In recent years, great progress has been made in the surgical treatment of kidney cancer. On the one hand, modern medical imaging technology has significantly increased the detection of early kidney cancer, which has led to the impact of kidney unit preserving surgery (including open surgery and laparoscopic surgery) on traditional radical kidney cancer surgery. On the other hand, the development of medical equipment and technology has led to the challenge of minimally invasive surgery for kidney cancer (including radiofrequency, microwave, high-energy focused ultrasound, cryoablation, intra-tissue irradiation, ethanol injection therapy, etc.) to nephrectomy surgery, which shows a broad application prospect. Qin Chao, Department of Urology, The First Affiliated Hospital of Nanjing Medical University
1 Radical nephrectomy is the most commonly used surgical procedure for kidney cancer and is the accepted gold standard of treatment. Robson has established the basic principles of this procedure, which requires that the kidney should be free outside the perinephric fascia and the fat capsule, kidney, lymphatic tissue, upper ureter and, if necessary, the ipsilateral adrenal gland should be removed in one piece; the blood vessels of the nephron should be ligated first; and the regional lymph nodes around the nephron should be cleared.
2 Nephrectomy with preservation of renal unit NSS mainly includes enucleation of renal tumor, partial nephrectomy, “bench surgery” + autologous kidney transplantation. Clinical studies in the past decade have confirmed that NSS is safe and effective for kidney cancer ≤4 cm. With the development of minimally invasive techniques, improved probe design and delivery systems, laparoscopic NSS is safe and clinically effective. There are also reports of successful nephrectomy or radiofrequency resection for kidney cancer, but the clinical outcomes of minimally invasive surgery are still controversial.
3 Laparoscopic radical nephrectomy The first case of laparoscopic nephrectomy by transabdominal route was reported by Clayman et al. at the University of Washington in 1991. Currently, laparoscopy is increasingly used for radical nephrectomy and has the tendency to partially replace open surgery. The advantages of laparoscopic surgery include small incision, minimal injury, low bleeding, rapid postoperative recovery, few comorbidities, short hospital stay, and no significant difference in recent tumor control rate compared with open surgery. The disadvantages are the need for general anesthesia, expensive instruments, complicated technique, long learning curve for proficiency, and long operation time in the initial stage. As the technique becomes more proficient, the operative time will be significantly shortened and the degree of complete resection can be exactly the same as that of open surgery.
4 Palliative or adjuvant nephrectomy With the development of modern immunology, biological therapy is considered to be the most promising therapy. Therefore, some scholars advocate palliative nephrectomy for advanced renal cancer, which can improve the efficacy of the next comprehensive treatment such as biological therapy, radiotherapy and chemotherapy through cytoreductive surgery; it can relieve the local symptoms of advanced renal cancer, such as bleeding, fever and pain; a small number of patients (1 /200) may have spontaneous regression of metastases (daughter tumors) after removal of the tumor kidney.
In conclusion, with the development of medical imaging technology, more and more asymptomatic renal cancer and early renal cancer will be detected; RN is still the most reliable standard procedure for renal cancer; NSS has become an elective procedure, but its efficacy needs to be tested in large randomized controlled studies and long-term postoperative follow-up; for local minimally invasive treatment, further research and improvement are needed.