Surgical Intervention
- 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)
- 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
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 enlarged or palpable lymph nodes seen in preoperative imaging tests
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