Radical Nephrectomy

The most common operation to treat renal cell cancer is called a 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 has its advantages in treating cancers of different sizes and in different locations in the kidney.

Laparoscopic Nephrectomy

This approach to radical nephrectomy has quickly become, for some doctors, a preferred method for removing kidney tumors.

The operation is done through several small incisions (which is why it is sometimes called "keyhole" surgery) as opposed to 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 has a small video camera on the end, which 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). The technique is thought to be as effective as open radical nephrectomy and usually involves shorter hospital stay, a faster recovery, and less pain after surgery.

Regional Lymphadenectomy (Lymph Node Dissection)

This procedure involves removing nearby lymph nodes to see if they contain cancer. Many doctors do this along with the radical nephrectomy, although not all doctors agree that it is necessary. The main reason for doing it is to try to more accurately stage the cancer by determining if it has reached the lymph nodes (instead of relying only on imaging study results). This can be important for predicting chances for survival and deciding on further treatment options. In theory, removing the lymph nodes might also increase the chances that all of the cancer is removed, but this has not been proven.

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.

This approach is used most often when there is a need to preserve some of the remaining kidney function, such as in people with cancer in both kidneys, those who only have one kidney and develop cancer in that kidney, or in people who already have reduced kidney function for some other reason. It may also be used to try to preserve as much kidney function as possible in people who are more likely to develop other kidney cancers in the future, such as those with von Hippel-Lindau disease.

A partial nephrectomy may also be done in patients with a single kidney cancer that is smaller than 4 cm (about 1¾ inch) across. Studies have shown the long-term results to be about the same as for removing the whole kidney. The obvious benefit is that you retain more of your kidney function. Partial nephrectomies are generally not done for larger tumors, if there is more than one tumor in the same kidney, or if the cancer has spread to the lymph nodes or distant organs.

Some doctors at major medical centers are now studying whether laparoscopic partial nephrectomy is a possible option. But it is a difficult operation to do, and it is generally thought of as an investigational procedure at this time.

Removal of Metastases

About 1 out of 4 patients with renal cell carcinoma will already have metastatic spread of their cancer when they are diagnosed. In some cases, surgery may still be helpful.

Attempts at curative surgery: In rare cases where there is only one 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. This may be done 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): In cases where 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.

Risks of Surgery

Risks with 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)

Other Local Therapies

Whenever possible, surgery is the main treatment for kidney cancers that can be removed. But for people who are too sick to have surgery, other approaches can sometimes be used to destroy kidney tumors. While they may be helpful for some people, there is much less data on their long-term effectiveness than there is for surgery, and some doctors may still consider them to be experimental.

Cryotherapy (Cryoablation)

This approach uses extreme cold to destroy the tumor. A hollow probe (needle) is inserted into the tumor either through the skin (percutaneously) or during laparoscopic surgery. Very cold gases are passed through the probe, creating an ice ball that destroys the tumor. To be sure the tumor is destroyed without too much damage to nearby tissues, the doctor carefully watches images of the tumor during the procedure (with ultrasound or other tests).

The type of anesthesia used for cryotherapy depends on how it is being done. Possible side effects include bleeding and damage to the kidneys or other nearby organs.

Radiofrequency Ablation (RFA)

This technique uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and advanced until the end is in the tumor. Placement of the probe is guided by ultrasound or CT scans. Once it is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells.

RFA is usually done as an outpatient procedure, using local anesthesia (numbing medicine) where the probe is inserted. You may be given medicine to help you relax as well. Major complications are uncommon, but they can include bleeding or excessive tissue damage.

Arterial Embolization

This technique is used to block the artery that feeds the kidney with the tumor. A small catheter (tube) is placed in an artery in the inner thigh and is advanced until it reaches the artery going from the aorta to the kidney (renal artery). Material is then injected into the artery to block it, cutting off the kidney's blood supply, causing it (and the tumor) to die. Although this procedure is rarely performed, it is sometimes done before nephrectomy to reduce bleeding during the operation.