Advanced kidney cancer is generally defined as having developed lung metastases, bone metastases, brain metastases, or distant metastases to organs such as the liver. For patients with advanced tumors, it was previously considered to be a systemic disease and primary site surgery was not performed. However, for advanced kidney cancer, it is possible to do subtractive surgery to cut out the primary foci of kidney tumor through subtractive surgery. Although radical cure cannot be achieved after surgery, it can improve the patient’s survival quality.
Which kidney cancer patients need to undergo subtractive surgery?
For most patients with metastatic kidney cancer, subtractive nephrectomy is only a palliative treatment and systemic therapy is essential. Subtractive nephrectomy not only maximizes tumor removal and improves quality of life, but also prolongs life expectancy. However, not all patients are suitable for surgical treatment, and a thorough evaluation of the patient by the clinician is required before a judgment can be made. Currently, subtractive nephrectomy is recommended for:
- patients in good physical status;
- patients with a large renal primary tumor but low metastatic load (not recommended for patients in poor physical status or at high risk, nor for patients with a relatively small primary site but high metastatic load);
- Patients with concomitant sarcomatoid differentiation.
What are the risks associated with tumor reduction surgery?
The risks to patients from subtractive nephrectomy are essentially the same as those from radical nephrectomy, primarily intraoperative and postoperative bleeding, so it is critical to do a good job of careful intraoperative separation and strict hemostasis. In addition, it is important to note:
- Patients with an underlying bleeding tendency and coagulation disorders should be excluded preoperatively.
- Patients with contralateral renal insufficiency are prone to acute renal insufficiency, so emphasis should be placed on enhancing the preoperative assessment of the patient’s renal function.
- The incidence of lymphatic fistula is not high and may be related to incomplete intraoperative ligation of the perinephric lymphatic vessels or re-dislodgement of the line nodes after ligation, especially in patients undergoing lymph node dissection; other complications such as peripheral organ injury, delayed incisional healing, and infection are the same as for other organs.
- The main risks of laparoscopic surgery are the same as those of open surgery, with attention to subcutaneous emphysema and hypercapnia associated with CO2 pneumoperitoneum, which can usually be prevented by careful handling and avoidance of prolonged surgery.
- Postoperative renal insufficiency is a more concerning risk because the vast majority of patients also require targeted drugs or novel immunotherapy postoperatively, many of which cannot be used without good renal function reserve.
It is also important to get patients to recover from the trauma of surgery and to receive follow-up systemic medications as soon as possible, and enteral nutrients can be given postoperatively to help the wound heal as quickly as possible.