Radical nephrectomy is indicated for large and/or complex renal tumors that are not candidates for NSS. This procedure entails removal of Gerota’s fascia and its contents including kidney and perirenal fat. The adrenal gland is also present within Gerota’s fascia; however, it is generally spared unless there is direct invasion or metastasis. Laparoscopic radical nephrectomy (LRN) is currently the standard of care based on equivalent long-term cancer control compared with open surgery, with hastened convalescence, and decreased postoperative pain. This procedure is typically performed transperitoneally but can be performed retroperitoneally as well. Hand-assisted LRN can be performed to decrease the learning curve of the procedure. There has been recent interest in further minimizing the invasiveness of nephrectomy through single-incision surgery, which has been shown to be safe and feasible in those with appropriately thin body habitus. Open radical nephrectomy (ORN) is rarely performed for localized kidney cancer, though it is the approach of choice in the presence of caval tumor thrombus because of superior exposure to the great vessels and the ability to mobilize the liver as necessary. ORN is performed if there is concern for local invasion, plan to resect visceral metastasis, or significant lymphadenopathy in the setting of cytoreduction.

We advocate sparing the ipsilateral adrenal gland during radical nephrectomy unless there is direct involvement or if there is an abnormality suggestive of metastasis. The adrenal should also be taken for upper pole lesions in which there is concern regarding surgical margins.

We do not routinely perform a regional lymphadenectomy with radical nephrectomy, as studies have shown that it does not appear to influence outcome. Indications for a nodal dissection include suspicious lymphadenopathy on preoperative imaging and/or concerning nodes detected intraoperatively.

Tumor thrombus extending into the renal vein or IVC occurs in 4% to 10% of patients. When there is isolated renal vein involvement, the vein can be controlled beyond the edge of thrombus and standard radical nephrectomy performed. However, extension into the cava requires opening the cava for extraction of thrombus. Primary repair, patch grafting, or interposition grafting can be employed in conjunction with a vascular surgeon. Extension to the diaphragm and/or chest may require mobilization of the liver, venovenobypass, and/or cardiopulmonary bypass with circulatory arrest in conjunction with a cardiothoracic surgeon. Caval thrombus is associated with high perioperative risks and modest long-term survival rates; however, long-term survival can be achieved with radical surgery in up to 50% of the patients depending on patient selection. Important predictors of survival include tumor stage, grade, lymph node status, presence of distant metastasis, and presence of systemic symptoms at diagnosis.

When RCC presents with a single site of metastasis, radical nephrectomy and metastectomy are recommended for patients with good performance status as resection may provide a cancer-specific survival advantage. Recent reports have suggested that there is a survival advantage with resection of multiple metastases as well when technically feasible. If a metachronous single metastasis occurs, resection of that metastasis is performed. Radical nephrectomy in the setting of advanced and/or metastatic disease is performed for “cytoreduction” to be followed by systemic immunotherapy in conjunction with a medical oncologist. There is thought to be an immunological benefit to removing the primary tumor; cytoreduction has been shown to confer advantages in terms of delayed progression and overall survival in selected patients with metastasic disease. Eastern Cooperative Oncology Group (ECOG) performance status 0–1 is an important selection criterion for pursuing this treatment approach. There are specific criteria described by
Motzer and colleagues that help predict survival in patients with metastatic RCC, and may help with decision-making regarding use of systemic therapy. There is active investigation of neoadjuvant immunotherapy in the setting of metastatic RCC, and recent prospective data has suggested a survival benefit of this approach in selected good-risk patients. Importantly, RCC is notoriously resistant to chemotherapy and hormonal therapy. Radiation therapy may be considered for palliation of bone and brain metastasis, but is not effective for treatment of the primary tumor.

Partial nephrectomy is currently the standard of care for treatment of most small renal masses. Historically, partial nephrectomy has been used primarily for patients with imperative indications for renal preservation (e.g., solitary kidney, bilateral renal tumors, preexisting CKD, genetic tumor syndromes). However, it is presently recommended for all patients with T1a and T1b disease, when technically feasible, based on equivalent long-term oncological outcomes of radical nephrectomy and decreased long-term risk of CKD. Indeed, there has been growing evidence of the relationship between radical nephrectomy and CKD, as well as the link between CKD and risk of cardiovascular morbidity and mortality. There has been ongoing concern in the urological field that partial nephrectomy has been underutilized because of technical demands and lack of education regarding risks of CKD.

The desired approach to partial nephrectomy depends on surgeon experience, but in general a minimally invasive approach including laparoscopic and/or robotic surgery is preferred. Laparoscopic partial nephrectomy (LPN) by experienced surgeons has been shown to have long-term oncological outcomes equivalent to open surgery, with decreased perioperative morbidity and hastened convalescence. Robotic techniques have recently been applied to minimally invasive partial nephrectomy (MIPN) and have demonstrated promising initial results; improved dexterity, magnification, and surgeon ergonomics have applied naturally to tumor resection and renal reconstruction. Ultimately, however, nephron-preservation should be prioritized over a minimally invasive approach, given the long-term benefits of renal preservation which outweigh the short-term and cosmetic benefits of laparoscopy and robotics.

Partial nephrectomy, whether open or minimally invasive, generally requires temporary clamping of the renal artery during resection of the tumor to minimize blood loss and to allow visual assessment of the deep tumor margin. Clamping of the renal vein may also be performed, though sometimes will cause back-bleeding and require release. Renal ischemia should be minimized to reduce the risk of acute kidney injury postoperatively and to ensure preservation of long-term renal function. Recent evidence has demonstrated that the safe duration of ischemia depends largely on non-modifiable patient factors like preexisting renal dysfunction. For open partial nephrectomy (OPN), the kidney is cooled via ice slush prior to resection to prolong the safe duration of ischemia by slowing renal metabolism; this is called “cold ischemia.” MIPN requires “warm” ischemia as there is not an opportunity to cool the kidney intracorporeally. It is typically thought that 30 minutes of warm ischemia will minimize the likelihood of long-term renal dysfunction, though shorter ischemia times are preferred. Cold ischemia is thought to prolong this safe duration for up to 4 hours.

Ablative treatments have also been developed to treat small renal tumors in minimally invasive fashion. Cryotherapy and radiofrequency ablation have been employed both percutaneously and laparoscopically to destroy a lesion while minimizing treatment morbidity and enabling preservation of the kidney. These approaches are typically used in older, comorbid patients, as retreatment rates are high and long-term efficacy has not been demonstrated.

Active surveillance has been increasingly utilized as a management strategy for patients with small renal masses and significant comorbidities that might compromise the safety of active intervention. Many small renal masses (20% to 30%) will be benign, and additional malignant lesions will have indolent biology; in an older, sicker patient, it may be reasonable to observe a mass for growth as a proxy for its aggressiveness, with the thought that the risks of surgical intervention exceed the potential benefits. The typical threshold for “safe” observation of a renal mass is 3 cm. Most small renal neoplasms that are observed have slow growth (0.15 cm/y) and incidence of metastasis in these observed populations is quite low. Ultimately, the decision to pursue active treatment versus surveillance requires a detailed conversation with the patient regarding the risks and benefits of alternative management strategies.

We favor the flank approach for open surgery as it enables an extraperitoneal dissection that avoids the abdominal viscera. The flank approach may be contraindicated in patients with severe cardiopulmonary disease or scoliosis based on positioning concerns. An incision is made from the interspace between the 10th and 11th ribs, and directed toward an area ∼1 cm above the umbilicus (see Fig. 2). Incisions below the 11th rib may not enable adequate access to the renal hilum, adrenal gland, and upper pole of the kidney. A traditional flank incision involves positioning the patient perpendicular to the bed. The patient can also be positioned in a modified flank position to improve access to the central abdomen, or depending on surgeon preference. This entails placing the patient with the ipsilateral abdomen tilted up 45 degrees. The patient is carefully strapped to the table and the table can be tilted in either direction as needed.

A thoracoabdominal incision is utilized for large upper pole masses or management of caval tumor thrombus on the right side. This incision may start as high as the eighth to ninth interspace and is directed toward the umbilicus. This incision enables excellent exposure of the upper pole and adrenal gland, as well as the suprarenal IVC. Frequently, the pleural space will be entered, which can be expeditiously closed at the end of the case with evacuation of pleural air.

For a flank incision, the patient should be positioned with the tip of the 12th rib over the kidney rest. An “axillary roll” is placed under the upper chest, though not in the axilla per se, to avoid direct compression of the axillary nerve and vessels. The legs are positioned with flexion of the lower leg to 90 degrees and straight extension of the upper leg, with careful padding. The contralateral arm can be tucked at the patient’s side, or extended perpendicular to the body on an arm board. The ipsilateral arm can be positioned in padded fashion over the patient’s chest above the xiphoid, or extended over
the bed and secured within a padded armrest. The table is generally flexed and kidney rest is utilized to increase the space between the costal margin and iliac crest.

A flank incision is typically made starting in the 10th to 11th rib interspace and extending toward the supraumbilical abdomen to the edge of the rectus muscle. Incision of skin and subcutaneous tissue is performed through the latissimus dorsi and external oblique fascia and muscle, continuing through the internal oblique and transversus abdominus. Transversalis fascia is divided near the tip of the 11th rib with care to avoid entering the pleural cavity, if possible. The retroperitoneal space is then developed by blunt and sharp technique. Resection of the rib is rarely needed to obtain the desired exposure. Care is made not to injure the intercostal neurovascular bundle which runs typically along the inferior border of the rib.