RENAL CELL CARCINOMA SURGICAL TREATMENT

Renal cell carcinoma: surgical treatment I
Surgery is the mainstay of treatment for RCC. Increases in diagnosis of smaller early-stage RCC and the concept of cytoreductive surgery for advanced disease has impacted on surgical treatment strategies of the disease, while reduction in mortality remains elusive.
Localized disease radical nephrectomy
Open approach
Though undergoing critical review due to the success of the newer approaches below, this remains the gold standard curative treatment of localized RCC. The aim is to excise the kidney with Gerota's fascia, perhaps with ipsilateral adrenal gland (tumours >5cm) and regional nodes (controversial), removing all tumour with adequate surgical margins. Surgical approach is transperitoneal (good access to hilar vessels) or thoraco-abdominal (for very large or T3c tumours). Following renal mobilization, the ureter is divided; ligation and division of the renal artery or arteries should ideally take place prior to ligation and division of the renal vein to prevent vascular swelling of the kidney. If present, excision of hilar or para-aortic/para-caval lymph nodes will improve pathological tumour staging. Complications include mortality up to 2% from bleeding or embolism of tumour thrombus; bowel, pancreatic, splenic, or pleural injury.

Laparoscopic approach
Well accepted for treating benign disease, this approach appears suitable for T1 (<7cm) RCCs. Approaches are either transperitoneal or retroperitoneal. The specimen is removed whole or morselated in a bag through an iliac incision. Advantages over open surgery include less pain, reduced hospital stay, and quicker return to normal activity. Morbidity is reported in 8 - 38% of cases, including pulmonary embolism and poorly understood effects on renal function. Long-term (10-year) results are not yet available, but reports of 5-year disease-specific survival >90% for T1 tumours are respectable.

Localized disease partial nephrectomy
Nephron-sparing surgery is the best option for multifocal, bilateral tumours, particularly if the patient has VHL syndrome or single functioning kidney when the prospect of renal replacement therapy looms; it has become acceptable to treat small (<4cm) tumours, even with a normal contralateral kidney, unless the tumour is close to the pelvicalyceal system. Arteriography or 3-dimensional CT reconstructions are helpful to the surgeon.
Open transperitoneal or loin approaches are used; laparoscopic partial nephrectomy is difficult in the best of hands. The renal artery is clamped and the kidney packed with crushed ice. Generally, results are comparable with open surgery.
Specific complications include failure of complete excision of the tumour(s) leading to local recurrence in up to 10% of cases, and urinary leak from the collecting system. Some patients develop hyperfiltration renal injury, eventually require renal replacement therapy: proteinuria is a prognostic sign. Laparoscopic partial nephrectomy is under evaluation at time of writing.

Post-operative follow-up
aims to detect local or distant recurrence (incidence 7% for T1N0M0, 20% for T2N0M0, and 40% for T3N0M0) to permit additional treatment if indicated. After partial nephrectomy, concern will also focus on recurrence in the remnant kidney. There is no consensus regarding the optimal regime: typically, stage-dependent 6-monthly clinical assessment and annual CT imaging of chest and abdomen for 3 - 10 years.

Renal cell carcinoma: surgical treatment II
Localized RCC lymphadenectomy
Lymph node involvement in RCC is a poor prognostic factor. Incidence ranges from 6% in T1 - 2 tumours, to 46% in T3a, to 62 - 66% in higher stage disease. Lymphadectomy at time of nephrectomy may add prognostic information, especially if there is obvious lymphadenopathy, but therapeutic benefit remains unclear. Formal lymphadenectomy adds time and increases blood loss, while nodes are clear in about 95% of cases.

Localized RCC treatment of local recurrence
Though uncommon, if there is local recurrence in the renal bed after radical nephrectomy, surgical excision remains the preferred treatment choice, provided there are no signs of distant disease. Local recurrence is more common after partial nephrectomy, where it can be treated by a further partial or total nephrectomy.

Localized RCC alternatives to surgery
Observation: small (<3cm) solid, well-marginated renal masses may be safely followed with repeat scans in elderly or unfit individuals; growth is slow and metastasis rare.
Cryosurgery: performed using intra-operative ultrasound by open, percutaneous, or laparoscopic routes; this is an emerging nephron-sparing treatment option.
High-intensity focused ultrasound: this extra-corporeal minimallyinvasive yet highly accurate treatment is under evaluation.

Locally advanced RCC
Disease involving the IVC right atrium, liver, bowel, or posterior abdominal wall demands special surgical skills. In appropriate patients, an aggressive surgical approach involving a multidisciplinary surgical team to achieve negative margins appears to provide survival benefit.

Adjuvant treatment
Radiotherapy: early studies suggested a role for pre-operative RT, though recent studies have failed to show a survival benefit for either pre- or post-operative RT. It may retard growth of residual tumour after nephrectomy.

Immunotherapy: randomized trials of adjuvant immunotherapy versus observation alone are ongoing for patients with positive nodes, surgical margins, and venous invasion.

Metastatic RCC
Nephrectomy has long been indicated for palliation of symptoms (pain, haematuria) in patients with metastatic RCC (if inoperable, arterial embolization can be helpful). There appeared to be no other tangible benefit to surgery. But recently, a median survival benefit of 10 months for patients with good performance status treated with cytoreductive nephrectomy prior to immunotherapy (interferon-γ) was reported. This has further expanded the indications for surgery in RCC.
Resection of solitary metastases is an option for a few patients, usually a few months after nephrectomy, thereby ensuring the lesion remains solitary.