Renal Masses Kidney Cancer & Kidney Surgery

Every year, 28,000 Americans learn they have kidney cancer. A mass on the kidney may be detected with an ultrasound or CT scan. Additional testing, including Magnetic Resonance Imaging, can help determine if the mass is cancerous. Even with proper imaging, approximately 20% of solid renal masses will ultimately prove to be benign.  Some people with kidney cancer may notice the presence of blood in their urine, back pain or an abdominal mass or hard lump or there may be no outward symptoms at all.

Kidney cancer is most common in men over age 40. Unfortunately, the disease often goes undiagnosed until it has spread. Surgical removal of the entire kidney may be required. Now there is a technique for removing the diseased kidney that is less invasive than traditional surgery.

The procedure is called a laparoscopic nephrectomy.

What is a laparoscopic nephrectomy? 
A laparoscopic nephrectomy is a procedure for removing diseased kidneys in place of conventional (open) surgery. It is a very delicate and precision-oriented procedure, which should be performed only by highly experienced surgeons. Laparoscopic surgery is sometimes called "keyhole" surgery because it involves relatively small incisions. The surgeon uses an endoscope (a narrow telescope) and small "ports" through which miniature instruments are passed. The scope enables the surgeon to watch what he or she is doing on video monitors.

In one variation of laparoscopic surgery, the surgeon may use one hand in the abdomen as a surgical instrument to increase the safety of the operation. This is called a hand-assisted laparoscopic nephrectomy often used to remove a cancerous kidney. A device is used which allows the surgeon to insert a hand through a small incision in the abdomen. The hand-assistance device forms a seal around the incision that holds the inflated abdomen intact. The kidney is removed intact by hand and later evaluated by a pathologist to help determine the grade and stage.

Surgical Risks: 
Any form of invasive surgery carries certain risks. Patients requiring kidney surgery should be advised of the possibility of experiencing complications, such as the following:

• Damage to blood vessels (aorta or vena cava)
• Damage to organs (spleen, pancreas, large or small bowel)
• Hemorrhage (bleeding) during surgery (intraoperative) or after surgery (postoperative)
• Incisional hernia (bulging at the site of the surgical incision, caused by imperfect healing or weakness of overlying 
  muscles)
• Infection
• Pneumothorax (air between the lung and chest wall)
• Conversion to open nephrectomy. This is performed if intraoperative findings or issues deem it the safest course of action.

Can you function normally without a kidney? 
The kidneys are part of the urinary system.  They are two fist-sized organs located in the mid back, one on each side of the spine. Their main function is to filter blood and produce urine to rid the body of waste. Most kidney cancers affect only one organ. People can function well with just one kidney if a diseased one is removed. In a few cases where kidney function is impaired, minor dietary restrictions may be recommended.  If the remaining kidney becomes diseased, some patients may have to go on dialysis.

What are the advantages of laparoscopic nephrectomy over traditional surgery? 
The laparoscopic nephrectomy is more difficult for the surgeon to perform than traditional surgery, but the procedure causes less trauma to the patient. The surgeon makes a few small incisions instead of one long 25-centimeter one. Disruption to the abdominal wall is slight. Patients have less pain and get back to their lives quicker with this less invasive surgery. The risk of complications is the same for both procedures.

With a laparoscopic nephrectomy, there is reduced postoperative pain and patients are able to get up and move about within a day. They usually stay in the hospital 2-3 days.  Many are able to return to work and recreation within two to three weeks. The scarring caused by the surgery is minimal as well.

With traditional surgery, four or five days of hospitalization are usually needed after kidney removal, plus six to eight weeks for recovery. Patients of open surgery typically require heavy pain medication over extended time, too.

Who is a candidate for this procedure? 
Ideal candidates for laparoscopic nephrectomy are those with malignant kidney masses or kidney and ureter problems requiring removal of the entire kidney or ureter. People who wish to donate a kidney for transplant can also benefit from this procedure.

Postoperative Information

Diet: 
When you return home you may return to your normal diet immediately. Because of the stress and anxiety, you might start with lighter foods (non-fried) but you really have no restrictions. To avoid constipation, drink plenty of fluids during the day (8 - 10 glasses).

Wound: 
Your incision is sealed from outside bacteria within two days of surgery. Nonetheless, you should protect it from dirt and soiling for the first ten days or so. The incision will be tender for the first week and the edges should NOT be pulled apart. If surgical staples were left in place, they will be removed in the office at your first postoperative visit. If a NEW area of redness or swelling occurs, please let us know.

You may take a shower, but not a bath for the first 2 weeks. Do not scrub the incision or staples. Just let the soap and water run over them and pat them dry.

Activity: 
You may resume normal activity including walking outside, climbing stairs and going out for dinner. You should not resume any form of strenuous activity (i.e. jogging, tennis, golf, treadmill, etc.) for 6 weeks after surgery. Then, increase this as tolerated.

You may drive a car locally 2-3 weeks after surgery as long as you are not having pain or taking narcotic pain medications.

Bowels: 
Some of the pain medications you received while in the hospital and after discharge can cause constipation. It is important to keep your bowels regular during the postoperative period. Use a mild laxative if needed and call if you are having problems. (Milk of Magnesia 2-3 Tablespoons, or 2 Dulcolax tablets for example). You may also wish to take a stool softener (Colace 100 mg twice per day) for a couple of weeks after surgery. If this results in loose stools, decrease to once per day or stop completely.

Medication: 
You should resume your pre-surgery medication unless told not to. Do not resume aspirin, warfarin (Coumadin), or Plavix until instructed to do so by your surgeon. In addition you will often be given some type of pain medication. These should be taken as prescribed on the side of the bottle unless you are having an unusual reaction to one of the drugs.

Problems You Should Report To Us: 
(If you have a problem, call our office or go to the Emergency Room) 

• Fevers over 101.5 Fahrenheit.
• Increasing pain, swelling or redness of the incision.
• Drug reactions (Hives, rash, nausea, vomiting, diarrhea).
• Persistent nausea or vomiting.
• Swelling of the legs or ankles after surgery

Follow-Up: 
You will need a follow-up appointment to monitor your progress. Call for this appointment at the number above when you get home or from the phone in your hospital room before leaving. Usually the first appointment will be about 7 - 14 days after your surgery.

Some patients who undergo surgery to remove a cancerous kidney, experience a recurrence of the disease.  The chance for recurrence is based upon the tumor grade and stage, which is reviewed at your follow-up visit.  Patients usually undergo a regimen of follow-up examinations after surgery, typically at 3 month intervals for the first year.  These examinations include a complete physical exam, a chest x-ray, complete blood tests, and assessments of liver and kidney functions.  Some patients may require follow-up imaging with CT scans as well. 

If the disease recurs but remains confined to a few small areas, additional surgery may be recommended. Radiation, biological, or chemotherapy also may be tried as additional treatments.