Kidney Cancer

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Well I’m really passionate about kidney cancer. 

I was one of the first in Australia to do laparoscopic or keyhole removal of kidney cancers and I presented that at our national conference and it’s a very, very interesting condition.

It’s not that common, it’s a little bit more common in males. 

These days we generally find kidney cancers found incidentally. 

So these renal cell cancers are detected when people have scans for other reasons such as an ultrasound for abdominal pain or a CT or CAT scan for another reason such as abdominal pain or bleeding. We then often find these lesions or lumps in the kidney incidentally and that’s the commonest way that patients present now. 

Traditionally patients use to present with pain, possibly swelling or a mass and bleeding but that’s less common. 

Patients can have a variety of symptoms with kidney cancer and interestingly they can produce a lot of unusual hormones and patients can have so called paraneoplastic syndromes with high blood pressure, high haemoglobin, high blood sugar level, and abnormal liver function tests.

So these all revert to normal once the kidney cancer is removed. 

We generally stage the tumour by doing at CT scan, a chest x-ray, some blood tests to ensure there’s no evidence of spread . Once the cancer is staged then we normally treat the cancer. 

A very, very important fact to take into account is that all the data recently has shown that if you have kidney cancer you should aim to take just the cancer and part of the kidney out rather than removing the whole kidney. 

Studies have shown that when patients have their whole kidney removed there’s an increased need for dialysis and an increased risk of developing renal failure. 

So we aim to remove part of the kidney whenever we can. 

The studies have shown cure rates when you remove part of the kidney are the same as when you remove all the kidney. 

So when feasible that is what we aim for. 

If you have a very large tumour, sometimes you need to do an open operation to remove those and that maybe a very large tumour that extends upwards towards the liver involving the inferior vena cava, (the main vein in the body returning blood to the heart) and sometimes we do what’s called a thoraco-abdominal incision, we make an incision through the chest into the abdomen and remove the tumour this way. 

I presented this data in our national meeting.  The recovery is surprisingly quite good with this approach. 

For smaller tumours that maybe effect most of the kidney we would now say the gold standard is a laparoscopic or keyhole removal and as I mentioned I was very fortunate to be one of the first in Australia to do that type of surgery and to do a transperitoneal, transperitoneal nephrectomy. 

The advantages for patients here is that they have much quicker recovery, they’re in hospital for a few days, they have much less pain and potentially less need for blood transfusion. 

We remove the kidney tumour through a small incision in the lower abdomen where we split the muscle as opposed to a big incision in the loin which is very painful for patients and results in significantly increased recovery time. 

So I believe the gold standard for larger tumours is a laparoscopic removal of the tumour.

Now critically, as mentioned, when tumours are smaller I believe patients should have a wedge resection and if it’s very complex we do that by an open operation and we sometimes freeze the kidney down, decrease the metabolic rate and remove a wedge but increasingly I’m doing this laparoscopically and now we’re embarking on robot assisted partial nephrectomy. 

The robot allows increased dexterity and allows us to do more difficult and complex tumours and remove them via partial nephrectomy where we remove a segment of the kidney with the tumour.

The advantage for patients is they still have their kidney left, there’s less complications down the track and particularly if you have kidney stones for example it’s very important to do a part resection.

So increasingly in the United States, the number of robot assisted partial nephrectomy operations are increasing dramatically. I believe we will eventually follow this trend and that this will probably be the gold standard for small kidney tumours. 

So I think it’s imperative when patients have kidney tumours they should look at all their options, they should consider them, ensure or check with their surgeons whether they’re suitable for a partial resection rather than complete removal.

The other very interesting thing about kidney tumours is their biological activity and there are a whole lot of extra treatments that are now available where it’s been shown that the prognosis or the cure rate for kidney cancer even when it’s spread has been improved with the use of these new agents.

These agents are increasingly being used and sometimes in conjunction with surgery for very active cancers. 

So kidney cancer is a very, very interesting topic, it’s imperative for patients to be fully assessed I believe and I think whenever possible once you perform a partial nephrectomy be it via an open, a laparoscopic or a robotic assisted method.