This document provides an overview of renal cell carcinoma (RCC). It discusses the epidemiology, etiology, molecular genetics, classification, clinical presentation, imaging, and TNM staging of RCC. Some key points include: - RCC accounts for 2-3% of all cancers and 90% of renal malignancies. Risk factors include tobacco, obesity, hypertension, and family history. - Clear cell RCC is the most common type, accounting for 70-80% of cases. Other types include papillary and chromophobe RCC. - RCC is often asymptomatic and detected incidentally via imaging such as ultrasound, CT, or MRI. When symptomatic, it can present with hematuria

1. Renal cell Carcinoma
Introduction
Rojan Adhikari
Urology Resident
SDNTC, Nepal

2. References

4. Epidemiology
• 2- 3% of all cancers and 90 % of renal malignancy 1
• male-to-female 1.9 : 1 1 1.5:1 2
• peak incidence between 55 and 75 years of age 2
• Majority are sporadic; only 4% to 6% are familial 3
• highest incidence occurring in Western countries 4
1 Siegel et al., 2017
2 Thorstenson, A., et al. 2014
3 Schmidt and Linehan, 2016
4 Chow et al., 2013

5. Etiology
• Tobacco exposure, RR 1.4 to 2.5 1
• Obesity, RR 1.07 for each additional unit of body mass index 2
• Hypertension 3
• Chemical exposure like aromatic hydrocarbons, trichloroethylene, asbestos or
cadmium, rubber, metals and paints 4
• family history of RCC RR 2.9 for 1st and 2nd degree relative with RCC 5
1. Cote et al., 2012; Cumberbatch et al., 2016
2. Bagheri et al., 2016; Ito et al., 2017
3. Colt et al., 2017; Lipworth et al., 2006; Ljungberg et al., 2011
4. Ishida et al., 2015
5. Gago-Dominguez et al., 2001.

6. • Regular usage of NSAID, RR 1.51; 1
• increased intake of dairy products, and increased consumption of coffee or tea ; 2
• Retroperitoneal radiation therapy; 3
• increased incidence in ESRD, patient on dialysis and certain familial syndromes
such as tuberous sclerosis, VHL ; 4
• Moderate alcohol consumption appears to have a protective effect 5
1. Cho et al., 2011
2. Ljungberg et al., 2011
3. Romanenko et al., 2009
4. Schmidt and Linehan, 2016
5. Bellocco, R., et al. Alcohol drinking and risk of renal cell carcinoma: results of a meta-analysis. Ann Oncol,
2012. 23: 2235.

7. Molecular Genetics
• Mutation in Chromosome 3 1
• Trisomy for chromosomes 7 and 17 as well as abnormalities on
chromosomes 1, 4, 7, 12, 16, 20; 1
• Translocations involving the TFE3 gene on chromosome Xp11, leading
to TFE3 overexpression; 2
• Defect in VHL , MET, Folliculin, PTEN gene associated 1
1. Schmidt and Linehan, 2016
2. Brok et al., Biology and treatment of renal tumours in childhood, Eur J Cancer 68:179–195, 2016

8. Alfred G. Knudson et al; 1970
Campbell-Walsh- Wein Urology, 12 th edition

9. Familial
Campbell-Walsh- Wein Urology, 12 th edition

10. Von Hippel-Lindau (VHL)
pathway
Campbell-Walsh- Wein Urology, 12th edition
Modified from Linehan WM, Ricketts CJ: Kidney cancer in 2016: RCC—advances in targeted therapeutics and genomics. Nat Rev Urol 14:76–78, 2017.

11. Classified by Pathologic Features
• Clear cell RCC
• Papillary RCC
• Chromophobe RCC
• Hybrid oncocytic chromophobe tumor
• Carcinoma of the collecting ducts of Bellini
• Renal medullary carcinoma
• Multilocular cystic clear cell renal cell neoplasm of low malignant potential
• MiT family translocation RCCa Xp11 translocation RCC and t(6;11) RCC
• Mucinous tubular and spindle cell carcinoma
• Tubulocystic RCC
• Acquired cystic disease–associated RCC
• Clear cell (tubulo) papillary RCC
• Hereditary leiomyomatosis RCC syndrome–associated RCC )
• RCC, unclassified Campbell-Walsh- Wein Urology, 12th editio

12. Heidelberg Classification
Sporadic Renal Cell Carcinoma:
• Conventional clear-cell 75% (60% VHL mutation)
• Papillary 12% (13% MET oncogene mutation)
• Chromophobe 4%
• Renal medullary carcinoma
• Collecting Duct 1%
• Unclassified* 3-5%
EAU 2020
Heidelberg et al, 1997

13. Conventional or clear-cell RCC
• Derived from proximal convoluted tubule 1
• 70% to 80% of all RCCs 1
• VHL gene defects in up to 60% either mutation or hypermethylation 2
• Chromosome 3p deletions or gain of chromosome 5q 2
• Aggressive behavior 1
1. Deng and Melamed, 2012; Moch et al., 2016;
2. Cancer Genome Atlas Research Network, 2013

14. • Typically well circumscribed, lobulated, golden yellow tumor but can be
infiltrative necrosis, hemorrhage, and cystic degeneration common, sometime
venous involvement

15. Papillary RCC
• Originates from proximal tubule 1
• 10% -15% of all RCC 1
• Loss of chromosome 4 and Y, trisomy 7 &17 or Mutation of C-MET proto-
oncogene in 13%. 2
• Acquired cystic disease and ESRD 3
• Multicentricity in 40%
1. Moch et al., 2016
2. Cancer Genome Atlas Research Network, 2013
3. Pal et al., 2018

16. Campbell-Walsh- Wein Urology, 12th
edition

17. Chromophobe RCC
• Origin: distal convoluted tubules or intercalated cells of collecting duct 1
• 3% to 5% of all RCCs 1
• Birt-Hogg-Dube (BHD) syndrome
• Folliculin (FLCN) gene mutation (17p11) or Loss of multiple
chromosomes (1, 2, 6, 10, 13, 17, 21, Y) or PTEN mutations 2
1. Algaba et al., 2011; Davis et al., 2014
2. Cancer Genome Atlas Research Network, 2013

18. Chromophobe RCC
Campbell-Walsh- Wein Urology, 12th editi
Courtesy: Dr. Ming Zhou, Cleveland, OH

19. Collecting Duct Carcinoma (of Bellini)
• Arise from medullary collecting ducts 1
• Younger patients
• Usually high grade, aggressive tumor with poor prognosis 1
• May share features in common with urothelial carcinoma, 2
1. Seo et al., 2017; Sui et al., 2017
2. Wright et al., 2009

20. Renal medullary carcinoma
• Originates from collecting duct
• Affects mostly young African-Americans 1
• Almost exclusively with sickle cell disease 1
• Highly aggressive and usually presents in 3rd decade with widespread
metastasis with low Life expectancy 1
1. Moch et al., 2016; Swartz et al., 2002

21. Clinical Presentation
• Incidental finding in over 60%
Symptoms of localized or locally advanced disease
• Haematuria
• Loin Pain
• Palpable Mass
• Classical Triad of hematuria, loin pain, mass in 10% “too late triad.”
Beisland, 2017; O’Connor et al., 2011
Campbell-Walsh- Wein Urology, 12 th edition

22. Symptoms of systemic disease
• Persistent cough
• Bone pain
• Cervical lymphadenopathy
• Constitutional symptoms like Weight loss, fever, malaise, night
sweating
Obstruction of the inferior vena cava
• Bilateral lower extremity edema
• Nonreducing or right-sided varicocele
Xie et al., 2017; Zhang et al., 2002
Campbell-Walsh- Wein Urology, 12 th edition

23. Paraneoplastic Syndrome (10% to 20%)
• Hypercalcaemia (PTHrP) – seen in approximately 13% 1
• Raised ESR seen in more then 50% 1
• Polycythaemia - may be associated with increased response to IFN 2
• Hypertension 2
• Stauffer’s syndrome: Abnormal LFT, Hepatic necrosis, Thrombocytopenia,
Neutropenia 3
1. Schwarzberg and Michaelson, 2009
2. Moreira et al., 2016
3. Kranidiotis et al., 2009

24. Take home
• The majority of cases of RCC are sporadic, 4-6% are familial
• Tobacco consumption, obesity and hypertension are the major risk
factor for development of RCC
• Different gene involved, multifactorial.
• Usually detected incidentally

25. Imaging in
Renal cell Carcinoma

26. Ultrasound
• sensitivity of 46% and specificity of 12% 1
• Colour Doppler USG: Sensitivity of 47% and specificity of 55% 1
• Color Doppler : venous tumor thrombus
C. Vogel et al. Imaging in Suspected Renal Cell Carcinoma: A Systematic Review

27. Geertsma et al

28. Carlo Trombetta et al; 2007; Evaluation of tumor thrombi in the inferior vena cava with intraoperative ultrasound

29. Contrast-enhanced ultrasound (CEUS)
FOR COMPLEX CYST
sensitivity of 94.5% and
specificity of 69%
IN DIFFERENTIATION OF RCC
FROM AML
sensitivity and specificity values
of 89% and 96%
renal vein invasion,
sensitivity 83% and specificity
96%

30. Yingyu Cai et al; Quantification of Enhancement of Renal Parenchymal Masses with Contrast-Enhanced Ultrasound

31. Computerized Tomograpy
• sensitivity of 88% and specificity of 75%
• Tumor location and complexity describe the relationship of the mass
with the renal hilum, collecting system, polarity, and endophytic
versus exophytic location
• Composite complexity profiles include the Renal nephrometry score,
the PADUA score, and the C-index
Davenport et al., 2017
Campbell-Walsh- Wein Urology, 12th edition

33. • score of 4-6: low complexity
• score of 7-9: moderate complexity
• score of 10-12: high complexity

36. • score of 6-7: low complexity
• score of 8-9: moderate
complexity
• score of >10: high complexity

37. •Yu-De Wang et al ; 2019

38. SAMPLE
SIZE : 50
C-index fared better than other two SS in
predicting trifecta outcomes; however, it is
difficult to calculate and has highest
interobserver variability.

39. MRI
• alternate standard imaging modality
• Enhancement of greater than 20% with intravenous gadolinium-based
contrast on MRI is suggestive of RCC 1
• Useful in masses smaller than 2 cm 1
• Complication nephrogenic systemic fibrosis (NSF) in patients with
CKD on dialysis 2
1. Donat et al., 2013
2. Bach and Zhang, 2008

41. Positron Emission Tomography
• Limited role
Bagheri et al., 2017

42. TNM

45. Renal tumour biopsy
• histology of radiologically indeterminate renal masses.
• considered in patients
- who are candidates for AS of small masses.
- obtain histology before ablative treatments.
- select the most suitable medical and surgical treatment strategy in the setting of metastatic
disease.
• not indicated for comorbid and frail patients who and considered only for conservative
management (watchful waiting) regardless of biopsy results.

46. Renal Biopsy
• Percutaneous sampling can be performed under local anaesthesia with needle core biopsy and/
or fine needle aspiration (FNA).
• Biopsies can be performed under US or CT guidance, with a similar diagnostic yield [130, 134](LE:
2b).
• Eighteen-gauge needles are ideal for core biopsies, as they result in low morbidity and provide
sufficient tissue for diagnosis [127, 131, 135](LE: 2b).
• A coaxial technique allowing multiple biopsies through a coaxial cannula should always be used
to avoid potential tumour seeding

47. EAU Guidelines

48. T1 Tumour <7 cm or less in greatest
dimension, limited to the kidney

49. Active surveillance(AS)
• Elderly and comorbid patients with incidental small renal masses have a low RCC-specific
mortality and significant competing-cause mortality [293, 294].
• Initial monitoring of tumour size by serial abdominal imaging (US, CT, or MRI) with delayed
intervention reserved for tumours showing clinical progression during follow-up [295].
• AS differs Vs watchful waiting;
- watchful waiting is reserved for patients whose comorbidities contraindicate any subsequent
active treatment and do not require follow-up imaging, unless clinically indicated.

50. Active surveillance
• Subsequent series have confirmed that many small renal masses
- will grow relatively slowly (median growth rate 0.12 to 0.34 cm/yr).
- and with a relatively low rate of metastasis (1.2% to 2.0% during 2 to 4 years of follow-up)
- AS may be a reasonable management strategy in carefully selected patients who are not
candidates for conventional surgery or thermal ablative approach. (Campbellet al, 2009;
Smaldone et al, 2012)s

51. Active surveillance
• AS is not appropriate for patients
- with larger (>3 to 4 cm)
- poorly marginated
- nonhomogeneous solid renal lesions
- when biopsy indicates a potentially aggressive RCC,except in patients with limited life
expectancy(Remzi et al, 2006; Kunkle et al, 2007).
• AS is also not advisable in younger, otherwise healthy, patients with small, solid tumors that have
radiographic characteristics consistent with RCC(Campbell et al, 2009; Lane et al, 2012)

52. Active surveillance

53. Thermal Ablative Therapies
1)renal cryosurgery
2) radiofrequency ablation (RFA)
• have emerged as alternative nephron-sparing treatments for patients with localized RCC (Murphy
and Gill, 2001; Sterrett et al, 2008)
• Both can be administered percutaneously or through laparoscopic exposure and thus offer the
potential for reduced morbidity and more rapid recovery (Johnson et al, 2004; Sterrett et al, 2008)

54. Thermal Ablative
• Ideal candidates for TA procedures may be
- patients with advanced age
- significant comorbidities
- who prefer a proactive approach but are not optimal candidates for conventional surgery
- patients with local recurrence after previous nephron-sparing surgery
- with hereditary renal cancer who present with multifocal lesions for which multiple PNs might
be cumbersome (Kunkle et al, 2008)

55. Renal Cryosurgery
• predates that of RFA and has been more extensive (Sterrett et al, 2008).
• rapid freezing, gradual thawing, and a repetition of the freeze-thaw cycle.
• Tissue cryodestruction involve immediate membrane and cellular damage followed by micro-
circulatory failure(Stein and Kaouk, 2007).
• Delayed microcirculatory failure occurs during the slow thaw phase of the freeze-thaw cycle, leading
to circulation arrest and cellular anoxia.
• Target lethal temperature of −20°C was achieved at a distance of 3.1 mm inside the leading edge of the
iceball as visualized by real-time USG.

56. Complications of cryoablation
• renal fracture
• Hemorrhage
• adjacent organ injury
• ileus
• wound infection
• major morbidity is decidedly uncommon
(Sidana et al, 2010; Tsivian et al, 2010).

57. RFA
• Application of high-frequency electrical current by RFA induces lethal sequence of
events
• observed at tissue temperatures above 41°C but increase directly with increasing
temperature and duration of treatment (Sterrettet al, 2008).
• Temperatures in excess of 100°C are typically obtained at the tips of the probes, and
thermosensors can be used to monitor progress.
• Temperature dissipates at points more distant from the probe tip, and multiple probes or
tynes are typically required to achieve adequate heating of the entire region of interest
(Murphy and Gill, 2001)
excitation of ions frictional forces heat
denaturation of intracellular proteins and
melting of cellular membranes

58. • Complications from RFA are uncommon
- acute renal failure
- stricture of the ureteropelvic junction
- necrotizing pancreatitis
- lumbar radiculopathy.

60. New modalities
These techniques are considered experimental.
• high-intensity focused ultrasound (HIFU)
• image-guided radio-surgical treatments (CyberKnife)
• microwave ablation
• laser Ablation
• irreversible electroporation
are also under development and may allow extracorporeal treatment of small renal tumors in
the future (Ponsky et al, 2007; Haber et al, 2010; Kroeze et al,2012)

61. Embolisation
• Before routine nephrectomy, tumour embolisation has no benefit.
• In patients unfit for surgery, or with non-resectable disease, embolisation can control symptoms,
including visible haematuria or flank pain .
Summary of evidence LE
In patients unfit for surgery with massive haematuria or flank pain,
embolisation can be a beneficial
palliative approach.
3
Recommendations Strength
rating
Offer embolisation to patients unfit for surgery presenting with massive
haematuria or flank pain.
weak
EAU Guidelines

63. NEPHRON SPARING
SURGERY

64. Nephron sparing surgery
Absolute indications
1. Bilateral RCC
2. RCC in solitary functioning kidney
Relative indication
1. Unilateral RCC with reduced or poorly functioning contralateral kidney
(hydronephrosis, chronic pyelonephritis, ureteral reflux, calculus disease)
2. Unilateral RCC in patients with co-morbidity associated with potential renal impairment( DM,
Renovascular disease).
3. Patients with an increased risk of second renal malignancy ( Hereditary RCC such as von Hippel-Lindau
disease)
Elective indications
Localised unilateral RCC with normal contralateral kidney.

65. Relative contraindications to partial
nephrectomy
Technical issues
• Cold ischemia time greater than 45 minutes (consider extra-corporeal approach)
• Less than 20% of global nephron mass retained
Cancer-related issues
• Diffuse encasement of renal pedicle by tumor
• Diffuse invasion of central collecting system
• Tumor thrombus involving major renal veins
• Adjacent organ invasion (stage cT4)
• Regional lymphadenopathy (stage cTxN1)

66. • score of 4-6: low
complexity
• score of 7-9: moderate
complexity
• score of 10-12: high
complexity

67. HISTORY
• The first partial nephrectomy was performed in 1884
by Wells for removal of a perirenal fibrolipoma
• In 1887, Czerny was the first to use partial
nephrectomy for excision of a renal neoplasm

68. DEFINITION
Complete local resection of diseased renal
parenchyma leaving the largest possible
amount of normal functioning parenchyma in
the involved kidney

69. INTRAOPERATIVE RENAL ISCHEMIA
• Occlusion of the renal artery(<30mins).
• diminishes intraoperative renal bleeding but also improves access to intrarenal
structures by causing the kidney to contract and by reducing renal tissue turgor.
• cellular injury due to imbalance between oxygen delivery and demand
• Endothelial injury due to leukocyte activation[cytokines, chemokines,
eicosanoids] and release of vasoactive substances >> swelling and cell injury

70. Arterial clamping only or both artery & vein

71. • The impairment is least when the renal artery alone is
continuously occluded.
• Continuous occlusion of artery and vein for an equal time
interval is more damaging, because it prevents retrograde
perfusion of the kidney through the renal vein and may also
produce venous congestion of the kidney.
• Intermittent clamping artery is more damaging than
continuous; because of the release and trapping of
vasoconstrictor agents within the kidney.
• Manual renal compression to control intraoperative
hemorrhage is more deleterious than simple arterial
occlusion.

72. Prevention of Ischemic Renal Damage
General measures
• Preoperative and intraoperative hydration.
• Prevention of hypotension.
• Avoidance of unnecessary manipulation or traction on the renal
artery.
• Intraoperative administration of mannitol.

73. Mannitol
• Mannitol is most effective when it is given 5 to 15 minutes before arterial occlusion (20%-
1mg/kg).
- increases renal plasma flow,
- decreases intrarenal vascular resistance,
- minimizes intracellular edema,
- and promotes an osmotic diuresis when renal circulation is restored.

74. Role of mannitol

75. Renal Cooling
• Used for complex lesions with prolonged expected warm ischemia time (>30min)
• Methods
– Surface cooling with ice-slush
– Retrograde cold saline instillation via ureteral catheter
– Intra-arterial cold perfusion

76. Approaches
• OPEN NSS.
• LAPAROSCOPIC NSS.
• ROBOTIC NSS.

77. Patient Positioning
Lateral decubitus position
dependent limb is flexed at knee
Pillow is placed between knees.
Axillary roll
Kidney bar

78. Incision
a finger breadth below and parallel to the
12th rib

79. Muscle layers
Serratus posterior inferior muscles
Lattismus
dorsi

80. Essential Steps
1) Expose and thoroughly mobilize the kidney.
2) Obtain control of the renal pedicle.
3) Cool the kidney with ice slush.
4) Excise the tumor with a rim of normal renal parenchyma.
5) Perform the appropriate renal reconstruction and obtain hemostasis within the resection bed.
6) Cover the repair with perirenal fat, Gerota’s fascia, or omentum.
7) Place a drain

81. • On the right:The hepatic flexure and duodenum were mobilized, freeing the kidney
superiorly and medially.
• On the left:The splenorenal ligament was mobilized, freeing the kidney superiorly.
• Using sharp and blunt dissection, the retroperitoneal fascia overlying the renal
vessels was separated, exposing the underlying main renal vein, which was carefully
dissected, mobilized, and encircled with a loop.
• Using gentle retraction on the renal vein, the main renal artery was identified deep
to this, dissected, and surrounded with a vessel loop.
• Having achieved control of the main renal vessels, attention was turned to the
kidney

82. General considerations
• Remove the perinephric fat around the normal parts of kidney. Don’t remove the perinephric fat over tumour.
• Mark the tumor and excise with caultry
• Visible open blood vessels are sutured with figure of 8 sutures
• Push 10ml methylene blue 1:1 diluted through RGC or into directly into renal pelvis; collecting system and clamp ureter and look
for collecting system leak.
• If any calyceal system opening is seen – close it by absorbable suture.(4-0)
• Close kidney over after Hemostasis achieved
• Kidney fixed to posterior musculature to avoid flipping

83. TECHNIQUES
1. ENUCLEATION
2. POLAR SEGMENTAL NEPHRECTOMY
3. WEDGE RESECTION
4. EXTRACORPOREAL PARTIAL NEPHRECTOMY WITH RENAL
AUTOTRANSPLANTATION.

84. Enucleation for Small Cortical Tumors
• Enucleation is indicated
- von Hippel–Lindau disease and
- multiple low-stage encapsulated tumors.
• surrounded by a distinct pseudocapsule of fibrous tissue
• circumferential incision of the renal parenchyma around the
tumor at any location, often with no vascular occlusion.
• higher risk of leaving residual malignant cells in the kidney.

85. Segmental Nephrectomy for Large Polar Tumors
• Indication: large polar(upper or lower)
tumors
• Performed by isolation and ligation of the segmental apical or basilar arterial branch.
• The apical artery is dissected, ligated, and divided

86. • A bulldog clamp is applied to the apical segmental artery (or basilar segmental artery for lower
pole tumors) and the line of ischemia is
observed.
• line of ischemia is optimal site for transection of kidney and marked with electrocautery.
• The apical segmental artery is ligated, then the renal pedicle is clamped en bloc with a curved
Satinsky clamp.
• ice slush
• renal capsule is incised along the line of ischemia.

87. WEDGE RESECTION
• Bleeding vessels: figure of eight
suture or argon beam or bipolar
cautery.
• Collecting system involvement:
checked with 10-20ml of diluted
indigo carmine injected into
pelvis, ureter clamped and
checked for leak if present closed
with 4-0 absorbable suture.

88. EXTRACORPOREAL PARTIAL NEPHRECTOMY(ECRS)
AND AUTOTRANSPLANTATION
• It was described by Calne 1973, Gittes and McCullough 1975
• Malignancy in solitary kidney
1. large central mass encroaching on the renal pedicle.
2. large, central renal pelvis tumor.
3. multiple subcorticle neoplasms.
ADVANTAGES
• Optimum exposure
• Bloodless surgical field
• Maximum conservation of renal parenchyma
• Greater protection of the kidney from prolonged ischemia
• opportunity to use an operating microscope.

89. A, The kidney is removed outside Gerota's fascia.
B, The tumor is excised extracorporeally
C, Pulsatile perfusion or reflushing is used to identify transected blood vessels
D, The kidney is closed on itself

90. Laparoscopic NSS

91. Modifies Flank Position – Operative side tilted up 45° using gel roll supporting back

92. Left Right Obese
Subcostal -
retraction
5mm subxiphoid –
Liver retraction
Trocars shifted
laterally
Port Placement

93. LEFT RIGHT
Subcostal Subxiphoid / Subcostal
Suprapubic Low midline

94. Method of Artery clamping
• Laparoscopic Satinsky clamp –
– Faster en-block clamping.
– Requires an additional 10-12mm port.
– Risk of inadvertent slippage.
– Not useful in retroperitoneal approach – less space.
• Bulldog clamp –
– application requires meticulous artery dissection
– Technical difficulty in manipulation – may increase WIT.

95. • Vascular Torniquet*
– Doesn’t require additional port.
– Not limited by number of vessels.
– Can be left in-situ after reperfusion for emergency re-occlusion if needed

96. Application of vascular
torniquet

97. Role of hemostatic agents
• TISSEEL/TISSUCOL (Baxter Healthcare)-Fibrin glue
• FloSeal (Baxter Healthcare), SURGIFLO® (Ethicon)- Gelatin based
• SURGICEL® (Ethicon)- Oxidized Regenerated Methylcellulose
• BioGlue® (Cryolite)- Glutaraldehyde-based adhesive
• TachoSil® (Nycomed)-Human fibrinogen and thombin
• Vivostat® (Alleroed) - autologous, platelet-enriched, fibrin sealant
applicator

98. Hemostatic agents
•
• No proper recommendation : lack of prospective randomized trials
• Adjuncts to proper laparoscopic suturing – Not substitutes

99. Complications
Intra-operative Bleeding
Trauma to adjacent organs
Post-op Bleeding
Infection
Urinary fistula
Ureteric obstruction
AKI
late HTN
Tumor recurrance
Aneurysm, Pseudoaneurysm
AV fistula
Hyperfiltration injury(FSGS,Proteinuria)

100. Complications
• Urinary fistula
- At 1 week(advised to keep the drain till 7-10days ).
- confirmed by drain fluid creatinine.
- treatment 3 tubes:
1. retroperitoneal closed suction drain to collect urinoma
2. D-j stent
3. Foleys catheterisation
- Resolve within 4-6 weeks.

103. Treatment of Locally
Advanced RCC

105. Definition of radical nephrectomy
• Classically Robson describe Radical nephrectomy as
complete removal of the kidney outside the Gerota’s fascia
together with the ipsilateral adrenal gland and complete
regional lymphadenectomy from the crus of the diaphragm
to the aortic bifurcation. 1
• Nowadays the definition has changed , adrenalectomy and
lymphadenectomy is not performed until it is involved 2
1. Robson et al. (1969)
2. Shah et al., 2017b

106. Indication
• tumors in nonfunctional kidneys,
• large tumors replacing the majority of renal parenchyma,
• tumors associated with detectable regional lymphadenopathy,
• tumors associated with renal vein thrombus.
• Tumors invading collecting system
Campbell-Walsh- Wein Urology, 12th edi

107. Surgical Procedure
Position : modified lateral decubitus position
incisions : subcostal flank
Campbell-Walsh- Wein Urology, 12th edit

108. On right
• The posterior parietal peritoneum on the white line of Toldt is incised from
the pelvis (region of the iliac artery) to the right upper quadrant (region of
hepatic flexure).
• anterior pararenal space is developed by dissecting in the plane between
the anterior renal fascia and the mesentery of the ascending colon.
• After mobilizing the hepatic flexure of the colon using sharp and blunt
dissection, the second part of the duodenum is mobilized medially using
the Kocher maneuver .
• With medially located tumors, mobilization of the duodenum should be
performed with extreme care to avoid injury.
Campbell-Walsh- Wein Urology, 12th editi

109. Campbell-Walsh- Wein Urology, 12th ed

110. • After mobilization of the duodenum, the IVC is identified posteriorly.
• Dissection anterior to the IVC will enable identification of the renal
vein and gonadal vein. Placement of a vessel loop will enable gentle
traction of the renal vein
• The renal vein is palpated for any tumor thrombus.
Campbell-Walsh- Wein Urology, 12th edi

111. • Next the renal artery is
identified posterior to the
renal vein.
• If identification of the
renal artery is difficult,
attention is turned to the
lower pole of the kidney
to identify the ureter and
gonadal vein.

112. • If technically feasible, the gonadal vein is spared. However, often
because of the large size of the renal tumor, the gonadal vein cannot
be safely left intact without the risk for avulsion from the IVC
• With ligation of the ureter, the kidney is lifted from a posterior to an
anterior position to aid in identification of the renal artery posterior
to the kidney.
Campbell-Walsh- Wein Urology, 12th ed

113. • With the renal artery controlled, the right kidney and tumor will
decrease in size and engorgement, easing the dissection of the kidney
at the hilum and the remaining sites.
• The right renal vein, which should now be flaccid, is examined for any
tumor thrombus
Campbell-Walsh- Wein Urology, 12th ed

114. On left
• Incision of the white line of Toldt from the splenic flexure to the common
iliac artery, the descending colon is reflected medially.
• The renocolic ligament is divided, and extreme care is taken to avoid injury
to the tail of the pancreas.
• The left renal vein is identified using the anterior surface of the aorta as a
guide.
• The left renal artery is usually located cranial and posterior to the left renal
vein.
Campbell-Walsh- Wein Urology, 12th edit

115. • After further mobilization of the lower pole of the kidney, the left ureter
and the left gonadal vein are identified.
• The left gonadal vein can be traced to its insertion to help identify the left
renal vein.
• The ureter is divided, and the inferior and posterior surface of the kidney is
mobilized to identify the left renal artery.
• Once the renal artery and vein are identified, the renal artery is ligated and
divided first then follows the vein.
Campbell-Walsh- Wein Urology, 12th edit

116. • Sometimes renal artery and vein cannot be separated individually
because of significant hilar lymphadenopathy or adhesion.
• Then, a whole pedicle clamp technique may be utilized to control the
hilar vessels. Although the risk for arteriovenous fistula may be
associated with en bloc ligation of the whole renal pedicle.
Campbell-Walsh- Wein Urology, 12th edition

117. Complications
Intra-operative Bleeding
Trauma to adjacent organs
Tumor seeding
Pneumothorax
Post-operative Bleeding
Infection
AKI
late HTN
Tumor recurrance
Aneurysm, Pseudoaneurysm
AV fistula

118. Adrenalectomy
• overall incidence of adrenal metastasis is less than 5% 1
• Indications 2
diffuse involvement by tumor,
large tumor size of upper pole (>10 cm),
extrarenal tumor extension,
tumor thrombus,
lymphadenopathy and regional metastasis, or an adrenal mass on
imaging.
1. Siemer et al., 2004
2. Campbell-Walsh- Wein Urology, 12th ed

119. Regional lymphadenectomy
• incidence of lymph node disease is about 5% 1
• The role of regional lymphadenectomy on RCC has remained controversial 2
• Indications 3
enlarged lymph nodes on imaging,
cytoreductive surgery for metastatic disease,
tumor size greater than 10 cm, nuclear grade 3 or greater,
sarcomatoid histology,
presence of tumor necrosis on imaging,
extrarenal tumor extension, and
tumor thrombus 1. Capitanio et al., 2013;
2. Sun et al., 2014
3. Campbell-Walsh- Wein Urology, 12th edition

121. Sample size: 772
RCC with N0M0 and
resectable, patients were
randomly into two group
Conclusion: The incidence of
unsuspected lymph-node metastases
is 4.0% and no survival advantage of
a complete lymph-node dissection in
conjunction with a radical
nephrectomy alone .

122. Conclusion:
• The existing literature does not support a survival benefit with LND in either
M0 or M1 RCC
• A small subset of patients with isolated nodal metastases experience long-
term survival after surgical resection.

123. Forest plot for meta-analysis of the association of lymph node dissection with oncological outcomes among M0 and
M1 patients. LND, lymph node dissection.

124. Inferior Vena Cava Involvement
• 4% to 10% of patients with RCC 1
• 45-70 % of patients with venous tumor thrombus can be cured with
nephrectomy and thrombectomy 1
• two components associated with IVC thrombi are tumor thrombus (tumor
cells contained within bland thrombus) and bland thrombus (blood
coagulum without tumor cells) 2
• In RCC with venous thrombus, 10% have associated positive regional lymph
nodes, 25% have associated metastases, and 50% have perirenal fat
invasion 2
1. Blute et al., 2004b;
2. Martinez-Salamanca et al., 2011

125. • MRI, CECT, and echocardiography are useful adjuncts in the pre- and
perioperative planning
• MRI is the preferred diagnostic study at many centers , however,
recent literature indicates that an appropriately performed CT can
provide essentially equivalent information
• venacavography, is rarely used and reserved for patients whom MRI
and CT are contraindicated
Pouliot et al., 2010
Campbell-Walsh- Wein Urology, 12th edition

126. Preoperative Considerations
• Anticoagulation with intravenous or low-molecular-weight heparin to
be started
• Temporary suprarenal IVC filters are also an option for patients with
level I, and II tumor thrombi but controversial as provoke
embolization to contralateral renal vein and hepatic vein
• Preoperative angioembolization can be considered because tumor
thrombi have an independent blood supply arising from the renal
artery and/or aorta in one-third of cases
Campbell-Walsh- Wein Urology, 12th edition

127. Mayo classification of macroscopic venous invasion
Level I: The tumor thrombus is either at the entry of the renal vein or within the IVC < 2 cm from the confluence of the renal vein and the IVC.
Level I IVC thrombus managed with a Satinsky clamp to achieve vascular isolation.

128. Level II: The thrombus extends within the IVC > 2 cm above the confluence of the renal vein and the IVC but still remains below the hepatic veins.
Level II IVC thrombus managed by sequential clamping of the
For right side lower IVC, contralateral renal vein, and cephalad IVC, along with mobilization of the IVC and occlusion of lumbar veins, allowing for vascular isolation
For left side Vascular control is obtained sequentially in the following order: (1) the ipsilateral (left) renal artery is ligated, (2) the infrarenal IVC is clamped, (3) the contralateral (right) renal
vein is clamped, (4) the suprarenal IVC is clamped,

129. Level III: The thrombus involves the intrahepatic IVC. The size of the thrombus ranges from a narrow tail that extends into the IVC to one that fills the lumen and enlarges the IVC.
Level III IVC thrombus managed by mobilization of the liver, providing exposure of the intrahepatic IVC and retraction of the thrombus to facilitate placement of the upper IVC clamp just below the level of the hepatic veins. Through this approach vascular
isolation is achieved in a manner similar to that in B. If the cephalad clamp must be placed above the level of the hepatic veins, a Pringle maneuver should be performed to temporarily occlude the hepatic blood flow

131. Patching, Replacing, and Interrupting the
Inferior Vena Cava
• If the IVC is expected to be less than 50%
of its original size, a patch cavoplasty is
necessary to prevent IVC stenosis and
thrombosis-related events.
• Autologous and bovine pericardium,
polytetrafluoroethylene (PTFE), collagen-
impregnated Dacron , or autologous
saphenous vein are materials that can be
used for patch cavoplasty.

133. Conclusion,
• In patients with non-metastatic RCC with thrombus, independent predictors of
recurrence include: BMI ≤20 kg/m2, preoperative haemoglobin , perinephric fat
invasion, IVC thrombus height, tumour diameter, nuclear grade and non-clear-cell
histology. Patients with >2 risk factors are at highest risk of recurrence and should
be considered for adjuvant therapy trials or increased surveillance.

134. • Conclusions
• Survival in patients with pT4 remains poor. pT4 is associated with a
locally and regionally invasive biology that requires specific attention
and warrants careful study

135. Complications
Intra-operative Air Embolism
Acute Pulmonary Embolism
Massive Hemorrhage
Hepatic dysfunction
Organ Ischemia
Trauma to adjacent organs
Post-op Hemorrhage
Infection
late Tumor recurrance
Aneurysm,
Pseudoaneurysm
AV fistula

139. Conclusions
The addition of adjuvant
therapy provided no survival
benefit but increased the rates
of adverse events for locally
advanced RCC patients.
• Twelve studies (5,936
patients)
• compared to placebo or
observation
• targeted therapy, and
immune therapy

140. Double-blind, phase 3
trial, randomization with
1:1 ratio, patients after
nephrectomy, with or
without metastasectomy,
to receive either adjuvant
pembrolizumab
total of 496 patients
were randomly
assigned to receive
pembrolizumab, and
498 to receive placebo
Conclusion:
Pembrolizumab treatment
led to a significant
improvement in disease-
free survival as compared
with placebo after surgery
among patients with
kidney cancer

141. • Thank You