eMedicine Specialties > Urology > Surgery

Nephrectomy, Radical: Follow-up

Author: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Coauthor(s): Hosam S Al-Qudah, MD, Consultant Urologist, Department of General Surgery, Saad Specialist Hospital, Al-Khobar, Saudi Arabia
Contributor Information and Disclosures

Updated: Nov 24, 2009

Outcome and Prognosis

Historically, 4-10% of patients with RCC have tumor thrombus extending into the inferior vena cava, and 1% have tumor involving the right atrium. Surprisingly, the prognosis for patients with resectable inferior vena caval extension without unresected vena caval wall invasion or lymph node involvement approaches that of stage I cancer. In the absence of metastases, an aggressive surgical approach provides the only hope for a potential cure.

Lymph node involvement and metastases are adverse predictors of survival. People with stage IV disease and with distant metastasis have a 5-year survival rate of less than 10%. If metastasis is discovered preoperatively, surgery is considered only for palliation, for entry into adjuvant treatment protocols, or, possibly, for a solitary metastasis. Metastases, particularly hepatic metastases, recognized at the time of surgery are associated with poor outcomes, and further surgery should probably be abandoned in these patients. Unfortunately, metastases after complete surgical resection is not uncommon. In these patients, postsurgical metastatic RCC is the most common cause of death.

Survival rates in relationship with surgical stage, type of therapy, and pathologic characterization of the primary tumor were studied in 326 patients treated at New York University from 1970-1982. At the time of diagnosis, 25.5% of tumors were stage I, 15% were stage II, 28.5% were stage III, and 31% were stage IV.11

The retrospective study showed that patients with tumor confined within the capsule achieved the highest 5-year and 10-year survival rates (88% and 66%, respectively). Survival rates decreased as tumor invaded perirenal fat (67% and 35%, respectively) or regional lymph nodes (17% and 5%, respectively).11 Tumor invasion into the renal vein alone did not significantly change 5-year survival rates (84%), but it did lower 10-year survival rates to 45%. Outcomes were poor in patients with metastases at the time of nephrectomy, regardless of the site of metastases or type of adjuvant therapy, except for those treated with surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis. These included a size smaller than 5 cm in diameter; lack of invasion of the collecting system, perirenal fat, or regional lymph nodes; and a predominance of clear or granular cells growing into a recognizable histologic pattern.11

Nephrectomy can ameliorate paraneoplastic syndromes, hemorrhaging, and tumor pain. Paraneoplastic syndromes associated with RCC include the following:

  • Anemia (21-41%)
  • Elevated sedimentation rate (50-60%)
  • Reversible hepatic dysfunction (10-15%)
  • Fever (7-17%)
  • Amyloidosis (3-5%)
  • Neuromyopathy (3%)
  • Hypercalcemia (3-6%)
  • Erythrocytosis (3-4%)
  • Hypertension (22-38%)
  • Elevated human chorionic gonadotropin levels
  • Cushing syndrome
  • Hyperprolactinemia
  • Ectopic insulin and glucagon production
  • Raised alkaline phosphatase levels (10%)
  • Cachexia, weight loss (35%)

Future and Controversies

Laparoscopy is gaining worldwide acceptance in the treatment of organ-confined renal cancer. Both laparoscopic radical nephrectomy and laparoscopic nephron-sparing procedures are viable alternatives to traditional open, radical, and partial nephrectomy surgeries. Advantages of laparoscopic radical nephrectomy over open nephrectomy include the following:

  • Decreased need for postoperative analgesic drugs (average of 24 mg of parenteral morphine compared with 40 mg in open surgery).
  • Shorter hospital stay (median of 1.5 d compared with 5 d in open surgery).
  • Shorter convalescence period (median of 4 wk compared with 8 wk in open surgery).

Laparoscopy appears to offer the same cancer control results as open surgery, with comparable disease-free survival at 5 years and, recently, at 10 years.

Laparoscopic radical nephrectomy can be performed using the transperitoneal or the retroperitoneal approach. The retroperitoneal approach showed some benefit in quicker vascular control and less operative time. Both approaches are similar in terms of other patient outcomes.

Although laparoscopic radical nephrectomy for organ-confined kidney cancer is now considered the standard of care, several reports concerning locally invasive kidney cancer treated laparoscopically show promising results. Now, the challenge for each urologist is to learn these new technologies if he or she wants to be part of this rapidly growing field.

Renal ablative cryosurgery and radiofrequency are emerging as the newest techniques for treating locally confined renal cancer.12,13 Limited experience has demonstrated their effectiveness in treating small peripherally located tumors, with minimum morbidity and a favorable outcome. These treatment modalities are still in their infancy, and clinical trials are currently underway to determine their long-term effectiveness. Despite their good intermediate results, these therapies are performed in patients who are not fit for surgery; NSS is still considered the criterion standard for these small tumors.

Sorafenib and sunitinib are vascular endothelial growth factor receptor inhibitors that are now FDA-approved for treating metastatic RCC. They have demonstrated promising initial results and can be used before or after radical nephrectomy, depending on the patient's general health. Other targeted treatments have been through phase II and III trials, with promising initial results.

 


More on Nephrectomy, Radical

Overview: Nephrectomy, Radical
Workup: Nephrectomy, Radical
Treatment: Nephrectomy, Radical
Follow-up: Nephrectomy, Radical
Multimedia: Nephrectomy, Radical
References
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Further Reading

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Keywords

radical nephrectomy, simple nephrectomy, kidney disease, kidney resection, radical kidney surgery, renal cell carcinoma, RCC, localized renal cell carcinoma, renovascular hypertension, renal artery disease, parenchymal damage, nephrosclerosis, pyelonephritis, reflux dysplasia, congenital dysplasia of the kidney, congenital kidney dysplasia, renal dysplasia, kidney dysplasia, renal lesion, simple nephrectomy, renal cyst, renal cancer, renal cell cancer, irreversible kidney damage, calculus disease, nephron-sparing surgery, NSS, partial nephrectomy, laparoscopic partial nephrectomy

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Contributor Information and Disclosures

Author

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Coauthor(s)

Hosam S Al-Qudah, MD, Consultant Urologist, Department of General Surgery, Saad Specialist Hospital, Al-Khobar, Saudi Arabia
Disclosure: Nothing to disclose.

Medical Editor

Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center; Professor and Vice Chairman, Department of Urology, New York Medical College
Michael Grasso, MD is a member of the following medical societies: American Medical Association, American Urological Association, California Medical Association, and Endourological Society
Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine
Martin I Resnick, MD † is a member of the following medical societies: American College of Surgeons, American Federation for Medical Research, American Institute of Ultrasound in Medicine, American Medical Association, American Society for Bone and Mineral Research, American Society for Reproductive Medicine, American Society of Andrology, American Surgical Association, American Urological Association, Association for Academic Surgery, Endocrine Society, National Kidney Foundation, Ohio Urological Society, and Pan American Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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