Perioperative Care Following Open Radical Nephrectomy for Renal Cell Carcinoma View PDF

Renal masses may be categorized as malignant, benign, or inflammatory. Alternatively, they can be grouped based on their imaging characteristics into simple cystic lesions, complex cystic lesions, fat-containing tumors, and other solid masses [1]. RCC, historically referred to as hypernephroma due to the mistaken assumption of adrenal origin, is also known as clear cell carcinoma or Grawitz tumor [2]. RCC is a malignant epithelial neoplasm arising from the renal tubular epithelium and is the most common primary cancer of the kidneys in adults.

It is the most common renal tumor, accounting for 85% of all renal malignancies and 2% of all cancer-related deaths. RCC is considered the most lethal urological tumor, and more than 40% of RCC patients die of the disease [3, 4]. Overall, approximately 12 new cases are diagnosed per 100,000 population per year, with a male-to-female predominance of 3:2. The majority of RCC cases are believed to be sporadic, and only 2 – 3% are familial [5]. Approximately 4 – 10% of patients with RCC develop a tumor thrombus that extends into the inferior vena cava (IVC), and in some cases, the thrombus may propagate further into the right atrium [6]. There appears to be an increase in the incidence of all stages of RCC over the past few decades, when imaging, such as ultrasound and computed tomography (CT) scanning, has become more common to investigate nonspecific abdominal symptoms. In fact, RCC was historically described as the “internist’s tumor” due to its tendency to present with systemic manifestations rather than localized symptoms. However, with the widespread use of modern imaging modalities and the high rate of incidental detection, it is now more appropriately considered a “radiologist’s tumor.” RCC most frequently occurs in individuals in their sixth to seventh decades of life [7].

Environmental studies have shown associations with the following smoking cigarettes, pipes, or cigarettes (1.4 to 2.3-fold increased risk; smoking cessation can reduce the relative risk by 20 – 50%) [8], hypertension (1.4- to 2-fold risk), obesity, renal failure and dialysis (30- fold risk), family history in a first or second-degree relative (relative risk of 2.9), analgesic phenacetin use, asbestos exposure, low socioeconomic status, and urban dwelling.

RCC histology includes conventional (70 – 80%), papillary (10 – 15%), chromophobe (5%), collecting duct (Bellini), and medullary cells [9].

RCC can spread through several pathways. Direct local extension can involve the adrenal gland, observed in approximately 7.5% of tumors larger than 5 cm, as well as invasion beyond the renal capsule into the renal vein (present in about 5% of cases at diagnosis), IVC, and occasionally the right atrium. Lymphatic dissemination typically affects the hilar and para-aortic lymph nodes (LN), whereas hematogenous metastasis most commonly involves the lungs (75%), followed by the bone (20%), liver (18%), and brain (8%) [10]. Gross invasion with penetration of the renal capsule, renal sinus, or collecting system has been reported in nearly 20% of patients. Incidental detection accounts for more than 50% of RCC cases [11]. Of the symptomatic RCCs diagnosed, 50% had hematuria, 40% had flank pain, 30% had masses, and 25% had symptoms or signs of metastatic disease [12, 13].

RCC treated by RN (laparoscopic RN or robotic-assisted RN), partial nephrectomy (PN), open PN (OPN), localized disease— tumor ablation therapy [14] (heating (radiofrequency ablation) and cryotherapy), novel techniques (high-intensity focused ultrasound, radio-surgical ablation (cyber-knife I and others)), microwave and laser interstitial therapy remain investigational [15], and lymphadenectomy.

Randomized trials of adjuvant immunotherapy vs observation alone and the use of new tyrosine kinase inhibitors (such as sorafenib and sunitinib) are ongoing for patients with large tumors, positive nodes, surgical margins, venous invasion, and metastatic RCC. Studies have shown that therapy with sunitinib or sorafenib, either alone or in combination with surgery, can result in complete remission [16].

This study aimed to report our experience with the management of patients with malignant renal masses in Al-Imamein Al-Kadhimein Medical City.