Urology, Pediatric Surgery Collaborate on Patients with Bilateral Wilms Tumor

Michael Daugherty, MD, and Meera Kotagal, MD, MPH, joined the Cincinnati Children’s faculty within a year of one another and quickly discovered a shared interest in optimizing surgical care for children with bilateral Wilms tumor. Together they perform between three and five surgeries a year on patients with this rare disease. We asked them how their collaboration has grown and how it enhances patient care.

What was the impetus for your collaboration?

Kotagal: Bilateral Wilms tumor is a relatively low-volume surgery, and developing surgical expertise on your own is difficult. Mickey and I have different perspectives, skill sets, and training backgrounds. Working together on many cases over the last four years has been an excellent opportunity to learn from each other and think through complex challenges.

What does the collaboration entail before and during the surgery?

Daugherty: When we get a referral for a child with bilateral Wilms tumor, we look at the imaging together and discuss surgical approaches to save as much of the intact kidney as possible. We also have tumor board conferences and informal conversations with radiology and oncology to maximize oncologic outcomes.

With bilateral Wilms tumor, we often need to do a one-sided nephrectomy and a partial nephrectomy on the other kidney. Meera accesses the kidneys and does the complete nephrectomy on one side, and then we look at the side for partial nephrectomy together. We have a radiologist do intraoperative ultrasound to help us mark the tumor’s location and evaluate for other lesions. Meera and I work side by side to do the nephrectomy and renorrhaphy.

Dr. Kotagal, what have you learned working with Dr. Daugherty?

Kotagal: Mickey is more experienced with partial nephrectomies than I am because of his urology training and care for adults with renal cell carcinoma. When I first started, I might see a mass on imaging and think, “That looks pretty straightforward.” But Mickey’s taught me to think more about where the mass is relative to vessels and what it will take to resect the tumor without compromising blood supply to the kidneys. I’ve also learned a lot from him about renorrhaphy technique.

What about you, Dr. Daugherty? What have you learned from Dr. Kotagal?

Dr. Daugherty: Pediatric urologists typically don’t have a lot of exposure to Wilms tumor during their residencies. I’ve picked up a lot of knowledge as the team walks through the goals of resection and which nodes to resect during a partial. In addition, Meera’s technical approach in surgery is different than mine. Just how the whole dissection goes, how she closes up the patient. It’s helpful to see all that.

What’s an example of how your approach has changed over the years?

Dr. Kotagal: There’s no standard of care in pediatrics to say whether you need to enucleate the tumor or leave a rim of renal parenchyma. Lately, we’ve been doing less enucleation as part of an overall strategy to avoid unnecessary radiation exposure.

Before or even during surgery, we’ll talk with the oncologist and the radiation oncologist and ask, “Do you plan to do radiation on this child if we enucleate? What about if we don’t?” Some kids will get radiation regardless—for example, if they have pronounced positive nodal disease. But if they do not necessarily need radiation, and we think we could spare them radiation by leaving a tiny margin of normal tissue around the tumor, we might do it. It’s very individualized.

What are some of the intangible benefits of your collaboration?

Daugherty: Meera and I, along with our pediatric oncology and radiology colleagues at Cincinnati Children’s, know one another well and depend on each other’s expertise. We view each case from multiple angles and don’t make decisions in isolation. And we reference previous cases to apply what we’ve learned over time. Ultimately, that leads to continuous improvement and better patient care.

For more information, contact Michael.Daugherty@cchmc.org or Meera.Kotagal@cchmc.org.