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The Contemporary Role of Surgery in Kidney Cancer
Abstract
Introduction:
Until recently, renal cell carcinoma (RCC) was thought of mainly as a surgical disease, as it is by and large one of the most chemo and radio-resistant tumours. Since the first nephrectomy performed for neoplastic disease by Langenbuch in 1887,(1) huge strides have been made in refining the surgical indications and technical aspects of surgery for RCC. The last quarter century has also witnessed the widespread use of new imaging modalities such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). These diagnostic tests now allow better preoperative staging and surgical planning of interventions. On the other hand, imaging has also shifted the stage at which RCC is being diagnosed and treated in the last 25 years, and it now begs the question of whether surgical treatment is still indicated for very small renal lesions, which in many cases, are turning out to have an indolent natural history.(2-4) At the other end of the spectrum, patients suffering from advanced stage RCC have benefited from the introduction of systemic immune therapy, with some having complete and durable responses.(5) Surgical treatment retains its place in this setting in the form of cyto-reductive nephrectomy.(6, 7) Further, the discovery of the VHL gene, and the understanding gained of the molecular biology of the disease have set the stage for the new exciting era of targeted therapies.(8) The role of cyto-reductive nephrectomy with the new tyrosine kinase inhibitors (TKI) remains however to be defined.
This review touches upon the indications and controversies surrounding surgical treatments for RCC. The evolution of surgical techniques and the introduction of laparoscopy will be discussed.
Until recently, renal cell carcinoma (RCC) was thought of mainly as a surgical disease, as it is by and large one of the most chemo and radio-resistant tumours. Since the first nephrectomy performed for neoplastic disease by Langenbuch in 1887,(1) huge strides have been made in refining the surgical indications and technical aspects of surgery for RCC. The last quarter century has also witnessed the widespread use of new imaging modalities such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). These diagnostic tests now allow better preoperative staging and surgical planning of interventions. On the other hand, imaging has also shifted the stage at which RCC is being diagnosed and treated in the last 25 years, and it now begs the question of whether surgical treatment is still indicated for very small renal lesions, which in many cases, are turning out to have an indolent natural history.(2-4) At the other end of the spectrum, patients suffering from advanced stage RCC have benefited from the introduction of systemic immune therapy, with some having complete and durable responses.(5) Surgical treatment retains its place in this setting in the form of cyto-reductive nephrectomy.(6, 7) Further, the discovery of the VHL gene, and the understanding gained of the molecular biology of the disease have set the stage for the new exciting era of targeted therapies.(8) The role of cyto-reductive nephrectomy with the new tyrosine kinase inhibitors (TKI) remains however to be defined.
This review touches upon the indications and controversies surrounding surgical treatments for RCC. The evolution of surgical techniques and the introduction of laparoscopy will be discussed.