Alexander Kutikov, MD, FACS, is the chair of the Department of Urology at the Fox Chase Cancer Center, a National Cancer Institute-designated Comprehensive Cancer Center research facility and hospital located in the Fox Chase section of Philadelphia, Pennsylvania. We spoke with him regarding his unique career path, changes he pioneered in the genitourinary (GU) surgical landscape over the past 20 years, and the state of GU oncology care moving forward.
Why did you become a GU surgical specialist? What was your inspiration?
Dr. Kutikov: I was in medical school in 2001 and my girlfriend at the time, to whom I’m now married, prompted me about what direction I wanted to take. I really didn’t have a clue at the time, but once I entered the surgical wards in the clinical rotations, I very quickly understood that I wanted to delve into surgery. Its intensity and challenges were a great attraction for me. I immediately sought to figure out which surgical field I wanted to enter.
The field of urology came into focus very quickly. I loved its procedural variety. I saw urologists go from one room, pulverizing stones with these small scopes and doing these seemingly miraculous things, to another room and taking out large tumors. I also clearly saw that urologists were some of the most gifted and versatile surgeons in the hospital, on whom a lot of other surgical specialists leaned on. Open techniques, laparoscopic techniques, and a little bit later, robotics, endoscopy, you name it, urologists kind of did it all, and I loved it.
I also loved the personalities. This was a group of people who loved taking care of patients and were incredibly good at it. Urologists tend to have a sort of great sense of humor, which definitely helps in the everyday challenges of modern medicine. I was very fortunate to be exposed to some great urologists as a young medical student (including Frank McGovern, MD), and I was hooked. I never looked back. I love the field to this day.
You seem to hold quite a few titles. In your own words, what is your title and how did this come to be?
Dr. Kutikov: I am the chair of the newly minted Department of Urology at the Fox Chase Cancer Center. I’ve been here since 2008, and this incredible team that I have the privilege of leading selected me as their inaugural Society of Urologic Oncology Fellow in 2008.
I have many mentors here who’ve been critical to my career. Chief among them is Robert Uzzo, the current chief executive officer of Fox Chase Cancer Center. He has been integral to my professional and personal growth. Rob is a tremendous clinician, academician, and leader. He’s the one who brought me here and has really helped me grow over the years.
Fox Chase is a tremendous place, and I’m so proud to be a part of it.
From the start of your tenure in 2008 through the present day, what have been your most meaningful or impactful contributions to the field?
Dr Kutikov: In 2009, I was the first author on the seminal manuscript for “The R.E.N.A.L Nephrometry Score: A Comprehensive Standardized System for Quantitating Renal Tumor Size, Location and Depth.” This publication significantly changed how surgeons examine, communicate, and compare surgical outcomes as well as the biology of renal masses.
This is a system that’s currently used worldwide to communicate anatomic kidney tumor complexity and has spawned numerous research efforts. The manuscript has been referenced over 2000 times, and it allows for very much more meaningful comparisons among surgical series and standardization of clinical care. There have been, and still are, significant clinical challenges. But before this manuscript, clinicians reported their surgical outcomes in a way that wasn’t comparable to other reported outcomes. For example, one clinician could say, “I did 100 partial nephrectomies and had no complications,” and another could say, “I did 100 partial nephrectomies and had a 20% complication rate.” These statements leave out valuable information. Were the clinicians doing partial nephrectomies on more complex tumors in the group that had lower complication rates? Did the clinicians who saw more complications take on more challenging cases?
The renal nephrometry system helped standardize the reporting of how the tumor relates to the rest of the kidney. Is it deep inside the kidney, in the middle, or sitting on the surface? Those detailed anatomical relationships from the tumor to the kidney were poorly or never communicated in the literature. The R.E.N.A.L Nephrometry Score is not perfect by any means, but it improved that communication.
Which of your current research endeavors in are you most excited about?
Dr. Kutikov: At Fox Chase, my role is to help my team make headway in the academic world. There are lots of projects that are in play, but the one I really have my eye on is our efforts to understand the prediction of the PT0 state in bladder cancer. When a patient comes in with muscle-invasive bladder cancer, and we give them chemotherapy, followed by a cystectomy—an incredibly morbid and life-changing procedure—even though about 30% of these patients don’t have any disease left in their bladder. For several reasons, the cystectomy is still justified. But we have a tremendous opportunity to enter these patients into clinical trials that investigate how we to spare their bladders and how to prevent tumors from recurring.
Currently, we don’t have a way to predict which patients will have disease still in the bladder after chemotherapy. However, we recently did a trial where we performed transurethral resections of bladder tumors minutes before cystectomy. We found that the prediction of this PT0 state, the 30% estimation, is very inaccurate when using current techniques. Twenty-five percent of muscle-invasive tumors were missed; upon transurethral resection, 1 in 4 bladders still harbored muscle-invasive disease. We found that it’s a gamble to let patients keep their bladders if the bladders look good from the inside.
We are working with our translational team on harnessing modern genomics and molecular tools to risk stratify patients whose bladders look good after chemotherapy or initial resection, so that we can save those patients from losing their bladders entirely.
What cutting-edge research, technologies, or surgical procedures have your attention at the moment?
Dr. Kutikov: Technologic advances have really boomed in recent years. What really excites me are efforts to understand the value-add of a particular technology. Do the additional costs and barriers to care justify those technologies?
For example, there’s a robotic platform that has largely stayed the same over the last 2 decades. There is an argument to be made that some notable improvements cannot be overlooked. Yes, it’s a little easier to dock and it pivots a bit better, but the added value is marginal. It is a single company that provides this technology, and there have been some barriers to entry into that space. It’s fair to say there’s a monopoly on the surgical robot right now. Finally, a new robot has entered the market, but it is still pending Food and Drug Administration approval.
The costs associated with robotics are mountainous and prohibitive. There is certainly value to robotics, but as a field we have to do a better job understanding that value. Also, not to be overlooked is our duty to train the next generation of surgeons on the techniques not performed by the robots.
To use another example, nephrectomies should be done laparoscopically because the costs are much lower than docking a robot with all the drapes, instrument costs, and not to mention the limitations for scheduling in the operating room at many institutions. It should be an available procedure to patients out there, but it’s a dying art because of the robots. In locations without robotics, patients may not be able to have this procedure because the newer generation of surgeons is not trained to do it.
If the field is moving in the direction of all-encompassing robotics, we then need to figure out how to lower the cost. It’s our responsibility to understand how the costs of the care impact health care delivery. There is tremendous opportunity for us to optimize the value of care that we provide, and in doing so, lower the costs for patients. Patients do not see any difference in outcomes for laparoscopic surgery versus many (not all) robotic surgeries, but the cost difference is substantial.
In your 22 years as a urology surgeon, how has the field evolved?
Dr. Kutikov: Some areas have been slow on advancement, while others have boomed. As for the surgical science perspective, we have made leaps and bounds. The urology field that I joined in 2001 was very much driven by opinions from key leaders rather than data. Although we still have a long way to go, we’ve made great strides in understanding from a data-driven perspective if the care we deliver translates into actual improved outcomes for patients. For example, we are much better at asking if we actually need to perform surgery, or if can we hold off and monitor patients, or lean on our medical oncology or radiation oncology colleagues for alternative or supplementary treatments.
Surgical techniques have also significantly evolved. As we discussed, a laparoscopic or robotic nephroureterectomy nowadays is a 1- to 2-day hospital stay, whereas when I was a medical student, the process to take out the kidney, the ureter, and a portion of the bladder involved the patient getting 2 very large incisions, getting a flank incision, taking care of the kidney part, “stuffing” the kidney and the proximal ureter down into the body, closing that incision, and then making another huge slash in the pelvis to do the rest of the surgery.
A long procedure like this, with a lot of morbidity, is now done through keyhole incisions. We pull the specimens out of an incision as big as an appendectomy, and we’re done. This is just one example of the great strides we’ve made in minimally invasive laparoscopic and robotic techniques. Now, patients recover much faster than they did 20-plus years ago.
Nevertheless, key surgical principles have stayed the same. I teach my fellows that when approaching a patient, it’s not about technique. They must be versatile surgeons, knowing how to do open surgery, pure laparoscopy, or robotics, and be able to offer patients the best operation on a case-by-case basis. The work we do is all about the patient, so it is paramount for us to be well trained in all modalities to provide comprehensive surgical oncologic care.