This is a relatively common cancer being responsible for 1in 30 of all adult cancers with a male to female predominance of 2 to 1. They fall into two main groups – those that arise from the ‘meat’ of the kidney called renal cell cancers and the less common but possibly more aggressive urothelial cancer that arises from the lining of the tube that takes the urine from the kidney to the bladder.
The major known risk factor is smoking although some genetic variants exist and use of some chemical reagents seen in certain industries.
Classically these tumours presented with blood in the urine, (Haematuria), flank pain and an abdominal mass. The majority we now see are being detected much earlier due to a patient having abdominal scans for other reasons. For patients therefore who notice blood in their urine or who have kidney abnormalities on an ultrasound scan, early and urgent investigation is vital. This usually involves a CT scan of the body and a camera inspection of the bladder under local anaesthetic – a cystoscopy.
The treatment of these tumours depends on what type they are, where they arise in the renal tract and the size or grade of aggressive they may be.
Renal Cell cancer
Due to increased use of abdominal scanning many patients are having their kidney cancers detected at very early stages. These tumours are often very small and can be difficult to determine whether they are malignant (cancer ) or benign. If malignant however, they have an extremely low chance of having developed secondaries elsewhere in the kidney or the rest of the body. Growth rates in cancers less than 2cm in diameter are only a few millimetres per year and patients often have a choice of observing these masses with regular scans with a chance of avoiding surgery or to have the tumour treated primarily.
With the improvements in surgical techniques seen over the last decade It is possible to treat these small tumours surgically without sacrificing the whole kidney. The advantage of this operation is the reduced risk of long-term kidney failure, but this has to be balanced against an increased risk of complications in the short term.
This is termed ‘Nephron Sparing Surgery”.
The potential options include percutaneous methods of destroying the tumour with freezing (cryoablation) or heat (radiofrequency ablation -rfa) or to surgically remove the tumour whilst leaving the rest of the kidney intact.
This latter approach is called Partial Nephrectomy and gives the benefit of pathological confirmation of tumour clearance whilst retaining kidney function.
For those with extensive expertise in this field the gold standard approach is now accepted to be the Laparoscopic ‘Keyhole’ technique using the DaVinci Robotic platform – Robotic assisted Laparoscopic Partial Nephrectomy
The risk of complications and cancer recurrence increases for bigger tumours, and decreases with surgical experience. The technically demanding nature of performing this operation means that experience with the intuitive DaVinci Robotic platform is crucial in reducing complications from this surgery. I have one of the largest experiences of Robot assisted / Laparoscopic Partial Nephrectomy in the UK and am able to offer it to patients with appropriate tumours.
Initially such surgery was reserved for small renal masses of 2cm or below but now has become a standard of care for tumours approaching 5cm and greater.
Although we strive to preserve renal function as much as possible there are, unfortunately, occasions when the tumour is best removed by the removal of the whole kidney - Nephrectomy. For tumours that are over 4cm in size for example the chance of having other areas of cancer in the same kidney is over 7% and sometimes removal of the kidney with the tumour is required to be curative.
Although we are seeing an increased number of tumours presenting incidentally at small size due to the increased use of abdominal ultrasound scans, it is still unfortunately not uncommon for patients to present with larger masses and patients with 7-10cm or even larger tumours are often referred to me for surgery
Although these tumours may appear quite sizeable, the kidney prevents cancer spreading by surrounding the tumour in a reactive ‘capsule.’ meaning that Nephrectomy can usually offer a cure.
The Laparoscopic ‘Keyhole’ approach results in lower complications and faster recovery than the traditional open approach and in the hands of experts is the default approach for removal of the kidney.
Laparoscopy kidney surgery provides patients with a safe and effective method of undergoing the majority of kidney operations via a ‘keyhole’ approach. In fact, the kidneys are more suited to laparoscopic surgery than many other organs of the body as the kidneys are located deep inside the abdomen being shielded from behind by the lower ribs and in front by many other organs and body wall.
This position in the body protects the kidney but also means that to access them through the traditional open approach requires a large muscle splitting (or usually cutting) incision that has a high incidence of long term complications including unsightly muscle bulging and pain.
In addition upper abdominal incisions have heightened postoperative pain on respiration and can lead to shallow breathing resulting in possible respiratory tract infection.
Laparoscopic approaches to upper abdominal organs such as the kidney and gall bladder have been shown to result in lower postoperative pain and analgesic requirements, less respiratory compromise and faster recovery from surgery both within the hospital and return to normality at home.
The laparoscopic approach is not necessarily the ideal one for all patients, however. There are patient and disease factors that may make the laparoscopic approach unsuitable or ‘contraindicated’. These mainly reflect the surgeons experience. Having performed over 1500 laparoscopic nephrectomies in the last 20 years this type of surgery has become my default approach and is reflected in my low complication rate despite the more complex nature of cases I perform.
Transitional Cell cancer
This is a cancer of the lining of the urinary tract and can occur in the bladder or at any point in the tube that connects the kidney to the bladder; the Ureter. It usually presents at a smaller size that Renal Cell cancer because of its tendency to cause Haematuria or even blocking the kidney. It is, however, a potentially more aggressive variant of cancer than Renal cell cancer and therefore for patients with Haematuria urgent investigation and opinion of a urologist is essential. If detected and treated without delay by surgical removal it still has an excellent chance of being cured.
The operation is called Nephroureterectomy and is more extensive than Nephrectomy as the ureter needs to be removed along with the kidney because of the high chance of multiple areas of tumour existing within it.
This traditionally this has required two large incisions – one remove the kidney and a separate one to disconnect the ureter from the bladder although many surgeons are now able to perform the nephrectomy part laparoscopically and use a single lower incision to disconnect the ureter from the bladder.
Use of the Davinci Robotic platform however, allows the entire operation to be performed Laparoscopically ( keyhole) using the instruments through the same ports to perform both the kidney and the bladder end of the operation
Over the last decade numerous reports in the medical literature have attested to the safety and effectiveness of the above procedures in expert hands and have been reviewed by the National Institute of Clinical Excellence (NICE). In light of the reduced morbidity and complications, the robot assisted laparoscopic approach should be the default standard for the above operations. Although not all patients are suitable for a laparoscopic option, in my experience this is fairly few.
Patient information sheet Partial Nephrectomy
Patient information sheet Radical Nephrectomy
Patient information sheet robot assisted Radical Nephroureterectomy
Laparoscopic Nephrectomy : http://guidance.nice.org.uk/IPG136
Laparoscopic Partial nephrectomy: http://guidance.nice.org.uk/IPG151