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FEW PATIENTS AWARE OF THE MINIMALLY-INVASIVE PROCEDURES AVAILABLE TO THEM, ACCORDING TO GERHARD FUCHS, LEADING RESEARCHER AND PHYSICIAN JOINING CEDARS-SINAI'S KIDNEY TRANSPLANT AND UROLOGY PROGRAMS
LOS ANGELES (June 13, 2000) - Equipped with slender, sophisticated instruments and years of research and clinical experience, Gerhard J. Fuchs, M.D., one of the world's pioneers in endourology, performs a variety of delicate surgical procedures on organs and structures accessible through the urinary tract without ever making an incision in a patient's skin.
And when a donor wishes to give a kidney to a relative in need, Dr. Fuchs removes the donor kidney through small abdominal ports instead of a long open incision -- sparing the donor months of painful recovery from what traditionally has been a muscle-splitting operation.
Dr. Fuchs and his team recently brought their expertise to Cedars-Sinai Medical Center, where Dr. Fuchs was named director of the Endourology Institute. He has served since 1997 on the Advisory Board of the Cedars-Sinai Endoscopic Surgery Training and Research Center. He also has been honorary consultant to the Division of Urology since 1986.
Since joining the medical center full time earlier this year, Dr. Fuchs and the transplant teams have performed 10 laparoscopic live donor nephrectomies -- kidney removals for transplantation -- and they are planning to continue at a rate of about two such surgeries each week for the next few months. Dr. Fuchs expects that number to increase to three per week by autumn.
"We expect that there will be tremendous interest among patients who need a kidney and their relatives," said Dr. Fuchs, noting that other major medical centers that began performing the operations laparoscopically quickly saw their live-donor surgical volumes increase from about 20 a year to 100, 200 and more.
"The kidney transplant program here at Cedars-Sinai, although small in number, has a history of producing very good outcomes," Dr. Fuchs noted. "It is a very strong program that can grow without compromising on patients' results."
Christopher R. Shackleton, M.D., director of the Center for Liver and Kidney Diseases and Transplantation at Cedars-Sinai, said the laparoscopic technique, which has been developed only within the past few years, is one way physicians and surgeons are "expanding" the kidney donor pool.
"If you are listed for a kidney transplant in this country, the average waiting time is about 3 1/2 years. The growth in the recipient candidate list far outstrips cadaver donor organ availability. Fortunately, the kidney is a paired organ; most of us were born with two of them and we can survive with only one. But a traditional donor nephrectomy is a big operation with a significant period of recovery and being off work," Dr. Shackleton said.
"In contrast, with video-assisted optics and precision instruments, laparoscopic live donor nephrectomy makes it possible to remove the kidney through a couple of mini-incisions," according to Dr. Shackleton. "This results in shorter hospitalization time, much-reduced need for pain medication, significant reduction in the need for blood products in the perioperative period, and much faster return to work. Most importantly, there is a greater ability and willingness on the part of individuals to consider living donation when this is presented as an option."
This "convenience" and risk-reduction for the donor has no down side, based on data gathered from Dr. Fuchs' own experience and from the few other transplant centers that have offered the laparoscopic technique. "It does not compromise the donor's health and it does not compromise the health or viability of the kidney," Dr. Fuchs said. "In other words, when the kidney is implanted into the recipient, it works the same way as if it had been harvested by the open surgical technique."
When Holly Miyagawa of Hermosa Beach was born 29 years ago, she had only one fully functioning kidney. A couple of years ago, she and her doctors discovered that it was starting to slowly deteriorate.
"Basically, I was just being monitored" since that time, she said. "I've always been very active and I started noticing a lack of energy around October and November (1999). I just couldn't figure out what was wrong. I didn't go to the doctor yet because I thought maybe I was just fighting a cold. Then my legs started swelling. That was the sign that my kidney was failing."
By December, Holly needed dialysis treatments to cleanse the impurities from her blood and assume the other life-sustaining activities that healthy kidneys normally perform. Her mother and brother hoped they might donate a kidney to Holly but when medical tests in January found that they would not be good candidates, more distant family members volunteered to undergo testing.
Holly's cousin, Darlene Navarrete, 38, a resident of Alta Loma, turned out to be an excellent candidate. When she started to go through the testing, she did not know about the laparoscopic technique. "I was just going to go along with any procedure to save my cousin," she said.
The transplant operations were performed on March 6, and Darlene's kidney was removed laparoscopically by Dr. Fuchs.
"When I came out (of surgery), I was in recovery and I was in no pain at all. I didn't take any pain pills," Darlene said. "They came in and asked me if I needed any medication for pain and I didn't. I had surgery on a Monday and I went home Tuesday afternoon. I was in there about 24 hours. They gave me a prescription for pain but I didn't use any."
Within a week, Darlene's routine had returned nearly to normal. "I got home on Tuesday. They put me on a liquid diet until Thursday and by Thursday evening I could have soft foods. Then Friday I was eating a regular diet. I think Friday I was already at the mall. I was walking a little slowly but I was still there."
She returned to work at the City of Los Angeles planning department the following week. "I was off work for six days," she said. "Everybody was amazed at work, like, 'What are you doing here?'" In contrast, a friend of Darlene's who donated a kidney in an open procedure was unable to return to work for about eight weeks.
With Darlene's "spare" kidney, Holly's life is returning to normal, also. She went back to work at a law firm two months after the operation and is returning to her active outdoor lifestyle, which includes playing beach volleyball and in-line skating.
So far, she is operating "on a much slower scale" than before but in time she expects to be back to 100 percent. "I still don't have quite the energy that I used to, but I'm back out on the beach. I started running a little bit, going to the gym, trying to get back what I had," Holly said.
Although Dr. Fuchs' expertise in laparoscopic kidney donor operations is a tremendous asset to the transplant program, this is only one of several areas in which he is having a significant impact, according to the chairman of Cedars-Sinai's Department of Surgery, Achilles A. Demetriou, M.D., Ph.D.
"His recruitment increases our capacity to do more complex urologic and related procedures in a non-invasive way," said Dr. Demetriou. "He's a urologist's urologist because he deals with patients who are referred to him by other urologists who have tried unsuccessfully to fix a problem. Dr. Fuchs has a very advanced practice aimed at managing complex urologic problems using sophisticated endoscopic techniques."
Dr. Demetriou said only a handful of urologic specialists in the country have Dr. Fuchs' level of skill, and he is a tireless innovator and researcher. "He applies the skills and techniques he has developed in an ongoing effort to devise new treatment modalities, less-invasive approaches to treating such problems as prostate cancer, kidney cancer, bladder cancer and a variety of other urologic problems."
In fact, Dr. Fuchs said his objective is to perform as many procedures as possible without ever making an incision. He prefers instead to navigate the urinary tract to reach and treat conditions ranging from blockages to kidney stones and even "transitional cell tumors" -- those that develop within the urine pooling region of the kidneys and in the tubes leading from the kidneys to the bladder. This approach not only minimizes pain and recovery time of surgery, but it often can save a patient's vital organs.
"To treat a tumor in the upper tract, such as a bladder tumor, most urologists take the kidney and the ureter out," said Dr. Fuchs. "This was a wise decision in the old days when most of these patients were in their 70s and 80s, but now we frequently see these tumors in 30- and 40-year-old patients. These people still have a long life ahead of them. But once the patient gives up a kidney, you cannot put it back. That is why the organ-preserving cancer treatment program is so important in my assessment and in the assessment of my peers who specialize in this field."
Endoscopes and laparoscopes are lighted "tubes" with magnification and tiny camera lenses that enable physicians and surgeons to see and work inside the body. Laparoscopes are inserted through small incisions or punctures in the abdomen. Endoscopes are typically used to work within a hollow organ or body cavity, such as the digestive tract. Dr. Fuchs is one of a very few specialists who have adapted the discipline of endoscopy to the study and treatment of the components of the urinary tract. Thus the term "endourology."
Dr. Fuchs said he hopes to decrease the number of "open" urologic procedures, both in the adult and pediatric population. "Many patients with urologic problems undergo open surgery because they don't know that there are options. This is something that needs to be explored with them. Furthermore, very few pediatric urologists are trained in endoscopic surgery. Therefore, children have open surgery. They are little with a little scar but when they grow, the little scar becomes a bigger scar. If they could have done without it, they probably would."
As part of Cedars-Sinai's cancer treatment efforts, Dr. Fuchs is now offering or preparing to offer minimally invasive oncology services, removing kidneys, adrenal glands, and prostate glands laparoscopically.
"It has been well established that laparoscopy -- both for benign and malignant disease -- is safe and has no drawbacks," Dr. Fuchs said. "The advantages for the patient are less morbidity, shorter hospital stay, and much quicker recovery and return to normal activities."
Prior to accepting the position at Cedars-Sinai, Dr. Fuchs has held a number of administrative and academic appointments at the University of California, Los Angeles during the past 15 years. He served, for example, as director of the medical center's Stone Center for kidney disorders since 1987, the same year he was named director of the Lithotripter, Endourology and Urologic Ultrasound Training Program. Also since that time, he was head of the Section of Endourology, Stone Disease and Laparoscopic Surgery within the School of Medicine's Department of Surgery and Division of Urology.
He continues to hold his academic appointment at UCLA's School of Medicine, where he has served as professor of clinical surgery/urology since 1992. He joined UCLA's faculty in 1985 as assistant researcher, became associate clinical professor in 1986, and associate professor in 1990.
Ralph V. Clayman, M.D., professor or urology and radiology at Washington University in St. Louis, Mo., and one of the other premier endourologists in the world, said Dr. Fuchs will be a tremendous asset to Cedars-Sinai's programs.
"He has certainly done more than anyone else on the West Coast in furthering rigid and flexible ureteroscopy, and in developing the concept -- which was his -- of retrograde intrarenal surgery," said Dr. Clayman, referring to the performance of kidney and related surgeries through the urinary tract. "As far as ureteroscopic surgeons in this country, he's certainly among the top 10, if not the top five."
Dr. Clayman said he has known Dr. Fuchs for 16 years when Dr. Clayman came to UCLA for training in extracorporeal shock-wave lithotripsy -- the technique of removing kidney stones without surgery, instead breaking them into fine particles with blasts of sound waves.
"He's certainly one of the pioneers in shock-wave lithotripsy. He also did a great deal of early work with laparoscopic surgery. I think he was the first person in the country to report on bilateral laparoscopic nephrectomies," Dr. Clayman added.
Dr. Fuchs' interests in research and education are evidenced by the number of articles published in scientific journals -- currently about 100 -- his scientific lectures -- more than 450 -- and the fact that he has contributed more than 70 book chapters.
Dr. Fuchs said providing training is one of his objectives at Cedars-Sinai. "I'm doing as much surgery as one person can do, but I am starting a program to enable other urologists to do the same kind of work. What I really want to do is to make this treatment modality, this technology, available to more patients. I go along with some of my colleagues at the Cleveland Clinic who say it is a shame not to offer this to patients."
Dr. Fuchs provides consulting services to many organizations and has been appointed to a number of committees for such groups as the American Urological Association. He serves on the editorial boards of national and international urology journals and is currently assistant editor of the Journal of Minimally Invasive Therapy and assistant editor for the extracorporeal shock-wave lithotripsy section of the Journal of Endourology.
In addition to serving for many years as a reviewer for the Journal of the American Medical Association -- a service he continues to provide on a periodic basis today -- Dr. Fuchs is a regular reviewer for a number of other professional publications, including Urology and the Journal of Urology.
Dr. Fuchs is a founding member of the International Society of Shock Wave Lithotripsy, the German Society for Extracorporeal Shockwave Lithotripsy, and the Society of Minimally Invasive Therapy, an international organization that first brought together endoscopic surgeons from a variety of specialty fields. In addition to maintaining membership in numerous other professional societies, he has been named an honorary member of organizations in the United States, Chile, Mexico, Malaysia, Paraguay, Costa Rica and other regions.
Dr. Fuchs received his undergraduate and medical degrees from the University of Heidelberg in Germany, where he also completed an internship in medicine, surgery and gynecology. He completed his residency in general surgery and urology at Katharinenhospital in Stuttgart, West Germany. Katharinenhospital is affiliated with Tuebingen University Medical School.
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