The kidneys are made up of different types of cells. Tiny tubules in the kidneys filter and clean the blood by taking out waste products and make urine. The causes and management of cancers arising from the part where urine is collected (renal pelvis) and transported differ from those arising from the tubules of kidney. The cancers mentioned here are those originating from the cells lining the tubules (the smallest tubes) inside the nephrons where urine is produced. In urology, these tumors, are named as Renal Cell Carcinoma with abbreviation of the initials of the words as “RCC”.
Each year 300.000 new cases of kidney cancer are diagnosed all over the world and it is more common in developed industrial countries. While the estimated rate of developing kidney cancer is 1/69 in a man’s whole life, this ratio is 1/116 in women; thus, kidney cancer is more common in males than females.
Formerly kidney cancer was regarded as a malignancy of elder and encountered in people over 65 years old, now younger patients are diagnosed as kidney cancer with frequent utilization of radiologic modalities and check-up programs in modern societies.
Risk factors for renal cell cancer:
The following factors can increase the risk for getting kidney cancer but does not mean that a person will get cancer if that factor exists.
- Older age
- Obesity (Being overweight)
- Hypertension (Having a high blood-pressure)
- Misuse of certain drugs (Use of pain medicines for a long time)
- Family history of kidney cancer
- Certain genetic factors (von Hippel-Lindau disease, tuberous sclerosis complex, hereditary papillary renal cell carcinoma or familial renal cancer)
- Long term dialysis
- Exposure to chemicals (Cadmium or some herbicides)
The classical symptoms of kidney cancer, lump in abdomen-blood in urine-abdominal pain and weight loss are seen only in 7% of the patients. More than 50% of kidney cancer patients are diagnosed incidentally due to other symptoms and referred to urology.
Kidney cancer is a very aggressive disease and must be immediately managed surgically if feasible. Unfortunately, 30% (1/3rd ) of kidney cancers have distant organ involvement (metastases) at the moment of diagnosis.
As stated before, most of kidney cancers are diagnosed incidentally as a rather small mass in the kidney, they do not possess distinct symptoms. However, certain hormones produced by the mass in the kidney are released into the bloodstream; these substances cause some symptoms and diseases which are referred as “Paraneoplastic Syndrome”.
These symptoms include:
- Increase in blood pressure (Hypertension)
- Fever of unknown origin
- Unintentional weight loss
- Inexplicable anemia
- Increase of sedimentation rate and/or CRP
- Impaired hepatic function tests
Diagnosis of Kidney Cancer
Diagnosis is usually after radiologic assessment of abdomen, either an abdominal ultrasonography or a computerized tomography (CT) or magnetic resonance imaging (MRI) of abdomen, requested by mostly internists due to vague symptoms. PET CT does not have any superiority over these radiologic studies.
Treatment of Kidney Cancer
Surgical removal of kidney with its surrounding tissues as soon as possible, is the only effective treatment of kidney cancer. Thus, treatment of kidney cancer is “surgery”. Satisfactory outcomes can be expected by experienced surgeons. If cancer has not spread to distant organs, surgery by itself is sufficient for the cure.
The preferred surgery for kidney cancer is the removal of kidney all together with its surrounding tissues in order not to spread tumor cells into the surgical field. This operation is termed as “Radical Nephrectomy”. This is a major surgery performed under general anesthesia. The classical approach is “Open Surgery”; however, the same procedure can be accomplished by “Laparoscopic Surgery”. We perform “Laparoscopic Radical Nephrectomy” by considering the size of tumor. In cases where the tumor size is too large, or the tumor coagulum extends into the big veins of abdomen, we prefer the classical approach for surgery.
Preoperative computerized tomography of a 57 years old male, scheduled for laparoscopic radical nephrectomy, with a left kidney tumor of 11 cm in size. Below, is the surgical specimen after the procedure.
Is It Possible To Preserve Kidney and Remove Tumor Exclusively?
With the emergence and widespread utilization of high sensitivity imaging technologies such as ultrasound, CT and MRI, as well as the expansion of check-up concept, today we can detect kidney cancer in a rather small size and at an early stage. In such cases we employ a surgical technique named “Nephron Sparing Surgery” or ”Partial Nephrectomy” where only the tumor is removed, and the other healthy part of kidney is preserved.
The diameter of the tumor must not exceed 7 cm and it has to be located in an appropriate site to be surgically removable. Tumor size is of high importance; removal of tumors exclusively over 7 cm in diameter carries a high possibility of development of a new cancer in the remaining tissue. Therefore, it is mandatory to remove the whole kidney in tumors exceeding 7 cm in diameter.
We perform “ Partial Nephrectomy” in kidney cancer patients with impaired renal function or who have only one kidney or who have a concomitant cancer on both kidneys. Thus, renal function is preserved to a degree and this can prevent the patient to undergo dialysis.
The tumor must be less than 7 cm in size and be located in a site suitable for surgery as well as the surgical team must be experienced in such tough surgical procedures.
Robotic Surgery For Kidney Cancer
In the video down below, you can watch removal of tumor in Robotic Partial Nephrectomy
In the video down below, you can watch Robotic Radical Nephrectomy
In the video down below, you can watch clamping of the main renal vein in Robotic Radical Nephrectomy
In the video down below, you can watch Robotic Surrenal Tumor Removal
In the video down below, you can watch a part of Robotic Nephroureterectomy
Treatment of Disseminated (Metastatic) Kidney Cancer
Formerly patients who had disseminated disease; i.e. metastatic disease, at diagnosis were not operated, in a sense, they were abandoned to live their fate. Nowadays, with the advent of “Modern Surgical Techniques” and introduction of new drugs better results could be expected in this patient group. Today metastatic kidney cancer is managed by “Radical Nephrectomy” whenever the patients’ medical condition allows, followed by administration of immunotherapeutic agents.
Surgical removal of cancerous kidney in disseminated disease is named “Cytoreductive Surgery”. So, in metastatic kidney cancer the diseased kidney is surgically removed by urologic surgeon when feasible first and then immunotherapeutic agents are administered by medical oncologist.
In disseminated (metastatic) disease, it has been demonstrated that survival and quality of life is 2,5 times better in favor of patients treated with surgical removal plus immunotherapy than those who were not operated or were not eligible for surgery and could be treated only with immunotherapeutic agents.
Surgical removal of cancerous kidney in metastatic disease not only controls discomforting local symptoms but also allows better therapeutic advantages of immunotherapy.
In metastatic disease, patient’s immune system has to function properly in order for medical oncologic therapy to be beneficial. Kidney cancer hampers one’s immune system; thus, surgical removal of the diseased kidney facilitates refreshment of immune system and helps to fight against malignancy. Unfavorable effects related to kidney cancer may subside after surgical removal.
Is Surgery Suitable for All Patients With Advanced Disease?
- Surgery for metastatic kidney cancer is a difficult and risky operation; thus, it should be performed by experienced surgical teams and in well-equipped medical facilities
- Preoperative evaluation must disclose dissemination to brain and liver
- Patient’s medical status must be suitable for this exhaustive surgery
- No sarcomatous elements must exist if a previous biopsy has been performed
Cancers Of Renal Pelvis and Ureter
These are the cancers that develop from the part where urine is collected (Renal Pelvis) and transported to bladder through a tube-like organ (Ureter).
Symptoms and Diagnosis
The most important and only symptom of this disease is blood in urine (Hematuria). This may be visible or may be discovered in urinalysis. In addition, there may be flank pain on the affected side.
Diagnosis; CT Urography, Cystoscopy (Visualization of the interior of bladder by inserting special instruments in order to see bloody urine draining from the affected side) and Ureterorenoscopy (URS: Visualization of the entire ureter and inner part of kidney on the suspected side by insertion of special instruments are the means for diagnosing cancers of ureter and renal pelvis. A biopsy can be performed during these procedures.
Treatment of this disease differs from the abovementioned kidney cancer. The kidney and ureter are completely removed surgically along with a cuff of bladder on the affected side. The bladder part where the ureter is attached is removed because following surgical removal the disease may recur in up to 70%.
After discharge we follow the patients at certain intervals by cystoscopies as stated in the treatment section to discover and treat appropriately any recurrence in the bladder.
Role of Chemotherapy
In cancers of renal pelvis and ureter chemotherapy is initiated if distant organ metastases are encountered on follow up or a cancerous dissemination is found in lymph node specimens removed during surgery.
What to Do If Cancer If Cancer Recurs in Bladder on Follow-up?
As stated in Bladder Cancer Section we perform an endoscopic surgical process and remove the tumor and have refer the specimen to pathologic evaluation. If pathology reveals invasion of bladder muscle by cancer (T2 High Grade) Radical Cystectomy, surgical removal of bladder, prostate and seminal vesicles along with lymph nodes must be performed. Patients who are not eligible for this extensive surgery are referred to radiotherapy.
If pathology confirms a tumor not invading muscle layer of bladder, intravesical drug administration and periodic cystoscopies are performed on follow-up.