Kidney cancer is potentially curable with surgery, with partial nephrectomy being an option for early-stage patients, and if partial resection is not appropriate, “radical nephrectomy” is usually preferred, which includes the kidney, perinephric fat, perinephric fascia, ipsilateral adrenal glands, upper ureter, and adjacent regional lymph nodes.
What should be done to prepare for the procedure?
The following tests are usually required before undergoing radical nephrectomy:
- Phlebotomy: To find out whether the general condition of the body can tolerate the procedure.
- Electrocardiogram and chest radiograph: to understand whether there are any lesions in the heart and lungs and to exclude contraindications to surgery.
- CT or MRI scan: to understand the location and size of the kidney tumor and to develop a surgical strategy. If you have already had a clear CT or MRI scan at another hospital, bring the film with you to your appointment and you may not have to repeat the test.
Preoperative preparation:
- With the exception of a small number of large tumors that require bowel preparation (“bowel cleansing”), most patients will be fine with 2 opioid plugs the night before surgery;
- Eat and drink normally the day before surgery, but do not eat or drink after 10 pm;
- No food or water on the morning of surgery, but patients with hypertension need to take antihypertensive medication (with a sip of water) first thing in the morning;
- Patients with high blood pressure need to take antihypertensive medication first thing in the morning.
- Patients for the first surgery are brought to the operating room at approximately 7:00 am (based on clinical practice in the Department of Urology at Fudan Cancer Hospital), and thereafter when the patient will be operated depends on the speed of the previous surgery, and no specific time can be predicted;
- On the day of surgery, no food or water can be consumed while waiting for surgery, and the physician will maintain the patient’s energy requirements through fluid infusion.
How is the surgery performed? How long does it take?
In the past, radical nephrectomy involved removal of one kidney, perinephric fat, perinephric fascia, ipsilateral adrenal gland, upper ureter, and adjacent regional lymph nodes. In the last 20 years, the extent of resection has been gradually reduced. If the tumor does not directly invade the adrenal glands, the adrenal glands are generally not removed; and regional lymph node dissection is considered only if the lymph nodes are significantly enlarged.
The overall duration of the procedure was approximately 1 to 2 hours.
Choose open surgery, or laparoscopic/robotic surgery?
Theoretically, compared with open surgery, laparoscopic surgery shortens the time of visceral exposure, is gentle, and does not strongly squeeze the kidney and surrounding organs, which can reduce the disturbance of the internal environment. At the same time, the laparoscopic field of view is good and can be magnified to improve the precision of operation. The surgical incision is small, the intercostal nerve is not easily damaged, and the postoperative pain is mild, enabling earlier bedtime activities.
Laparoscopic/robotic surgery has the same efficacy as open surgery and has the advantages of less bleeding, shorter hospital stay, faster recovery, and fewer complications. Therefore, laparoscopic/robotic surgery is recommended when conditions allow. If the technical conditions are limited, the tumor is too large, or the intra-abdominal adhesions are severe, etc., open surgery is still preferable.
Does preoperative renal artery embolization need to be done?
Usually not, but if the tumor is large (diameter >10 cm), prior renal artery embolization can result in significant tumor shrinkage, disappearance of renal artery pulsation, atrophy of the surface veins of the tumor, edema of the surrounding tissues, easy separation, significant reduction in bleeding, shorter operative time, safer and easier, and much higher resection rate.
Do I need to remove the adrenal gland at the same time?
If the tumor invades the adjacent ipsilateral adrenal gland, it needs to be removed; if the tumor is confined to the interior of the kidney, the adrenal gland does not need to be removed.
Do I need to do a lymph node dissection?
Lymph node metastasis in kidney cancer is unpredictable, and metastatic lymph nodes may be located around the kidney, along the aorta and around the inferior vena cava, or involve the mediastinal and pelvic lymph nodes. In most patients, it is not necessary to remove all of these lymph nodes, but only those that are suspicious. For enlarged lymph nodes around the kidney, they are usually removed during surgery along with the tumor.
Do I need a kidney transplant after total kidney resection?
Usually, as long as one functioning kidney is preserved, even if the other kidney is completely removed, it is “enough” and a kidney transplant is not needed. This is because there are 2 million kidney units in each person, and under normal circumstances, as few as 500,000 kidney units are working properly to maintain metabolism.
Of course, it is important to protect the function of the remaining kidneys after surgery and to avoid drugs that are damaging to the kidneys if possible. A small percentage of patients may have slightly higher-than-normal blood creatinine after surgery, but it usually does not affect the body’s physiologic metabolism either.
What are the risks of surgery? How can these risks be reduced?
There are risks associated with any surgery, both in terms of what the doctor does and the patient’s body type. In fact, the surgeon will operate carefully and cautiously to minimize the risks as much as possible, and if they do occur, they can also be effectively remedied and recovered if they are identified and addressed in a timely manner.
The main risks of radical nephrectomy are:
- Intraoperative and postoperative bleeding, for which the surgeon will carefully exclude patients with bleeding tendencies and coagulation disorders preoperatively, and will carefully separate and strictly stop the bleeding intraoperatively.
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Acute renal insufficiency, which usually occurs in patients with contralateral renal insufficiency, for which the surgeon will perform a preoperative renal function assessment;
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Lymphatic fistula, which is often caused by incomplete ligation of the lymphatic vessels or dislodgement of the line nodes during lymph node dissection, has a low incidence.
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Other: peripheral organ injury, delayed incisional healing, infection, etc.
- The main risks of laparoscopic surgery are the same as those of open surgery, except that preoperative filling of the abdominal cavity with carbon dioxide may cause subcutaneous emphysema and hypercapnia, for which the surgeon operates carefully and tries to avoid prolonging the procedure.