Multidisciplinary Team
There are a variety of surgical procedures and approaches used to remove the kidney, and the specialist multidisciplinary team (MDT) meeting is the forum in which the most appropriate will be recommended, taking into account all factors of a renal tumour in a particular patient.
The aim will be to offer the patient the operation that will maximise curative intent, while using the least invasive route, thereby optimising post-operative recovery.
The MDT will assess the size of tumour, its site in relation to the renal hilum, and identify extra-renal spread or evidence of lymph node involvement. This information will be provided by the specialist radiologist’s interpretation of the computerised tomography (CT) scan. A discussion regarding any co-morbidities, patient habitus and other determining factors will be undertaken with surgeons, pathologists, oncologists, clinical nurse specialists (CNSs) and other members of the MDT, in order that the most appropriate operation is selected for each individual patient.
In the UK, the National Institute for Health and Care Excellence (NICE) published guidance in 2002 on the management of urological cancers. This guidance suggests that 80% of renal cancers can be managed locally, but that certain patients would benefit from treatment at a specialist centre where the higher number of procedures performed annually ensures maintenance and development of techniques and skills to deal with complex cases. Operations that may need to be undertaken at such specialist centres include those in patients with evidence of;
- Renal vein or inferior vena cava (IVC) involvement (5%); a cardiac surgeon may need to perform a cardiac by-pass
- Solitary kidney
- Bilateral disease
- Resection of metastases
- Von Hippel-Lindau syndrome
- Suitability for nephron-sparing (partial) nephrectomy
- Suitability for radio-frequency ablation or cryo-ablation
Surgical Approach
Surgical resection may be achieved using a number of different approaches;
Radical nephrectomy
- Open
- Laparoscopic
- Robotic
Partial (nephron-sparing) nephrectomy
- Open
- Laparoscopic
Surgical ablation
- Radio-frequency ablation
- Cryo-ablation
Open radical and partial nephrectomy are the traditional surgical procedures to treat RCC. Laparoscopic and, more recently, robotic approaches have been developed over the last two decades, and are both showing promising and comparable outcomes in terms of the survival of renal cancer patients.
Partial (nephron-sparing) nephrectomy was historically reserved for patients with single kidneys or other compounding factors, but in recent years the benefit of this surgical procedure for preserving healthy functioning renal tissue has led to it becoming more commonly used for small tumours (<7cm).
Operation
Radical nephrectomy involves complete removal of Gerota’s fascia, affected kidney, perinephric fat and ipsilateral adrenal gland (COHEN 2011).
Inspection of local lymph nodes is essential during the operation to ensure that the disease has not spread. There is no increase in morbidity, but no survival advantage in lymphadenectomy in patients with localised disease (Culp and Wood, 2009).
Nephron-sparing surgery involves resection of the affected section of kidney only, preserving healthy functioning renal tissue. Patients suitable include those with;
- Contralateral renal disease
- Solitary kidney
- Co-morbidities, such as hypertension, diabetes and von Hippel-Landau syndrome, where a normal, contralateral kidney is under potential future threat.
- Small, early stage tumours (<7cm) where radical nephrectomy may represent overtreatment and resect healthy renal tissue unnecessarily.
Open Nephrectomy (Radical and Nephron-sparing)
The incision may be:
- Flank (transverse)
- Thoraco-abdominal
- Transabdominal
Factors that influence the choice of incision include tumour location, size, characteristics and surgeon preference.
Laparoscopic Nephrectomy (Radical and Nephron-sparing)
- Laparoscopic radical/nephron-sparing nephrectomy uses a minimally invasive approach to perform exactly the same procedure as open nephrectomy.
- Under general anaesthesia, trocars (cylindrical tubes) are placed into the abdominal cavity through 3-5 tiny incisions, from 0.5cm-1cm in length, to allow insertion of the laparoscope.
- Carbon dioxide is injected through one of the incisions to enlarge the cavity and separate the abdominal wall from other organs.
- A laparoscopic camera provides a magnified view, making it possible to identify vessels and structures more clearly than in open surgery.
- Access to the kidney is as for open nephrectomy.
- The intact kidney (or diseased portion of the kidney in the case of nephron-sparing laparoscopy) is enclosed in a bag and removed through an incision.
- Hand-assisted laparoscopic nephrectomy allows the surgeon to place one hand in the abdomen while maintaining the pneumoperitoneum (introduction of air into the peritoneum) required for laparoscopy. A small incision is made which is just large enough for the surgeon’s hand and an airtight ‘sleeve’ device is used to form a seal around the incision. At the end of the procedure, the intact kidney can be removed through this incision.
Robotic Nephrectomy
The newest innovation in surgery is the Da Vinci® robotic system. In this alternative laparoscopic approach, the surgeon is remote from the patient and his ‘workstation’ is a computer console from which he directs the surgery. It is extremely costly, but has advantages over the open or traditional laparoscopic approaches in that it uses a 3-dimensional optical system to provide excellent views of the local anatomy and allows a remarkable degree of precision for resection and reconstruction. The Da Vinci® is only available in a limited number of hospitals in the UK at the present time.
A small study undertaken by a single surgeon performing all approaches described (open, laparoscopic and robotic), demonstrated minimal differences overall in relation to blood loss, use of narcotics post operatively, operating time, length of hospital stay and overall cost (Asimakopoulos et al, 2014).
Radiofrequency Ablation (RFA) / Cryoablation
Both these are emerging techniques and likely to be undertaken at specialist centres. They are minimally invasive techniques suitable for selected high risk patients, such as;
- Renal cell tumours of <4cm, in patients where radical surgery is contra-indicated, but symptoms necessitate active treatment
- Patients with a single kidney
- Patients with poor renal function
- Patients who are unable to tolerate surgical excision due to other co-morbidities, such as von Hippel-Lindau syndrome.
Probes are placed percutaneously, under CT or ultrasound guidance, directly into the site of the tumour, and an energy source generated to destroy the malignant tissue.
Cryotherapy (or cryosurgery) is a localised procedure, which kills cancer cells by freezing them to -100⁰C. A metal probe is pushed through the skin and into the renal tumour itself. Liquid nitrogen is injected through the probe to freeze the renal cancer cells. Usually this procedure is conducted under local anaesthetic to the kidney and surrounding tissue, and is therefore suitable for patients who are not well enough to tolerate a general anaesthetic, who have high blood pressure, or who refuse to have open surgery. However, as with any operation there will be pain once the local anaesthetic wears off and the patient will need to be followed for longer than after open surgery to monitor for recurrence. Early indications for cryotherapy show that the success rate for appropriately selected lesions is as good as partial nephrectomy, and the local control rate is better than that for radio-frequency ablation (see below). There are limits with respect to the size of the tumour that can be ablated (less than 4cm diameter), location of the tumour (accessibility and proximity to pelvic blood vessels) and risk of compromising renal function.
In the UK, the National Institute for Health and Care Excellence (NICE) issued guidance on cryotherapy for renal cancer in January 2007, which was later updated in 2011. The guidance states that cryotherapy is successful at destroying cancerous tissue, it is best for small tumours (less than 4cm) and it is a safe procedure. However, the guidance states that reoccurrence rates are similar but slightly higher than surgery. The guidance recommends that cryotherapy can be offered on the NHS but it must be kept for people who are not fit enough for major surgery or who refuse surgery. However, this technique is not widely used.
Radio-frequency ablation (RFA), like cryotherapy, is a localised treatment using radiowaves (heat) to destroy the cancerous lesions. A high frequency alternating current is applied to heat the tissue to temperatures exceeding 60⁰C. Under ultrasound guidance, the surgeon inserts a needle through the skin and into the tumour under local anaesthetic. Radiowaves are passed down the needle and directly into the tumour. RFA is most often used as adjuvant therapy after surgery to treat recurrent tumours or metastases in the liver. Clinical trials have shown that RFA is successful at destroying renal tumours, but treatments may have to be repeated. There have also been some clinical trials using RFA during a laparoscopic procedure; however, the surgeons concluded that this should only be done if it is difficult to put a needle through the skin due to the proximity of the tumour to other body organs. Like cryotherapy, the long-term success of RFA as a cure for early stage renal cancer and its effectiveness in comparison to conventional surgery are yet to be proven. RFA has similar advantages and limitations as cryotherapy, for example it is a good procedure for those patients not suitable for open surgery and it avoids the risks associated with nephrectomy. However, there are limitations as to the size of the tumour that can be treated with RFA, the location of the tumour and the risk of compromising renal function.
NICE have also issued guidance on RFA for the treatment of renal cancer; the guidance suggests that although RFA is a safe procedure, there is not enough evidence yet to prove its effectiveness. RFA should only be used if open surgery is not an option for the patient.
Larger tumours can sometimes be treated with RFA or cryoablation, but would need to receive several treatment sessions. The likelihood of failure increases as the size of the tumour increases, so it is only used in such cases when other treatment modalities are not recommended.
References
National Institute for Health and Care Excellence (NICE): Improving outcomes in urological cancers, September 2002. http://www.nice.org.uk/guidance/csguc
COHEN Eric P.(2011) Cancer and the Kidney: The Frontier of Nephrology and Oncology (2nd edition), p121-160) Oxford University Press,
Culp S H and Wood C G (2009). Should patients undergoing surgery for renal cell carcinoma have a lymph node dissection. Nature Clinical Practice Urology, 6 (3), pp126-7.
Asimakopoulos et al .BMC urology 2014/ http://biomedical.com (accessed 07 september 2017)
National Institute for Health and Care Excellence interventional procedure guidance IPG402: Percutaneous cryotherapy for renal cancer. Issued July 2011 https://www.nice.org.uk/guidance/ipg402 (accessed 07 september 2017)
Breen, DJ, Bryant, TJ, Abbas, A et al. (2013) Percutaneous cryoablation of renal tumours: Outcomes from 171 tumours in 147 patients. BJU International Doi:10.1111/bju.12122.
National Institute for Health and Care Excellence interventional procedure guidance IPG353: Percutaneous radiofrequency ablation for renal cancer. Issued July 2010. https://www.nice.org.uk/guidance/ipg353