288 CHAPTER 6 Urological neoplasia
Renal cell carcinoma: surgical treatment I
Surgery is the mainstay of treatment for RCC. Increases in diagnosis of smaller early-stage RCC and the concept of cytoreductive surgery for advanced disease has affected surgical treatment strategies of the disease, while the absolute reduction in mortality remains elusive.
Localized disease—radical nephrectomy
Open approach
This remains the gold-standard curative treatment of localized RCC, however, properly performed laparoscopic techniques are becoming the “new” standard at many centers. The aim is to excise the kidney with the perinephris (Gerota fascia), perhaps with ipsilateral adrenal gland (for tumors >5 cm, upper pole tumors, or with evidence of adrenal invasion) and regional nodes (controversial), removing all tumor with adequate surgical margins.
Surgical approach is usually transperitoneal (subcostal, midline), which provides good access to hilar and major vessels, or thoracoabdominal (for very large or T3c tumors). Smaller masses can be approached retroperitoneally through a flank incision.
Following renal mobilization, the ureter is divided. Ligation and division of the renal artery or arteries should ideally take place prior to ligation as well as division of the renal vein to prevent vascular swelling of the kidney. If present, excision of hilar or para-aortic or paracaval lymph nodes will improve pathological tumor staging (for adequate TNM classification at least 8 nodes are necessary, but nodes may not be easily identified).
Complications include mortality up to 2% from bleeding or embolism of tumor thrombus; and bowel, pancreatic, splenic, or pleural injury.
Laparoscopic approach
Well accepted for treating benign disease, this approach is becoming commonplace for larger renal masses as experience increases. Masses of up to 10–12 cm can usually be removed by this approach, with larger masses requiring advanced skills.
Approaches are either transperitoneal or retroperitoneal, using straight laparoscopic technique or hand-assisted laparoscopic technique.
The specimen should be removed whole in a bag through the hand port or similar-sized (7–8 cm) lower abdominal incision; morcellation interferes with complete pathologic evaluation.
Advantages over open surgery include less pain, reduced hospital stay, and quicker return to normal activity.
Morbidity is reported in 8–38% of cases, including pulmonary embolism. Long-term (10-year) results demonstrate similar outcomes for both laparoscopic and open techniques.
Localized disease—partial nephrectomy
Nephron-sparing surgery is the best option for multifocal, bilateral tumors, particularly if the patient has VHL syndrome or single functioning kidney
RENAL CELL CARCINOMA: SURGICAL TREATMENT I 289
when the prospect of renal replacement therapy looms. It has become acceptable to treat small (<4 cm) tumors, even with a normal contralateral kidney, unless the tumor is close to the pelvicaliceal or hilar vessels. Arteriography or three-dimensional CT/MRI reconstructions are helpful to the surgeon.
Open transperitoneal or flank approaches are used; laparoscopic partial nephrectomy is now standard at most U.S. centers. The renal artery is clamped and, if the procedure is expected to last >30 minutes, the kidney packed with crushed ice for open procedures. “Enucleation” of masses <4 cm with a rim of normal tissue is also acceptable.
Results of partial nephrectomy performed laparoscopically are comparable to those with open surgery and should be considered for patients with small peripheral lesions who otherwise meet the criteria for open partial nephrectomy.
Specific complications include failure of complete excision of the tumor(s) leading to local recurrence in up to 10% of cases, and urinary leak from the collecting system.
Postoperative follow-up
The aim is to detect local or distant recurrence (incidence is 7% for T1N0M0, 20% for T2N0M0, and 40% for T3N0M0) to permit additional treatment if indicated. After partial nephrectomy, concern will also focus on recurrence in the remnant kidney.
There is no consensus regarding the optimal regimen; typically, it includes stage-dependent 6-month clinical assessment and annual CT imaging of chest and abdomen for 3–10 years.
Localized disease—tumor ablation therapy
Given the relatively benign nature and progression of the small renal mass, the increase in detection of these smaller lesions of the kidney and the improvements in technological ablative therapies have become more frequently employed. These technologies include thermal ablation by heating (radiofrequency ablation, or RFA) and cryotherapy and may be accomplished by open, laparoscopic, or percutaneous approaches.
According to the AUA 2009 guidelines,1 “ongoing concerns include increased local recurrence rates when compared to surgical excision, controversy about radiographic parameters of success and difficulty with surgical salvage if required. Nevertheless, even in their current iteration, cryoablation and RFA represent valid treatment alternatives for many older patients or those with substantial comorbidities, presuming judicious patient selection and thorough patient counseling.”
In series reviewed to date, cryoablation is associated with a lower rate of incomplete ablation (4.8%) than RFA (14.2%).
Technologies that employ novel techniques (HIFU, radiosurgical ablation [“Cyberknife”, others]) and microwave and laser interstitial therapy remain investigational.
1 AUA Guidelines for Management of the Clinical Stage 1 Renal Mass. (2009). AUAnet.org.
290 CHAPTER 6 Urological neoplasia
Renal cell carcinoma: surgical treatment II
Localized RCC—lymphadenectomy
Lymph node involvement in RCC is a poor prognostic factor. Incidence ranges from 6% in T1–2 tumors, 46% in T3a, to 62–66% in higher-stage disease.
Lymphadenectomy at the time of nephrectomy may add prognostic information, especially if there is obvious lymphadenopathy, but therapeutic benefit remains unclear. Formal lymphadenectomy adds time and increases blood loss, while nodes are clear in about 95% of cases.
Localized RCC—treatment of local recurrence
Though uncommon, if there is local recurrence in the renal bed after radical nephrectomy, surgical excision remains the preferred treatment choice, provided there are no signs of distant disease. Local recurrence is more common after partial nephrectomy, where it can be treated by a further partial or total nephrectomy.
While radiation therapy can palliate distant metastasis, it is not considered to be effective in local recurrences.
Locally advanced RCC
Disease involving the IVC right atrium, liver, bowel, or posterior abdominal wall demands special surgical skills. In appropriate patients, an aggressive surgical approach involving a multidisciplinary surgical team to achieve negative margins appears to provide survival benefit.
Adjuvant treatment
Early studies suggested a role for preoperative RT, though recent studies have failed to show a survival benefit for either preor postoperative RT. It may retard growth of residual tumor after nephrectomy, but toxicity is high.
Randomized trials of adjuvant immunotherapy vs. observation alone and the use of the new tyrosine kinase inhibitors are ongoing for patients with large tumors, positive nodes, surgical margins, and venous invasion.
Metastatic RCC
Nephrectomy has long been indicated for palliation of symptoms (pain, hematuria) in patients with metastatic RCC (if inoperable, arterial embolization can be helpful).
A recent study demonstrated a median survival benefit of 10 months for patients with good performance status treated with cytoreductive nephrectomy prior to immunotherapy (interferon A-2B) and has further expanded the indications for surgery in RCC.1
Resection of solitary metastases is an option after nephrectomy and can extend survival.
1 Flanigan RC et al. (2001). Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med. 345(23):1655–1659.
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