Kidney cancer arising from the kidney cells themselves is most commonly of the Renal Cell Carcinoma (RCC) histologic type. This an evermore common diagnosis in the general population as patient receive investigations for other reasons, and imaging turns up small renal masses eventually diagnosed as RCC.
RCC are conventionally resistant to both chemotherapy and radiation and thus, surgery is the first line of therapy in most cases.
Depending on the histologic type, tumor size and location, you and your Urologist may decide to go ahead with one of a spectrum of possible therapies:
If the renal mass is small (less than 2cm), then it may be amenable for surveillance in which you would be scheduled for regular imaging tests such as ultrasounds or CT scans. If the characteristics of the lesion should change on these tests, then a decision to escalate therapy may be recommended.
An up and coming mode of therapy for renal lesions includes radiofrequency ablation or cryotherapy. In both, the procedure is an outpatient procedure in Radiology in which a needle is introduced through the skin, into the tumor under CT guidance and then the tip of the probe is rendered extremely hot (RFA) or cold (cryo), thus causing permanent injury to the cancer cells, killing them where they are. A biopsy is done just before the treatment phase of the procedure such that histologic confirmation of the tumor can be performed.
Risks related to this procedure include: missing the tumor during treatment, tumor recurrence, bleeding, urine leak, damage to surrounding organ structures from the needle access or from the treatment energies.
This mode of surgery has come of age over the past 20 years in Urology and has become the de facto standard of care for most cases of kidney cancer. If the renal mass is of a size amenable to an MIS approach, then your Urologist may discuss going forward with an MIS partial or radical nephrectomy for you. In both operations, you would be admitted to the Hospital and go to the OR where you will be given a general anesthetic and placed on your side such that the affected side is facing up. You will be secured in this position, and access to the abdominal cavity will be achieved in order to puff up the abdomen with CO2 gas to generate a working space for the rest of the operation. A 12mm telescope port will be placed at this point through the skin and into the insufflated abdomen, followed by additional working ports numbering 2-3 and between 5mm and 12mm in size. As the kidney is the structure furthest back in the body, and the approach is from the front, a lot of the operation involves mobilizing the colon and overlying organs from overtop of the kidney to provide room to dissect the kidney out. Once the kidney is isolated the section of the kidney which harbours the tumor will be removed in a partial nephrectomy, reconstructing the remaining kidney together in watertight, hemostatic fashion. In a radical nephrectomy, the main renal artery and vein are secured and cut with a special stapler which leaves 6 rows of micro-titanium staples to secure the vessels. The operation takes between 2-5 hours depending on the complexity of the procedure.
Potential complications from these operations include, bleeding, tumor spillage, urine leak, and injury to surrounding organ structures. “Conversion” is the term used to describe an operation that was started laparoscopically, and then changed to the traditional “open” procedure if some issue was noted during the course of the operation, or a complication was encountered, or the progress of the operation laparoscopically was not adequate. Conversion occurs less than 5% of the time.
A further variation on these procedures followed the invention of the daVinci Surgical Robot which is also available for these procedures. The robot helps the surgeon by providing a 3D view of the operative field, finer control of the instruments, motion scaling and smoothing as well as a platform for newer technologies which ultimately assist with improving patient outcomes (reduce blood loss, less pain, shorter length of Hospital stay, improved tumor resection, etc). As your doctor if you are interested in this mode of therapy.
The traditional 30cm incision along the lower ribs on the side of the body is called the flank incision and has been the standard for many years prior to the advent of laparoscopic surgery. It is well documented, that this incision is associated with a fair amount of discomfort postoperatively as there is a lot of muscle that must be incised in order to reach the kidney via this approach. As well, there is risk that a rib will be fractured and/or removed and damage to the nerve and vascular bundle running along the bottom of the ribs may be incurred. The diaphragm is the structure which contracts and relaxes, pulling the lung open and closed for breathing, and happens to be inserted on the back of the lower ribs as well. Thus, there is a chance of breaking into the diaphragm and pleura and introducing air into the lung cavity (pneumothorax) which would have to be repaired as well.
One of the advantages of open surgery is that the operation usually takes less time and can be completed in 1.5-3 hours. Potential complications run similar to that as mentioned previously for MIS surgery.
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