Surgery to remove the affected kidney (nephrectomy) is usually the first thing doctors consider and it can be a cure if the cancer is at an early stage. Even some more advanced cancers can be cured if all the cancer can be removed. However, removing a kidney is a major operation so you need to be fit enough to cope and recover afterwards. That’s why this treatment may not be possible for everyone. Surgery can also be used to remove metastases in some cases of advanced kidney cancer.
Removing part of the kidney containing the tumour is called a partial nephrectomy or kidney/nephron sparing surgery. The aim of this surgery is to remove the whole tumour while leaving as much normal tissue as possible. It means that some working kidney is left behind. For this reason, partial nephrectomy is carried out for people who only have one kidney, who have kidney disease, or who have tumours in both kidneys. Specialist surgeons now treat most early stage (stage 1) kidney tumours that are less than seven cm in size with partial nephrectomy, if possible.
During a radical nephrectomy the whole kidney and the surrounding fatty tissue, the adrenal gland, and nearby lymph nodes are usually removed, although the extent of a radical nephrectomy can vary between patients. You can live perfectly well with just one working kidney, but if both kidneys are removed because of bilateral renal cell carcinoma, or because they are not working you will need dialysis for the rest of your life or a kidney transplant.
A radical nephrectomy may be carried out using open surgery, during which the surgeon usually makes a large incision or cuts below the lower ribs on the side of the affected kidney. The whole kidney and surrounding tissues are removed through this incision.
Keyhole (laparoscopic) and robotic surgery
Sometimes it is possible to use keyhole surgery or laparoscopic nephrectomy to remove the affected kidney, for which you will need a referral to a specialist urological surgeon with particular experience in laparoscopic kidney surgery. Laparoscopic surgery can also be used to carry out a partial nephrectomy.
Laparoscopic nephrectomy can be used when open surgery is not an option, for example patients with high blood pressure. The operation is carried out using several small incisions or cuts in the skin of the tummy (abdomen), rather than one large incision. A thin tube with a camera and a light at the end is inserted into the abdomen through one of the cuts. This instrument is called a laparoscope, and it enables the doctor to see inside your tummy. Other small instruments are inserted through the other cuts and used to remove the kidney or part of the kidney containing the tumour.
There may be some advantages to having keyhole surgery. For example, you may experience less pain after the operation, need a shorter stay in hospital and have smaller scars. However, keyhole surgery, like any operation, has some risks, so you should discuss the options with your specialist before surgery.
Assisted robotic surgery is a type of laparoscopic surgery in which a special machine or robot is used by the surgeon to help carry out the surgery. The surgeon has a 3D view of the inside of your tummy and the area can be magnified 10-12 times. Robotic surgery is only available at a few specialist centres in the UK.
After your operation
After the operation you will be given an intravenous drip of fluid and salts until you can eat and drink normally. Tubes will drain excess fluid from your wound to assist healing. These will be taken out before you go home. You will probably have a catheter fitted to drain your urine into a bag. This is usually taken out after a day or two.
Most people go home between four to ten days after their operation, depending on the type of surgery they had. The time it takes for you to feel fit enough to get back to leading a normal active life will vary. It may help to talk to your doctor or clinical nurse specialist (specialist nurse) about this.
A nephrectomy is a major operation and, as with any operation, there can be some risks, such as infection or blood clots (thrombosis) in the legs, arms or chest. If you are concerned by any of these, or if you have any symptoms of an infection (fever, feeling generally unwell) or a wound infection (redness, pain, swelling and oozing from the wound), please see your doctor.
Some people may find the scarring or changes to their body and how it works, difficult to deal with. Some may have concerns about the effects of the operation on relationships. You may need support to enable you to cope with such changes. Please talk to your doctor or nurse about how you feel and they will be able to put you in touch with somebody who can help.
You should get a follow up outpatient appointment to check your recovery six weeks after your surgery, where your consultant should discuss with you your prognosis and/or treatment options and follow-up schedule.
Follow-up after surgery
There are no guidelines for the method and timing of follow-up examinations after surgery. You will be followed-up for signs of recurrence of the cancer or spread of the cancer to other parts of the body. The frequency of follow-up visits and the tests that you receive during these visits will depend upon whether you experience any complications as a result of your operation, the function of your remaining kidney, and the risk of recurrence of the cancer or spread to other parts of the body. In general, you should have follow-up visits at six months and one year after your surgery, and then annually for at least five years. Patients at a low-risk of recurrence or cancer spread should have an ultrasound scan or chest X-ray, and blood tests to check kidney function at each visit. Patients at an intermediate or high-risk of recurrence or spread should have a CT scan and blood tests at each visit. These patients, or those with complications after their operation may be seen more frequently.
Other surgical treatments
Doctors have been researching less invasive ways of removing kidney tumours. These treatments can be used to remove small tumours (less than four cm in size) and for people who are unable to have surgery. They may also be used to treat people with multiple kidney tumours or tumours in both kidneys (bilateral disease).
Cryotherapy kills the cancer cells by freezing the tumour; however, there is only limited data to prove how effective this procedure is. The doctor inserts one or more fine needles or probes through the skin (percutaneous) and into the tumour. Argon gas or liquid nitrogen is passed through the needles under pressure to freeze the tumour. Regular CT scans are carried out during the procedure to ensure the needles are positioned correctly in the tumour and the entire tumour has been frozen. Cryotherapy is usually carried out under general anaesthetic, or sedation if a general anaesthetic is not suitable. Cryotherapy can also be carried out using keyhole surgery.
Complications or side-effects after cryotherapy include pain, infection and bleeding. A small number of people experience damage to the bowel and a blockage or damage to the ureter, the tube from the kidney to the bladder through which urine passes. However, in specialist centres that perform a lot of cryotherapy procedures, these complications are minimal.
National Institute for Health and Care Excellence (NICE) has issued guidance for percutaneous cryoablation; however, this procedure is only available at a few specialist centres in the UK. Further research is needed to compare the long-term outcomes of cryotherapy with those of other treatments for kidney cancer.
Radiofrequency ablation (RFA) uses heat from an electric probe to destroy the tumour; however, there is only limited data to prove how effective this procedure is. Fine needles are inserted through the skin (percutaneous) and into the tumour. An electric current is passed through the needles to heat the cancer cells and destroy them. Regular CT or ultrasound scans are carried out during the procedure to ensure the needles are positioned correctly. RFA is usually carried out using local anaesthetic and sedation, and can also be carried out using keyhole surgery.
Complications or side-effects after RFA include pain, infection and bleeding. A small number of people experience damage to the kidney causing urine leakage and a narrowing of the ureter, making it difficult to pass urine. However, in specialist centres that have a lot of experience of RFA procedures, these complications are minimised.
National Institute for Health and Care Excellence (NICE) has issued guidance for percutaneous RFA; however, this procedure is only available at a few specialist centres in the UK. Further research is needed to compare the long-term outcomes of RFA with those of other treatments for kidney cancer.
High intensity focused ultrasound
High intensity focused ultrasound (HIFU) directs strong beams of sound at the tumour, which heats up the cancer cells and kills them. HIFU is only available in clinical trials for the treatment of kidney cancer in the UK, and research is ongoing to determine the effectiveness of this technique.
The main advantage of cryotherapy, RFA and HIFU is that they can be done using probes through the skin so you don’t have to have surgery. These approaches may be useful if your tumour is small, or when open or keyhole surgery to remove your kidney is not an option. However, these techniques are not widely-used and their success is yet to be proven. These treatments may be repeated if not successful first time.
If your surgeon is confident that all your cancer has been removed during surgery, you won’t need any further treatment. However, if there is concern that some cancer cells were left behind after surgery, you may need to have treatment with a drug called a targeted therapy or a course of radiotherapy. Your doctor or clinical nurse specialist (specialist nurse) will discuss this with you.
- Partial nephrectomy (open or keyhole)
- Radical nephrectomy (open or keyhole)
- Laparoscopic (keyhole) surgery or robot assisted surgery
- Radiofrequency ablation (RFA)
- High intensity focussed ultrasound (HIFU)