Surgery for Kidney Tumors

How is kidney cancer treated?

Treatment of kidney tumors depends on whether the tumor is large or a “small renal mass” (see section on “small renal mass”).

Large tumors generally require complete surgical removal of the kidney along with the tumor and surrounding tissue (radical nephrectomy). Systemic therapy (pills designed to kill kidney cancer, immunotherapy) is also administered in conjunction in patients with stage 4 disease (metastatic cancer). This often involves a medical oncologist physician.

There are several other strategies that can be employed for small renal masses and these will be discussed in the respective section.

Radiation is generally not used in the treatment of kidney cancer.

Large Renal Tumors

Radical nephrectomy

Radical nephrectomy involves complete surgical removal of the kidney, tumor, and surrounding fat. Sometimes the adrenal gland also has to be removed as well depending on the location of the tumor. Generally there is no consequence after removing a single adrenal gland (humans have 2 adrenal glands and only 1 is needed). Radical nephrectomy is usually performed in stage 2 or 3 kidney cancer (large tumors or locally advanced tumors). Unlike other cancers, where the organ of origin is not removed in patients who have stage 4 metastatic cancer (cancer that has already spread), radical nephrectomy is often performed in patients with stage 4 kidney cancer. Such patients often have a better response to systemic therapy (targeted therapy, immunotherapy) after removal of the primary tumor.

In patients who have normal or reasonable kidney function, removal of a single kidney does not cause chronic kidney failure and does not result in dialysis.

Patients with medical conditions that can predispose to or cause chronic kidney disease (diabetes, high blood pressure, high cholesterol, obesity, smoking) are at risk of accelerated kidney function decline after radical nephrectomy and should work diligently with their family physician to ensure that these risk factors are optimized with medication, diet, etc. Your family physician or urologist may refer you a nephrologist (kidney function specialist) in such instances for additional advice.

How is radical nephrectomy performed?

Radical nephrectomy can be performed with the traditional open approach (via a large incision either in the abdomen or the flank) or via a minimally invasive approach. Minimally invasive surgery is often called “key hole surgery” but the correct term is laparoscopic surgery or MIS surgery.

During laparoscopic radical nephrectomy, a camera is used to visualize the abdominal contents through a small incision, and instruments are introduced through 2-3 additional small incisions (non larger than 1-2cm). The instruments are used to the free the kidney from the surrounding structures, and once the kidney is completely freed, a separate incision (usually about 10cm) is made in the lower abdomen to extract the kidney. The extraction incision is much smaller and in a location that is much less painful, than the standard incision used in open surgery.

The advantage of laparascopic surgery is less post operative pain, quicker recovery, less blood loss, better cosmetics, and shorter hospital stay.

How does my surgeon decide between open or laparoscopic nephrectomy?

This decision depends on many factors including size, location, and extent of the tumor, previous abdominal surgeries, and factors related to your general medical condition.

The cancer control between open and laparoscopic surgery is equivalent.

What should I expect before and after laparoscopic radical nephrectomy?

Laparoscopic radical nephrectomy generally takes 2-3 hours. A general anesthetic is required. You will be seen by anesthesiology and sometimes and internist before surgery to ensure your heart and lungs are healthy enough for anesthesia and surgery.

After laparoscopic kidney removal you will spend 1 or 2 nights in hospital. You can eat a solid diet usually within 24 hours but you should start slow with small meals that are not too rich and heavy. You can get out of bed and walk the morning after surgery (can often sit up in your bed, sit in a chair immediately after surgery).

You will be discharged home with a prescription for pain medication. These are often necessary for the first few days only. Most prescription pain medication can be constipating so rather than taking these a good strategy is to use plain Tylenol/acetaminophen (325mg) 1 or 2 tablets every 4 hours AND regular strength Advil/ibuprofen 200mg every 8 hours regularly or as needed. If this is not enough, you may use your prescription pain medication instead.

Prescription pain medications often contains tylenol/acetaminophen as well, so if you are taking these, do not take regular Tylenol in addition. Ask your pharmacist if you are not sure.

To prevent constipation while taking prescription pain medication, make sure you drink plenty of water, and use prune juice or over the counter stool softeners or Metamucil regularly while you are using the pain medication.

After major abdominal surgery, it is often normal not to have a bowel movement for 2-3 days after surgery. If you feel constipated or have not had a bowel movement within 3 days, please use the above strategies, stop prescription pain medication if your pain permits, and consult your surgeon if the above measures are not effective.

A good over the counter stool softener is “PEG 3350.” The brand name varies so ask your pharmacist to point you in the right direction. Take 1 scoop per day (dissolved in water) and drink plenty of water throughout the day (8 glasses). You may continue 1 scoop/day until you have had a soft bowel movement.

DO NOT lie in bed all day after discharge from hospital. Move around your house and go for short walks every day. Inactivity will slow your recovery and increase the risk of blood clots in your legs.

DO NOT lift anything over 15 pounds, do sit-ups or pull-ups, or do strenuous exercise for 6 weeks after surgery. You could develop a hernia at incision if you are not compliant with this recommendation.

The incisions are generally closed with dissolvable sutures, which are hidden under the skin. These are covered with thin strips of tape called “steri strips” and the larger extraction incision is subsequently covered with a large white dressing. The smaller incisions usually only have steri strips. You may shower 72 hours after surgery. Simply peel the white dressing off before you shower and leave the steri strips on the incisions. These can get wet and there is no need to cover them. The steri strips will eventually fall off after a few days or can be peeled off after 7-10 days.

Sometimes your surgeon may use “dermabond” instread of steri strips. This is a see through waterproof glue that is applied to the incision. In this case, simply peel off the white dressing and shower comfortably.

Try not to take a bathe or use public pool/hot tub for 2 weeks.

You should consult your surgeon or go to the emergency room if you have/develop the following

Fever over 38 degrees Celsius (do not routinely check your temperature after surgery, rather only if you feel unwell/have chills)
Significant redness around or discharge from your incision (a small amount of “ooze” or bloody discharge for the first 24-48 hrs is normal)
Vomiting
Asymmetric swelling of your lower leg or calf muscle with or without pain (this could be a sign of blood clot)
Chest pain or shortness of breath
Inability to urinate

What should I expect after open radical nephrectomy?

Recovery and post-operative precautions are similar to laparoscopic nephrectomy, except with a longer stay in hospital and slower recovery at home.

Your anesthesiologist will sometimes discuss placement of an epidural catheter with you. This is often placed in the operating room before you go to sleep. It consists of a small catheter placed in the space around the spinal cord and is used to administer pain medication continuously after surgery to keep you more comfortable. This is often removed in the first 48 hours after surgery.

After open surgery, stay in hospital is generally 3-5 days.

Please refer to “What should I expect before and after laparoscopic radical nephrectomy?” for all post operative instructions.

What are the complications of radical nephrectomy?

Lung and heart complications (ie. Pneumonia, heart attack) which is inherent to every major surgery
Blood clots in legs and lungs (inherent to major surgery)
Wound complications (infection, hernia)
Bleeding requiring blood transfusion
Injury to other organs:
- Lung
- Liver
- Spleen
- Pancreas
- Bowel
If laparoscopic surgery is being performed there is a possibility (1-2%) that the surgery has to be converted to an open approach due to intraoperative difficulty
Long term risk of chronic kidney disease (more prevalent in patients with already compromised kidney function, obesity, diabetes, high blood pressure)

Partial Nephrectomy

What is partial nephrectomy?

Partial nephrectomy is surgical removal of the tumor and a small amount of surrounding healthy kidney tissue and preserving as much of the kidney as possible. The alternative is radical nephrectomy, which is complete removal of the kidney and the tumor (see section on “radical nephrectomy”)

What is the rationale for partial nephrectomy?

The goal is to save as much kidney function as possible without compromising cancer care. There is excellent date to show that there is no difference in cancer control between radical and partial nephrectomy in tumors <4-5cm.

Data also shows that patients who undergo partial nephrectomy have better post-operative kidney function and are less likely to develop advanced chronic kidney disease in the long run.

Therefore, partial nephrectomy is the ideal surgical treatment for small renal masses (<4-5cm).

In certain cases, because of the location of the tumor and proximity to vital structures in the kidney (blood vessels, ureter) a partial nephrectomy may not be possible.

Partial nephrectomy may sometimes be performed in well selected patients with tumors >4-5cm. Your surgeon/urologist will discuss this with you if appropriate.

How is laparoscopic partial nephrectomy performed?

Partial nephrectomy is generally performed via a minimally invasive approach. Minimally invasive surgery is often called “key hole surgery” but the correct medical term is laparascopic surgery or MIS surgery.

Laparoscopic partial nephrectomy is performed under a general anesthetic. You will be seen by anesthesiology and sometimes and internist before surgery to ensure your heart and lungs are healthy enough for anesthesia and surgery.

Surgery generally lasts 3 hours.

Using 4-5 small incisions (<2cm), a camera and small instruments are introduced into the abdomen. The kidney is exposed and the fat on the kidney is removed to expose the tumor. The main blood vessels to the kidney are identified and controlled. The blood vessels are clamped to stop blood flow to the kidney, the tumor is cut out, and the defect is reconstructed with sutures. Once the kidney is reconstructed, the blood flow to the kidney is re-established.

The surgeon’s goal is to minimize the amount of time that the blood supply to the kidney is disrupted, because if this is excessively prolonged, irreversible kidney damage can occur. However, current data shows that the most important factor in preservation of kidney function, is the amount of healthy kidney that is removed.

The tumor is subsequently extracted through one of the small incisions.

A surgical drain is often placed and removed before you are discharged home.

How is open partial nephrectomy performed?

Tumor removal and kidney reconstruction is technically much easier via the traditional open versus the laparoscopic approach. Therefore in highly complex tumor (depending on size, depth, and location) your surgeon may suggest an open partial nephrectomy via flank or abdominal incision.

The surgical steps are identical to laparoscopic partial nephrectomy.

The main disadvantage is longer post-operative stay, longer recovery, and more post-operative pain.

What are the complications of partial nephrectomy?

Although the cancer control is equivalent and the preservation of renal function is superior, data shows that partial nephrectomy has a higher incidence of complications that radical nephrectomy.

In radical nephrectomy the entire kidney is removed and for lack of a better term, is no longer in the body to cause problems. Complications unique to partial nephrectomy occur when the reconstructed kidney bleeds etc.

Complications include:

Excessive bleeding from the reconstructed kidney – this can occur during surgery or early after surgery. Blood transfusion rates are higher than radical nephrectomy, but overall still quite low. Delayed bleeding from the reconstructed kidney can occur as late as even a few weeks after surgery. Patients present with delayed pain, blood in the urine with clots. Angiography is sometimes needed to stop the bleeding.
Urine leak
Small chance of renal loss – rarely a partial nephrectomy cannot be completed due to complexity in reconstructing a kidney, and the entire kidney will have to be removed
Lung and heart complications (ie. Pneumonia, heart attack) which is inherent to every major surgery
Blood clots in legs and lungs (inherent to major surgery)
Wound complications (infection, hernia)
Injury to other organs
- Lung
- Liver
- Spleen
- Pancreas
- Bowel
If laparoscopic surgery is being performed there is a possibility (1-2%) that the surgery has to be converted to an open approach due to intraoperative difficulty

What should I expect before and after laparoscopic partial nephrectomy?

You spend generally 2 nights in hospital. You can eat a solid diet usually within 24 hours but you should start slow with small meals that are not too rich and heavy. You can get out of bed and walk the morning after surgery.

You will have a catheter draining your bladder. This is usually removed the morning or afternoon after surgery once you are mobilizing. Your surgical drain will be removed usually on the day of discharge if the outputs are low.

Prescription pain medications often contains tylenol/acetaminophen as well, so if you are taking these, do not take regular Tylenol in addition. Ask your pharmacist if you are not sure.

DO NOT lie in bed all day after discharge from hospital. Move around your house and go for short walks every day. Inactivity will slow your recovery and increase the risk of blood clots in your legs.

DO NOT life anything over 15 pounds, do sit-ups or pull-ups, or do strenuous exercise for 6 weeks after surgery. You could develop a hernia at incision if you are not compliant with this recommendation.

Try not to take a bathe or use public pool/hot tub for 2 weeks.

You should consult your surgeon or go to the emergency room if you have/develop the following

A lot of blood in the urine/blood clots – blood in the urine immediately after surgery while you are in hospital is ok, but it is not normal for you to develop blood in the urine (especially with clots) several days to weeks after surgery
Significant abdominal or flank pain
Fever over 38 degrees Celsius (do not routinely check your temperature after surgery, rather only if you feel unwell/have chills)
Significant redness around or discharge from your incision (a small amount of “ooze” or bloody discharge for the first 24-48 hrs is normal)
Vomiting
Asymmetric swelling of your lower leg or calf muscle with or without pain (this could be a sign of blood clot)
Chest pain or shortness of breath
Inability to urinate

What should I expect after open partial nephrectomy?

Recovery and post-operative precautions are similar to laparoscopic partial nephrectomy, except with a longer stay in hospital and slower recovery at home.

After open surgery, stay in hospital is generally 3-5 days.

Please refer to “What should I expect before and after laparoscopic partial nephrectomy?” for all post operative instructions.