• 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