Diagnosis: How is kidney cancer diagnosed?


The majority of renal neoplasms are diagnosed during the execution of an abdominal scan request for other reasons. In case of suspicion of renal cancer and to obtain further information regarding the location of the tumor and the possible involvement of other organs, people resort to the use of computerized tomography (CT) with contrast medium or nuclear magnetic resonance. Then, the Urologist specialist may require any further diagnostic investigations depending on the individual clinical case, in order to correct the staging of the tumor and to evaluate the best course of action. These exams can include a bone scan, RX/CT of the thorax and Eco/CT guided renal biopsy.


Treatment: How is kidney cancer treated?


The treatment of kidney cancer is basically surgical with multiple types of intervention, depending on the characteristics of the tumor and the patient (open surgery, laparoscopic and robotic).


According to the current international guidelines, the "strategic philosophy" is to propose a conservative surgery (called "nephron sparing") in all cases in which, considering the seat dimensions and any compressions, it is both technically and oncologically possible to preserve the maximum residual global functionality. 


Moreover, in selected cases (elderly patients, severe renal impairment, severe comorbid and associated pathologies) and renal lesions of small dimensions, a renal Eco/CT guided biopsy for the definition of the type of renal tumor can be performed to define a possible active monitoring program, instead of surgery.


At Our Division, the treatment of kidney diseases of surgical interest was directed towards minimally invasive approaches such as laparoscopy and robotic surgery and the use of ablative energy sources since the 90s. Currently, more than 90% of surgical procedures performed for the treatment of renal cancer involve applying these techniques.


Types of surgical treatments performed at our center


§  Radical nephrectomy


Radical nephrectomy involves removing the kidney, the kidney fat and the outer sheath that surrounds it (Gerota band). In the case of cancer involving the upper pole of the kidney removal of the adrenal gland is also typically removed if affected by the tumor. This surgery can be performed with an open technique or with abdominal incision or more frequently by laparoscopy. 


Our center has adopted the laparoscopic technique since the late '90s and it is therefore considered one of the pioneering centers. The laparoscopic technique requires general anesthesia with positioning of the patient on their side with the bed at 30° angle. Generally, there are 4-5 operating ports (small abdominal incisions of about 0.5-1cm) and at the end of the intervention there is an extension of one of these ports for the extraction of the surgical specimen. Furthermore, at the end of the procedure a drainage tube is usually placed in the in renal loggia and removed after 2-3 days after surgery. 


The surgery usually lasts from 90 to 180 minutes. The hospitalization time is normally between 3 and 5 days. If laparoscopic surgery is not executable due to the general condition of the patient or the size and extent of the tumor, you should opt for an open surgery, which is usually performed through a xipho-umbilical median incision (from the sternum to the navel) or a subcostal incision. The loss of a kidney does not necessarily mean renal failure, unless the contralateral kidney is also diseased.


§  Partial resection of the kidney


Partial kidney resection consists of the removal of the kidney tumor with a margin of healthy tissue safety, with preservation of the remaining renal parenchyma. This intervention, where technically and oncologically safe, is offered to most patients with kidney cancer. The commonly used surgical alternatives at Our center, depending on the size and location of the tumor to be treated, include the open surgical approach, classic laparoscopy or robotic surgery. Robotic surgery is the evolution of the laparoscopic technique and it is mainly used by highly specialized and dedicated centers. This technique makes use of the assistance of the Da Vinci robot, and, in our experience, enables one to perform a minimally invasive procedure even in particularly complex cases. 


It is performed under general anesthesia, positioning the patient on their side with the bed under 30 degrees angle. The surgery usually lasts from 90 to 180 minutes. Generally, there are 4-5 operational ports (small abdominal incisions of about 0.5-1cm) and at the end of the intervention an expansion of one of these ports is placed for the extraction of the surgical specimen. During the temporary interruption of blood flow to the kidney for optimal tumor resection is frequently used. 


At the end of the procedure, a drainage tube is placed, which is generally removed 2-3 days after surgery. The hospitalization time is normally between 3 and 5 days. The ability to preserve the surrounding healthy renal parenchyma is certainly an important advantage of partial kidney resection compared to nephrectomy. Recent studies have also shown a substantial equivalence in the treatment capacity of the partial resection of the kidney compared to radical nephrectomy. 


A risk associated with partial renal resection is the persistence of the tumor or the appearance of local recurrence of the disease, with an incidence of 4-10%, often through the expression of multiple neoplastic foci not detectable at the time of surgery. 


If laparoscopic or robotic surgery is not executable due to the general condition of the patient or the size and extent of the tumor, one should opt for an open procedure, in which a xipho-umbilical midline incision (sternum to navel) or a subcostal incision is usually performed. 


Our center is considered one of the pioneers for partial kidney resection as Our data have been shared with the scientific community since 2010 along with the most important centers in the world. From 2008 to present day (2013) there have been performed more than 150 kidney-saving interventions and our center can be considered as the first in Italy and among the first in Europe for this surgical technique.


§  Renal cryoablation


Renal cryoablation is one of the surgical techniques of great success and prestige at our center. We have already started to use this surgical technique in 2000 and today Our case study is to be considered first in Europe and the first places in the world. We are a reference center for performing cryoablation for years and we are also mentoring at other centers. 


This surgical technique consists in the destruction of kidney cancer by freezing the renal lesion using an injection (through open, laparoscopic or percutaneous approach) with special needles, which generate an "ice ball" aimed at destroying cancer cells that die later becoming scar tissue. 


This method has the advantage, compared to classical lumpectomy, in that it does not require clamping of the renal vessels and depending on the patient's general condition as well as the size of the tumor, an open, laparoscopic or percutaneous approach can be used. Used in well-selected cases, it represents a viable therapeutic alternative to renal lumpectomy, with comparable results in terms of cure rates. 


The average duration of this type of intervention is 90-180 minutes with an average hospital stay of 3-4 days. From '00 to present day (2013) there have been performed more than 200 operations with excellent oncologic results. Our case studies in the past were shared with the scientific world as demonstrated by the following scientific work.


What should I do after surgery?


In most cases, surgery is decisive from an oncological point of view and further treatment (radio / chemotherapy) is not required. However, after the intervention, it is recommended to perform close follow-ups, which can slightly vary depending on the type of surgery performed and the type of cancer, but it basically involves periodic assessment of renal function (blood count, blood urea nitrogen and creatinine), and radiologic imaging (ultrasound of the abdomen and chest, abdominal CT or MRI) at defined time intervals (e.g. 1, 6, 12 months after surgery). After the execution of the control tests the patient is reassessed periodically during specialist urological visits.