Surgery for Kidney Cancer

Surgery is often part of the main treatment for kidney cancer. Sometimes it might be the only treatment that’s needed, especially for cancers that are still only in the kidney.

Types of surgery for kidney cancer

Depending on the stage and location of the cancer and other factors, different types of surgery might be done.

• For tumors in the kidney, surgery might be done to remove the entire kidney (known as a radical nephrectomy) or the just the part of the kidney with the tumor (known as a partial nephrectomy).
• Sometimes, nearby lymph nodes might also be removed (known as a lymphadenectomy).
• If the cancer has spread (metastasized), sometimes surgery might be an option to remove the tumor(s) in another part of the body.

Some people whose cancer has spread to other organs may be helped by surgery to take out the kidney tumor. This might also help with symptoms such as pain or bleeding.

Radical nephrectomy

In this operation, the surgeon removes the kidney, the fatty tissue and Gerota’s fascia around the kidney, and some nearby lymph nodes. Sometimes the adrenal gland on top of the kidney is removed as well, especially if there’s a high risk of the cancer spreading there (such as if there’s a larger tumor in the upper part of the kidney).

Open radical nephrectomy

This operation is done through a single, long incision in the skin to reach the kidney.

The surgeon can make the incision in several places. The most common places are the middle of the abdomen (belly), under the ribs on the same side as the cancer, or in the back, just behind the kidney. Each approach has its benefits in treating cancers of different sizes and in different parts of the kidney.

If the tumor has grown from the kidney through the renal vein (the vein leading away from the kidney) and into the inferior vena cava (the large vein that carries blood from the lower part of the body back up to the heart), the heart may need to be stopped for a short time in order to remove the tumor. The patient is put on cardiopulmonary bypass (a heart-lung machine) that circulates their blood while bypassing their heart. If you need this, a heart surgeon will work with your urologist during your operation.

Laparoscopic nephrectomy and robotic-assisted laparoscopic nephrectomy

These operations are done through several small incisions instead of one large one. If a radical nephrectomy is needed, many doctors and patients now prefer to use these methods when they can be done.

Laparoscopic nephrectomy: For this approach, the surgeon inserts special long, thin instruments through the small incisions to remove the kidney. One of the instruments is a laparoscope, which is a long tube with a small video camera on the end. This lets the surgeon see inside the abdomen. Usually, one of the incisions has to be made longer toward the end of the operation to remove the kidney (although it’s not as long as the incision for an open radical nephrectomy).

Robotic-assisted laparoscopic nephrectomy: In this approach, the surgeon sits at a panel near the operating table and controls robotic arms with long, thin surgical instruments on the ends. The robotic system lets the surgeon move the instruments more easily and with more precision than during standard laparoscopic surgery.

Both types of laparoscopic surgery are complex and take time for surgeons to learn. If you are considering either type of laparoscopic surgery, be sure to find a surgeon with a lot of experience.

In experienced hands, either type of laparoscopic nephrectomy is about as effective as an open radical nephrectomy. The main benefits of these approaches are that they usually result in a shorter hospital stay, a faster recovery time, and less pain after surgery. However, the laparoscopic approach may not be a good option for larger tumors or for tumors that have grown into the renal vein or spread to lymph nodes around the kidney.

Partial nephrectomy (nephron-sparing surgery)

In a partial nephrectomy, the surgeon removes only the part of the kidney that contains the cancer, leaving the rest of the kidney in place. The benefit of this approach is that the person keeps more kidney function. Studies have shown the long-term results from partial nephrectomy are about the same as when the whole kidney is removed.

For people with early-stage kidney cancer, a partial nephrectomy might be a good option if:

• The kidney tumor is smaller – usually less than about 10 centimeters (about 4 inches) across, and it isn’t in the central part of the kidney.
• A person already has (or is likely to have) reduced kidney function, for example if they only have one working kidney, if they have tumors in both kidneys, if they’re at risk for some type of chronic kidney disease, or if they have an inherited condition that increases their risk of more kidney tumors later on.

A partial nephrectomy might not be an option if:

• The tumor is very large.
• The tumor is in the central part of the kidney.
• There is more than one tumor in the same kidney.
• The tumor has reached the renal vein or inferior vena cava, or the cancer has spread to the lymph nodes or distant organs.

Partial nephrectomy typically is a more complex operation than a radical nephrectomy, so it should only be done by a doctor with experience.

As with a radical nephrectomy, this operation can be done in different ways.

Open partial nephrectomy

For an open partial nephrectomy, the surgeon operates through one long incision in the skin. The surgeon can make the incision in several places, depending on factors like the location of the tumor.

Laparoscopic partial nephrectomy and robotic-assisted laparoscopic partial nephrectomy

These operations are done through several small incisions instead of one large one.

Laparoscopic partial nephrectomy: For this approach, the surgeon inserts special long, thin instruments through the small incisions to remove the kidney. One of the instruments is a laparoscope, which is a long tube with a small video camera on the end that lets the surgeon see inside the abdomen.

Robotic-assisted laparoscopic partial nephrectomy:  In this approach, the surgeon sits at a panel near the operating table and controls robotic arms with long, thin surgical instruments on the ends. The surgeon can move the instruments more easily and with more precision than during standard laparoscopic surgery.

Done by an experienced surgeon, either type of laparoscopic partial nephrectomy is about as effective as an open partial nephrectomy. The main benefits of these approaches are that they usually result in a shorter hospital stay, a faster recovery time, and less pain after surgery.

However, both types of laparoscopic partial nephrectomy are complicated operations, and the laparoscopic approach may not be a good option for more complex kidney tumors.

It also takes time for surgeons to learn how to do these operations. If you are considering either type of laparoscopic surgery, be sure to find a surgeon with experience.

Lymphadenectomy (lymph node removal)

In this procedure, the surgeon removes nearby lymph nodes to see if they contain cancer. Some lymph nodes near the kidney are often removed as part of a radical nephrectomy.

A more extensive lymphadenectomy in which more lymph nodes are removed (known as a lymph node dissection) may be done if the tumor has features suggesting it is at high risk of spreading to the nodes, such as if it has a higher grade. Lymph nodes are also removed if they look enlarged on imaging tests or feel abnormal during the operation.

Some doctors might also remove these lymph nodes to check them for cancer spread even when they aren’t enlarged, to help better stage the cancer. This might affect whether a person should get further (adjuvant) treatment after surgery.

Removal of metastases

In some people with kidney cancer, the cancer has already spread (metastasized) to other parts of the body by the time it’s found. The most common sites of spread are the lungs, lymph nodes, bones, and liver. For some people, surgery to remove these tumors may still be helpful.

Attempting a surgical cure

If the cancer has spread to very few spots outside the kidney that can all be removed safely, surgery to remove these tumors may lead to long-term survival in some people.

The metastasis may be removed at the same time as a radical nephrectomy or later if the cancer recurs (comes back).

Surgery to relieve symptoms (palliative surgery)

If other treatments are no longer helpful, surgery might be done to help relieve pain or other symptoms caused by tumors, although this type of surgery isn’t intended to cure the cancer.

Risks and side effects of surgery

The short-term risks of any type of surgery include reactions to anesthesia, bleeding (which might require blood transfusions), blood clots, and infections. Most people will have at least some pain after the operation, which can usually be helped with pain medicines, if needed.

Other possible risks of surgery include:

• Damage to organs and blood vessels (such as the spleen, pancreas, aorta, vena cava, or large or small bowel) during surgery
• Pneumothorax (unwanted air in the chest space around the lungs)
• Incisional hernia (bulging of internal organs near the surgical incision due to problems with wound healing)
• Leakage of urine into the abdomen (after partial nephrectomy)
• Kidney failure (if the remaining kidney fails to function well)

Ask your doctor what to expect after surgery. You might want to ask about your recovery time, if there are any limits on what you can do, common side effects to watch out for, and when you should contact someone on your cancer care team if you’re having problems.