placement where we can put our ports and where we can orient double bot. This came also with a newer generation of robots which have higher flexibility of their arms, ability to reach different areas, and basically with these kinds of changes, together with the advancement in the robotic systems, we can exactly do the same job that we do in open surgery. So, the advantages will be less pain, less blood loss and faster recovery with the same oncologic outcomes as open surgery.
Were you the first person to do this on both sides?
DR MANSOUR: No. It has been reported in the past. However, only a few cases have been reported in the literature nationwide. However, our technical modifications allow the procedure to be more efficient, to be done in reasonably the same time as the open surgery and of course, safety is our utmost priority.
Can you give me some comparisons with the traditional open surgery, with the robotic surgery, you know, recovery time in traditional is this long with robotic?
DR MANSOUR: So, with open surgery, it involves an open surgical incision. This incision extends from the chest bone down to across the abdomen, down to the pelvis. The complications associated with the wound are significant.
Can you be really specific?
DR MANSOUR: So, pain, wound infections, wound adhesions. These are what kind of complications that can happen with any large incision. The most important thing is that most of these young men and kids, they want to be back on their feet as soon as possible. They are in college, they’re starting to work, their time is very precious for them, and I think the major advantage is they’re fast and ability to return to their mobile activity.
How much quicker recovery?
DR MANSOUR: I would say within a couple of weeks. I’m amazed within a couple of weeks many of them resume their normal activities.
How many incisions with the robotic surgery?
DR MANSOUR: So, one other advantage about this procedure is that there is no big specimen that you need open a big cut for to take it out. So, for example, if you’re taking, you know, a kidney out, it’s a big mess. So, after you do the procedure through the small holes, you would have to make an incision in order to take the kidney out. In majority of these cases, most of the lymph nodes can be taken out in specific bags through the force of the robot without need to extend them into a bigger size.
Is it one incision?
DR MANSOUR: No. So, he’s going to have like five small incisions each, about a half an inch. There is no additional incision for specimen extraction, for removal of the lymph nodes.
In traditional surgery, we didn’t quite say. What’s the recovery? You said back to normal in two weeks?
DR MANSOUR: It takes about a month in order to get back on their feet.
Now is it more cost efficient then because?
DR MANSOUR: That’s another thing that we’re looking at as well. You know, there is an initial upfront cost of the robot and the instrument. This can be offset by the less hospital stay and possible better, faster return to normal activities in addition to the in-hospital stay is not as much demanding compared to the open surgery at the initial period.
So, compared to the in-hospital stay it’s like two days of it compared to five?
DR MANSOUR: So, our patients that we did stay in the hospital for three days just because we want to monitor them because they’re just the initial cases, but they were ready to go home the next day so compared to an open surgical patient who would be staying in the hospital for at least a week.
Can you tell me a little about a little bit about Antonio’s case?
DR MANSOUR: So, he’s 21 years old. He, sort of, traditional presentation, found a lump in his testicles and then was found to have significant lymph node involvement. He underwent the initial surgery, which is taking the testicle out and underwent three cycles of chemotherapy.
Are there stages in testicular cancer?
DR MANSOUR: Of course, that’s why the stages guide our treatment decisions
Do you remember what Antonio’s was?
DR MANSOUR: He was stage three B and because of his stage he was recommended chemotherapy. After chemotherapy we monitored the disease by what’s called tumor markers, and his tumor markers were normal. However, he still had significant amount of residual disease in his lymph nodes, which were just along the major vessels. We offered him, because of his disease location and his disease burden, both the open approach and the robotic approach, and they explained to him that that’s something which is kind of newer. However, these are the advantages, and he was actually up for it, and since then we have done three more cases and they all have followed the same pattern of excellent recovery.
Explain what we’re seeing here.
DR MANSOUR: This is a diagram showing both kidneys and the major vessels feeding the body. The red vessel is called the aorta, which supplies the blood to the vessel to the main organs of the body, and the blue vessel is called the vena cava, which gets the blood from all the organs in the body and delivers it back to the heart. The testes develops actually when we are embryos first next to these vessels up here, and as the fetus grows in the uterus, it descends down to this quarter. When the testicular cancer spreads to the lymph nodes, the enlarged lymph nodes are usually lymph nodes which are up high next to the major vessels, the aorta and the vena cava. In some cases, we offer what’s called a primary lymphadenectomy which is a primary procedure to remove these lymph nodes prior to chemotherapy. This is reserved for earlier stages. In more advanced stages, chemotherapy is the mainstay of treatment. But after chemotherapy, on some occasions, there is still residual masses and lymph nodes which are next to these vessels. Now getting them out, even open surgery may require complex maneuvers to try to take these lymph nodes off the major vessels without any kind of vascular injury to these vessels. With robotic surgery, our main aim is to offer the same quality of open surgery with the advantages of minimally invasive approach. So, we do make sure that all the lymph nodes are cleared in the template of open surgery. So, the template extends from these vessels over here which are the vessels that deliver the blood to the kidneys. The vessels, down to the vessel down here which are the vessels which deliver the blood to the pelvis and to the lower extremities. So, all this area from here up to here is the traditional template that we offer lymphadenectomy for previous attempts involves previous attempts to involve the half site, have a template and what used to be called a modified template because there were limitations in the ability of the robot to fit and to approach the whole – both sides of the body. That’s why it was called a modified template and in many cases it was reserved for patients who did not receive chemotherapy in the past.
You’ve done it a couple of times after Antonio?
DR MANSOUR: Three times.
Do you think it’s going to quickly become the standard of care?
DR MANSOUR: So, we are an academic institute, and we follow the academic steps in order to promote this kind of newer procedure. We have different phases in development of newer surgical intervention. We are currently in collaboration with major academic institutes are developing a protocol in which this kind of approach with a technical modification is promoted to other centers. We’re planning on getting clinical trial which involves multiple institutions of major expedients in this field in order to find out what would be the outcomes of such procedure on a larger scale and hopefully offering it to more patients who would benefit from it.
END OF INTERVIEW
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