Kidney Cancer

Page updated Winter 2023.

Disclaimer: Medicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, American Journal of Roentgenology,  UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.


Symptoms of kidney cancer may include flank pain, gross hematuria, and palpable abdominal mass; however, this triad is rarely seen now.

Most kidney cancers are diagnosed incidentally with imaging while they are still small and localized. 

TNM staging: click here.

AJCC staging: click here.

Preoperative Predictions

Pre-Operative Prediction of Cancer, Aggressive Cancer, and Freedom from Metastases in Patients with Small Renal Masses


We recommend renal mass biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. 

Multiple core biopsies are preferred over fine needle aspiration. 

Partial Nephrectomy

Is preferred for solid or Bosniak 3/4 complex cystic renal masses which meet the following criteria if technically doable:

- T1a disease

- Anatomic or functionally solitary kidney

- Bilateral tumors

- Multifocal masses

- Known familial RCC

- Preexisting CKD, or proteinuria

- Comorbidities that are likely to impact renal function in the future including hypertension, diabetes mellitus, recurrent urolithiasis.

Partial Nephrectomy Technique

Click here. 


Deep renorrhaphy: 3-0 V-Loc™ Suture on V-20 Needle

Capsular renorrhaphy: O Vicryl Suture on CT-1 Needle

Managing Bleeding after PN

Acute Abdomen (stable or unstable): Ex- lap

Benign Abdomen, Unstable: IR embolization

Benign Abdomen, Stable: Observe if remains stable. IR if transfusion it is dependent, or if there is persistent gross hematuria needing CBI. If no CKD,  CTA is advised before IR embolization. 

Radical Nephrectomy

Is advised if we think partial nephrectomy would be challenging and if overall renal function is OK.

There should be a normal contralateral kidney.

We perform adrenalectomy if adrenal gland is involved.

We perform lymphadenectomy if lymph nodes are enlarged.

We remove the venous thrombus if there is one.

Outcomes after PN or RN

Outcomes Immediately Following Partial or Radical Nephrectomy

Adjuvant Treatment after Neprhectomy

Patients with a high risk of recurrence should be counseled regarding systemic adjuvant options and/or considered for enrollment into adjuvant clinical trials.

Locally Recurrent Disease

We offer surgical resection of locally recurrent disease when a complete resection is possible.

Active Surveillance 

Active surveillance is an option for patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those <2cm. Risk of metastasis is less than 2% in well selected patients over the initial 3 years of AS. 

In older adults with life expectancy <5 years, and high comorbidities, active surveillance is an option if tumor size is <3 cm, tumor growth <55 mm/year, tumor is non-infiltrative and has favorable histology.

Thermal Ablation

Thermal ablation is an alternate approach for the management of T1a renal masses <3 cm.  

International consensus panels support the following indications for ablative therapy: 

Small renal tumor (< 4 cm), increased risk of multiple RCC tumors, poor surgical candidate, and a solitary kidney.

There might be a higher local recurrence rate relative to that of partial nephrectomy.

A renal mass biopsy should be performed prior to ablation.

Cryoablation, RFA, and MWA are most often used techniques.

A percutaneous technique is preferred over a surgical approach whenever doable.

IR Cryoablation

Cryoablation allows direct visualization of the approximate ablation zone, a so-called ice ball.

Cryoablation is ideal for tumors touching the renal sinus fat.

Cryoablation is not associated with increased risk of hilar bleeding as MWA and RFA are.

Cryoablation is not associated with a heat-sink effect near the hilar vessels.

Cryoablation is associated with a decreased risk of ureteral damage because the ability to observe the ablation margins in real time.

There might be an increased recurrence rate if tumor is endophytic.

Needs general anesthesia.

Patient should be NPO for 8 hours before procedure.

INR should be < 1.5.

PTT should be WNL.

Platelets should be >50,000.

Tumors within 1 cm of bowel are at risk of bowel injury.

Tumors within 1- 1.5 cm of ureter are at risk of ureteral injury.

Hydrodissection and air dissection are important techniques if tumor is close to colon, liver, spleen, pancreas, intercostal nerves, and genitofemoral nerve.

Pre-procedural ureteric stent placement is advised for medial lower pole tumors for pyeloperfusion which is performed using warm saline at a rate of 100 cc/hr.

Lesions at anteromedial upper pole of the kidney near the adrenal gland need blood pressure monitoring during the procedure. Preprocedural α blockers may be considered.

In case of postprocedural active bleeding, renal angiogram and embolization of the bleeding source maybe needed.

Metastatic Disease

Risk Group

To determine the patient's risk group, click here.

Cytoreductive Nephrectomy

Favorable risk patients: Early nephrectomy

Intermediate risk patients: Primary systemic therapy and delayed nephrectomy.

Poor risk patients: Nephrectomy is not advised 

Systemic Treatment for Clear Cell Histology

Favorable risk group:

Pembrolizumab (targeting PD-1)+ Axitinib (TKI)

Pazopanib (TKI), Sunitinib (TKI)

Intermediate and poor risk groups

Pembrolizumab plus Axitinib

Ipilimumab (targeting CTLA-4)+Nivolumab (targeting PD-1)

Cabozantinib (TKI)

Managing Metastases

Metastasectomy is discussed with favorable risk patients.

Stereotactic radiotherapy for bone or brain metastases.

Prediction of Survival

Predicted 12-Month Progression-Free Survival for Patients with Metastatic Renal Cell Carcinoma


Selective renal angioembolization is the treatment of choice in patients with acute hemorrhage.

Prophylactic intervention in women of child-bearing age is recommended.

Surveillance with serial imaging is advised in patients with a lesion < 4 cm (except women of child-bearing age)

For lesions > 4 cm, surveillance, IR selective arterial embolization, partial nephrectomy and radical nephrectomy are options.

When considering observation of a lesion > 4 cm, assessment of intralesional aneurysm size with a thin-slice CT angiogram is advised.

An intralesional aneurysm >5 mm is predictive of subsequent hemorrhage.

Complications for embolization include potential renal infarction, infection, abscess, and postembolization syndrome (characterized by fever, pain, and leukocytosis).

Everolimus is indicated for the management of larger, multifocal AMLs in patients with tuberous sclerosis complex.