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BackTable / Urology / Article
Kidney Cancer Surgery: Nephrectomy, Lymph Node Dissection, When & Why
Ishaan Sangwan • Aug 2, 2021 • 333 hits
Choosing the correct type of kidney cancer surgery is essential, as taking an aggressive approach with a radical nephrectomy may leave the patient with poor renal function. A surgeon must also decide whether or not to perform a lymph node dissection, especially if nodal involvement is not seen radiographically. More recently, minimally invasive robotic surgery has also become an option for certain patients.
Dr. Margulis shares his approach to these procedures. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• The decision of a partial vs. radical nephrectomy depends on the extent and aggressiveness of the tumor, the condition of the patient, and the presence of a tumor thrombus.
• Lymph node dissection must be performed in clinically node positive disease.
• In node negative disease, the decision to perform a lymph node dissection depends on the patient’s risk factors for nodal disease.
• Robotic surgery is minimally invasive, and may be performed for small tumors. It can also be used for lymph node dissection, and some venous reconstruction.
Table of Contents
(1) Partial vs. Radical Nephrectomy for Kidney Cancer
(2) Lymph Node Dissection During Kidney Cancer Surgery
(3) Robotic Approach to Kidney Cancer Surgery
Partial vs. Radical Nephrectomy for Kidney Cancer
The decision to perform a partial or radical nephrectomy is a multifactorial one, and depends on the tumor margin, the patient’s condition, and intraoperative factors. If the tumor extends into the perinephric sinus, a radical nephrectomy is usually indicated. If a tumor does not look biologically aggressive but is located such that a radical nephrectomy may be required, a biopsy can be performed to see if the tumor can be safely monitored instead. If a tumor thrombus is present, it is possible to resect the tumor with a partial nephrectomy and reconstruct the venous system. Other factors, such as the patient’s renal function, venous invasion, and an elective setting, may also make a partial nephrectomy more plausible.
[Dr. Aditya Bagrodia]
Okay. Perinephric sinus involvement, is that a reflex? And I'm talking about extending towards Gerota’s, is that a reflex radical nephrectomy in your hands?
[Dr. Vitaly Margulis]
Nothing should be reflex, but generally yes. I mean, if we have clear-cut evidence of the tumor's central... if it extends into the sinus certainly. Some of the tumors extend outward of the kidney. Again, you have to... it's a multi-factorial decision. You have to think, "Okay, is this obviously in an elective setting? Is an imperative setting? Borderline? How technically is partial feasible?"
And it's also now the discussion that has to be held with the patient. Obviously, last thing you want to do is do something like this in an elective setting, get into the tumor, have local tumor recurrence, and we've all had these disaster cases where patients came in with peritoneal carcinomatosis from an attempted nephron sparing that shouldn't have been performed. So I think it's a nuanced decision. Does it automatically mean radical nephrectomy? No, but I mean, I think one has to evaluate this from the multi-factoral perspective.
[Dr. Aditya Bagrodia]
And what about sinus fat? One thing I recall is oftentimes for very central tumors, you will obtain a biopsy just to make sure that you're... and a patient that's a high risk of receiving a radical nephrectomy potentially that you want to make sure that this isn't something that's a benign or likely to be a very little oncologic threat. Are you still doing that?
[Dr. Vitaly Margulis]
I'm doing this. So if you have... there's a smaller tumor that doesn't look biologically aggressive, but located in this such location that perhaps you may have hard time finding it, or where you know that if you start opening the kidney up and getting to the sinus, there's pretty good chance for a radical nephrectomy. And so I would probably obtain a biopsy of this to confirm that this is in fact, a cancerous lesion before performing a surgery that could potentially result in a kidney loss. It would be a shame to do something like this for oncocytoma and something that can be safely monitored and then have a patient lose the kidney.
[Dr. Aditya Bagrodia]
And of course there's patient's back factors, there's renal function, reserve and so forth. But if you have central tumors that are relatively smaller concern for segmental, subsegmental venous branch invasion or sinus fat invasion, do you still keep partial nephrectomy as a part of your armamentarium?
[Dr. Vitaly Margulis]
It's really hard to definitively show a segmental radiographically segment involvement of the venous system by a tumor and a lot of this stuff, a lot of the times this is artifactual. So you have to make a decision whether you could, again, in your hands, and again, it's different from surgeon to surgeon. You have to factor in your experience and your comfort level into the equation, but for an elective setting, I would have a pretty good reason not to offer radical nephrectomy, honestly, if I highly suspect that there's venous involvement in an elective setting.
[Dr. Aditya Bagrodia]
What about if you encounter a tumor thrombus intraoperatively?
[Dr. Vitaly Margulis]
Well, again, I mean, if the partial goes well, and there's a nodule of the tumor that goes through the vein, that I'm confident that I've removed appropriately and all the tumor's out, then I would probably complete a partial nephrectomy, reconstruct the venous system and move on. Certainly at that point, you've already committed, most of the tumor's been dissected properly, and you're getting a negative margin. There's pretty good data to suggest that partial nephrectomy provides equivalent oncologic outcome compared to radical nephrectomy in that setting. So if you get all the tumor out and margins are good and the outcomes long-term are the same, whether you performed a partial or radical.
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Lymph Node Dissection During Kidney Cancer Surgery
A thorough lymph node dissection must be performed if there is evidence of nodal disease with radiographic imaging. However, there is insufficient data to justify routine lymph node dissection in cases with clinically node negative disease. Dr. Margulis often prefers to perform lymph node dissections in certain high-risk populations, as the added morbidity of performing one with a nephrectomy is limited. Genetic testing can also be used to identify individuals with rare gene translocations that make them more susceptible to nodal disease.
[Dr. Aditya Bagrodia]
I'll ask you to just talk a little bit about the role of lymph node dissection in those patients, as well as the performance of routine lymph node dissection in other high-risk patients without radiographic evidence of nodal involvement?
[Dr. Vitaly Margulis]
Certainly your first case scenario where we have gross radiographic evidence of nodal disease with modern imaging, those most certainly will have a metastasis that seems pretty rare to have a false positive. And if this is the only side of their disease, then I think a resection of the primary, the thorough lymph node dissection, not just node plucking, probably template dissection as something that should be performed.
It gets a little bit more murky, I would say, with a lymph node dissection in the setting of clinically node negative disease. The data has gone back and forth over the years. I certainly can make a reasonable case to perform this in high-risk population. So these are your thrombus cases, these are the cases perhaps where there is a super bulky tumor with ipsilateral adrenal involvement, for example. I can make an argument to perform lymph node dissection, even if they’re radiographically or clinically negative, because there's high risk for regional nodal involvement.
The implication of that is a little bit less clear, but we certainly all had cases over the years where lymph node dissection was not performed. And we had to go back in to remove that lymph node. So it’s a lot easier to get it at the time of surgery. I would say that added morbidity to performing a regional lymph node dissection at the time of the nephrectomy, is I would say limited. This can be not quickly without significant morbidity to the patient. So I do this and I show you the data that it changes patient outcome routinely, it probably can't. But if you, if you look at the description of a classic nephrectomy, it's still a hint to remove the regional lymph nodes with the bulky primary.
[Dr. Aditya Bagrodia]
Okay. And again, I recall from training and my understanding of the literature that certain high risk populations where you're suspecting say HL RCC, or any of the more aggressive hereditary cancer syndromes, you'll oftentimes do a lymph node dissection, even if a partial nephrectomy is planned. Is that right?
[Dr. Vitaly Margulis]
Yeah. That's a good point. And these are, again, nuanced situations. So things like, certainly HLRCC or probably even more common in my practice will be your translocation carcinomas. So these are young folks with translocation tumors, that have a higher propensity for nodal disease. And so these are the patients I would offer a routine lymph node dissection in the setting of clinically negative nodes. But this is a minority. These are very few of them. The real question is whether we should be doing lymph node dissections or just in your regular average, bulky tumor, and here's the data is a little bit murky.
Robotic Approach to Kidney Cancer Surgery
Robotic surgery is a minimally invasive approach that may be an option for some tumors, provided that the surgeon is comfortable with this tool. If a tumor is small enough, and the surgeon is able to get good retraction, a robotic approach is preferred. Lymph node dissections and minor venous reconstruction are also possible with a robotic approach. However, tumor thrombus cases, where there is significant venous involvement, are still treated with open surgery.
[Dr. Aditya Bagrodia]
Yeah. And I think that leads me into one of the other things that I just wanted to quickly touch on which globally, I'm going to guess that we agree that really use the tools that you're comfortable with and most adept with, but robotic versus open, you'd mentioned thrombus cases, those are pretty much going to be open. I think that's the case at most centers, other than a few select centers. Tumor size, lymph nodes, what are some of the factors that are going into whether this might be a reasonable patient for a robotic or minimally invasive approach?
[Dr. Vitaly Margulis]
Again, as we have all gotten more and more comfortable with the robotic/laparoscopic approach, I think more and more cases now, I do robotic that I was doing open in the past. The main factor here is the size of the tumor. Will it be able to get good retraction on the tumor, on the kidney and still be able to see the structures that I need to see? And if that's the case, and that's my judgment then I usually do those cases robotically.
I think robotic platform allows you to do an additional lymph node dissections, even venous reconstruction, and that's something that I think most of us were not comfortable doing that with pure laparoscopic approach. So the bottom line is that a tumor's small and in even the presence of lymph node disease, as long as it's not super bulky and encasing the vessels, a lot of these tumors, I would do it with robotic approach.
Podcast Contributors
Dr. Vitaly Margulis
Dr. Vitaly Margulis is a Professor of Urologic Oncology at UT Southwestern Medical Center in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2021, July 1). Ep. 10 – Management of Locally Advanced Kidney Cancer [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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