• The preferred treatment for renal cell carcinoma
• The choice of surgical procedure depends on the extent of the disease, as well as patient-specific factors such as age and comorbidity
• May be carried out through a conventional approach or by a minimally-invasive approach

Partial Nephrectomy or Nephron-Sparing Surgery (NSS)

• Indicated in patients with solitary kidney, one kidney with contralateral renal function and bilateral synchronous renal cell carcinoma (RCC)
  • Suitable for patients with unilateral stage I-III tumors if technically feasible or with renal insufficiency, bilateral masses, familial renal cell cancer or in uninephric state
• May also be considered in young patients or those with comorbidities at relative risk for progressive chronic renal disease 
• Preferred surgical management for patients with stage I (pT1a, pT1b)
• Only the diseased or injured portion of the kidney is removed
• Contraindicated in patients with locally advanced tumor growth, tumor in an unfavorable location, or with confirmed nodal metastases

Radical Nephrectomy

• The most widely used approach and the preferred procedure if there is evidence of invasion into the adrenal gland, renal vein or perinephric fat
• Involves the removal of the entire kidney along with a section of the tube leading to the bladder, ureter, adrenal gland and fatty tissues surrounding the kidney
• Preferred surgical management for patients with stage II-III
• With increased risk for chronic kidney disease and cardiovascular morbidity and mortality compared to NSS

Ablative Techniques

• Have higher local recurrence rate compared to conventional surgery and may need multiple therapies to achieve similar oncologic results

Cryoablation

• Indicated for <3 cm solitary renal tumor located away from the collecting system

Microwave Ablation

• Indicated for frail patients at high surgical risk with ≤3 cm solitary renal tumor, renal impairment, hereditary RCC or multiple bilateral tumors

Radiofrequency Ablation

• An alternative treatment in patients with contraindications to nephrectomy, Von Hippel-Lindau disease and unfit elderly patients
• Creates molecular friction, denaturation of cellular proteins and cell membrane disintegration
• Heat-based tissue destruction with a high-frequency electrical current (400 to 500 kHz)

Other Procedures

Adrenalectomy

• Considered in patients with large upper pole tumors or abnormal-appearing adrenal glands on CT scan and must be decided on an individual basis

Cytoreductive or Debulking Nephrectomy

• Mostly involves the removal of the primary tumor from the kidney
• Recommended in patients with good performance [Eastern Cooperative Oncology Group (ECOG) performance status <2] preceding systemic therapy and no brain metastasis
• May be considered in patients with stage IV or relapsed disease if primary tumor is surgically resectable

Metastasectomy

• The lungs, bones, brain and liver are the most common sites of metastasis
• Patients with stage IV disease may be considered for metastasectomy if:
  • Primary RCC and oligometastatic sites (includes lung, bone, brain) present upon initial diagnosis
  • Patient develops oligometastases after prolonged disease-free interval after nephrectomy

Regional Lymph Node Dissection

• May be considered in patients with resectable enlarged or palpable lymph nodes seen in preoperative imaging tests or visible or palpable lymph nodes during surgery

Risks and Side Effects of Surgery

• Short-term risks includes reactions to anesthesia, excess bleeding (may require blood transfusions), blood clots and infections
• Damage to internal organs and blood vessels (spleen, pancreas, aorta, vena cava, large or small bowel) during surgery
• Leakage of urine into the abdomen (after partial nephrectomy)
• Kidney failure (if the remaining kidney fails to function well)

Palliative Surgery

• For management of spinal cord compression or possible/confirmed fractures in weight-bearing bones in select patients