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Surgical Treatment

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Understanding the various surgical approaches to the most common form of kidney cancer

Surgery is considered the primary treatment for most kidney cancers. A variety of surgical procedures are available, depending on the type, size of tumor, extent of disease and the patient’s overall physical condition. Your doctor will discuss the surgical options that are appropriate for you.

Traditional Surgery: Removing All or Part of the Kidney

Treatment of most kidney cancers begins with removal of the primary tumor in an operation called a nephrectomy. The purpose of surgery is to remove the primary tumor and involved tissue in the kidney. Even if cancer has already spread, a nephrectomy may still be beneficial because your body then has less cancer to fight through treatments that your doctors might recommend after surgery. In fact, a recent study of 245 patients with operable metastatic kidney cancer demonstrated that patients who had a nephrectomy before systemic therapy with interferon alfa had a higher survival rate than patients treated with interferon alfa alone.

A nephrectomy is a well-defined and common operation. Thousands of nephrectomies are performed every year for kidney cancer as well as for other diseases. Although it is a major surgery, the potential risks are well defined and it is usually quite safe if you do not have any underlying illnesses, such as heart disease or liver disease. Mortality rates are typically less than 1% for patients whose cancer has not metastasized and around 1% for patients with metastatic disease. Complications are not common unless the tumor is locally advanced, such as when the tumor extends into the renal vein or inferior vena cava (the large vein through which blood from your legs and internal organs returns to the heart), or the tumor has spread beyond the kidney. Extension of the tumor into the vein requires blood vessel surgery to remove the affected portion of the vein. This problem is well understood, but it prolongs the operation, and blood transfusions are often needed. Blood transfusions may not be required for smaller, localized tumors.

Though nephrectomy is the most common treatment for kidney cancer, it is important to note that in some cases it may not be appropriate. Your oncologist and/or urologist will explain the factors that influence the decision on whether to proceed with a nephrectomy.

There are 2 basic types of nephrectomies for kidney cancer. In an open partial nephrectomy, the surgeon removes just the part of the kidney that contains the tumor. An open radical nephrectomy involves removal of the entire kidney, and often includes the adrenal gland above the kidney, the surrounding fatty tissue, and the lymph nodes adjacent to the kidney.

Most often, the surgeon will perform a radical nephrectomy because it is more effective in eradicating the cancer. However, partial nephrectomy can often achieve the same results in patients with smaller cancers. Partial nephrectomy is particularly indicated in patients with either kidney failure or a problem with the opposite kidney. The size of the tumor can also determine whether a partial nephrectomy is performed. Partial nephrectomies are sometimes associated with their own set of complications, including temporary shutdown of the kidney or prolonged drainage of urine, but these are usually related to the size and location of the tumor. In the past, partial nephrectomy was used only when a patient had a solitary (only one) kidney, but it is considered safe enough now that it is often appropriate for a patient who has a normal kidney on the other side.

A radical nephrectomy requires more extensive surgery. The adrenal gland, which is located immediately above the kidney, is often removed during a radical nephrectomy. It may be appropriate to leave the adrenal gland behind, however, especially when the tumor is relatively small or located in the lower portion of the kidney. Partial or complete removal of the lymph nodes during surgery also may be helpful to determine if the tumor has spread, but again, this decision depends on a variety of factors. A pathologist will examine the lymph nodes under a microscope to see if any kidney cancer cells are present in the lymphatic system.

Laparoscopy and Kidney Cancer

Open radical or partial nephrectomies – performed through a typical surgical incision — are the most common surgical techniques used to remove a diseased kidney. Recently, however, less invasive surgical techniques have been developed and are gaining increasing acceptance. These are now referred to as “minimally invasive surgeries,” and involve the use of a laparoscope, an instrument that is passed through a series of small incisions or “ports” in the abdominal wall. Laparoscopy, which is sometimes called “band-aid surgery,” can be used for both radical and partial nephrectomies and accomplishes the same things as traditional surgical techniques.

Laparoscopic radical or partial nephrectomy can result in decreased blood loss, a shorter hospital stay, less need for narcotic pain medication and shorter recovery time when compared with open radical nephrectomies.

Most medical centers and many surgeons offer laparoscopic radical nephrectomy. But the use of laparoscopic instrumentation can be technically difficult. Therefore, hand-assisted techniques have been developed to facilitate the procedure in select cases. Surgeons sometimes make a short incision in conjunction with the instrument ports in order to insert one hand to assist the laparoscopic maneuvers. Hand-assisted laparoscopy may make laparoscopic nephrectomies more widely available while maintaining the benefits of minimally invasive surgery.

Laparoscopic partial nephrectomies can be done, too, but they are performed by a much more limited number of surgeons at the present time because of the technical expertise and experience required.

Laparoscopy has also been successfully combined with two other surgical techniques, called cryosurgery and radiofrequency ablation (RFA), to destroy small kidney tumors in select patients. Cryosurgery, or cryoablation, uses freezing temperatures (achieved by using liquid nitrogen or carbon dioxide) to destroy diseased tissue. RFA destroys tumors with thermal energy (heat). In selected patients, these procedures can also be done by passing tiny probes directly through the skin into the tumor under x-ray guidance, without an incision.

All of these laparoscopic procedures hold much promise but may not be suitable for all patients. The long-term safety and results of these techniques remains to be determined. Ask your doctor what surgical technique is best for your particular case.

The Role of Nephrectomy in Advanced Disease

Nephrectomy has become an integral part of the management of patients with metastatic kidney cancer. In the past, nephrectomy was performed in this setting only in certain circumstances – mostly to relieve pain or as a response to intractable bleeding. But indications that some patients had spontaneous regression of their metastatic disease following nephrectomy, and the fact that the primary tumor rarely, if ever, responded to systemic therapy, prompted more widespread integration of nephrectomy into the management of patients with metastatic disease.

Performing nephrectomy in patients with advanced kidney cancer is not without risk, however. The very real chance of significant metastatic disease progression during the postoperative period or complication before or during surgery that may prolong postoperative recovery could potentially delay or prevent the administration of systemic therapy in the postoperative period. Patient selection for surgery remains critical for success. Patients should be good candidates for surgery, and have a relatively small tumor that can be impacted significantly by surgery. Patients with complicating factors, including extensive metastases to the liver, brain, or bones, may not be good candidates for surgery because of their poor overall prognosis.

Arterial Embolization

A procedure called arterial embolization is sometimes used before an operation to make surgery easier. Small pieces of a special gelatin sponge or other material are injected through a catheter to block the artery that feeds the tumor-containing kidney. This procedure can shrink the tumor by depriving it of the oxygen and nutrients it needs to grow and may reduce bleeding during the operation. It is also used to provide relief from pain or bleeding when surgical removal of the tumor is not an option because of poor health or other reasons.

How to Think About Your Tumor

Your tumor and the removed tissue may be important – both to you as a cancer patient and for cancer research in general. The tumor and other tissues that are removed surgically provide potentially important information to your doctors about your specific cancer that may help estimate your risk of relapse, help guide further treatments or contribute to research. For example, the tumor is a storehouse of white blood cells and various other constituents of the immune system that your body has recruited to fight your cancer. In some cases, always as a part of a research protocol, the tissue may be used to prepare a vaccine or may be saved for other purposes. Not surprisingly, tissue will not be available if your tumor is destroyed by cryosurgery or RFA.

Some promising new therapies use material extracted from the surgically removed tumor to fight any malignant cells left behind. (These promising new therapies include adoptive immunotherapy and vaccine therapy and are discussed later in this book.) It is important to note that many of these therapies are investigational. Before surgery, you should discuss with your doctor what the most appropriate use of your tissue should be after it is removed. If your doctor approaches you about saving blood samples and tumor tissue, be sure to listen carefully and consider what he is asking. At present, there is no reason to routinely save tissue. You should consult your doctor for a recommendation.

Before the Operation

If your doctor recommends a nephrectomy, you will probably have lots of questions and concerns. Be sure to share these with your doctor. You will want to know where the surgery will be performed and who the surgeon will be. Your surgery should be performed in a hospital or medical center that is experienced in dealing with kidney cancer. Your surgeon should be a board-certified urologic surgeon. If you do not know whether your hospital or doctor meets these requirements, ask questions before scheduling or agreeing to surgery. No one will be offended by your prudence. You may also want to know how you will feel after the operation and how any pain you might experience will be addressed. You may want to know when you can resume normal

activities and what kind of follow-up treatment is planned. Getting answers to these questions can help relieve or reduce your anxiety so you can focus on healing and fighting your cancer.

The Day before Surgery

Your surgeon may want you to check into the hospital the day before surgery, however, it is becoming more common to admit patients on the day of surgery. On this day, some simple final tests will be performed. These tests are done primarily so that your anesthesiologist has information on how much anesthetic gas to give you during the operation. You may also be required to take a laxative and to drink fluids to flush out your bowels; to reduce the risk of infection during surgery, your surgeon does not want you to have anything in your stomach or intestines. You may also be asked to wash your body with special antibacterial soap. Men are advised to shave on the night before. You won’t get a chance to shave for several days after surgery, and there’s no point to having an itchy beard or face.

Even if you are a sound sleeper, you’ll probably be a little anxious the night before surgery. You may be offered a sleeping pill to make sure you get a good night’s rest before surgery. Take it without worry.

The Day of Surgery

If your surgery is scheduled to start in the morning, you will be awakened early. You may be asked to take an antibiotic and mild sedative. You will be wheeled on a gurney or in a wheelchair down to surgery.

When you arrive in the “pre-op” area, the anesthesiologist will prepare you for surgery. Different anesthesia techniques can be used to keep you free from pain. One common technique involves the use of an epidural catheter to administer a direct flow of anesthetic to your nervous system. This process usually starts with an injection of a local anesthetic into your back, followed by the insertion of a catheter into your back at the spine, just above your kidneys. The catheter is connected with a thin plastic tube to a pump that will give you small injections of anesthetic to prevent any pain. By administering a small, precise dose at frequent, predetermined intervals, the anesthesiologist can achieve greater safety and pain relief. Less anesthetic is administered and there are few, if any, side effects. (This system is also widely used for childbirth.)

You will be transported into the operating room and the anesthesiologist will put you to sleep using a combination of anesthetic gases. The surgery will begin. You will be totally asleep and have no awareness of pain during surgery.

After the surgeon has completed the procedure and the incision is closed and bandaged, you will spend some time in a surgical recovery room. You will be carefully watched and you will slowly wake up as the effects of the anesthetic gases wear off.

You will also be very “mellow” from the medications used to control surgical pain. Your surgeon will want you to have as little pain as possible because if you are comfortable, you will heal better. Try to relax and sleep.

If your surgery has been extensive, you may be put in an intensive care room where your recovery can be closely monitored for several days. You probably won’t remember the operation or going to the recovery room. Your first recollection will probably be waking up in your hospital room or in intensive care.

If you are in intensive care when you wake up, you may be surprised if you have not seen an intensive care room before. The IV bottles, the oxygen tubes, electronic heart monitors, and other gear are there for only one reason — your safe recovery. Though they are distracting, they play an important role in your recovery.

In the intensive care unit, you will be closely watched by nurses and doctors. In some hospitals, you may even have nursing staff assigned exclusively to you 24 hours per day. Your blood pressure and temperature will be checked hourly. Samples of your blood will be drawn frequently. Certain drugs may be administered to help your safe recovery.

If you want something or feel uncomfortable, communicate your needs to the hospital staff. They are there to help you. Depending on the hospital and your condition, you may be allowed to have visitors while you’re in intensive care. Generally, visits are limited to your immediate family and only during certain hours. However, as a consequence of your medication, your visitors should not expect you to engage in much conversation. Don’t expect to remember the details of your conversations while you’re in the intensive care unit. It may also be upsetting for some family members to visit you in intensive care, particularly because they may not understand that all the tubes and wires are there to help you get better and serve a medical purpose. The best policy may be to tell the hospital staff to restrict your visitors until you are feeling better.

A Few Days after Surgery

After 2 or 3 days in your room, you will advance to the next stage of recovery. The various tubes and other support equipment will be removed. You may be allowed to have more visitors. You will be able to read, listen to music, watch television, and take telephone calls.

Your doctors will visit regularly to check your medical condition. Medical staff will check your incision and change the bandage. You will also be told the first results of pathology tests run on the tissue that the surgeon removed. These tests will indicate the type of tumor, whether the tumor had spread, and other facts that are important for you to know. If you have questions, don’t hesitate to ask your doctor.

About 4 or 5 days after your operation, the way you are given pain medication will change and the epidural catheter in your back will be removed. Milder pain medications may be given by intravenous injection and/or orally. Some of these medications, particularly oral pain relievers, may cause constipation. If so, mention this problem to your doctor. He or she may decide to switch your medication or give you something to relieve your constipation.

Exercise is an important part of recovery. It improves your circulation and respiration, and helps prevent blood clots in your legs. The day after surgery, you will be asked to get out of bed and perhaps do some walking. Getting out of bed may not be easy at first, although walking or shuffling along may be no problem. Getting into and out of bed is difficult because during a full, open nephrectomy, the surgeon may need to cut through your flank muscles. He or she may also have removed one or more of your ribs. During surgery, your cut muscles and tissues were sutured back together internally before the incision was closed by stapling or stitching your skin. When you perform complex movements like getting into and out of bed, these muscles may hurt, strain against their internal sutures, and prevent the freedom of motion that you are used to. When the muscles are healed, you’ll feel much better. Despite any discomfort, get out of bed and walk. It’s good for you.

About 3 or 4 days after surgery, you may get some solid food to eat. You will rejoice! Take care to eat well. Your body will be rebuilding muscles and other tissues. Good nourishment will help the healing process.

Going Home About 1 week — or even less — after surgery, the surgical staples or sutures will be removed from your incision. This removal does not hurt. The incision will be lightly bandaged. You will be discharged and sent home to recover. You will still be taking medications to relieve pain and a prescription sleeping medication to help you sleep at night. You will still find it difficult to get into and out of bed by yourself because your back muscles are still healing. You may find it most comfortable to sit in a soft chair or even sleep in a chair, preferably one with strong arms so you can help yourself into and out of it.

It is a good idea to get some walking exercise every day. You won’t be able to do any physical work or lift much weight. Take advantage of this time to relax. There isn’t much you can do to speed up the healing process, so don’t aggravate yourself. One word of caution — a real belly laugh can hurt, so be careful of funny movies and excessive humor.

Depending on the type of dressing used to bandage the incision, you may be able to take a shower. If a shower is not possible, take regular sponge baths. Try to take good care of yourself. It will make you feel better.

Your surgeon will probably want you to visit his or her office about 2 weeks after going home. The purpose of this visit is to check the healing of your incision, follow up for complications, conduct blood and urine tests, and check your general health. If you are having any problems or feel something isn’t going right, be sure to discuss these concerns with your doctor.

After about 3 weeks, you may return to work with your doctor’s permission if you are feeling up to it. But you still need to take things slow and easy. It takes a full 3 months for your muscles to heal and for you to regain your strength.

About 2 months after your surgery, you can start doing more exercises. Build up to the level of exercise that effectively works different muscles but is still comfortable for you. Exercise will help restore your muscle tone and your energy level.

The recovery process described above is typical for open radical nephrectomies. With the newer laparoscopic procedures, recovery times may be considerably shorter. For example, in one study, 24 patients experienced a 64% more rapid return to normal non-strenuous activity after laparoscopic surgery than with open surgery. It’s always a good idea to ask your doctor’s advice before resuming exercise after surgery. Your doctor may have a procedure that is different from other doctors — and it may be dependent on the extent of your surgery.

Prognosis The good news is that survival rates for kidney cancer have improved, as they have for all types of cancer. The probability of long-term survival depends on a combination of factors, particularly the spread of the tumor as defined by stage. About half of all patients have localized disease (Stage I or II) and have a good prognosis for long-term survival.

Survival is also determined by the grade level of your tumor, TNM stage and performance status. The grade refers to how closely the cancer cells look like normal kidney cells. Tumor grade is defined by the size and density of cancer cell nuclei, as judged by pathologic microscopic evaluation. Renal cell cancers are graded on a scale of 1 through 4. More information about the grading and staging of kidney cancer can be found in Chapter 2 of this book.

Grade 1 cells are most like normal cells. They often grow slowly, and patients with grade 1 cells generally have a good prognosis. At the other extreme, grade 4 cells are very different from normal cells. They are more invasive and more likely to metastasize. As tumor spread increases, so does the probability of lymph node involvement and the chance that malignant cells will be carried to other parts of the body.

Despite the statistical research on survival, be careful not to generalize from average survival summaries to your own case. Survival statistics vary from study to study. Many survival studies have used small samples so the results may not be applicable to larger patient populations. Moreover, no kidney cancer case is average. Every case is unique. These facts cannot be emphasized too much.

Your probability of long-term survival will depend on the stage and the type of tumor, your age and physical condition, what follow-up and treatment you receive after your nephrectomy, and a host of other factors. You should discuss your survival prognosis with your doctor, because he or she is most familiar with the unique medical characteristics of your case. But don’t be surprised if your doctor is reluctant to give you an exact answer. Your doctor is aware of the many variables that can affect survival and knows that there is no precise answer.

You should also keep this last thought in mind: the longer you survive, with or without disease, the better your chances of receiving a new, more effective treatment. Significant advances have been made in the past 2 decades and much exciting research is being done at this very moment. The longer you stay alive, the more benefit you may get from this research.

Medical Follow-Up After nephrectomy, you should have frequent medical check-ups. How often and what tests are scheduled will be determined by your doctor based on your situation at the time of diagnosis, the pathology of your particular tumor, and other factors. Your doctor may schedule regular diagnostic tests. If after a period of several years no more cancer is evident, your doctor may decide to reduce the frequency of these tests.

Just as the stage of your cancer (I, II, III or IV) helps determine the treatment options that will be considered by your health care team, it also affects the follow-up care that you will receive following your initial treatment.

In general, the higher your stage of cancer at the time of initial treatment, the more aggressive your follow-up care will be. The frequency of doctor visits, for example, will be higher for Stage III patients than it is for Stage I patients. Follow-up procedures may also be more intense; for example, a simple chest x-ray may suffice as a check up for early-stage patients, but a CT scan may be necessary for later-stage patients.

Often Stage I and II patients receive no other treatment than close follow-up care. Patients with Stage III disease may be treated with more aggressive follow-up that includes some form of additional treatment – known as adjuvant therapy (see below). Patients with Stage IV disease are almost always treated with aggressive follow-up that includes some form of additional treatment.

During your follow-up period, you should watch for the unique signs and symptoms that occurred when you first noticed the disease. For some people, certain symptoms or blood test abnormalities may be useful indicators of recurrent disease.

You should also keep a journal of your aches and pains and any other physical ailments you experience. Bring your journal to your check-ups. If you experience any unusual pains or symptoms between check-ups, call your doctor. If something is wrong, you will get help sooner. If nothing is wrong, you will have peace of mind after talking to your doctor. Even if your prognosis is excellent, you and your doctor should be vigilant. If any metastases occur, you want to catch the problem early and treat it promptly because immediate attention will prolong your survival.

Things to Look for Between Check-ups Your doctor does not work alone in keeping you healthy. He or she relies on you to discuss any problems you have. If you experience any of the following problems, be sure to call them to your doctor’s attention: weight loss, loss of appetite, weakness, headache, changes in your mental status, fevers or high temperature, abdominal or skeletal pain, cough, shortness of breath, enlarged lymph glands, or blood in your urine. Be careful. Do not dismiss symptoms of illness as unimportant. Your doctor will not criticize you for being cautious.

Treatment of Metastatic Disease

If there is no evidence of metastases after your nephrectomy, your doctor may decide, based on current medical information, that no additional treatment is necessary beyond medical check-ups. However, if you do fall into the category of “high risk” recurrence, you might require additional treatment – known as adjuvant therapy — after your nephrectomy. The most commonly used treatments for kidney cancer are immunotherapy, vaccine therapy, or target therapy. These treatments, though quite different from one another, will be part of a clinical trial since their effectiveness in preventing your disease from coming back is being studied.

Many patients ask about the use of radiation or chemotherapy as a treatment for their kidney cancer. It’s important to note that kidney cancer is not as responsive to these therapies as other forms of cancer are; thus radiation and chemotherapy are not used as primary treatment.

Summary

For most kidney cancer patients, nephrectomy will be a part of your recovery plan. This surgery is performed thousands of times every year and is quite safe and effective. New advances in surgical technique offer less invasive forms of the surgery and shorter hospital stays. If your cancer is treated by surgery early enough, complications are few and prognosis may be good. For patients with more advanced-stage cancer, additional treatment may be required; still, surgery remains the cornerstone of kidney cancer treatment.

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