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Surgical management of large renal tumors

Nature Clinical Practice Urology volume 5, pages 35–46 (2008)Cite this article

Abstract

In addition to an increased occurrence of small, localized, incidentally discovered renal cell carcinomas (RCCs), there has been an upward trend in the incidence of advanced renal tumors per unit of population and in disease mortality worldwide. As radical nephrectomy remains the standard of care in treating localized RCC, this manuscript focuses on surgical approaches. We defined 'large renal tumors' as those greater than 7 cm or those with venous involvement. We discuss operative strategies in both open and laparoscopic surgery as well as approaches to special circumstances, including patients with tumor thrombus and the indications for nephron-sparing surgery in patients with greater than T2 RCC. The literature pertaining to controversial areas such as preoperative renal artery embolization and the clinical utility of metastectomy and cytoreductive therapy are also reviewed. The theoretical basis and potential applications of neoadjuvant therapy for larger renal tumors is examined as well.

Key Points

  • In addition to an increased incidence of asymptomatic localized RCC, there has also been an upward trend in advanced tumors per unit population and in disease mortality

  • Familiarity with both anterior and flank/thoracoabdominal incisions is paramount in maximizing exposure of the kidney and minimizing morbidity in patients with large renal tumors

  • Venous tumor involvement is a distinct scenario that should be managed by a multidisciplinary team at a tertiary care center; tumor thrombus at or above the level of the hepatic veins mandates venovenous bypass and can be performed via a minimal access technique

  • Initial results on laparoscopic radical nephrectomy in select patients with T2 or greater disease have been encouraging. An intraperitoneal approach is generally preferred

  • Only under extenuating circumstances, such as bilateral synchronous tumors or a solitary kidney, should partial nephrectomy be considered in patients with large renal tumors

  • Cytoreductive therapy and neoadjuvant therapy are developing modalities that might become further used with the progression of molecular targeted therapies

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Figure 1: Right renal mass with associated tumor thrombus at the infrahepatic level in a 50-year-old male patient with no pertinent past medical history.
Figure 2: Angiograms from the patient in figure 1 (50-year-old male).
Figure 3: Renal venous collecting system demonstrating extensive collateral drainage that might occur with renal vein obstruction.
Figure 4: Removal of infrahepatic vena cava tumor thrombus.
Figure 5: Minimally invasive approach for circulatory arrest in the management of suprahepatic venous tumor thrombus.
Figure 6: Intraoperative image of locally invasive renal cell carcinoma into the liver.

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Author information

Authors and Affiliations

  1. C Wotkowicz is a Urology Resident and JA Libertino is the Chairperson of the Urology Department, MF Wszolek is a Urology Resident, at the Lahey Clinic, Burlington, MA, USA.,

    Matthew F Wszolek, Chad Wotkowicz & John A Libertino

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  1. Matthew F Wszolek
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  2. Chad Wotkowicz
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  3. John A Libertino
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Correspondence to John A Libertino.

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Wszolek, M., Wotkowicz, C. & Libertino, J. Surgical management of large renal tumors. Nat Rev Urol 5, 35–46 (2008). https://doi.org/10.1038/ncpuro0963

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