Treating Localised Renal Cell Cancer

Localised renal cell cancer (the most common type of kidney cancer) is cancer that is still contained within the kidney (or has grown only into the immediately surrounding structures) and has not spread elsewhere. Most localised renal cell cancers are curable, and there is often more than one reasonable option. The right choice depends on the tumour’s size and position, your kidney function, your general health, and your own priorities. This is a shared decision.

Not every small kidney tumour needs immediate treatment. For small tumours, particularly in older patients or those with other health problems, careful monitoring with regular scans is a reasonable and safe option. Many small kidney tumours grow slowly or not at all, and surveillance avoids the risks of treatment for tumours that may never cause harm. If a tumour grows or changes, treatment can still be given.

Wherever it is technically possible, the preferred operation for a localised renal cell cancer is a partial nephrectomy — removing the tumour with a margin of healthy tissue while preserving the rest of the kidney. Keeping as much working kidney as possible protects long-term kidney function, which matters for heart health and overall wellbeing. This is not possible for every tumour. And in patients who have good kidney function and no risk factors for kidney disease, preserving the maximum amount of kidney may not add much benefit — so a kidney-sparing approach is prioritised, but not at any cost.

This is most often performed using robot-assisted keyhole surgery, which allows the precise, controlled movements needed to remove the tumour and reconstruct the kidney through small incisions, with less blood loss and a quicker recovery than open surgery. Partial nephrectomy is the standard approach for smaller tumours, and in experienced hands it can be extended to more complex tumours.

Partial nephrectomy can even be an option for some more locally advanced (small T3a) tumours where the anatomy is favourable and preserving kidney function is important — for example in patients with a solitary kidney or reduced kidney function. Our own research found that, in younger, healthier patients, partial nephrectomy for small (under 4 cm) T3a tumours gave long-term survival comparable to that for smaller confined tumours, though the chance of a positive margin was higher and careful selection matters.

When a tumour is large, centrally placed, or otherwise not suitable for a kidney-sparing approach, the whole kidney is removed — an operation called radical nephrectomy. Most people manage well with one kidney. This too is most commonly performed robotically or by keyhole surgery, reserving open surgery for the largest or most complex tumours, or those involving the large veins.

For selected small tumours, the cancer can be destroyed in place rather than cut out, using cryotherapy (freezing) or radiofrequency ablation (heat), usually through a needle guided by a scan. Ablation spares the kidney and suits patients who prefer to avoid surgery or are less fit for an operation. It is best suited to small tumours in a favourable position, and needs careful monitoring afterwards, because cancer can occasionally remain or return.

Renal cell cancer was long thought not to respond well to radiotherapy, but modern, highly focused radiotherapy — stereotactic body radiotherapy (SBRT) — can control selected small kidney tumours in patients who are not suitable for surgery or ablation. It is a developing, non-invasive option delivered over a small number of sessions, and your suitability is assessed individually.

For many localised renal cell cancers, surgery, ablation and surveillance can all be reasonable, so the decision often comes down to the tumour’s characteristics, your kidney function and fitness, and your preferences.