Surgery for kidney cancer

Surgery is the main treatment for most renal cell carcinomas. The chances of surviving a renal cell cancer without having surgery are small. Even patients whose disease has spread to other organs may benefit from surgery to take out the kidney tumor. Depending on the stage and location of the cancer and other factors, surgery may be used to remove either the cancer along with some of the surrounding kidney tissue, or the entire kidney. The adrenal gland (the small gland that sits on top of each kidney) and fatty tissue around the kidney may be removed as well.

Radical nephrectomy

In this operation, the surgeon removes your whole kidney, the attached adrenal gland, and the fatty tissue around the kidney. (Most people do just fine with only the one remaining kidney.)

The surgeon can make the incision in several places. The most common sites are the middle of the abdomen (belly), under the ribs on the same side as the cancer, or even in the back, just behind the cancerous kidney. Each approach has its advantages in treating cancers of different sizes and in different locations in the kidney. Although removing the adrenal gland is a part of a standard radical nephrectomy, the surgeon may be able to leave it behind in some cases where the cancer is in the lower part of the kidney and is far away from the adrenal gland.

If the tumor has grown from the kidney through the renal vein (the large vein leading away from the kidney) and into the inferior vena cava (a large vein that empties into the heart), the heart may need to be stopped for a short time in order to remove the tumor. The patient is put on cardiopulmonary bypass (a heart-lung machine) that circulates the blood while bypassing the heart. If you need this, a heart surgeon will work with your urologist during your operation.

Laparoscopic nephrectomy: This approach to radical nephrectomy has quickly become a preferred method for removing kidney tumors.

The operation is done through several small incisions instead of one large one. Special long instruments are inserted through the incisions, each of which is about 1/2-inch long, to perform the operation. One of the instruments, the laparoscope, is a long tube with a small video camera on the end. This allows the surgeon to see inside the abdomen. Usually, one of the incisions has to be made longer in order to remove the kidney (although it's not as long as the incision for a standard nephrectomy).

This approach can be used to treat most renal tumors that cannot be treated with nephron-sparing surgery (see below). In experienced hands, the technique is as effective as open radical nephrectomy and usually means a shorter hospital stay, a faster recovery, and less pain after surgery. This may not be an option for large tumors (those larger than10 cm [4 inches]) and tumors that have grown into the renal vein or spread to lymph nodes around the kidney.

Partial nephrectomy (nephron-sparing surgery)

In this procedure, the surgeon removes only the part of the kidney containing cancer, leaving the rest of the organ behind. As with a radical nephrectomy, the surgeon can make the incision in several places, depending on factors like the location of the tumor.

At first, this approach was only used when there was a reason not to remove the entire kidney. This included people with cancer in both kidneys, those who only had one kidney and developed cancer in that kidney, and people who already had reduced kidney function for some other reason. It was also used in people who were likely to develop cancer in the other kidney in the future, such as those with von Hippel-Lindau disease and other hereditary forms of kidney cancer.

This type of surgery is now the preferred treatment for patients with early stage kidney cancer. It is often done to remove single small tumors (those less than 4 cm across), and can be done in patients with larger tumors (up to 7 cm across). Studies have shown the long-term results to be about the same as those when the whole kidney is removed. The obvious benefit is that the patient keeps more of their kidney function. A partial nephrectomy may not be an option if the tumor is in the middle of the kidney or is very large, if there is more than one tumor in the same kidney, or if the cancer has spread to the lymph nodes or distant organs. Not all doctors are able to do this type of surgery. It should only be done by someone with a lot of experience doing this procedure.

Some doctors can even do this procedure laparoscopically or using a robot. But again, this is a difficult operation, and it should only be done by a surgeon with a great deal of experience in this procedure.

Regional lymphadenectomy (lymph node dissection)

This procedure removes nearby lymph nodes to see if they contain cancer. Some doctors do this along with the radical nephrectomy, although not all doctors agree that it is always necessary. Most doctors agree that the lymph nodes should be removed if they are enlarged based on imaging tests or how they look during the operation. Some doctors also remove these lymph nodes to check them for cancer spread even when they aren’t enlarged, in order to better stage the cancer. Before surgery, ask your doctor if he or she plans to remove the lymph nodes near the kidney.

Removal of an adrenal gland (adrenalectomy)

Although this is a standard part of a radical nephrectomy, the adrenal gland does not have to be removed in every case. If the cancer is in the lower part of the kidney (away from the adrenal gland) and imaging tests show the adrenal gland is not affected, it may not have to be removed. Again, similar to lymph node removal, this is decided on an individual basis and should be discussed with the doctor before surgery.

Removal of metastases

About 1 in 4 patients with renal cell carcinoma will already have metastatic spread of their cancer when they are diagnosed. The lungs, bones, brain and liver are the most common sites of spread. In some patients, surgery may still be helpful.

Attempts at curative surgery: In rare cases where there is only a single metastasis or if there are only a few that can be removed easily without causing serious side effects, surgery may lead to long-term survival in some people. The metastasis may be removed at the same time as a radical nephrectomy or at a later time if the cancer recurs (comes back).

Surgery to relieve symptoms (palliative surgery): When other treatments aren't helpful, surgically removing the metastases can sometimes relieve pain and other symptoms, although this usually does not help patients live longer.

Also, removing the kidney containing the cancer can help patients live longer even when the cancer has already spread to distant sites. This is why a doctor may suggest a radical nephrectomy even if the patient's cancer has spread beyond the kidney. Kidney removal can also be used to ease symptoms such as pain and bleeding.

Risks of surgery

Risks of surgery include:

• Bleeding during surgery or after surgery that may require blood transfusions
• Wound infection
• Damage to internal organs and blood vessels (such as the spleen, pancreas, aorta, vena cava, large or small bowel) during surgery
• Pneumothorax (unwanted air in the chest cavity)
• Incisional hernia (bulging of internal organs near the surgical incision due to problems with wound healing)
• Kidney failure (if the remaining kidney fails to function well)