Kidney Cancer Surgery

Kidney or renal cell cancer is a disease in which malignant (cancer) cells form in the tubules of the kidney. In Singapore, it accounts for 1-2% of all cancers or approximately 2.4 and 1.3 of every 100,000 men and women respectively. The prevalence of this disease has been rising in recent years at an annual rate of approximately 2-3% and this has been attributed to the use of ultrasonography and computed tomography (CT) scan for other complaints.

The majority of those with kidney cancers are diagnosed when they are investigated for other complaints, even though they have no specific symptoms related to the disease. Kidney cancer diagnosed this way is usually small and at an early stage. On the other hand, about a third of all those with the disease will present late with the disease at an advanced stage.

Possible signs of symptomatic renal cell cancer include:

• Blood in the urine
• A mass in the abdomen
• A pain in the side that does not go away
• Loss of appetite or weight loss for no known reason
• Anaemia (low blood count)

Causes of kidney cancer

As is the case for other human cancers, kidney cancer is a disease commonly affecting the elderly with nearly two out of three people diagnosed over 65 years old. Kidney cancer is rare in people under 50.

In most cases, there is no identifiable cause for the disease, although there are some associated risk factors :

• Smoking. Smokers have approximately double the risk of nonsmokers.
• Contact with certain chemicals. Workers in contact with chemicals such as aniline dye and heavy metals have a higher risk.
• Obesity.
• End-stage kidney diseases that require dialysis.
• Chronic intake of mild painkillers, such as paracetamol, and nonsteroidal anti-inflammatory drugs (NSAID) such as ibuprofen and aspirin.
• Hereditary kidney cancer. Most of those affected have a sporadic or a non-hereditary form of kidney cancer. A hereditary form of the disease occurs in a small subset of patients (less than five percent of total) due to the presence of faulty genes. These inherited conditions that predispose one to kidney cancer include von Hippel-Lindau (VHL) syndrome, tuberous sclerosis, Birt-Hogg-Dube syndrome, and hereditary non-VHL clear cell and papillary renal cell cancer.

Further tests to confirm the presence and extent of kidney cancer may include :

• Ultrasound or Computed Tomography (CT) scan. Detailed images are taken of the kidney to show the size, characteristics and extent of spread of the kidney tumour.
• Kidney biopsy. Samples of kidney tumour tissue are removed and examined under the microscope to confi rm presence of cancer.
• Cystoscopy. A small tube, a cystoscope, is passed through the opening of the urethra in the penis. It contains a lens and light system that helps the doctor see the inside of the urethra, prostate and the bladder to identify any additional tumours in those who have blood in the urine and a kidney tumour.

Early kidney cancer

The treatment options for early cancer may include:

Surgery

Surgery is the standard treatment option for those with kidney tumours who are fit for surgery. The extent of surgery may be categorised into two types :

• Partial nephrectomy where the tumour is removed with a margin of normal tissue, preserving the rest of the unaffected kidney.
• Radical nephrectomy. where the whole kidney including the tumour is removed.

Partial nephrectomy is performed when the tumour is small or if the person has a single kidney left or has impaired kidney function. Radical nephrectomy is performed when the tumour is large and very close to the blood vessels or ureter.

Kidney surgery may be performed using the conventional open laparoscopic or robot-assisted techniques, depending on the kidney tumour characteristics and patient suitability.

Radiofrequency ablation

This is a minimally invasive ablative procedure that uses thermal energy to destroy tumour cells.

Active Surveillance

In prostate cancer, male sex hormones can cause prostate cancer to grow. Hormonal therapy works by removing the Selected patients with a very small kidney tumour may be monitored closely with kidney scans to assess the growth rate or changes in the tumour appearance.

Radiofrequency ablation and active surveillance are more suited for elderly patients with multiple medical problems and are not fit for surgery.

As only one good kidney is needed to lead a normal life, most people with one kidney removed do not end up with kidney failure requiring dialysis. Your treating doctor will counsel you on the risks of impaired kidney function after surgery which depends on the presence of factors such as diabetes, high blood pressure and advanced age.

Advanced Kidney Cancer

For selected patients who present late with kidney cancer that has spread to other parts of the body, surgery to remove the kidney in combination with systemic therapy has shown to be effective treatment even in advanced kidney cancer.

Systemic treatment in this group of patient may include:

• Targeted therapy. Uses drugs that target specific tumour growth pathways in the cancer cell.
• Immunotherapy. Uses drugs that incite the body’s immune response towards the cancer.

If you are not fit for surgery, immunotherapy or targeted therapy may be given to control the disease with or without surgery later, depending on your response to treatment. It is reassuring to note that there are still very effective treatments for patients presenting late with advanced stage of kidney cancer.