Surgery for Kidney Cancer

Surgery is the main treatment for most kidney cancers and many times it can cure the cancer by itself.

Depending on the stage and location of the cancer and other factors, surgery might be done to remove the entire kidney including the tumor (known as a radical nephrectomy) or the cancer alone along with some of the surrounding kidney tissue (known as a partial nephrectomy). Sometimes, the adrenal gland (the small organ that sits on top of each kidney) and fatty tissue around the kidney is removed as well. In certain cases, the nearby lymph nodes might also be removed.

Some people whose cancer has spread to other organs may benefit from surgery that takes out the kidney tumor. Removing the kidney might also lessen symptoms such as pain and bleeding.

Radical nephrectomy

In this operation, the surgeon removes your whole kidney, the attached adrenal gland, nearby lymph nodes, and the fatty tissue around the kidney. Most people do just fine with only one working 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 in the back, just behind the kidney. Each approach has its benefits in treating cancers of different sizes and in different parts of 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 vein leading away from the kidney) and into the inferior vena cava (the 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 and robotic-assisted laparoscopic nephrectomy

These approaches to the operation are done through several small incisions instead of one large one. If a radical nephrectomy is needed, many doctors and patients now prefer to use these approaches when they can.

Laparoscopic nephrectomy: Special long instruments are inserted through the incisions, each of which is about 1/2-inch (1.27cm) long, to remove the kidney. One of the instruments, the laparoscope, is a long tube with a small video camera on the end. This lets the surgeon 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 radical nephrectomy).

Robotic-assisted laparoscopic nephrectomy:  This approach uses a robotic system to do the laparoscopic surgery remotely. The surgeon sits at a panel near the operating table and controls robotic arms to operate. For the surgeon, the robotic system may allow them to move the instruments more easily and with more precision than during standard laparoscopic surgery. But the most important factor in the success of either type of laparoscopic surgery is the surgeon’s experience and skill. This is a difficult approach to learn. If you are considering this type of operation, be sure to find a surgeon with a lot of experience.

In experienced hands, the technique is as effective as an open radical nephrectomy and usually results in a shorter hospital stay, a faster recovery, and less pain after surgery. This approach may not be an option for tumors larger than about 7 cm (3 inches) across or tumors that have grown into the renal vein or spread to lymph nodes around the kidney.

Partial nephrectomy (nephron-sparing surgery)

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

Partial nephrectomy is now the preferred treatment for many people with early-stage kidney cancer. It is often done to remove single small tumors (less than 4 cm or 1½ inches across), and can also be done to remove larger tumors (up to 7 cm or 3 inches across). Studies have shown the long-term results to be about the same as when the whole kidney is removed. The obvious benefit is that the patient keeps more kidney function.

A partial nephrectomy might not be an option if the tumor is in the middle of the kidney, if it 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 can do this type of surgery. It should only be done by one with a lot of experience.

Laparoscopic partial nephrectomy and robotic-assisted laparoscopic partial nephrectomy

Many doctors now do partial nephrectomies laparoscopically or using a robot (as described above). But again, this is a difficult operation, and it should only be done by a surgeon with a great deal of experience.

Regional lymphadenectomy (lymph node dissection)

This procedure removes nearby lymph nodes to see if they contain cancer. Some doctors do this when doing a radical nephrectomy. More lymph nodes may be removed if the tumor has features suggesting it is at high risk of spreading.

Most doctors agree that the lymph nodes should be removed if they look enlarged on imaging tests or feel abnormal during the operation. Some doctors also remove these lymph nodes to check them for cancer spread even when they aren’t enlarged, to better stage the cancer. Before surgery, ask your doctor if they plan to remove the lymph nodes near the kidney.

Removal of an adrenal gland (adrenalectomy)

Although this is a standard part of a radical nephrectomy, 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 might not have to be removed. Just like with lymph node removal, this is decided on an individual basis and should be discussed with the doctor before surgery.

Removal of metastases

In about 1 in 3 people with kidney cancer, the cancer will already have spread (metastasized) to other parts of the body when it is diagnosed. The lungs, lymph nodes, bones, and liver are the most common sites of spread. For some people, surgery may still be helpful.

Attempting a surgical cure

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 later 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 people live longer.

Risks and side effects of surgery

The short-term risks of any type of surgery include reactions to anesthesia, too much bleeding (which might require blood transfusions), blood clots, and infections. Most people will have at least some pain after the operation, which can usually be helped with pain medicines, if needed.

Other possible risks of surgery include:

• 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)
• Leakage of urine into the abdomen (after partial nephrectomy)
• Kidney failure (if the remaining kidney fails to function well)