Kidney Cancer - Diagnosis & Surgery

The majority of kidney cancers (renal cell carcinoma, or RCC) are discovered incidentally - detected by chance on an ultrasound or CT scan done for an unrelated reason such as back pain, a check-up, or abdominal symptoms. This is increasingly common as imaging is used more frequently. The classic triad of loin pain, blood in the urine, and a palpable abdominal mass now occurs in only 10% of cases and usually indicates advanced disease. This is why a kidney mass found incidentally should always be taken seriously - even if you feel completely well.

No. Not all kidney masses are cancer. Common benign masses include: angiomyolipoma (AML - fatty tumour, usually easily identified on CT by fat content), oncocytoma (benign tumour that can be difficult to distinguish from RCC on imaging alone), and simple cysts (Bosniak I and II - almost never cancer). Complex cysts (Bosniak IIF, III, IV) carry increasing cancer risk. Solid masses without fat content that are growing or have certain imaging features are treated as RCC until proven otherwise. A CT scan with contrast (and sometimes an MRI) allows accurate characterisation in most cases. Biopsy is used selectively.

Partial nephrectomy (nephron-sparing surgery) removes only the tumour and a small rim of normal tissue, leaving the rest of the kidney intact. The whole kidney is removed in radical nephrectomy. Partial nephrectomy is the gold standard for tumours up to 7 cm (T1 stage) because it preserves kidney function - which is directly linked to long-term cardiovascular health and survival. Cancer control outcomes (recurrence and survival) are equivalent to radical nephrectomy for T1 tumours. Dr. Nitin performs robotic partial nephrectomy for most T1 and selected T2 kidney tumours at Apollo Hospital Gurugram.

Robotic partial nephrectomy uses the Da Vinci Surgical System to perform kidney-sparing surgery through 4–5 small incisions (each 1–2 cm). The robotic arms provide 10x magnified 3D vision and fine instrument control that allows precise tumour excision with minimal warm ischaemia time (the period when blood supply to the kidney is temporarily clamped). Compared to open surgery, robotic partial nephrectomy has less blood loss, fewer complications, shorter hospital stay (2–3 nights vs 4–6 for open), and equivalent cancer control. Apollo Hospital Gurugram has the Da Vinci Surgical System - one of the few centres in Delhi NCR offering this.

Kidney cancer is staged T1–T4: T1a (tumour ≤4 cm, confined to kidney), T1b (4–7 cm, confined to kidney), T2 (>7 cm, confined to kidney), T3 (extends into major veins or perinephric tissue but not beyond Gerota's fascia), T4 (beyond Gerota's fascia). N0 = no lymph node spread; N1 = regional lymph nodes involved. M0 = no distant metastases; M1 = distant metastases (lung, bone, liver most common). For T1 tumours: partial nephrectomy preferred. For T2: radical nephrectomy usually needed. For T3: radical nephrectomy, sometimes with thrombectomy (removal of tumour extending into the renal vein or IVC). For M1 disease: surgery may still be considered alongside targeted therapy or immunotherapy.

Most kidney cancers are sporadic (not inherited). However, approximately 3–5% are hereditary. The most common hereditary syndrome is Von Hippel-Lindau (VHL) disease - which causes clear cell RCC, often bilateral and at younger ages, along with cysts and tumours in other organs. Other hereditary syndromes include hereditary papillary RCC (PRCC2 mutations), Birt-Hogg-Dubé syndrome (chromophobe RCC and oncocytoma), and HLRCC (fumarate hydratase mutation, associated with aggressive papillary RCC type 2). Genetic testing and counselling is recommended if: kidney cancer before age 46, bilateral tumours, multiple tumours, or family history of kidney cancer.

Active surveillance (AS) means monitoring a small kidney tumour with regular imaging rather than immediate surgery. It is appropriate for: small tumours (typically ≤2 cm, sometimes ≤3 cm), older patients (>75 years) or those with significant comorbidities, patients who prefer to avoid surgery, and incidentally found masses where imaging characteristics are reassuring. Tumours are monitored with CT or MRI every 3–6 months initially. Intervention is triggered by growth rate >5 mm/year, tumour enlargement beyond a threshold, development of symptoms, or patient preference. The risk of metastatic progression with surveillance for T1a tumours is very low (<2%).