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Primary surgery for kidney cancer


Medical editor Bjørn Brennhovd MD
Urologist
Oslo University Hospital

General

Primary treatment of kidney cancer is intended to radically remove the primary tumor. This is usually performed as a radical nephrectomy. In cases of small tumor, studies have shown that renal resection has a similar cure rate as nephrectomy.

Radical nephrectomy and renal resection can be performed as open surgery (transperineally or retroperitoneally) or laparoscopically. The method of access chosen will depend on the size of the tumor, stage, tumor thromboses in vessels, and metastases to retroperitoneal lymph nodes. The experience of the surgeon will also play a role.  

It is not documented whether the different modes of access influence the cure rate.

Goal

  • Curative treatment
  • Part of multimodal treatment of metastasizing kidney cancer

Indication

  • Malignant disease of the kidney(s).

Equipment

  • Abdominal surgery tray
  • Vessel forceps

Preparation

  • Antibiotic prophylaxis (occasionally)
  • Thrombosis prophylaxis

Implementation

Radical nephrectomy

The following organs and tissues are removed:

  • Perirenal fat tissue
  • Adrenal gland including periadrenal fat tissue in specific cases if CT shows proliferation to adrenal glands
  • Kidney and ureter with surrounding fat tissue down to the pelvic inle
  • Retroperitoneal fat tissue with lymph nodes in the renal hilum area if CT shows suspicion of spreading to lymph nodes

If there is clinical suspicion of lymph node metastases, the resected nodes should be examined by frozen sectioning technique. If metastases are confirmed, a lymph node dissection should be performed on the same side.

If tumor thromboses are present in the renal vein, the renal vein should be removed with a collar of the caval vein. If there is tumor thrombosis in the caval vein, the vein must be occluded above and below, opened, and the tumor thrombosis removed from the wall of the vein. If the tumor thrombosis stretches to the level of the crus, the procedure must be modified to a thoracoabdominal procedure.

Kidney resection

  • Dissect the renal vessels and clamp with forceps. 
  • Dissect the vessels of the hilum and identify them to the segment of the kidney supplying the tumor.
  • Ligate the relevant vessels.
  • Resect the kidney in the anemic border with good margins from the tumor. 
  • Ligate (possibly suture) the vessels and calyx on the surface of the wound.
  • Release blood flow and supply with additional hemostasis. 
  • Insert a drain if necessary.

Follow-up

Complications

Postoperative bleeding may occur. If there is no bleeding on the first postoperative day, the drain is removed.

Follow-up

If free resection margins are not present after the kidney resection, a nephrectomy must be performed.

If the final result from the pathologist shows metastases to retroperitoneal lymph nodes, the case should be discussed with an oncologist for multimodal treatment.


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