So it's my pleasure to introduce Ben Chung. So Dr. Chung is an associate professor of urology. He, it's been a pleasure to work with Ben. We work very closely in taking care of our patients. He trained in Boston and then moved, did a fellowship up in Cleveland Clinic in minimally invasive disease. So Ben has brought to us the ability to do surgeries in a minimally invasive fashion. And he heads our laparoscopic surgical group here at Stanford and his clinical interests and research interests are really looking at developing new techniques in patients with minimally invasive disease. He does both our robotic kidney operations and prostate operations as well. And it's a pleasure to have Ben talk about what the surgical options are for patients with kidney cancer. Thanks Ben. Thanks for introduction. I'm gonna switch gears a little bit from kind of pathologic diagnosis to, what actually happens a lot of the times with these patients with patients who are diagnosed with kidney cancer. I have no financial disclosures to reveal to you.  In the past, before we had some of these technologic advances, we were doing a lot of these surgeries because of lack of technology through really maximally invasive means which will go through. Fortunately, over the past 10, 15, 20 years, we've actually made great strides in accomplishing equivalent safety and oncologic efficacy by using minimally invasive techniques which really benefits the patient to a large extent from a recovery standpoint. So we really rolled the clock back about 53 years to modern radical nephrectomy which was described by several people but in the literature by Dr. Robson and in Toronto, Canada. And the principles really are, well basically to make a very large incision in that time basically going through the rib cage all the way down here. And the principle was to really control the vessels to the kidney very early to prevent any sort of spread of cancer in tumor cells and then remove the whole kidney along with the adrenal gland and the surrounding fat to make sure the cancer was removed. At that time, the overall survival was not real great. 52% five year overall survival. Of course, this is an era before that preceded CT scan, ultrasound, MRI and any of those modalities. So really it was really hard to find these tumors until really they had spread. And of course, once they spread, there wasn't a lot that could be done that time to really check that spread. So really this was the gold standard for kidney masses at that time was to move the whole kidney. And that's how it was for several decades and we'll get into that. The thing about kidney cancer is that it can do interesting things, especially to the blood vessels that course through your body. So actually kidney cancer can spread through the veins of the kidney directly into the vena cava. And that happens about four to 10% of the time. And how that usually presents, in addition to other symptoms is that patients can have a deem of their leg. They can have a varicoseal, which is being portrayed here where the veins around the right testicle are enlarged. And they can present with a tumor that's spread into the lungs and having shortness of breath, the pulmonary embolism. There are a lot of ways to stage them, but this is a peculiar thing about kidney cancer that it can do such things to the point where it can go all the way into the heart. So we'll go through this real quick. A level on thrombus is simply a thrombus, tumor thrombus that's in the vein. And these usually can be managed with kind of minimally invasive methods. Oops, let me go back. The more extensive the tumor thrombus, the more difficult the procedure. So level two goes into the vena cava here, which is portrayed right here. Level three starts to go up towards the veins that drain the liver. Level four ends up in the atrium. And as you can probably imagine dealing with these types of challenges technically can be pretty difficult. With level four, usually a patient needs to be put on coronary pulmonary bypass, like you would have done for a bypass graft to the heart for coronary artery disease. Stop the heart, drain the blood. Kidney cancer can range from something that's relatively amenable to something with a robotic or laparoscopic approach to something that's really gonna be managed with multiple teams of surgeons to safely remove the tumor. Luckily, most patients actually do fairly well. So as you can see, the topic of this talk is kind of from the most invasive to the least invasive. And luckily, if patients did not have metastatic disease or metastases, then they actually did pretty well. Of course, we don't have a lot of data from the current era of tyrosine kinase inhibition. So we don't actually know how well these patients do. But in general, the feeling is that whether or not they have metastatic disease at this point, we try to take it out. We try to take it out. The thing about the kidney from a surgical standpoint, everyone has to remember is that no matter what we do to the kidney, it has a very avid risk of bleeding. And that's really because of its blood supply. So as you can see here, this is the vena cava and this is the renal vein and this is the right kidney. The kidney is located in a location that's really right next to the main blood vessels of the body, the aorta and the vena cava. And there's a lot of blood flow running through them. So no matter what we do, unlike other organs that say like the liver, believe it or not, which can be controlled with minimally minimal effort, the kidney's not that way. And it can be a very unforgiving organ to operate on, which we can get into on future slides. But for example, if the vena cava is invaded with a tumor thrombus, really need to make sure that you get control of the vena cava before you pull the tumor thrombus out. So again, this is not a trivial thing. And again, we're going from maximally invasive to minimally invasive, but these are the ways that kidney cancer can present in a very aggressive fashion. And as I mentioned, if the tumor thrombus is more extensive within the vena cava, then you're gonna need to control every single blood vessel that enters into the vena cava, that point, open up the vena cava, and pull out the tumor thrombus. And again, just like Dr. Kyle's talk, if there's any questions, feel free to interrupt me. This should be an interactive, informal type of forum. So, and you can see from this curse works too well, but you can see that little yellow-ish kind of knob pushing out. That's actually the tumor thrombus, and actually that's pushing out of the renal vein, the main kidney vein that drains this kidney, which I think is the left kidney because of the length of the vein. And typically, that's what kidney cancer looks like. It's like this bright yellow-ish-looking tumor, which is very characteristic, grossly. I don't know if Dr. Kyle went into that. And as I mentioned, when tumor thrombuses get really extensive within the vena cava, then this is what we need to do, which is drain the entire blood volume out of the body, cool the patient, pull out the thrombus, open up the heart, close it, otherwise the patient would bleed to death. There's just too much blood flow running through that area. So, we can pass on this slide. So, again, we start from maximally invasive, and we're gonna start the progression down the timeline of minimally invasive surgery. So, like lots of surgical techniques, kidney surgery has not been an exception as far as evolution from something that was rather morbid from a patient standpoint, to something that's a lot better tolerated. And that started in the early 90s. Dr. Klayman, who's now at UC Irvine, I think he was at Wash U at that time, described the first laparoscopic nephrectomy, removing an entire kidney through laparoscopic means, through small incisions, not that big incision, which I showed you from that original description from 1963. And then, 1993, started talking about taking out part of the kidney through laparoscopic means, through small incisions. Whereas before, the concept of even moving part of the kidney was not really that well-established. People said, well, take the whole kidney, you have two kidneys, why not? You have another kidney, you should be fine. That's not necessarily true, we'll get into that. And as the 90s went along, people recognized that and realized that saving the kidney, if at all possible, was beneficial to the patient for a variety of reasons. So, people started trying to do this laparoscopically, which was of great benefit from a patient morbidity standpoint. And then, people started putting their hand in there to facilitate laparoscopic or minimally invasive techniques. And in the 2000s, we have robotic platforms, which we can get into now. This is actually a robot, right? So, it's not like, if I were gonna do robotic surgery, I kind of go to my office, push a button, leave, have a cup of coffee like this. I wish, that would be fantastic. And now I could just go, I don't know, surf the web or watch YouTube or whatever, watch the Olympics, have a cup of coffee. Oh, it's done perfect, I can come back. No, that's not how it works. I wish, maybe Sunday. But robotic surgery really is really a refined laparoscopic technique, where your instrumentation's a lot more sophisticated and your visualization's three dimensional and high depth. So, it's not that there's some automaton doing your surgery, not yet at least, I wish. So, laparoscopic techniques, these have been around, as you can see for over 20 years. How is it compared to open techniques? Well, all the data thus far to date over that past 20 plus years has shown it's equivalent. So, there's no disadvantage of doing it this way, where in the beginning of that learning curve, at the beginning of that era, people said, well, you shouldn't do it that way, it's not proven, et cetera, et cetera, well, I think it is proven. Unless you have a good reason to do it open, then there's, you don't have to because of a cancer control aspect. And the, right, so the aggregate data, again, confirms the safety of this type of approach. And again, the difference is in incision are significant. So, the kidney for a variety of reasons is kind of under the rib cage, so to get there is actually not that easy. And I don't know if any of you have broken a rib, that's not all that comfortable either. So, to get through there and get into that space with enough exposure is not easy for anybody, especially the patient. And a lot from a laparoscopic approach, we're putting small incisions, probably the biggest port is gonna be the width of the tip of your thumb. So, there's gonna be a lot less pain and a lot less hospital stay and a shortened time to recovery. Now, patients always amass me this. So, when you take a radical defect, you may take the kidney out, right? What do you do with the kidney? Just leave it in there. No, I'm just kidding. Yeah, I say that most of the time. Either they laugh or they're kind of aggastic. What? How do you leave? Well, no, no, of course not, you know.  That's okay. It's normal. Just kidding. So, we kind of put into this bag inside the body and there's a little straw string on the bag and we pull it out.   Well, you know, what about tumor size? You know, can we, what can we do from a, you know, minimally invasive standpoint? Well, the tumor, as you can see, is marked out by that yellow arrow and it's taken up about half the kidney, which is kind of the limit of what you can expect to be able to save the kidney. You need to save about half. Anything less than half, generally the kidney doesn't do all that great. But, you know, there's really no limitation from a laparoscopic standpoint, as long as it's feasible. And a lot of time, you know, if the tumors are really large, which we don't see that much of anymore, to be honest with you. We do still, but, you know, the, and we'll go into this, you know, with the proliferation of CT scans, MRIs, ultrasounds, you know, we're finding these earlier and earlier stages, which is a benefit to the patient. So fortunately, we don't see a lot of this, but you know, these can still be approached, you know, through a minimally invasive approach if feasible, you know, and you've probably seen some scans, but again, this is a, you can see the tumor pretty clearly on this cross-sectional imaging study marked by the yellow arrow. Again, these can be accessed through a minimally invasive approach. As you probably know, or I've talked about, one of the things that kidney cancer insidiously does is it, you know, recruits blood flow. Like cancer, you know, and that's the basis of all these medications we have, really. I mean, not the immunotherapies, but the TKIs is really to stop that process of recruitment of blood flow, you know, and I'm not in Southern California, so I can probably say this. It's like stealing water from the Delta for Southern California, right? It's like buying an island in the middle of Delta and trying to get a pipeline to whisk it off to someone's lawn in Orange County. Okay. When I said in Southern California, I didn't get a very favorable response. They didn't appreciate that. I guess they really want to water that grass, but anyway, that's my, you need to divert blood flow and actually through a laparoscopic approach because what you're doing is you're actually filling the entire belly with carbon dioxide. All those little arrows, arrows point to all of these little vessels which have been kind of insidiously recruited to feed this tumor and actually the laparoscopic approach by insufflating the abdomen with carbon dioxide actually exceeds the pressure of those, a lot of those blood vessels so the bleeding is gonna be less. So it's a side benefit. So, you know, it's always good to see a video because otherwise, and I think it gets kind of boring.  I don't wanna hear about facts. I just wanna see some videos, right? I mean, it's a YouTube generation, so. But anyway, so this is a video of a tumor thrombus that's kind of in, I can repeat the video, that's kind of encapsulated by, well, first of that vessel loop, but we'll go back through that again. So basically the principles as Dr. Robson described for, for kidney cancer or for kidney removal is to really control the blood vessels. And back then, you know, controlling blood vessels meant in an open surgery, like tying them off with suture. Actually, we don't have to do that anymore. We can use things like a stapler.  Well, they're titanium staples and what happens is they, the stapler throws six rows of staples and then there's a little blade that cuts in between. So there are three rows of staples on each side. And actually it's very secure. I know it sounds kind of weird. It's like, I staple my papers, you know, I mean, what, and it doesn't work very well, you know, if it's really thick, I can't staple it. Well, of course, right? So I mean, those considerations are germane here too, but at the same time, you know, this is actually a very safe way of dealing with it. So again, the deal with the kidney had the first stop, the blood flow of the artery, which is what we're doing with the stapler. You can see kind of that pulsation down below. And then there is a tumor thrombus in this, you know, a kidney vein on the right side. And you can kind of see that yellowish thing kind of above that reddish vessel loop. And the stapler actually is a very efficient way of dealing with this. And you can see the staple line on either side. So again, you know, dealing with pictures and diagrams and figures and cartoons can be somewhat abstract. It's kind of better just to see what it'd like in real life. And we don't have to really get into this because we've talked about this. Now what about patients with metastatic disease? Unpresentation, you know, should we take the kidney out? Well, the general consensus is we should. And if there's, you know, if the kidney is removable, we should take it out. And if there's a solitary site of metastasis, should try to take that out as well because there is survival benefit. Now, I don't think we have all the data yet to guide us, you know, through this. And I can, we can go through that.  We know that patients did better if you took the kidney out from a survival standpoint. This is in the interferon era, which we don't think we ever use interferon anymore, or IL-2, which we rarely use. So I think that, you know, the consensus still, you know, and we don't have randomized data yet. I don't think Sandy, like the Carmina trial, I don't know when that's coming out. Probably the next year, probably. Yeah, we're gonna have randomized data soon to guide us with respect to, is there a survival benefit taking the kidney out in patients with metastatic disease if they, you know, in today's era of TKI's? But the data we do have to date suggests that it is a benefit. And, you know, back then, what they found was that, you know, there was a small survival benefit, but definite benefit, and those who did best actually had the best performance status. They were the healthiest, or they had better prognostic features of their cancer. It wasn't as aggressive appearing, or they had metastasis only to the lungs, which is the most favorable site. As far as, you know, when we talk about minimally invasive approaches, I think if you can do it minimally invasive, you should, because the patients actually can recover faster to get back on medication, to get back on therapy. So if you can, you should do it that way. Talked about this. So these are the trials that are ongoing, that are designed to understand, you know, is this truly helpful when patients who are getting SUTEN, for example, you know, taking out the kidney first, or SUTEN, right? I mean, both of these trials are designed to answer the question about SUTEN, which was the first line treatment when the trial was started, probably in 06 or 07. So we'll know soon, but again, the data we have to date, which is not randomized, suggests that it is a benefit to remove the kidney. If at all possible. I can skip this. And we talked about this. Now, let's talk about kidney cancer and how it's being diagnosed. And, you know, I think I touched on this. So, you know, back in 1963, when kidney cancers were being diagnosed, they were being diagnosed because people having blood in their urine, they're having, you know, their intern has felt something on their abdomen, they had pain, you know, and we didn't have CT scans. We didn't have MRIs. We didn't have any of that stuff. You know, I remember, how many of you have seen The Exorcist? Yeah, so I saw The Exorcist, like for the first time in the theater, like in 1999. Scared the, you know, what out of me? But back then, you know, this is a movie from the 70s and they're trying to diagnose the possessed girl with some kind of brain thing. But all they have is angiograms. I mean, they're just basically cannulating an artery and just shooting contrast to see if there's anything abnormal. That's the only way you could find kidney cancer at that point. You were shooting a, you know, contrast into an artery near the kidney and seeing if there's something that lights up. I mean, basically what you're doing is you're opening the patient up and looking for a kidney tumor. It's very, it was very, very crude, obviously. You know, so obviously things are different.  And it's going up mostly because what we're finding is tumors less than four centimeters in size.   And then, oh, you got an ultrasound. Oh, you have a kidney tumor. Luckily in those situations, for the most part, they're less than four centimeters and, you know, four centimeters or less. That's a stage one for the most part. They're not gonna present with widespread disease. So things have changed from a paradigm standpoint. And because of that comes the concept of, well, why take the whole kidney out, right? And we're finding a lot of tumors that are small. Why can't we just save the kidney? Well, it's a good question, right? So, you know, people have looked into this probably from about 15, 20 years ago to now. And it's clear that there's no difference in cancer control whether you take the whole kidney out or not. In a tumor that's less than four centimeters. So you really should try to save the kidney if at all possible. There's no difference in cancer survival. Of course, there's, okay, so the other thing is that it might be that these smaller tumors have a higher incidence of not being cancer, which is controversial. That data is mostly from the Mayo Clinic, which suggests that if you have a small tumor it may not be cancerous. So you probably, again, should try to save the kidney if at all possible, because you may be removing a benign tumor. And not surprisingly, if you're taking the whole kidney out, your kidney function overall globally is gonna be a lot worse. And that's no surprise. You know, so what? Why is that a problem? We'll get into that. And again, as I mentioned, robotic surgery, you know, I showed you that one little picture. Here's a couple more. So again, it's not some, you know, automaton. It's not a self-driving car. You know, not that I have a self-driving car, but it's not a self-driving car. You have to control every movement. Kind of the nice thing is that as a surgeon, kind of the nice thing and not nice thing is that you're not actually sterile. You're not actually scrubbed. You're not actually next to the patient. You're actually in this little console. That's in the same room. Doesn't have to be actually, but it's in the same room. And you're operating kind of hand controls and pedals that actually control every movement of the robot. So it's not the traditional surgery where you're actually next to the patient, you know, your hands are on the patient. No, actually you're, you know, five, six feet away. They're even assisting who's changing instruments, but you're not actually there right next to the patient. So, you know, you could check text messages and I'm just kidding, but it's a different paradigm with regards to this. Now, what I tell patients and they're very surprised about with regards to moving part of the kidney is that it's actually harder than moving the whole kidney. You said what? I mean, why? Well, I'll show you why. So when we remove part of the kidney, we have to stop all the blood flow to the kidney. So we have to put these clamps on the artery and vein to stop blood flow. We have to cut the tumor out accurately so we don't leave any cancer behind. And then we got to suture the whole kidney back together. So in other words, you know, as I mentioned, the kidney has a very robust blood supply. So let me repeat this.  The kidney blood supply is so robust, if there were no clamps on the kidney at this point in time, the patient would bleed to death. It would just be a torrent of blood. And, you know, if you were not to repair the kidney, the same thing would happen. It would just be a torrent of blood. I mean, the patient would probably bleed out their entire blood volume in about one minute. So because of that, you have to be extremely careful about what you do. And actually the robot gives you that flexibility to do so. So, you know, because of all the suturing that's involved, you know, to repair the kidney, the robotic instruments, because they're quite facile and articulating and all that can actually help you do this in an accurate fashion. Because in the past, you know, what you were doing was using laparoscopic instruments and that the, you know, the technical facility was somewhat crude. You know, this is a lot better to be able to do it in a controlled, controlled, accurate fashion.  So you can't actually just, you know, take your time and say, okay, well, you know, see you later. I gotta, you know, run to the restroom. I'll come back. You know, basically you have about 30 minutes worth of time until the kidney starts to deteriorate functionally. So you're kind of under the gun from a, you know, technical standpoint, but also from a time standpoint. You really just can't, you have to act expeditiously because the kidney, you know, it's like your heart, right? Your heart attack, you gotta revascularize, you gotta get blood flow back to the heart, or otherwise the heart will die. Same thing with the kidney.  Well, actually, warm up scheming time. So what's that? That's how long the kidneys clamp for. Again, it should be less than 30 minutes. It's actually a lot faster doing robotically for the reasons you can see. I mean, it's just a lot easier to do these suturing maneuvers.  So, you know, I think, you know, actually for someone who is actually doing a lot of laparoscopic partial effectiveness, you know, it could be done, sure. But it can actually be done better if you have a, you know, better platform.  You can drive, you can't drive very fast. You could redline the car, you know, trying to get on the freeway and get re-randed. Or you could drive, I don't know, take your pick McLaren, who cares, whatever, something. Something really expensive, right? Hey, it's better. I mean, it is. It's more expensive. And the robot is no different. It's about one and a half million dollars. But it's better for the patients. Yes? Yeah, radical and effectiveness can be very variable in blood loss, really depending on how big the tumor is. Mostly because of those parasitic vessels. So sometimes you can just lose a lot, a lot of blood, you know, during a radical. If it's a smaller tumor, not generally not. So, and actually we have updated data, but, you know, robotics, you know, that as far from a partial, from a kidney standpoint, really started taking off around 0607. Now I would say that in 2016, what percentage of partial ineffectiveness had been done robotically? I would say it's about 65, 70%. So, you know, it's kind of showing that, you know, the technique is better. And it's better for the patient and it's kind of, you know, people recognize it's better, you know, on all fronts, you can skip this.  I'm sorry. So, stage two would be difficult because you're talking about tumors that are, you know, upwards of seven centimeters, you know. In other words, the larger the tumor, the less chance you'll have to save the kidney. But, you know, there are patients who you can try to move up to seven centimeters. If it's in a location that's amenable to that, you should, if you can. Just sometimes it's not. Just not going to be located and you take out a seven centimeter or less tumor or six centimeter, let's say, T1B. The kidney doesn't work very well and you just end up taking the whole kidney out. And again, since I guess tumor growth can be asymmetric, if it winds up going past the centerline, probably you might, I guess, take the whole thing out because it's wound up being periphery. Yeah, I mean, the best place is really on either the very top or very bottom because you can kind of just chop it off. Once it gets in the middle, then that becomes more complicated because all the blood flow's running through the middle and the more reconstruction you need to do, the more a potential compromise of blood flow. And the other thing inside the kidney is that, you know, yeah, there's blood flow, there's also urine.  There's a urine collection system. And if that gets violated, you know, that could just, you know, leak. So, I mean, there's a kind of a risk stratification that has to occur, right? I mean, if you're 88 years old, you know, probably shouldn't be trying to do something like this. If you're 28, yeah, you should. So, I mean, I think you have to, you know, think about it sometimes individually in the context of the patient. So, you know, we've been talking about cutting things out, you know, but there are other ways to deal with this and that would be ablation. So what does that mean? Well, it means either freezing it or burning it. And here's a still picture of a freezing procedure where there's a probe stuck directly into the tumor and it's frozen. And the accepted techniques for doing such are either percutaneously or through the skin, you know, usually it's an interventional radiologist putting a needle into it under CT guidance in the tumor and freezing it. Or burning it, which is radiofrequency ablation. And you could do it laparoscopically as well, you know, put a probe in under direct vision during a laparoscopic approach and freeze it or burn the tumor. And there are newer things like microwave ablation or Haifu or high frequency ultrasound, which are not quite there yet as far as accepted techniques, but you know, they're expanding the gamut of these types of things. Now, you know, that sounds great, you know, just freeze it. Why cut it out? What's the difference? Well, there's a difference as far as cancer control. So basically, I mean, this paper was from several years ago, but basically between, where is this? Yeah, so the risk of local occurrence was about seven times higher with freezing it at that time. So, you know, if you can, so basically I think the bottom line is if you're gonna freeze or burn something, that's fine, you know, but it has to be again, kind of measured to the individual context of the patient. Now if someone's 89 and they have a small tumor and they really wanna treat it, well, you could do something like this, you know. If they occur, okay, fine. Their life expectancy is probably less than 10 years.  If they're 28, you shouldn't be. You shouldn't be, you just have a long window which you have to have confidence in. We just don't have that data, don't have that data. But in certain patients, it's actually a very good thing to have this type of technology available, which we do here. And I'm highly reliant on my inventoryologists and these kind of patients who are not great surgical candidates and doing this type of thing. And finally, there's surveillance. So, in other words, you find the tumor, you just watch it. Why would you do that? Well, we generally know how fast these things grow, which is actually not that fast. It's like a couple millimeters a year. And when tumors are small, like less than three, four centimeters, their chance of spreading is actually quite low, quite low. And we have very good imaging modalities as we've alluded to to follow these things. Again, it's not appropriate for someone who's in their 30s or 40s. But patients who are much older and they have competing risk, let's say, heart disease, stroke, whatever, you don't necessarily have to treat them. These tumors, you can watch them and if any hand gets forced, you might freeze them or burn them. But these patients are not great surgical candidates. There's no reason to really diminish their quality of life by trying to do something definitive. So I think in conclusion, surgical options, as you can see, are continuing to evolve into less invasive techniques, which is great for patients. And continuing advancements technically really lead to increasing safety for doing these things, which again are beneficial for patients. Hopefully the trial data on removing kidneys and metastatic disease will be out soon, so we can talk more about that next year. And there are non-surgical options, there are blative options which really have to be weighed in face of the individual patient context. Thank you very much. This doesn't relate directly to surgery, but perhaps you could address it. And that is originally my cancer was found incidentally with a clot. So then what happened was as I was therapeutic on Warfarin and I still wound up getting another clot. So they went on and said, well, what's going on? They found this out. So they wound up getting the cancer out, but still I'm taking anti-coagulants and I've actually thrown another clot. Why?  What's going on? I don't know if Sandy, you wanna start with that? I mean, basically sure. Having cancer can render one more prone to have a clot. It might have just unmasked some sort of underlying tendency you had already. And unfortunately, you know, I don't know if there was residual clot there or whatnot, even something structural that's persistent that's causing that. So I didn't really get it from the presentation, but why exactly is a radical removal more the consensus instead of like partial nephrectomy? Why is radical movement more easy? More what? More preferred than the consensus. More preferred? So why is radical removal compared to partial? Okay. Oh, well, again, I think if you can't say the kidney, you should. But in instances, you can't, then you have to remove the whole kidney. And part of that has to do with the overall global kidney function, which again, in the past, back in the 60s, 70s, like, well, you have two kidneys who cares, just take one out. That's why you have two kidneys, right? Well, sure, right? I mean, it's better to have two kidneys than one. I mean, that's true, right? And I mean, you don't have two livers or two spleens or two whatever. But what we found recently is that, sure, right? I mean, people who have, let's say, donated a kidney for a transplant, like to a relative, they actually do very well. And why is that? Well, because those patients are very heavily picked out and screened. You're not gonna take a kidney out of someone who's kind of on dialysis range kidney function.  So those patients actually do very well. It's the patients that come in with a diagnosis of kidney cancer, who already have, let's say they're in the 60s or 70s, they have high blood pressure, diabetes, and that's pretty common. They're not gonna do as well if they have compromise. And not only from a kidney function standpoint, where they could end up going on dialysis, which is not good for anybody, but actually we find that people who have diminished kidney function are also at risk for a variety of cardiovascular risks as well. So I think things evolve to the point where there's clear evidence to suggest that the more well your, the better your kidney function is globally, the better off you are. But sometimes technically for whatever, not for whatever reason, usually cause the tumors are too large, you can't save the kidney in that situation, then you have to take the whole kidney out. Why not do surgery on a stage four patient if the tumors are very defined and? You mean if it's doable, why not do it? Yeah. You should. Unless for some reason the patient's so ill that doing it would risk their life. And sometimes you find, I mean, once in a, because people are getting scanned all the time, we'll find patients that say they're 95 or something. They have a tumor that could be resected, but they have so many other issues that you could actually kill them doing the surgery, then right. It's like, how much are you really buying here? Cause we don't know actually how much the survival benefit is. It might be like from that paper from 2004 from the New Lane Journal, it was about three months. It might be more. There's other side benefits to that obviously, because these things can bleed and then that can cause a lot of issues, but right. I mean, if you can and if you can, you should. And sometimes you can't because of other issues that come into play. But that's the most controversial thing, right?  There's no great added value of removing the primary. I think kidney has just been so unusual in that, removing the kidney has resulted in an improvement in longevity. And so that's why it's been done. But you know, the last 10 years because we have had such good drugs to treat kidney cancer, it's come into question as to is there any value added by removing that kidney? And as Ben said, we are awaiting the randomized trial, but I think our strategy here at Stanford is we individualize it. We look to see what is the extent of tumor outside the kidney and should we be doing drug therapy first, followed by kidney removal or should we just take directly get the kidney out and then proceed to drug therapy? So a couple of questions about the surgery. So if the cryoablation and other types of ablation are advancing very quickly, is Stanford kind of the primary research center or advancement center of cryoablation relative to say Kaiser if a patient was in Kaiser or something or is it mostly the same everywhere? It's not. I mean, it takes a, it's just like anything, right? The more of this you do, the better you're gonna be at it. And I've, I didn't get into this, we can get into this now. I mean, I've actively been pushing the envelope to our interventional radiologist from cryo standpoint. Generally the feeling was that if it was three centimeter or greater than three centimeters of tumor, then it wasn't really that approachable with some sort of ablation. But I've been sending them patients, because they're not great surgical candidates for a variety of reasons, five, six centimeters. And they've been successfully treating these. So I think it has to do with your level expertise. And I think level expertise of our radiologists, interventional radiologists here are very high. I don't, I can't speak at other places, but I know that I've seen patients sent here directly from other interventional radiology practices to do such things. So it's, I think it's just again, about how much you do. And we see quite a bit of that here. And that brings me to another question. Since we're finding small and smaller tumors, how come the paradigm just doesn't adjust to the point where at age 40 there's a routine MRI or CT scan, you find really small one centimeter tumors very early, just cryo plate them and the person goes. Yeah, I wish. So. And the sequence be in that order. So, you know, because we deal, we're dealing with dollars and cents at that point. And we start talking about that. And we start talking about policy. We start talking about healthcare, money. We start talking about Medicare. We start talking about deficits. The problem is actually when you look at the data, it's not cost effective to do that. In other words, kidney cancer is not common enough to make it worthwhile from a global, not global, but national health standpoint to advocate screening, unlike breast or unlike prostate, which is controversial as well, or unlike colon. So, and you know, the Japanese actually probably were the last people to look at this and they found that it was not cost effective. So that's why it's not being done. It just really from a dollars and cents standpoint.  I'm not saying that's what you should do. You know, and you know, that's not necessarily the answer, but that's the reason why. It's unfortunate for us, I guess. But then third and final question is, if we say cryoblation doesn't have the same decisive removal as a laparoscopic PN, but there's a lot of drugs coming out. And if somebody's young, is it maybe a good idea to just cryoblate a two centimeter tumor and then go on drugs because it's minimally evasive and you won't lose the kidney or even part of the kidney? Well, I mean, doing a two centimeter partial is very, you know, it's very straightforward. Going on drugs is not without side effects. So you don't want to, first of all, it's not an indicated, it's not indicated to give someone drugs for a two centimeter tumor that's been cryoblated. Plus you wouldn't want to necessarily assume the risk of side effects for what's the end point. It's probably lifelong. You know, when do you start, when do you stop? So, you know, again, if you're young, you should really go with the gold standard from a cancer control stamp. When you could go with cryoblation, the problem is that the risk of recurrence is higher. If it does recur, then we start to run out of options to a certain extent. So, you know, from a, which I didn't get into this, but you know, it's just like anything. When someone else has been there before, trying to go back in there is gonna be more difficult. So with cryoblation, there's gonna be a certain amount of scarring that occurs around the kidney. It's gonna make saving that kidney downline much, much more difficult. So, you know, until we have data that shows or suggests that cryoblation is equivalent, which we don't have yet, then we have, you know, for someone who's young and healthy and has a long life expectancy, we should really stick with the modality that has the best cancer control. Yep. Yeah, I have a very basic question. When you're talking about cryoblation, you're talking about going in there, you're freezing the tumor. Is the tumor then taken out? Is it left there?  Could you just explain to me? Yeah, it's like you get frostbite of your finger. Eventually, their fingertip falls off. You know, that's the idea. So, you know, they'll put a probe or two or three how many they need to cover the tumor. And actually, cryoblation, in a lot of ways, is preferred to radiofrequency ablation. So freezing is preferred to heating it. The reason is that because when you freeze it, you actually see kind of an ice ball forming around the tumor, engulfing the tumors. You can actually objectively see that it's being treated. But what's going on is when you freeze something, it bursts the cell, it kills the cells. And that's the idea, just kill the cells. You don't take it out afterwards. What you do is you're going to continue to monitor it to make sure there's no sign of it coming back. And that follow protocol, surveillance protocol, will start, for me, I started three months, three months for the first year, then six months, and that looks fine then every year. So that's the idea. You don't want to really go in there and take it out because if you were, then you should have just done in the first place. Other questions? Great, thank you Ben. Thank you so much for taking your time.


All of them have designed the one question that they submitted to us in advance. They all know what their own question is and they've set it up and then they hit it out of the park. All of their peers will have to respond to the same question on the plot. We will start to this round with Dr. Swinkie from English and we have a question from Dr. Swinkie. Everybody, whether through natural disasters, infectious pandemics, global warfare or zombie outbreaks, cultural representations of apocalypse involve violence. In these post-apocalyptic worlds, even people committed to non-violence find themselves forced into inherently violent situations, whether literal or figurative. What is a violent aspect of your discipline and how might your discipline's relation to violence help to rebuild civilization? One minute. I didn't realize I was going first. I didn't realize I was going first. But, okay. One, my partner who also happens to be a colleague of mine in the English department often says that education is an inherently violent act. It asks you to confront something that you are completely unfamiliar with and if you do the learning, completely change your own perspective. So one of the things that literature does is that it forces us to come to the understanding that how we see the world is just the way that we see the world. That every single person in this room, even though we have the shared experience of what's going on right now, has their own interpretation of what is going on right now. And so what literature does, the study of literature asks us not to seek truth with a capital T, but to understand the multiple truths that are always at play and to ask us to navigate those truths to try to find some kind of shared common ground. Most violence happens because of discomfort with difference. And that is something that's central to the study of literature and culture. I'll give you a text message from my cell phone, which is comprised of elements necessary to operate your cell phone. It says here on 10-7, gas, emergency, raise on earth notification. Gas coming from chemistry building area, avoid central campus. Now, the inherent danger in that comes from gas being leaked. It's also been a natural affiliate in that text message with the chemistry building. So yes, there is danger associated with understanding molecular destruction, or how these molecules can interact, but also the skill set of learning chemistry and biochemistry can allow one to be able to critically think through methods and approaches and develop techniques to combat these types of dangers, which not only could affect dictionary and manuscript, but our nation and our world. Well, hi. That's what history is all about. There's no censorship in history. And I'll just be short because, you know, I did so much time before. But yes, learning from those, you know, it's not just about learning about those mistakes, but because those mistakes are human pain. And so the same way that literature, you know, creates that sort of community that I was talking about, so that's history because, at least, our reading is not grounded in fiction or fact, you know, but we do kind of look at the record and try to avoid that bias and think. I think my discipline provides solutions to the natural dangers that are in our world. The viruses that affect us, the bacterial diseases that get us, the genetic components of our own bodies that betray us. We have solutions from molecular biology, from medications development to combat those dangers.  Our second question will come from Dr. Adams in Chemistry. The question from Dr. Adams is, what contribution does your discipline make to an individual's physical and mental health or the health of the environment? One more time. What contribution does your discipline make to an individual's physical or mental health and the health of the environment? So, the two things that brought to my mind were just some things that made us as a society who kind of moved forward as a populist, one of the main things, one of the posts, one of the main things was our physical being. It has been discussed tonight about the biological significance of understanding how to develop growths from plants and things of that nature are critical for our survival. However, in order to get a physical amount of growth, a necessary growth from a plant, it takes a whole lot of plants. And, yes, remember, we are coming out with a populist. We don't have no plants. So, populists should come up with that kind of initiative. And the nuance is that organic, things like organic chemistry, although that is not a word that brings pleasant thoughts in people's minds. It is a necessary aspect of understanding the culture and life processes in order to be able to design in the laboratory monocles that can be used to deliver growths through nanotechnology and other fast-paced, fast-changing, technical biological advances. I'll ask the panel, is passing allowed? What contribution does your discipline make to an individual's physical and mental health or the health of the environment? Okay, so it's most popular here. And as you said, the resources are not there. Sure, we can have the technical abilities to do that, but we also need some organization. And to organize society, we need a kind of leadership that will coordinate the people to get to that point. So, yes, I will want to have that amount of biology, which we have also studied as a historian of science, and then I will have, you know, the leadership necessary and provide that kind of sense of organization that comes from knowing the learning skills that come from research, the best research that you possibly do is through the records that we have left. Without those records, you cannot make that scientific leap into what is coming next. So, those records won't have, whatever is left will have to be analyzed as well. Thank you. Please understand that the nature of the apocalypse was not explained before we took the stage. If there are no plants, as I explained to my cell biology class this morning, you can kiss a goodbye. We won't be eating anything. So, let's move on from there and assume that are. And because of my discipline's understanding is what our bodies need for our brains to operate, for our muscles to operate, and what organisms need to survive in order to interact with each other, I believe that biology sciences brings the only solution to bringing the nutrition to ourselves, our brains, and harmony to the environment. The picture of Doreen Gray writes that art annihilates the desire to act. And it's not a nihilistic view of the world or a pessimistic view of the world. It's a view that in this world we have, we need outlets to keep our sanity. And art, literature, culture, although we need the sustenance and the nutrients to nurture our bodies, our minds and our mental health, and our ability to sympathize and build community with others relies heavily on our ability to create new things, to be artistic, to be original, to be unique, and also to find those points of connection with other individuals. That's what nourishes the mind. So I'm sure that having an English professor or someone who is well versed in the very decent literature will be useful in that regard to balance, just the physical health that we also need to describe it. Dr. Brogie with History, our question from History Tonight is as follows. History shows that in an apocalyptic situation, humans may find solidarity, but they more often become less human. There will be a struggle for scarce resources. There will be factions forming, conflicts, chaos leading into further destruction. How is your discipline to prepare students to maintain peace and cooperation in an apocalyptic situation? Okay, well, with the formation of conflict and factions, there will be leaders, and some of them will be a little hard, and a little bit contoured.  It will be able to show that the emperor has no clothes, and going back to that Sydney Harris quote, the skills of history research will allow you to see the risks in this well-concealed disguise, to show the resemblance that are with the mistakes and the lies about the past. Our friend Adolf here was famous for saying, if you tell a big enough lie, and tell it freely enough, it will be believed. History is without question the best antidote we have for our delusions of omnipotence, and on the science, self-knowledge. From history it is indispensable to self-control for the nation, as well as for the individual. Chaos is something that can form when people have the energy for chaos. If you don't have food, if you don't have water, if you don't have what you need to live, you form peaceful coalitions to find those resources that are critical to go on to the next day. I believe my discipline provides the knowledge that is necessary to find those resources to sustain ourselves, and to establish a sustainable system for the future. And so I believe it's that nation that will avoid and disrupt chaos. History shows that in an apocalyptic situation, humans may find solidarity, but they more often become less human. There will be a struggle for scarce resources, there will be factions forming, conflict, chaos leading in a further destruction. How does your discipline prepare students to maintain peace and cooperation in an apocalyptic situation? Again, all of those things that create divides and separation are the biggest things that undermine civilization as a whole. If any of you are familiar with any zombie films, or specifically if we're thinking about The Walking Dead, there's always stranded numbers, right? Me, don't go off by yourself into the middle of the zombie apocalypse because you're going to die, that's just how it works. So the thing that we absolutely need is a discipline for people who understand that there are stranded numbers and that conflict resolution and finding our points of shared interest is absolutely key to survival. And again, the way that we do that, the way that we find common ground is through storytelling, through shared narratives that everyone can latch onto and take what they need from those narratives in order to move forward. Notice that a lot of us keep coming back to examples from literature or from shows or even from history that we're still always involved in telling stories because that's what brings it alive and that's what makes people connect. So any scientific understanding of anything as well needs to be just an example, a story to help you remember it. One of the things that makes the study of natural sciences and biochemistry, the technical nuance that's required to develop basic skillset, to general skillset requires that there's a relevant critical thought from a different point of view. I think that basic knowledge, basic understanding of how to accurately think through certain senses, particularly negative certain senses, even if they don't have to do with atoms and molecules or physiological or biochemical processes together with us as people in society to be able to work through chaotic situations to come through these. This comes from Dr. Henry with biology. Biology's questions and ideas. Those attempting to rebuild civilization will need to be able to find, create, or exploit a number of resources. What resources will the new society need in order to survive and how does your discipline prepare us to find, create, or exploit those resources? First of all, understanding my discipline, which is the study of life, but it's the chemistry and physical nature of life gives me probably one of the broadest backgrounds at the table. It also gives me an understanding of what we need to find, grow, sustainably create over and over, which is a focus. We don't know with this apocalypse whether or not plants are gone, animals are gone, but the fact that we have a full understanding of microorganisms all the way through hairy animals like ourselves gives us the capability, the understanding of what it is we need to find and when we need to find it and what's created. So I believe that puts us in a best position to create resources that are not only immediate but to create sustainable resource solutions for the upcoming future, whatever that may be and I still hold. If we have no plants, it doesn't matter. The biggest resource that we have moving forward in a post-conflict world are ourselves. Are the other people who also share the space and whatever it is that is left over if you make a plant. Hopefully we got plants. That's what I'm telling you. But you know, I'm not a scientist but I know how to garden. So... There you go. It's really important for all of us to understand we need all of these disciplines. We need all of the people, hopefully that survive have basic skill sense and hopefully they all have a nice broad base of liberal arts education so they know how to plant things and they know how to boil their water filter. I don't know, other lecturers, I think we can maybe do that for a while. Sometimes the best thing is, as many of the romantic poets do, sometimes you need to leave the modern world behind and return to nature to really find out who you are and what you value. So in that sense, I think, again, the biggest resource we have is ourselves. And knowing that we're all connected and finding ways to now we leave that new world together. We want to provide the sustainability that's necessary to rebuild our post-independent society. It is imperative that we maintain some sort of general understanding of how monocles impact our society and all of our plans to re-grow and continue to grow these things. They have to be protected against pesticides, the environmental, the academic, the understanding of electrical instruction and the knowledge to develop these types of compounds that can help to keep parasites and other microorganisms that also can be efficient and also can be detrimental. And, again, I understand how to liberate our communities that have fun in the middle of it and this approach aiming at sustainability for our society. So we have two skill sets here that specialize in how to master resources and two sets of skills that will help us master the human nature that should lead us to those resources. So, yes, I agree with all of us that in the end, it's about how we organize this research towards those resources. I've gone from a country that has gone through a lot of periods of starvation and poor resources going on and we have the same in my country that it's the art of managing and how many times we have managed and, frankly, we have been pretty well learning from those lessons because of how as a society and how from our long, long history we have learned how to reorganize and rebuild from scratch again. So we have very little to resort to and we don't even have the technical tools to kind of operate those chemical compounds. Perhaps, you know, the necessary human condition that will help us understand that you can do little. You can do a lot with little. Maybe that's what we can learn from us as humans. Let's conclude the questions we have from the faculty who are on the stage. However, what some of you may not know is that we were supposed to have a fifth member with us here tonight representing the Department of Theater. The performing arts can conquer a lot of things. Bronchitis is not one of them. In the spirit of the fine arts we want to include that question for the panel because they all would have had to answer it. So a question in the spirit of the fine arts and whoever wants to take this first can take this first. How does a healthy understanding of an appreciation for performing arts make students or practitioners in your field better at what they do? We do what we do because other people believe in what we can do provide us the resources with what we can do because we're good enough performing and convincing to get them to give us the money and the necessary equipment performing arts. Are you kidding? Everything we do is performance. We're selling. We're trying to tell you how it's going to help you so that we can do what we think is important for you. It's performance and it's a sales job. But in the end hopefully it does help. Education is inherently a it's also violent and it's also inherently performative. We are all performing on stage today in order to get a point across. If I go back to my original example of Frankenstein most of you have probably encountered Frankenstein in a movie and stage adaptations of Frankenstein were actually the most crucial in terms of making that narrative widely accessible to a broad audience, much more than the book. So absolutely performance is key to keeping something alive. Adaptation of itself is inherently performative in nature because it requires an adaptation and an understanding of its surroundings and finding the way to best express itself in those environments and for new audiences. So the fine arts and performance is absolutely key in terms of both keeping our stories alive especially if we don't have lots of books to read we'll all be performing these stories around a campfire at night and also because in terms of learning anything in order for it to truly stick it needs to be performative and adapt to its audience. A scene traverses there's a double head a helical structure of atoms put together so that this ion can go from one side of the cell to the other side of the cell and to be able to understand how these internal arrangements and be able to actually visualize that's art to see how people visualize through our understanding of fundamental nature of atoms that we can't see without a naked eye we can visualize using other approaches such as computers and other visualization programs allow us to use chemistry as a source of power I think that visualizing something is one of the most fundamental keys to actually strengthen one's ability to learn to use what we learn from techniques at the atomic level to be able to connect to a visualization program that provides an education and also provides a level of artistic interpretation History as art history as performance it happens all the time whenever I feel that I'm boring the pants off of my students I show them history through fiction and historical movies or I show them Dr. Strane's Love so I mean let's have Frankenstein to see how the apocalypse may happen so to nurture that human nature we need sometimes to kind of embellish history a little bit I will not have a screen, I will not have a projector at least I will not have books probably but the problem the point is exactly this that it will stay in here so we will just narrate it that way and we will add some costumes


Thanks for checking out this episode of brutal battle beer break today. We have an interesting beer It's by Mars Community Brewing Company out of Chicago, Illinois It is a beer called jungle boogie and it is a pale wheat ale with ribos tea That's how I say ribos. I know there are many other ways that people say it Also, I have to say I'm a big fan of this tea So I'm hoping that I can taste a lot of it in this beer. I say 5.5 percent. I don't remember if I did or not. Oh Guess I have to show you label is pretty cool Look at all that. Oh flowers and whatnot. Maybe that's what the tea looks like. I'm not sure So for being a pale wheat I was actually expecting the color to be a lot more yellowish But it's actually very like orange almost a little bit of a brownish hue to it Pretty clear nice huge bubbles on there Looks nice. Oh Smells quite hoppy Nice citrusy. Mmm. Very nice citrusy hot note. Oh, it's very very tropical actually I guess the name jungle boogie is really good for it like guava mango Pineapple like super tropical. I Can smell a little bit of that ribos in there It's hard to get though. If you didn't tell me that it was in there. I wouldn't know to look for it Really like clementine Citrusy as well. Oh my gosh. It's like all the citrus all the tropical It's just like tons of it in this jungle boogie is the right name for the smell on this thing I'm hoping it tastes the way it smells because it smells amazing Whoa, okay Mmm, you get that weedy characteristic in there Then what you're smelling is not nearly as vibrant with all the tropicality and the citrus although it is there The reason for that being there's a lot of bitterness to it and a lot of that weedy flavor kind of brings a bunch of those notes down as well But this is nice. This is very balanced Hmm wow Tastes a little floral almost like a you know like floral hobby quality to it as well It's really nice really nice beer I get a little bit of that Ruebo's tea in there I'd actually like a little bit more just because I'm such a big fan of Ruebo's But I don't know if that would throw things out of kilter in this beer. Unfortunately a smooth It is tasty. It's got the citrus. It's got the floral. It's got the bitter. It's got that weedy quality Which makes it a little bit bread-y biscuit-y It's a lot of things is what this beer is and it's a lot of good things. So Wow Mars community brewing You done you done right you done real right Anyway, everybody if this sounds good to you I got it from craft beer temple or the beer temple I think I think it's just craft beer temple comm or beer temple comm something like that When the Chris Quinn runs you can order online in a lot of states he will ship to so Check it out. You might be able to buy some although last time I checked it was sold out But you can get your hands on a jungle boogie Very awesome. Like I said, it is so many different things all at once Anyway, thank you everyone for checking this out and go ahead yourself an awesome beer