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   Chris Anderson
   P O Box 58534
   London
   SW13 9QQ

   Tel: 0781 360 1792
   Fax: 020 8741 0093

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  Kidney Cancer Treament

Please click on the following options to view:




  Surgical Options for Early stage RCC

Surgery is almost always utilized for the treatment of patients with renal cell cancer unless patients are too ill to tolerate the procedure. Currently, most physicians agree that the primary cancer should be removed even when patients have widespread cancer at diagnosis.

In patients with stage T1 and T2 renal cell cancer, surgery alone can cure the majority of patients; 75-96% of patients with stage I disease and 63-95% of patients with stage T2 disease are cured with surgery alone. (7)

Surgery can be curative for stage T3 renal cancer depending on the extent of disease, and the percentage of patients with this stage who are cured with surgery alone drops to 38-70%. (7)

Surgical removal of some metastatic cancers can also be curative. Surgery can also relieve symptoms caused by the cancer in patients with stage T3 and T4 renal cell cancer and in those with recurrent disease.

There are several surgical approaches that are utilized, depending on the extent of disease and the condition of the patient.



  Partial Nephrectomy (Nephron-Sparing Surgery)

Removing only the cancer and some surrounding healthy tissue-a procedure called a partial nephrectomy-is now considered the standard of care for the treatment of small renal cancers. The main benefit of this approach is that kidney function is preserved, which is particularly valuable for patients who:
  • already have poor kidney function
  • have only one kidney
  • have lesions in both kidneys (bilateral)
  • have an increased tendency to develop cancer in the other kidney (inherited diseases)
The benefits and safety of this approach have been repeatedly demonstrated in the treatment of patients with stage T1a renal cancer, which is defined a cancer that is less than 4 cm in diameter.(8/9)

Partial nephrectomy also appears to be a viable treatment option for patients with stage T1b cancers (which are 4-7 cm in diameter) if an adequate amount of normal tissue surrounding the cancer can be removed.(10) Patients with these slightly larger stage T1b cancers who are treated with partial nephrectomy have been shown to live as long and experience a similar cancer-free duration as patients treated with radical nephrectomy. (11) However, longer follow up aimed at confirming these findings is ongoing.

For those patients with stage T1b cancer that is more centrally located or those with multiple tumours, radical nephrectomy may be a better option.

A detailed and dedicated renal protocol CT scan helps plan the surgery. A renogram might be necessary to elucidate the relevant function of each kidney.


Figure 6: Intraoperative picture of open partial nephrectomy. The tumour has been excised

A partial nephrectomy interestingly is a much more complex operation than a radical nephrectomy. This is because it involves removing most of the surrounding fat of the kidney and isolating and clamping of the artery going to the kidney ( renal artery) as well as the vein draining from the kidney ( renal vein) . The purpose of this is to render the kidney free of flowing blood while one cuts into the kidney tissue to excise around the tumour.

Consequently, for a time the kidney does not get the oxygen that the incoming arterial blood usually supplies - a circumstance called ischaemia. Kidneys can tolerate ischaemia for a limited time (30 mins: preferably 20 mins or less) hence putting the surgeon under pressure to do the tumour excision rapidly. In anticipated complex cases ice slush is sometimes put around the kidney to cool it down allowing the kidney to tolerate a longer ischaemic time (45 minutes)

Figure 7: Ice slush packed around kidney to enable longer ischaemic time

Complications of partial nephrectomies are similar to that of radical nephrectomies. They carry a more significant risk for intra- and postoperative haemorrhage. Postoperative urinary leaks may occur, and an urinoma (urine collection) may collect which may necessitate drainage. Occasionally a ureteric stent may be inserted to control and slow a urinary leak.

Selected urological surgeons have a high level of experience doing open partial nephrectomies. Patients should avoid the surgeon who only does it occasionally! To do a partial nephrectomy laparoscopically is even more challenging due to the greater difficulty using long rigid instruments. (See - laparoscopic nephrectomy). Patients should particularly seek out surgeons with the requisite skills and track record in laparoscopic partial nephrectomy if this option is being considered.

Transperitoneal, retroperitoneal and hand-assisted laparascopic techniques have all been described. In comparative studies, Laparoscopic partial nephrectomy has shown early functional advantages over the open procedure in terms of earlier resumption of diet and shorter hospital stay. (12).

I was one of the early adopters of the Robotic approach to Partial Nephrectomy in the UK. The popularity of the robotic approach has increased considerably as the enhanced dexterity and maneuverability I of the "wristed" instruments have made the excision of the tumour and subsequent reconstruction (all done under considerable time pressure whilst the blood vessels are clamped) easier than pure laparoscopy. (see - Robotic renal surgery).



  Radical Nephrectomy

Surgery for some Stage T1 and most StageT2 renal cell cancer typically involves removing the entire affected kidney and the attached adrenal gland, the proximal one-half of the ureter and lymph nodes adjacent to blood vessels entering the middle of the kidney. This is called Radical Nephrectomy.

In some cases, the adrenal gland may not need to be removed. The adrenal glands are complex organs that work with the brain to produce and regulate important hormones, including adrenaline for coping with physical and emotional stress, corticosteroids for suppressing inflammation, and cortisol for controlling the body's use of fats, proteins, and carbohydrates.

Researchers have reported that patients who underwent nephrectomy but did not have the adrenal gland removed survived as long and were not at any higher risk of postoperative complications than patients who underwent nephrectomy with removal of the adrenal gland. (13)

This operation was traditionally performed as an open procedure via a number of different approaches. Open radical nephrectomy, nowadays is normally reserved for large (i.e. more than 8-10 cm) tumours, or tumours that have invaded the renal vein or further major veins (inferior vena cava). If successfully removed then the likelihood of recurrence in the renal bed has been reported to be 2 to 3% (14).

The Standard approach for a radical nephrectomy nowadays is a Laparoscopic Radical Nephrectomy. (See - laparoscopic nephrectomy)

I have been one of the pioneers in robotic renal surgery in the UK and interestingly feel that the place of robotics is more suited to Partial Nephrectomy than Total Nephrectomy. (see Robotic renal surgery). The capability of the fine dissection afforded by the robot is not as important in total nephrectomy as it is an operation where only "removal" of a whole organ takes place , with no reconstruction needed. Hence the pure laparoscopic approach is perfectly adequate and the greater expense of robotics, with no specific gain for the patient (in this particular operation) probably doesn't justify the routine use of robotics in nephrectomy.



  Surgery in Advanced Renal Cancer and removal of metastases

Surgery for Stage T4 involves radical nephrectomy if the patient is fit enough. This is followed by systemic therapy. Results from clinical trials have shown that radical nephrectomy appears to improve survival of patients with metastatic renal cell cancer.

For patients with Stage T4 disease whose cancer has spread locally, but not to distant sites in the body, radical nephrectomy may be curative. However, because most patients with Stage T4 renal cell cancer have distant metastases, surgery is typically followed with additional systemic treatment. Surgery is considered a local therapy because it treats cancer in a specific area but does not treat cancer that has spread to other locations in the body.

Some patients can experience long-term cancer-free survival after surgical resection of metastatic cancers. Results of a clinical trial indicate that renal cell cancer that has spread to the lungs can be removed with surgery. Among patients treated with surgery for lung metastases but no evidence of cancer elsewhere in the body, including the kidney, nearly 40% survived five years or more. Patients with only a single site of cancer in the lung experienced the best outcomes; nearly 50% survived five years or more compared to 19% of patients who had more than one site of cancer removed. (15)

An alternative to surgery: It is frequently not possible to perform a radical nephrectomy in older or debilitated patients. In these cases a procedure called arterial embolization is sometimes used to provide relief from pain or bleeding. During arterial embolization small pieces of a special gelatin sponge or other material are injected through a catheter to clog the main renal blood vessel. This procedure shrinks the cancer by depriving it of the oxygen-carrying blood that it needs to survive and grow. Arterial embolization may also be used prior to surgery to make the procedure easier.



  Laparoscopic Nephrectomy

Laparoscopic nephrectomy is a well-accepted technique for renal malignancies. Initially, a large tumour size was considered to be a contraindication, but has become less of an issue. The limitation tends to be expertise of the laparoscopic urologist.

It involves inserting rigid tubes (ports) through 3 or 4 tiny (0.5-1cm) holes in the body wall .Long rigid instruments and a camera are placed through these ports thereby enabling one to operate with the help of seeing the image on a TV screen.

The kidney or other tissue is placed in a bag when it has been dislodged from its attachments inside the body and one of the incisions is extended on the skin to pull the bag through.


Figure 8: port placements for transperitoneal laparoscopic nephrectomy.

The advantages for the patients are well described and involve;
  • shorter operation time (in skilled hands)
  • less blood loss
  • rare blood transfusion requirements
  • less post operative pain and pain killers
  • quicker mobilisation
  • shorter hospital stay
  • earlier resumption of normal activities.
Approaches can be either transperitoneal (through the front of the abdomen) or retroperitoneal (through the flank). A comparison of the two shows no difference in operating time, cost, and length of stay or postoperative convalescence.

Hand-assisted laparoscopic surgery is also common. This has the advantage of one of the surgeons hands being inside the body and therefore able to retract, dissect and guide the laparoscopic instruments with tactile feedback. Also, it allows a port large enough to remove the kidney whole.

The complication rates for laparoscopic nephrectomy ranges from 8% to 17%, with conversion to an open procedure occurring in up to 4% of cases (16).


Figure 9: hand assisted laparoscopy



  Minimally Invasive Ablative Techniques

With ablative techniques the tissue is destroyed in situ rather than be surgically extirpated. The procedures have appeared owing to the demand for minimally invasive techniques and the acceptance of nephron-sparing surgery.

The two most common ablative procedures are cryotherapy and radiofrequency ablation (RFA). Other techniques have been employed such high-focused ultrasound (HIFU), microwave thermotherapy and laser interstitial thermal therapy but are still very much in the development/pilot stage.

The techniques are still being developed and refined. Furthermore the inclusion criteria based on size, site and patient selection needs to be more clearly defined.



  Cryotherapy

The first cases to be performed in the UK were performed by me in December 2004. I have since accumulated one of the largest personal series in Europe and remain an opinion leader in the UK. I am a proctor in teaching others for UK and Europe

What is laparoscopic cryotherapy?

Cryotherapy is a procedure whereby tissue in the body is destroyed by the technique of freezing. The tissues are subjected to an extremely low temperature ( -40 degrees Celsius) and cells inevitably undergo complete destruction. There have been many studies shown to prove this.

In the context of renal Cryotherapy, the tumour is punctured with needles which are subsequently frozen with a view to destroying the cancer cells completely. The tumour becomes enveloped in an "ice ball" during the procedure. This results in both immediate and delayed tissue destruction. By freezing and then thawing tissue, the effects are cell destruction (necrosis) and ultimately scar tissue formation (fibrosis) (17).

Cryotherapy is a relatively new treatment for early stage renal cancer and although international studies show very promising results the follow up of these patients is only 3- 5 years. This places the procedure in a category where one cannot comment on the long term cancer control achieved. Therefore not everyone should be automatically considered eligible for the procedure and patients need to be fully informed of its technique and outcomes before choosing it.

Who is eligible for this treatment?

This method is only applicable to small renal lesions, usually below 4cm. It is ideally suited to people who have small renal tumours but who, for a clinical reason are not able to be subjected to the metabolic demands of a large open operation in order to remove it.

Another group of patients would be those who have a single kidney with either single or multiple tumours. By targeting these lesions with needles one invariably only freezes the tumour cells and spares the surrounding normal renal tissue. It is therefore preferable for such cases as it is a procedure where as much normal renal tissue is spared. It is also ideal in someone who has impaired renal function as the impact of this treatment on renal function is negligible.

A final group in whom it has been shown to be successful is those who have a familial tendency to develop multiple renal tumours from a young age (particularly Von Hippel Lindau syndrome), as these patient are likely to require multiple surgical attempts to remove their cancers over a lifetime it is sensible to spare as much normal renal tissue from the start by using this minimally invasive technique.

How is it done?

The procedure is done as part of a laparoscopic operation. This means that it is a minimally invasive procedure (keyhole surgery) with its obvious advantages. These advantages pertain to less post operative pain and earlier return to normal activity.

Multiple needles are inserted into the tumour and by forcing pressurised Argon gas through the needles one is able to reduce the temperature at the tip of the needle to extremely low temperatures ( -40 degrees Celsius) . These needles are then thawed by passing pressurised helium through the needles.

This procedure is undertaken mainly laparoscopically by a Urologist. One method is hand assisted laparoscopy, whereby an incision of a 6-7cm is made through the umbilicus and this will allow the insertion of the surgeons hand to help direct the needle. There will be two 1cm incisions in the flank and possibly a further 1cm incision in the mid-line above the umbilical incision.

Alternatively, pure laparoscopy might be used. In this case there will merely be 3 or four 1 cm cuts on the skin surface. The procedure takes about three hours and one would expect pain control to be excellent.

In the USA there are some centres doing it directly through the flank under X-ray imaging guidance (percutaneously) and performed by a Radiologist.


Figure 9: hand assisted laparoscopic renal Cryotherapy. Note the inserted cryotherapy needles.

The advantage of the laparoscopic approach is that the tumour can be visualised, the kidney fully mobilised and thus minimise damage to surrounding structures. Monitoring of the 'ice ball' produced during the procedure is done under ultrasound guidance. The less invasive percutaneous route has been used with MRI control .


Figure 10: renal tumour being frozen during cryotherapy

What to Expect

It would be expected that you would be discharged on the second morning after the operation.

In the longer term, you would have CT scans performed to monitor the progress of the kidney and the first would be expected at three months post operatively. In the event of tumour recurrence one would have to re-evaluate the best form of management which might involve a repeat of the same procedure or alternatively a larger undertaking with the removal of the entire kidney if feasible.

Is the treatment effective?

There have been numerous studies that have shown the efficacy of this method. The largest laparoscopic study describes the outcomes of 150 patients, of which 56 had more than 3 year follow up. (Gill I S, Remer EM, Hassan WA et al. Renal Cryoablation: outcome at 3 years. J Urol 2005173:1903-7) There was a 75 % shrinkage of tumour size seen at 3 years and of the entire series there were 2 patients who had recurrence of tumour. They went on to have their kidney removed with no further problems.

The results were best in those patients who have an isolated renal tumour (commonly called sporadic) in one kidney: here there was a 98 % survival rate from renal cancer at 3 years.

In patients who had tumours in both kidneys , the results showed a 3 year survival of 89% .The reason for this is the fact that the tumour treated with cryotherapy was in some cases obviously being done on a metastasis ( spread) rather than a primary tumour.

Of the probe-ablative therapies currently available for renal tumours, cryotherapy is the most studied and clinically applied treatment. Relatively short term results are very encouraging but long term data is needed to compare cancer control with total or partial removal of the kidney. Patients have to be carefully selected: those with small, peripheral, renal lesions are best suited.

Are there limitations?

One of the main problems is that cryotherapy (and all other ablative treatments like RFA and HIFU) does not generate pathological specimens for the pathologist to study and stage the cancer accurately. This is in contrast to a partial nephrectomy where the tumour alone or total nephrectomy where a whole kidney is given to the pathologist for analysis.

Another critique is that we have to rely on CT or MRI scans to determine whether there is a good response to cryotherapy and also whether there is any recurrence of tumour subsequently. This requires long term, meticulous follow up. Patients need to be prepared for and committed to this.



  Radiofrequency Ablation

This procedure uses radiofrequency waves and converts them into heat, resulting in thermal (heat) damage to the kidney tissue. The radiofrequency electrodes are introduced either percutaneously or laparoscopically under radiological or visual guidance.

Preliminary results from initial trials were promising but there have been concerns about the reliability of RFA as a monotherapy for RCC. Success of the technique is shown in postoperative CTscans . If the procedure has been successful then the lesion should not enhance with contrast CT. Some studies have shown small areas of still viable cancer in lesions that have been treated with RFA some 12 to 24 months previously.

However, these findings may not be due to the technique, but rather the inability to accurately monitor the lesion during ablation. Improvements are needed to predict and assess the precise margin of ablated tissue (17).

generator radiofrequency probe
Radiofrequency Probe and Generator




  Robotic Technology

The development of the daVinci robot system is gradually being incorporated into urological surgery. The results from robot-assisted radical prostatectomy are encouraging and more and more procedures are reaping the benefit of the advantages robotic surgery offers.
There have been a number of reports of the daVinci system being employed for radical nephrectomies as well partial nephrectomies. Although in its early stages robot technology may revolutionise urological surgery.



  Therapy for advanced Kidney Cancer

Approximately 70 % of patients are potentially curable if they present with localised or locally advanced disease, by nephrectomy alone. Patients with metastatic disease have a median survival of 1 year and 5-year survival of 0-20 %.(18)

Renal cell cancers are typically treated with both local and systemic therapy. Local therapy consists of surgery to remove the entire affected kidney and any surrounding cancer. Systemic therapy is directed at destroying cancer cells throughout the body and may include chemotherapy, targeted therapy, or immunotherapy. The best results are achieved when combining two or more of these approaches.Radiotherapy is applied in selected cases.



  Immunotherapy

- Immunotherapy works by stimulating the immune system to fight the cancer. The two most frequently used types of immunotherapy are Proleukin® (interleukin-2) and alfa interferon.

Proleukin® (interleukin-2): Prior to the FDA-approval of new targeted therapies, interleukin-2 was the standard of care for patients with renal cell cancer. It is typically administered in high doses as an inpatient treatment and has historically been associated with severe side effects. However, the safety of high-dose Proleukin has significantly improved over the past decade. The high dose regime of Interleukin 2 has shown complete response rate in patients with metastatic disease in 7% (19).

Alpha interferon: Interferon is naturally produced in the body and stimulates the immune system. Alpha interferon is a compound produced in a laboratory that mimics the action of natural interferon and has been shown to stimulate the immune system to recognize and destroy some types of cancer cells.

Treatment of renal cell carcinoma with alpha interferon appears to produce anticancer responses in less than 15% of patients with advanced renal cell cancer. Because side effects can be severe and it has not been shown to improve survival, the use of interferon alone in the treatment of renal cell carcinoma remains controversial. It is approved for treatment of RCC in Europe with objective response rates of 11-15% and a complete response rate in 2% (20).

Unfortunately combination trials of interferon- and interleukin-2 have not shown any significant benefit and were shown to be no better than high dose interleukin-2. However, evaluation of this combination is still ongoing.



  Chemotherapy

Chemotherapy has traditionally shown disappointing results in the treatment of RCC. Many trials have explored their potential use but with little avail. Only 10-15% of patients experience an anticancer response to currently available single chemotherapy drugs.

However, combinations of chemotherapeutic agents have given better results. The results are similar to that of cytokine-based immunotherapy and are very much dependant on prognostic factors and individual patients.



  Targeted Therapy

A targeted therapy is one that is designed to treat only the cancer cells and minimize damage to normal, healthy cells. The advantages of cancer treatments that "target" cancer cells may include reduced treatment-related side effects and improved outcomes.

Currently, there are three targeted therapies that are FDA-approved for the treatment of advanced renal cell cancer. With the FDA-approval of the targeted therapies Nexavar® (sorafenib), Sutent® (sunitinib), and Torisel® (temsirolimus), surgery followed by targeted therapy has become the standard treatment for metastatic renal cell cancer, in the USA.

Sutent® (sunitinib): Two Phase II clinical trials have shown that approximately 40% of patients with recurrent renal cell cancer respond to treatment with Sutent, and approximately one-quarter of patients experienced stable disease for three months after treatment.(21)

Additionally, a Phase III trial that compared Sutent to interferon-alfa in the initial treatment of patients with metastatic renal cell cancer has shown that patients treated with Sutent experienced significantly longer survival without cancer progression than patients treated with interferon-alfa. Also, more than one-third of the patients treated with Sutent experienced at least a partial reduction in detectable cancer, compared with only 9% of patients treated with interferon-alfa.(22)

Nexavar® (sorafenib): A large clinical trial comparing Nexavar to placebo in the treatment of more than 900 patients who had experienced cancer progression while receiving other treatments is not yet complete. However, preliminary results suggest that patients treated with Nexavar survive longer without a worsening of their cancer.(23) Nexavar was FDA-approved based on the findings of this large trial.

As an initial treatment, Nexavar has been shown to stabilize disease in patients with metastatic renal cell cancer. Patients treated with Nexavar for 24 weeks were more likely to remain free of cancer progression at six months after treatment than patients treated with placebo.(24)

In addition to improving survival of patients with advanced disease, Nexavar does not appear to negatively affect overall quality of life and even relieves certain symptoms compared to placebo. The symptoms that were improved with Nexavar include cough, fever, and shortness of breath. Overall, Nexavar did not worsen the quality of life, including physical, emotional, social, and functional well-being.(25)

Torisel® (temsirolimus): The clinical trial that prompted FDA approval of Torisel included 626 patients with metastatic RCC who had a poor prognosis and had not received prior therapy.(26) Patients were treated with either Torisel, interferon alfa, or a combination of Torisel plus interferon alfa (combination group).
  • Patients treated with Torisel had longer survival by nearly 3.6 months and significantly longer progression-free survival than patients treated with interferon alone.
  • Patients in the combination group did not experience a significant improvement in survival compared with patients treated with interferon alone.
  • Fewer patients suffered from severe side effects in the group treated with Torisel than in the group treated with interferon.




  Radiation Therapy

Radiation therapy uses high-energy radiation to kill cancer cells. External beam radiation therapy uses radiation delivered from outside the body that is focused on the cancer. Radiation therapy is sometimes used as the main treatment for kidney cancer for patients whose general health is too poor to undergo surgery. Radiation therapy can also be used to temporarily palliate or ease symptoms of kidney cancer such as pain, bleeding or problems caused by metastasis. Unfortunately, renal cell cancer is not very sensitive to radiation and while the growth of cancer can be slowed, it cannot be entirely eliminated.

Currently, the use of radiation therapy before or after removing the cancer is not routinely recommended because clinical studies have not shown any improvement in patient outcomes.



  I am Having Surgery � What to Expect

Please select from the following:

  Open Partial Nephrectomy   Laparoscopic Radical or Partial
    nephrectomy
  Laparoscopic Cryotherapy  


  Open Partial Nephrectomy

Before the operation
  • You will be admitted to the ward on the day of surgery.
  • You will need to have some tests done prior to your operation. These will be a blood test, a chest x-ray and an ECG. This will be on the day of admission or organised before your admission.
  • Mr Anderson will mark your body with a cross or arrow to indicate the correct side for the operation.
  • You need to have no food or drink 6 hours before the surgery
  • Approximately 4 hours before the surgery we will insert a drip into your arm for hydration. During this period you must not eat any food or drink until after the operation.
  • You will wear anti-embolism socks (like very tight stockings) to prevent blood clots forming in your legs.
  • The anaesthetist will see you before or on the morning of surgery.
After the operation
  • You will be in the High Dependency Unit for 1 to 2 nights
  • You will probably have:
    • Oxygen and a tube in your nose (NG tube)
    • A drip in your neck (central line)
    • An epidural or morphine machine to control your pain
    • A wound drain to remove excess blood and fluid (7 days)
    • A catheter to drain your bladder (2 to 3 days)
  • You will gradually be allowed to eat and drink.
  • You may need laxatives to help you regularly open your bowels.
  • The physiotherapist will help you to exercise and to get out of bed
  • Your blood will be tested almost every day (for full blood count and kidney function).
  • You will probably be ready to go home 5 to 7 days after the operation.
  • Your wound care can be conducted by a District Nurse your GP or at the hospital.
  • We will arrange regular appointments for follow up tests and scans.
  • We can provide you with a sickness certificate to cover your time in hospital.
At home
  • You will feel tired for about 2 to 3 months.
  • Take gentle exercise.
  • No heavy lifting such as children or luggage.
  • Do not drive for 4 to 6 weeks due to the risk of internal damage if you have to do an emergency stop.
  • Keep the wound clean by taking a shower rather than a bath.
  • Watch for signs of wound infection such as pain, redness, and swelling and discharge (oozing).
  • Watch for any swelling or pain in your abdomen. This can be a sign of a leak of urine from your kidney. If you notice this, contact the ward or Mr Anderson directly.
  • Talk to your GP or District Nurse if you have any concerns. You can also contact Mr Anderson directly.
Are there any risks?

This is a common and safe procedure, but every procedure has some risks associated with it. Below is a list of risks for a partial nephrectomy that has been compiled by the British Association of Urological Surgeons:

Common
  • Temporary insertion of a bladder catheter and wound drain.

    Occasional
  • Bleeding requiring further surgery or transfusions.
  • Total nephrectomy will be performed if partial is thought to be not possible.
  • Entry into lung cavity requiring insertion of temporary drainage tube.
  • Need of further therapy for cancer control.
  • Infection, pain or bulging of incision site requiring further treatment.

    Rare
  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, deep vein thrombosis, heart attack and death).
  • Rarely urinary leak from kidney edge requiring further treatment or stent.
  • Involvement or injury to nearby local structures -blood vessels, spleen, liver, lung, pancreas and bowel requiring more extensive surgery.
  • May be abnormality other than cancer on microscopic analysis.
  • Need for further treatment if histology suggests incomplete removal.

    Further information on some of the risks involved are detailed below.
    • Chest infection may occur. It is extremely important to do deep breathing exercises and cough up any phlegm after the operation. The physiotherapist will help you. If you develop a chest infection, you may require antibiotics and more intensive physiotherapy.
    • Bleeding may occur during the operation. If this happens, you might need a blood transfusion which will be done at the same time as the operation.
    • Diaphragm Perforation: a small puncture in the diaphragm may occur during the operation. If this happens a chest drain may be required which will help remove fluid from your lungs until the puncture has healed (about 3 days).
    • A blood clot may occur in the legs or in the lungs which means you will require medication to keep your blood thin for several weeks or months.
    • Paralytic ileus may occur. This is when the bowel becomes distended (swollen) with gas and causes abdominal swelling. The bowel needs to be rested for 24 to 48 hours. You will not be allowed to eat or drink. You will have a drip for hydration. This condition invariably settles in 2 to 3 days.
    • Bowel injury may occur. A surgical instrument might damage the bowel during the procedure. This is usually noticed at the time and dealt with. It should not cause you any problems.
    • Urinary leakage: urine may leak from the kidney into surrounding tissue. The doctors and nurses will monitor the fluid in your drain bag and send a sample to the laboratory. If urine is leaking, the drain will need to stay in for 10 to14 days whilst the leak dries up.
    • Bulging at incision site may occur due to damage to the nerves that usually keep the muscles in that area firm. If this happens, you might need a corset-like support or even further surgery to correct the bulge. This is a complication that unfortunately develops in some people. It is unpredictable as to who might be affected.




      Laparoscopic Radical or Partial nephrectomy

    What is a laparoscopic Radical nephrectomy?

    It is an operation to remove the kidney using key hole surgery. The surgeon makes 2 to 3 small incisions (cuts), with one longer incision at the end of the operation to remove the kidney. The operation takes approximately 2 hours.( link to radical nephrectomy)

    What is a laparoscopic Partial nephrectomy?

    It is an operation to remove a cancerous tumour in the kidney and leave behind the remaining normal kidney using keyhole surgery. The surgeon makes 2 to 3 small incisions (cuts). The operation takes approximately 2-4 hours.( link to radical nephrectomy)

    Before the operation
    • You will attend an arranged appointment before the day of admission for various tests. These will be certain blood tests, ECG, chest X-ray.
    • You will be admitted to the ward on the day before surgery. Sometimes it may be on the day of surgery
    • Mr Anderson will mark your body with an arrow to indicate the correct side for kidney removal
    • You need to have no food or drink 6 hours before the surgery.
    • Four hrs before surgery, we will set up a drip which means that you will not be allowed any food or drink until after the operation. A drip is a tube inserted into a vein (in your arm) to allow fluids (or drugs) to be given directly into the blood stream.
    • You will wear anti-embolism socks (like very tight stockings) to prevent blood clots forming in your legs.
    • The anaesthetist will see you before surgery; either at an arranged time or on the day of surgery.
    After the operation
    • You might be in the High Dependency Unit for 1night if necessary.
    • You will probably have:
      • Oxygen and a tube in your nose (NG tube)
      • A drip in your neck (central line)
      • Morphine machine to control your pain
      • A wound drain to remove excess blood and fluid (1 to 2 days)
      • A catheter to drain your bladder (1 to 2 days)
    • You will be allowed to eat and drink quite soon after the operation.
    • You may need laxatives to help you regularly open your bowels.
    • The physiotherapist will help you to exercise and to get out of bed.
    • Your blood will be tested almost every day (for full blood count and kidney function).
    • You will probably be ready to go home 3 to 4 days after the operation.
    • You may have dissolvable stitches (that disappear naturally after a while) or wound clips (a District Nurse, or the hospital can remove the clips).
    • We will arrange regular appointments for follow up tests and scans.
    At home
    • You might feel tired for about a month.
    • Take gentle exercise.
    • No heavy lifting, such as children, luggage.
    • Do not drive for 3 to 4 weeks due to the risk of internal damage if you have to do an emergency stop.
    • Keep the wound clean by taking a shower rather than a bath.
    • Watch for signs of wound infection such as pain, redness, swelling and discharge (oozing).
    • Talk to your GP, District Nurse or contact the ward or Mr Anderson directly if you have any concerns.
    Are there any risks?

    This is a common and safe procedure, but every procedure has some risks associated with it. These are related to the anaesthetic and the surgery itself:
    Below is a list of risks for a laparoscopic nephrectomy that has been compiled by the British Association of Urological Surgeons:

    Common
    • Temporary insertion of a bladder catheter and wound drain.
    Occasional
    • Bleeding requiring further surgery or transfusions.
    • Entry into lung cavity requiring insertion of temporary drainage tube.
    • Need of further therapy for cancer control.
    • Infection, pain or bulging of incision site requiring further treatment.
    Rare
    • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, deep vein thrombosis, heart attack and death).
    • Rarely urinary leak from kidney edge requiring further treatment or stent.
    • Involvement or injury to nearby local structures -blood vessels, spleen, liver, lung, pancreas and bowel requiring more extensive surgery.
    • May be abnormality other than cancer on microscopic analysis.
    • Need for further treatment if histology suggests incomplete removal.
    Further information on some of the risks involved are detailed below:
    • Bleeding may occur during the operation. If this happens, you might need a blood transfusion which will be done at the same time as the operation.
    • Diaphragm Perforation: a small puncture in the diaphragm may occur during the operation. If this happens a chest drain may be required which will help remove fluid from your lungs until the puncture has healed (about 3 days).
    • A blood clot may occur in the legs or in the lungs which means you will require medication to keep your blood thin for several weeks or months. It is very important to get out of bed and move around as soon as possible after the operation.
    • Chest infection may occur. It is extremely important to do deep breathing exercises and cough up any phlegm after the operation. The physiotherapist will help you. If you develop a chest infection, you may require antibiotics and more intensive physiotherapy.
    • Paralytic Ileus may occur. This is when the bowel becomes distended (swollen) with gas and causes abdominal swelling. The bowel needs to be rested for 24 to 48 hours. You will not be allowed to eat or drink. You will have a drip for hydration. This condition invariably settles in 2 to 3 days.
    • Bowel injury may occur. A surgical instrument might damage the bowel during the procedure. This is usually noticed at the time and dealt with. It should not cause you any problems.




      Laparoscopic Cryotherapy

    What is laparoscopic cryotherapy?

    Cyrotherapy is a procedure whereby tissue in the body is destroyed by the technique of freezing. The tissues are subjected to an extremely low temperature ( -40 degrees Celsius) and cells inevitably undergo complete destruction. There have been many studies shown to prove this. In the context of renal Cryotherapy, the tumour is punctured with needles which are subsequently frozen with a view to destroying the cancer cells completely.

    Cryotherapy is a relatively new treatment for early stage renal cancer and although international studies show very promising results the follow up of these patients is only 3- 5 years. This places the procedure in a category where one cannot comment on the long term cancer control achieved. Therefore not everyone should be automatically considered eligible for the procedure and patients need to be fully informed of its technique and outcomes before choosing it.

    Who is eligible for this treatment?

    This method is only applicable to small renal lesions, usually below 4cm. It is ideally suited to people who have small renal tumours but who, for a clinical reason are not able to be subjected to the metabolic demands of a large open operation in order to remove it.

    Another group of patients would be those who have a single kidney with either single or multiple tumours. By targeting these lesions with needles one invariably only freezes the tumour cells and spares the surrounding normal renal tissue. It is therefore preferable for such cases as it is a procedure where as much normal renal tissue is spared. It is also ideal in someone who has impaired renal function as the impact of this treatment on renal function is negligible.

    A final group in whom it has been shown to be successful is those who have a familial tendency to develop multiple renal tumours from a young age (particularly Von Hippel Lindau syndrome), as these patient are likely to require multiple surgical attempts to remove their cancers over a lifetime it is sensible to spare as much normal renal tissue from the start by using this minimally invasive technique.

    How is it done?

    The procedure is done as part of a laparoscopic operation. This means that it is a minimally invasive procedure (keyhole surgery) with its obvious advantages. These advantages pertain to less post operative pain and earlier return to normal activity. Multiple needles are inserted into the tumour and by forcing pressurised Argon gas through the needles one is able to reduce the temperature at the tip of the needle to extremely low temperatures ( -40 degrees Celsius) . These needles are then thawed by passing pressurised helium through the needles.

    What to Expect

    You would be prepared for a general anaesthetic in advance of the procedure which would involve the taking of some blood tests and possibly chest x-ray and ECG, depending on your level of fitness and age. The procedure would be done on the same day as arrival and you would be seen by the anaesthetist on that day.

    As mentioned, a minimally invasive technique is used. One method is hand assisted laparoscopy, whereby an incision of a 6-7cm is made through the umbilicus and this will allow the insertion of the surgeons hand to help direct the needle. There will be two 1cm incisions in the flank and possibly a further 1cm incision in the mid-line above the umbilical incision.

    Alternatively, pure laparoscopy might be used. In this case there will merely be 3 or four 1 cm cuts on the skin surface. The procedure takes about three hours and one would expect pain control to be excellent. You might have a rubber tube coming out of one of the small above mentioned holes, which would be there for a day. You will also have a catheter in the bladder which will come out the following morning. Finally, you would have an intravenous line in one of your arms.

    It would be expected that you would be discharged on the second morning after the operation. Once home, we would suggest a gradual return to normal activity over a period of about a week. Return to work needs to be decided on the nature of the work and each individual case would be discussed.

    In the longer term, you would have CT scans performed to monitor the progress of the kidney and the first would be expected at three months post operatively. In the event of tumour recurrence one would have to re-evaluate the best form of management which might involve a repeat of the same procedure or alternatively a larger undertaking with the removal of the entire kidney if feasible.

    Are there complications?

    Common
    • Temporary insertion of a bladder catheter and wound drain.
    Occasional
    • Bleeding requiring further surgery , transfusion or further intervention to stop the bleeding
    • Entry into lung cavity requiring insertion of temporary drainage tube.
    • Need of further therapy for cancer control.
    • Infection, pain or bulging of incision site requiring further treatment.
    Rare
    • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, deep vein thrombosis, heart attack and death).
    • Rarely urinary leak from kidney edge requiring further treatment or stent.
    • Involvement or injury to nearby local structures -blood vessels, spleen, liver, lung, pancreas and bowel requiring more extensive surgery.
    • May be abnormality other than cancer on microscopic analysis.
    • One can develop a hernia at the site of one of incisions, this usually takes a long period of time to develop but can be managed surgically at a later date if this is problematic.
    Is the treatment effective?

    There have been numerous studies that have shown the efficacy of this method. The largest laparoscopic study describes the outcomes of 150 patients , of which 56 had more than 3 year follow up . (Gill I S, Remer EM, Hassan WA et al. Renal Cryoablation: outcome at 3 years. J Urol 2005173:1903-7) There was a 75 % shrinkage of tumour size seen at 3 years and of the entire series there were 2 patients who had recurrence of tumour. They went on to have their kidney removed with no further problems.

    The results were best in those patients who have an isolated renal tumour (commonly called sporadic) in one kidney: here there was a 98 % survival rate from renal cancer at 3 years.

    In patients who had tumours in both kidneys , the results showed a 3 year survival of 89% .The reason for this is the fact that the tumour treated with cryotherapy was in some cases obviously being done on a metastasis ( spread) rather than a primary tumour.

    Of the probe-ablative therapies currently available for renal tumours, cryotherapy is the most studied and clinically applied treatment. Relatively short term results are very encouraging but long term data is needed to compare cancer control with total or partial removal of the kidney.

    Are there limitations?

    One of the main problems is that cryotherapy (and all other ablative treatments like RFA and HIFU) does not generate pathological specimens for the pathologist to study and stage the cancer accurately. This is in contrast to a partial nephrectomy where the tumour alone or total nephrectomy where a whole kidney is given to the pathologist for analysis.

    Another critique is that we have to rely on CT or MRI scans to determine whether there is a good response to cryotherapy and also whether there is any recurrence of tumour subsequently. This requires long term, meticulous follow up.Patients need to be prepared for and committed to this.



      References

    1. Statistics from Cancer Bacup, 2003
    2. McCredie M, and Stewart JH . risk factors for renal cancer in New South Wales-cigarette smoking, Eur J Cancer 28A(1992) 2050-2054
    3. Prineas RJ, Folsom AR, Zhang ZM.,et al. Nutrition and other risk factors for renal carcinoma in post menopausal women.Epidemiology,8(1997)31-36
    4. Wolk A, Gridley G,Niwa S, Lindblad P,McCredie M, Melemgaard A et al. International renal cell cancer study VII. Role of diet. ,Int J cancer,65(1996)67-63
    5. Ms Laughlin JK, Chow WH, Mandel JS et al. International renal cell cancer study VIII. Role of diuretics , other antihypertensive medications and hypertension. Int J Cancer 63 ( 1995) 216-221.
    6. Vamvakas S , Bruning T , Thomasson B et al.Renal cell cancer correlated with occupational exposure to trichloroethylene.J Cancer Res.Clin .Onc 124(1998) 374-382
    7. Lam JS, Shvarts O, Pantuck AJ. Changing concepts in the surgical management of renal cell carcinoma. European Urology. 2004;45:692-705.
    8. Becker F, Siemer S, Humke U, et al. Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: Long-term survival data of 216 patients. European Urology. 2006;49(2):308-13.
    9. Joniau S, Vander Eeckt K, Van Poppel H. The indications for partial nephrectomy in the treatment of renal cell carcinoma. Nature Clinical Practice Urology. 2006;3(4):198-205.
    10. Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. Journal of Urology. 2004;171(3):1066-70.
    11. Dash A, Vickers AJ, Schachter LR, et al. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm. British Journal of Urology International. 2006;97(5):939-45.
    12. Schiff JD, Palese M, Vaughan ED, Sosa RE, Coll D, Del Pizzo JJ. Laparoscopic versus open partial nephrectomy in consecutive patients: the Cornell experience. BJU Int 2005; 96 (6): 811-14
    13. Siemer S, Lehmann J, Kamradt J, et al. Adrenal metastases in 1635 patients with renal cell carcinoma: outcome and indication for adrenalectomy. Journal of Urology. 2004;171(6 Pt 1):2155-9.
    14. Itano NB. Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol 2000; 164: 322
    15. Friedel G, Hurtgen M, Penzenstadler M, et al. Resection of pulmonary metastases from renal cell carcinoma. Anticancer Research. 1999;19(2C):1593-1596.
    16. Tanagho EA, McAninch JW. Smith's General Urology 16th Ed. McGraw Hill. New York. Pg 152-156.
    17. Anderson CJ, Havranek EG. Minimally invasive ablative techniques in renal cancer. BJU Int 2004; 93: 707-709
    18. Lam JS, Shvarts O, Leppert JT, Figlin RA, Belldegrun AS. Renal cell carcinoma 2005: new frontiers in staging prognostication and targeted molecular therapy. J Urol 2005; 173 (6): 1853-1862
    19. Yang JC, Sherry RM, Steinberg SM. Randomized study of high-dose and low-dose interleukin-2 in patients with metastatic renal cancer. J Clin Oncol 2003; 21: 3127-32
    20. Mancuso A, Sternberg CN. What's new in the treatment of metastatic kidney cancer? BJU Int 20005; 95: 1171-1180
    21. George D, Motzer R, Rini B, et al. Sunitinib malate (SU11248) shows antitumor activity in patients with metastatic renal cell carcinoma: updated results from Phase II trials. Proceedings from the 2005 annual Chemotherapy Foundation Symposium. New York, NY. Abstract #18.
    22. Motzer RJ, Hutson TE, Tomczak P et al. Phase III randomized trial of sunitinib malate (SU11248) versus interferon-alfa (IFN-a) as first-line systemic therapy for patients with metastatic renal cell carcinoma (mrcc). Presented at the 2006 ASCO Annual Meeting. Abstract #LBA3.


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