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 the tumor, the 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
The treatment of many 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.
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.
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 two 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 cancer. However, a partial nephrectomy can often achieve the same results in patients with smaller cancers.
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.
Laparoscopy and Kidney Cancer
Although open radical or partial nephrectomies performed through a typical surgical incision have been the most common surgical techniques used to remove a diseased kidney, Less invasive surgical techniques have been developed and are frequently used. These “minimally invasive surgeries,” 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 results as previous traditional surgical techniques.
Laparoscopic radical or partial nephrectomy can result in decreased blood loss, a shorter hospital stays, less need for narcotic pain medication and shorter recovery time when compared with open radical nephrectomies.
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 remain 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.
Your Tumor Tissue
The removed tissue from your tumor 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 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. 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 have questions and concerns. Be sure to discuss these with your doctor. 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.
The Day before Surgery
Your surgeon will provide you instructions for dietary restrictions such as clear liquids and bowel cleansing (enema or liquid to drink). This is based on the type of surgery and the surgeon’s preference.
You will receive instructions from the anesthesiologist on dietary and medication restrictions allowed on the morning of your surgery.
The Day of 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 during your recovery from surgery. The techniques used for pain control will be discussed prior to surgery.
You will be transported into the operating room and the anesthesiologist will put you to sleep. The surgery will begin.
After the surgeon has completed the procedure and the incision is closed and a dressing is applied. 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.
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, or you will be transferred to your room to begin your recovery.
After Surgery Recovery in the Hospital
Your time in the hospital depends mainly on the type of surgery performed.
Laparoscopic Nephrectomy 1-2 days
Partial Nephrectomy 4-5 days
Radical Nephrectomy 5-7 days
It will be important to get out of bed to prevent blood clots, wake up your bowels, and prevent pneumonia. Walking is very important in your recovery. The medical staff will assist you with getting out of bed to sit up in the chair and to walk several times a day.
Your dressing will be removed within 24 hours after surgery and you will be able to shower. Once your bowels wake up (passing of gas), you will be allowed to start drinking fluids, and slowly start to eat solid food.
Discharge from the Hospital
When discharged from the hospital, you will be provided with pain medication and stool softeners. Your medical team will provide you with instructions regarding any restrictions on activity, diet, etc. It is important to follow what the medical team advises.
Recovery will take about 4-8 weeks, depending on the type of surgery and the individual patient.
A post-operative appointment will be scheduled per the Physician’s preference.
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.