cytoreductive radical nephrectomy is the exact same operation as
a laparoscopic radical nephrectomy. However, the laparoscopic cytoreductive
nephrectomy is done in the setting of kidney cancer that has extended
outside of the kidney and its surrounding tissues. The extent of
the cancer may be limited to tissues in the area around the kidney
known as the lymph nodes, or the kidney cancer may have more extensively
spread to other organs such as the lung or liver.
Considering a laparoscopic cytoreductive radical nephrectomy
implied that, prior to the surgery, your doctor already knows that
the cancer has spread outside the kidney to another organ and therefore
removal of the kidney alone is not going to result in cure. After
the laparoscopic cytoreductive radical nephrectomy, other systemic
treatment strategies will be needed to increase the chance of cure
and to extend life as much as possible.
Laparoscopic cytoreductive nephrectomy is the same
operation as an open cytoreductive nephrectomy. Any cytoreductive
nephrectomy is very challenging and the laparoscopic approach should
be utilized only in selected cases in which the risk of the kidney
cancer having grown into surrounding organs is limited. Only very
experienced surgeons dedicated to advanced laparoscopy should be
performing this procedure, and it should often be scheduled in conjunction
with a surgeon who specializes in open
In the past, open and laparoscopic cytoreductive
nephrectomy were not performed unless the patient required the procedure
to treat symptoms such as pain or bleeding. However, it has been
proven in two separate large clinical trials that a cytoreductive
nephrectomy affords healthy patients with advanced kidney cancers
a slight improvement in survival, and will extend life for a period
of time that is usually in the range of three months to a year.
The laparoscopic cytoreductive radical nephrectomy
uses a minimally invasive approach (laparoscopy) to perform exactly
the same procedure that is done in open cytoreductive radical nephrectomy.
In any radical nephrectomy (open or laparoscopic) the entire kidney
including the kidney cancer is removed. With the cytoreductive radical
nephrectomy, it is possible that other involved organs will have
to be removed as well.
The laparoscopic approach to cytoreductive radical
nephrectomy means that no large incisions are required to perform
the procedure. Instead of a large incision, three or four 1/2 cm
to 1 cm incisions (less than 1/2 inch) are made. The spaces in the
body are gently filled with gas to make working space and a small
camera is placed into the body through one of the incisions. The
other small incisions are used to place working instruments which
can be used to perform the procedure.
cytoreductive radical nephrectomy for kidney cancer is performed
by a Urologist (kidney surgeon) in an operating room. Only laparoscopic
surgeons with tremendous experience with advanced laparoscopy and
the laparoscopic treatment of kidney cancer should perform laparoscopic
cytoreductive radical nephrectomy as the procedure is very challenging.
Prior to scheduling the procedure, each patient should have an extensive
consultation with their Urologist regarding the nature of their
kidney disease as well as all of the available treatment options.
This discussion should review all the advantages and limitations
of each surgical and non-surgical approach.
Once you and your Urologist have decided on laparoscopic
cytoreductive radical nephrectomy, a date for surgery is chosen.
Typically, a patient goes to the hospital on the day of surgery.
General anesthesia (you are completely asleep) is required. The
Procedure is then done through three or four small incisions which
are either ½ a centimeter or 1 cm in length (less than ¼
to ½ an inch). The kidney is then identified but never actually
seen, as it is surrounded by both fat and the leathery layer known
as Gerotas fascia. The surgeon identifies and controls the
renal artery (blood supply to the kidney). Once the artery is controlled,
attention is turned to the vein, which is also controlled. The entire
specimen is then separated from all of its attachments to the body
and put into a sack while still inside of the body.
Often tissues around the kidney known as lymph nodes
are involved in this type of advanced kidney cancer. In laparoscopic
cytoreductive nephrectomy, the surgeon will often take the lymph
nodes around the area as a specimen in an effort to remove as much
of the kidney cancer that is in the body as possible. Any other
organs that are involved such as the liver, pancreas and spleen
are also removed. While, in the hands of very experienced experts,
the removal of other organs is possible, advanced kidney cancer
involving other organs will often require the conversion from the
laparoscopic approach to an open approach to maximize the patients
safety and minimize the risk of complications.
are a number of important patient and tumor parameters that are
critical in deciding the type of treatment that is best for kidney
cancer. Considerations are numerous but include: the size and general
radiographic appearance of the mass, the local anatomy of the mass,
the overall age and health condition of the patient, overall kidney
function, the number of lesions in the kidney, patient personal
preference, etc. The decision on a proper strategy for the treatment
of kidney cancer is challenging and should be made by each patient
in conjunction with a Urologist who is experienced in managing kidney
Candidates for laparoscpopic cytoreductive radical
nephrectomy include relatively healthy patients with kidney cancer
that has extended beyond the kidney and its immediate surrounding
tissues (metastatic kidney cancer). The operation tends to benefit
patients who can perform basic activities of daily living by themselves
and who do not have symptoms from their kidney cancer. Before undergoing
this type of surgery, patients should discuss their situation with
a Urologist who specializes in advanced kidney cancer and who has
extensive experience with this laparoscopic radical cytoreductive
Advantages / Disadvantages:
cytoreductive radical nephrectomy has the advantages intrinsic to
any laparoscopic or minimally invasive procedure in that patients
recover more quickly and with less pain. However, in the setting
of advanced kidney cancer, the minimally invasive advantages of
recovery are more important than ever as a rapid recovery may allow
patients the strength to receive the additional systemic treatments
that are required more quickly. While there is no proven benefit
to getting treatment more quickly, it is possible that expediting
the systemic treatment could improve the overall outcome.
Typically, with laparoscopic cytoreductive radical
nephrectomy patients get all the benefits of a minimally invasive
procedure. Blood loss is less with laparoscopic cytoreductive radical
nephrectomy compared to open cytoreductive radical nephrectomy.
Pain is also significantly less with laparoscopic cytoreductive
radical nephrectomy. The decreased blood loss, pain, and trauma
to the body also result in faster overall recovery from the operation
which, as previously stated, could be very important to outcome
by allowing systemic treatment to be initiated more rapidly.
The major disadvantages of laparoscopic cytoreductive
radical nephrectomy are that the procedure can only be safely performed
by surgeons with special training and extensive experience with
advanced kidney cancer laparoscopic procedures. Additionally, while
pre-operative imaging will currently provide surgeons with a good
understanding of the disease, it is impossible to determine the
exact extent of the kidney cancer until the time of surgery. As
such, there is a significant chance that a laparoscopic radical
cytoreductive nephrectomy will require open conversion
(change of approach to open cytoreductive radical nephrectomy) to
optimize the control of the cancer and minimize the risk of complications.
Results The tissue that is removed during the lapraroscopic
cytoreductive radical nephrectomy (entire kidney with the kidney
cancer and surrounding tissues) is sent to a pathologist who must
fix (preserve) the specimen, prepare slides, and evaluate
the tissue under the microsope. The final pathology
reveals the type of kidney cancer that has been treated, and also
stages the kidney cancer (determines how extensive the local spread
of the disease has been).
Activity after surgery - While patients will
typically be able to do routine activities such as eating and taking
care of every day needs, it is generally suggested that no heavy
lifting or vigorous activity be performed for four to six weeks
to allow the body to recover. While it is surgeon dependent, most
surgeons will suggest only light lifting (less than 10lbs), gentle
activity, and no driving for one to two weeks after surgery. It
is typical for patients to feel drained or lack energy for several
weeks after surgery, and complete and full return to activity will
usually take four to six weeks. However, every patient is different
and recovery is somewhat variable. Generally, the patient will feel
better day by day.
Wound care and bandages - With laparoscopy,
wound care is generally very easy. The dressings (bandages) are
usually removed by the patient at home the second day after surgery.
Under the bandages there are small pieces of surgical tape. Once
these start to peel off on their own, the patient may remove them.
Removing the tape in the shower may be helpful and the adhesive
will soften and allow the tape to be removed gently and without
pain. Under the tape are the small wounds. The stitches are below
the skin and do not have to be removed as they absorb by themselves.
Bathing - Swimming and bathing in a tub should
not be done for one week after surgery, but showering is usually
permitted any time after the second day after surgery. The shower
should be with regular soap and water. An effort should be made
not to allow the shower to directly hit the wounds for the first
several days. The wounds should be cleaned with a dry and clean
towel and left uncovered. A small amount of oozing is possible for
the first few days after surgery, and a clean gauze with surgical
tape can be used to keep clothing dry. However, if there is any
significant leakage from the wound or if the would should become
red, hot, tender, or swollen, you should contact your doctor immediately.
Follow-up visit Your doctor will typically
call with the final pathology report results one week after the
surgery has been performed. A follow-up visit with the surgeon is
usually scheduled approximately four weeks after the procedure has
been done. With cytoreductive radical nephrectomy of any type, the
combined efforts of urologic surgeons and medical oncologists who
provide systemic treatments must be carefully coordinated to provide
each patient the best timing for treatment.