Editing CUA: Surgical Management of RCC (2014) (section)

===== '''Special considerations''' =====

* '''Adrenalectomy'''
** '''The ipsilateral adrenal gland should be preserved at the time of the nephrectomy provided it appears normal on imaging and there is no sign of direct tumour invasion'''
*** The incidence of ipsilateral adrenal involvement is 1.9% to 7.5%
*** CT imaging has been shown to have as high as 99.4% specificity and a 99.4% negative predictive value.
*** Ipsilateral adrenalectomy may be performed for patients with abnormal imaging, advanced stage (T3-4), or upper pole tumours greater than 7 cm.
* '''Lymphadenectomy'''
** Routine lymphadenectomy at the time of RN or PN is not routinely recommended in patients with clinical N0 disease.
** Lymphadenectomy is recommended in patients with clinical N1M0 disease.
** Lymphadenectomy may be performed for diagnostic purposes in patients with clinical N1M1 disease
* '''T4N0M0 (Local tumour extension to adjacent organs without metastatic disease)'''
** RN with resection of adjacent organs if feasible
*** Remove all known disease, with possible concomitant resection of involved organs, such as the adrenal gland, liver, pancreas, diaphragm, and bowel.
*** 5-year survival is poor and the oncological benefits of surgery should be carefully considered in the context of surgical morbidity.
*** Regional lymphadenectomy should therefore be considered for adequate pathologic staging
* '''TanyN+M0 (Radiographic and clinical evidence of lymph node enlargement)'''
** RN and regional lymphadenectomy
** There are no randomized trials assessing the effect of lymphadenectomy for patients with RCC and clinical lymphadenopathy. However, a subset of patients with regional lymph node metastases will be cured, or experience prolonged survival following surgery.