Office-based, Ultrasound-Guided Renal Mass Biopsy: Technique and Results - Jaime Landman

March 27, 2019

Colleagues, Jaime Landman and Zhamshid Okhunov discuss office-based, ultrasound-guided renal mass biopsy. Jaime details the simplicity of this technique, the best candidate for this procedure, and the value in doing a renal biopsy with this technique. 


Jaime Landman, MD Professor and Chairman, UCI Department of Urology, UC Irvine Medical Center

Zhamshid Okhunov, MD, Urology Fellow, Department of Urology, University of California-Irvine

Read the Full Video Transcript

Zhamshid Okhunov: Hi, I'm Zhamshid Okhunov. I'm currently in the Urology Fellow with the Department of Urology at University of California Irvine. Today I'm here with UroToday and my friend and colleague Jaime Landman. He's currently the Chair and Professor of Urology at University of California Irvine. Today we will be talking about renal biopsy, his work that was presented here at EAU 2019 in Barcelona. Dr. Landman, it’s a pleasure to have you. 

Jaime Landman: Likewise, pleasure to be here with you. 

Zhamshid Okhunov: I'd like to ask you some questions about your work that was presented here at the EAU. This work presented as a video presentation, why video? Usually, people submit abstracts in a written format. Why video?

Jaime Landman: You're absolutely right, we typically don't do a whole lot of videos. In this case, we thought it was really important. The concept of renal biopsy is a little foreign to urologists in general and particularly the concept of doing it in the office. It's something, as you know quite well, we've been working on in the lab for a long time. Freehand biopsies was really tough so we worked with some companies and we were able to develop what a bunch of companies have, we call it the facilitated ultrasound technology. I think everyone's familiar with the concept where the little dotted line is created on the screen so the needle follows it perfectly, and using that now with an abdominal transducer as opposed to the transrectal transducer, that we as urologists are all comfortable with, we've been able to pretty reliably and easily knock out these biopsies. 

The reason we wanted to do the video, which again we don't do real often, is because we wanted people to see that the technique is actually extremely simple and straightforward and that pretty much anyone can learn it. You do need to have a little bit of ultrasound skill, but as with most urologists, I don't have a whole lot and have been able to do it rather successfully.

Zhamshid Okhunov: What is the technique? It's traditionally been done with CT guidance in the CT unit, so title of the presentation is Office Space Ultrasound Guided, so can you tell us a little bit more about the technique?

Jaime Landman: Absolutely and that's the whole point is that you can do this in the office extremely efficiently, so it's very quick, extremely safe, and with typical skills that urologists have. When somebody presents with a small renal mass the question first is are you going to have a biopsy? That is a very complex question as you know in urology today, which I think we'll save for another time but we firmly believe that, just as with all other tumors, you really should have a diagnosis before you start talking about treatment strategies. 

If that's the case and there's plenty of people we don't biopsy, a 90 year old with two-centimeter tumor certainly in most cases would require active surveillance and doesn't need a biopsy. But if we're going to consider some type of intervention we feel strongly somebody should have the biopsy. On that day we would discuss it, that's the first visit. If indeed we believe they qualify for the biopsy then we'll just do an ultrasound in the office and mark their flank with a little rectangle, give them the marking pen and ask them to come back on another day because usually, we need to set up for these procedures. They come back and what we used to do is tell them to take some kind of sedation, oral sedation, and place EMLA cream. Now that EMLA cream is actually kind of magical and something I absolutely would not leave out of the algorithm. The reason being is it numbs up the skin well enough that people feel almost no pain. 

You know our data as well as anyone, the fact is people really feel almost no pain and the pain scales that we've been measuring are somewhere between zero and two for the intraoperative procedure and typically zero afterwards. They come in about a week later because that's just practically when we have office hours. Under ultrasound guidance, we’ve prepped and draped them, we take a look, we identify the tumor, anesthetize the skin, and using the targeting technology we're able not only to anesthetize the skin but the entire tract all the way down. The patient has no sedation and they're your partner in this, so you ask them to breathe to bring the tumor where you want and hold their breath. We're then able with the technology to hit the tumor several times with a standard biopsy gun, the same thing we use for prostates. 

The reason we have I think very, very low complication rate, in fact, lower than our interventional radiology colleagues, is because they're not sedated and they're your partner. They're not moving and I think the clean puncture in and out of that kidney results in very little trauma. Of course, there's a risk of bleeding but quite small. I think in the 60 or so we've done in the office we have no complications. You take your biopsies, the number of cores is highly dependent on how well we see the tumor. If you really feel like you got it in one or two cores you might just stop there. Sometimes we go up to three or four cores. Then we just put on a dressing, we wait an hour, we just observe the patient. 

I'll go back and work and see a couple of other patients and then just go ahead and repeat the ultrasound an hour later to make sure there's nothing around the kidney. I'll usually just do a quick duplex evaluation, make sure there's no bleeding anywhere. Then they send them home. Couple of days later we have the pathology and then we start making some decisions.

Zhamshid Okhunov: That's amazing, so tell us a little bit about your patient selection process. Do you have an algorithm, how do you approach these tumors?

Jaime Landman: Actually, I think that's the key question and that's something perhaps that wasn't in the video that should be, is that we do select pretty carefully who we want to biopsy. Our biopsy results have actually improved dramatically. Early on I think we had about 80% successful biopsies with about 20% indeterminate. I think that's dropped dramatically that if we looked at the last few it's probably about 10%, which is more in line with what most people will quote and it's because we figured out who was hard. 

We haven't looked at it formally but I think the skin to tumor distance is really a key factor. If somebody is large and has over 10 centimeters it's really hard to get that needle all the way down to hit it. Smaller tumors, so a two-centimeter tumors obviously harder to hit than a bigger tumor. The upper pole, anyone who's done renal ultrasound knows the upper pole's a little bit harder to see. Those could be a bit challenging. The ones that are very anterior where sometimes you have to go through some kidney. 

I'm very upfront about this. I don't think everyone's a candidate for the office version of the renal biopsy. Certainly, there's a fair number of patients and I think it really depends on your experience with ultrasound. Like I said, I'm not terrific with it and that's why my initial results were a bit sub-optimal, and now with better selection, I think we are probably getting the 90% results because we're just a little bit smarter about who we biopsy. I don't think we formally looked at the results but I think about 70% of the T1a's and this whole conversation is about T1a renal cortical neoplasms. I think about 70% of those really do well with the office biopsy and 30% go to our colleagues in IR and we have an awesome interventional radiology team. As you know, we have a great relationship with them and quite frankly doing these biopsies in the office has not threatened that relationship because they know that in the end, they're getting plenty of work from us, the whole biopsy concept has increased their volume dramatically.

Yes, being very careful about who you select, particularly early on. If you can see it really nicely in the office, of course, you'll see it really nicely when you go ahead and do your biopsy later on in the office. Slightly larger, slightly more posterior and non-upper pole tumors are probably your best targets.

Zhamshid Okhunov: You mentioned a little bit about your learning curve, can you elaborate on that? What would be the learning curve for average urologist who's not familiar with the ultrasound and how did that impact your results and can you summarize your results? What are the results now?

Jaime Landman: Sure, so learning curve depends on your skillset. I didn't have much of a skillset. I took the AUA course, which if you haven't taken and you want to do renal ultrasound, is fantastic. The American Urological Association, Pat Fulgham in particular, put together this course and transformed the process for me and now I use a lot of ultrasound in the office. Once you're comfortable with that, getting one of these biopsy technologies where the needle guide tells you where your needle's going to go, really facilitates things. Freehand is tough. That could be a rate-limiting step because not everyone has that, but pretty much all the ultrasound manufacturers have them.

Then just using good judgment with the metrics that we just discussed, who would be a good candidate to have this in the office. I think that's important. In terms of results, the biggest reason that urologists and this has been well quoted, I think Dr. Clayman, Roshan Patel, published a really nice survey, 5,000 urologists they got 20% answer, so about 1,000 urologists really answered. 80% of the reason that urologists don't biopsy is it doesn't change outcome. Let's talk about the real bottom line here is what does biopsy do and what has it done for us and in other centers?

There was a recent article by Tony Finelli out of Toronto that you're well aware of as well. It does change the outcome. We have 40% of people now going onto active surveillance. That means that they either had a benign tumor or a very indolent renal cancer that is not going to kill an older person like a chromophobe or a papillary type one. That's great. What else has it done? Zero percent incidence of doing a partial nephrectomy or any active treatment for people with benign tumors. That's fantastic. We used to be at 19% before we started biopsying, which is better than the national average of 24%. But now almost zero percent and the truth is the reason we're not at zero percent is you get those seven or eight-centimeter tumors that turn out to be oncocytomas, maybe that was appropriate or inappropriate, that's to be debated later. We have a zero percent of T1a renal cortical neoplasms going to the OR, so zero percent complication rate for those patients, zero pain, zero cost other than the biopsy, which is much less than the procedure.

The value of biopsy is huge and as you know I meet a lot of resistance in the urology community as to why we shouldn't biopsy, why it's unnecessary. But really it's the standard in every other field, every other tumor, every other surgeon does it. It's pretty obvious that we should do it. The video that we presented here just makes it a little bit easier for urologists to be able to do it on their own, so it takes away a little of the challenge. 

Zhamshid Okhunov: One of the most important questions is people are not used to, as you mentioned, people are not used to doing biopsy. Obviously, as you said, your intervention rate has gone 40% down. How do you fight that culture? People want to operate, people want to intervene with these tumors, they don't want to biopsy. How to overcome that challenge?

Jaime Landman: I know most urologists just want to do the right thing and this is clearly the right thing. Thank you very much for taking the time to interview me.

Zhamshid Okhunov: Thank you, Jaime.

Jaime Landman: A real pleasure.

Zhamshid Okhunov: Pleasure.
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