Dr. med. Dirk Manski

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Radical Nephrectomy for Renal Cell Carcinoma

Indication for radical nephrectomy:

Radical nephrectomy is the gold standard of therapy for a large renal cell carcinoma.

Relative contraindications for nephrectomy:

Partial nephrectomy should be the preferred treatment for smaller tumors or even in large tumors, if partial nephrectomy is technically possible. This is especially important for patients with impending renal failure. Risk factors for impending renal failure after nephrectomy are increased serum creatinine, proteinuria, diabetes mellitus, arterial hypertension, bilateral renal cell carcinomas or familial renal cell carcinoma.

Surgical technique of radical nephrectomy:

A variety of surgical techniques are available: laparoscopic nephrectomy, retroperitoneoscopic nephrectomy, open transperitoneal nephrectomy or nephrectomy via a flank incision (Robson et al, 2002).

Laparoscopic and retroperitoneoscopic nephrectomy have a lower morbidity and are oncologically equivalent (Hemal et al, 2007). No significant clinical differences were found between the laparoscopic or retroperitoneoscopic approach (Desai et al, 2005). Laparoscopic nephrectomy has become the method of choice for T1–2 renal tumors, which are not suitable for partial nephrectomy and if the tumor size allows the endoscopic technique (EAU guideline, Ljungberg et al, 2010).

Open nephrectomy via a midline incision, subcostal incision or flank incision is preferred for an advanced local tumor stage, e.g. vein invasion with tumor thrombus, infiltration of neighbouring organs, lymph node enlargement or large tumor diameter. Open surgery is also advisable, if significant intraabdominal adhesions from previous surgery are suspected or if the technical skills of the surgeon are inadequate for laparoscopy.

Treatment of renal cell carcinoma with venous tumor thrombus:

Important for treatment planning is the accurate determination of the cranial extension of the tumor thrombus:

For technical details of the surgical management please see section radical nephrectomy.

Adrenalectomy in the context of tumor nephrectomy:

The need for routine adrenalectomy is hardly seen today. Using blunt and sharp dissection, the adrenal gland is separated from the adipose capsule and left in-situ. The involvement of the adrenal gland (1-3%) is almost never an expression of a continuous tumor growth, but represents often metastasis with a poor prognosis (Han et al, 2003). The probability of correct imaging of adrenal involvement using CT is 97%. If adrenal involvement is suspected, adrenalectomy is performed together with radical nephrectomy.

Regional lymphadenectomy:

Lymphadenectomy is not necessary for T1–2 tumors without suspicious lymph node enlargement, since no survival benefit could be demonstrated in a large EORTC study (Blom et al, 1999 and 2009). Some authors advocate on the basis of retrospective studies a lymphadenectomy if advanced tumors or enlarged lymph nodes are present. Lymphadenectomy is recommended from the crus of the diaphragm to the aortic bifurcation. For left-sided tumors the para-aortic lymph nodes are removed, for right-sided tumors the paracaval lymph nodes are removed, and regardless of the side the interaortocaval lymph nodes should be removed (Capitanio et al, 2011).

Oncological results after nephrectomy:

Please see Table T stage and survival and Robson stage and survival for oncological results after nephrectomy.

T stage of RCC and survival: five-year survival rates after radical nephrectomy (Tsui et al, 2000).
T stage Five-years survival rate
pT1 91 %
pT2 74 %
pT3 67 %
pT4 32 %

Clinical stage and survival: five-years survival rate after radical nephrectomy (Guinan et al, 1995).
Clinical tumor stage Five-years survival rate
Stadium I (limited to the kidney) 75–92 %
Stadium II (limited within Gerota's fascia) 63–77 %
Stadium III (venous invasion, pN+) 38–47 %
Stadium IV (pT4 or M1) 11–12 %

Adjuvant therapy after nephrectomy:

There is a high risk of disease progression for advanced renal cell carcinoma (pN+, T4 oder G3–4 tumors). To date, no effective adjuvant treatment for renal cell carcinoma has been described, neither for adjuvant immune therapy or targeted therapy.

Autologous tumor cell vaccination was able to show a therapeutic effect in one large randomized study, but the study has been disputed (Jocham et al, 2004). Studies with adjuvant immunotherapy with interferon or interleukin-2 were without clinical benefit.

Follow-up after radical nephrectomy:

There are no firm recommendations for follow-up of renal cell carcinoma. The EAU (Ljungberg et al, 2007) recommends follow-up after nephrectomy in dependence of the probability for metastasis, which can be assessed using the Mayo scoring system [Leibovich et al, 2003].

For low risk patients, clinical checks and ultrasound scans are sufficient, CT scans should only be initiated for typical symptoms of tumor progression. For patients with medium and higher risk, regular CT scans should be added to the follow-up. The frequency of CT scans is adapted according to the probability of metastasis (every 6 months to a year). For patients with bone pain or elevated AP, a bone scan is indicated.

Mayo Scoring System [Leibovich 2003] to assess the risk of metastases after nephrectomy.
Low-risk cancers (0–2 points) develop in 2% metastases after 3 years and in 7.5% metastases after 10 years.
Intermediate-risk carcinomas (3–5 points) develop in 20% metastases after 3 years and in 36% metastases after 10 years.
High-risk carcinomas (>6 points) develop in 63% metastases after 3 years and in 76% metastases after 10 years.
Risk factor Points
T stage
T1a 0
T1b 2
T2 3
T3–4 4
Tumor size
<10 cm 0
>10 cm 1
Lymph node status
pNx/pN0 0
pN1–2 1
1–2 0
3 1
4 3
Tumor necrosis
absent 0
present 1

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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