Kidney cancer surgery · Dr Swati Shah · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Shah’s Gastro, Cancer & Robotic Surgery Centre — trained at national cancer centres, fully qualified in surgical oncology, and operating on urological cancers every week.
Dr Swati Shah
MS, DrNB (Surgical Oncology)
Kidney Cancer Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
For a kidney tumour there are two operations, not one. A partial nephrectomy removes the tumour and a thin rim of kidney around it, and leaves the rest of that kidney working. A radical nephrectomy removes the whole kidney with the tumour inside it. Both are cancer operations and both can cure. The governing principle in this unit is to keep working kidney wherever it is oncologically safe to do so, because every avoidable radical nephrectomy is an avoidable kidney problem later.
Patients are often told only the second half of that — that the kidney will be removed and the other one will take over. The other one does take over. It does not, however, replace what was lost. A person with one kidney lives with roughly half the reserve they were born with, and the consequences of that are slow, silent and permanent. They are worth a serious conversation before the operating list is booked, not after.
The great majority of kidney tumours today are discovered on an ultrasound or CT done for something else entirely — a stone, an abdominal pain, a routine check. The old textbook triad of flank pain, a lump and blood in the urine is a late presentation, and its absence proves nothing at all.
Painless blood in the urine at any age needs the kidneys, the ureters and the bladder all looked at, not just one of them. There is also a group of presentations that get attributed to something else for months: unexplained anaemia, a high calcium, a raised red cell count, deranged liver tests with a normal-looking liver, unexplained fever or weight loss, and a newly appeared varicocele — particularly on the right side, or one that does not empty when the patient lies down, which can be the first sign of tumour growing into the kidney vein. Kidney cancer also has a habit of appearing first as a deposit somewhere unexpected — bone, lung, liver, thyroid, pancreas — sometimes years after the kidney itself was never examined.
A proper multiphasic CT — a scan before contrast and then in three phases after it — is the single investigation that decides whether the kidney can be saved. A single-phase scan cannot measure enhancement, and without that measurement a haemorrhagic cyst or a fat-poor benign tumour can be mistaken for a cancer and a kidney removed for nothing.
The report needs to answer specific questions, and it is reasonable to ask for them by name: the size of the tumour, its nephrometry score, whether it sits buried in the kidney or bulges out of it, whether it touches the hilum or the collecting system, the number and pattern of the renal arteries, whether there is tumour growing into the renal vein or the vena cava and how far up it reaches, whether lymph nodes are involved, and — the question that is left out most often — what the other kidney looks like.
Alongside the scan, kidney function is measured properly rather than glanced at: creatinine, eGFR, and a urine test for protein. Where the loss of working kidney is a live question, a split-function scan tells us how much of the total function each kidney is actually contributing. A single creatinine reading is not an assessment of the kidneys; it is one number from one morning.
A needle biopsy of the tumour is not needed before removing an obviously malignant mass in a fit person. It is needed before any ablation, before starting drug treatment for advanced disease, and whenever the result would genuinely change the plan — for instance before committing an older patient with several other illnesses to a major operation, or where a lymphoma or a deposit from another cancer is possible. Cystic lesions are graded on the Bosniak system; the lowest grades need no follow-up at all, the middle grade is watched, and the higher grades are treated as cancer.
A partial nephrectomy is the standard of care for a small kidney tumour wherever it is technically feasible — including when the other kidney is perfectly normal. It preserves working kidney tissue permanently. In exchange it accepts a set of risks that a radical nephrectomy does not carry, and those risks are specific and named at consent.
The operation asks more of the surgeon than removing the kidney does. The blood supply is controlled for as short a time as possible; the target is well under half an hour, and where the anatomy allows, the clamp comes off early, only the feeding branch is clamped, or the tumour is taken out without clamping at all. The margin needed is a negative one, not a wide one — a clear margin of a millimetre is oncologically adequate, and for suitable tumours shelling the tumour out along its own capsule is acceptable. Cutting away extra kidney for reassurance destroys the purpose of the operation. If the collecting system is opened it is closed watertight and that fact is written into the operation note, because it changes how the drain is managed afterwards.
The specific risks are these. Urine can leak from the collecting system afterwards and occasionally needs a stent. A small artery can form a false aneurysm and bleed some days later; the answer to that is an embolisation by the radiologist, not a second operation, because embolisation usually saves the kidney and re-opening usually does not. The margin can come back involved and need further treatment. And the operation may have to be converted to a radical nephrectomy on the table if the tumour cannot be removed safely or a clear margin cannot be achieved — which is why that conversion is consented for before every partial nephrectomy, without exception. You are agreeing to the possibility on the day you sign.
Larger tumours, tumours that have grown through the kidney’s covering fat or into the vein, and tumours where a safe clear margin cannot be obtained are treated by radical nephrectomy. That decision belongs in a multidisciplinary discussion with the nephrometry score in front of it — not to a judgement made on the morning of surgery.
Two old habits have gone. The adrenal gland is no longer removed routinely; it comes out only when imaging or the operation itself shows it is involved, or when an upper-pole tumour is sitting against it. A wide lymph node clearance has no proven survival benefit and is done for staging when nodes look involved, not as a matter of course in a clinically node-negative patient.
Tumour growing into the vein is a separate operation and is planned as one. The level it reaches is classified before surgery on CT or MRI, and where it extends behind the liver or above the diaphragm, cardiac and vascular colleagues, cell salvage and bypass availability are arranged in advance. This is never an unplanned finding to be improvised around; an unsuspected venous thrombus discovered during an operation is a reason to stop and call for help rather than to continue.
After a radical nephrectomy you permanently lose about half your kidney reserve. The remaining kidney compensates and the blood tests often look reassuring at discharge, which is exactly why this is the item that gets under-heard. A meaningful number of patients go on to develop chronic kidney disease afterwards, and a small number eventually need dialysis.
Three things follow from that, and they are certainties rather than risks:
This is the reason the partial-versus-radical conversation matters so much, and the reason it is not left to the day of surgery. The difference between the two operations is not felt in the first week. It is felt in the twentieth year.
For the smallest tumours, and for frail or heavily comorbid patients, there are two legitimate alternatives to operating: watching the tumour on a schedule, and destroying it with heat or cold through the skin. Both are proper options with proper rules, not ways of avoiding treatment.
Active surveillance suits tumours under about two centimetres, and any small tumour in a patient whose other illnesses make surgery a poor bargain. It is a protocol, not a dismissal: imaging at three to six months, then six-monthly, then yearly if things are stable, with a biopsy at the start where the histology would change the threshold for acting. We act if the tumour grows faster than about five millimetres in a year, if it crosses four centimetres, or if the patient simply wants it out.
Thermal ablation — radiofrequency or cryotherapy — suits small tumours in patients unfit for surgery, local recurrence after previous surgery, inherited multifocal disease, tumours in both kidneys, and a single kidney where removing more tissue would be dangerous. A needle biopsy is done as a separate procedure beforehand, not at the same sitting. Ablation is not appropriate for tumours much above three to four centimetres, or for tumours at the hilum or close to the upper ureter, when other options exist.
★★★★★
“We are very thankful to Dr. Swati Shah for successfully operating on our relative for kidney cancer. From the first consultation to the surgery and follow-up, she was very supportive, caring, and explained everything clearly. Her expertise and confidence gave our family great reassurance during a difficult time. We are happy with the treatment and recovery. Highly recommended Dr. Swati Shah for her dedication and excellent care.”
Naween. Soni · Google review, Apollo Hospital, Bhat
★★★★★
“Dr. Swati Shah performed a robotic partial nephrectomy for my mother around 4–5 years ago. We are very happy with the results, and she has been doing well since then. Dr. Shah is highly skilled, experienced, and provided excellent care throughout the treatment. We are truly grateful and would highly recommend her to anyone looking for a reliable cancer surgeon.”
Dhruvin Patel · Google review, Apollo Hospital, Bhat
★★★★★
“My relative had a large kidney mass requiring radical nephrectomy. Excellent uro cancer specialist in Gujarat.”
Hitesh Shrimali · Google review, Gota clinic
Recovery follows an enhanced-recovery pathway: sitting out of bed the same evening, sips of fluid early, walking three times on the first day, and food advanced over the next two or three. The single most important prescribing rule afterwards is that anti-inflammatory painkillers are avoided entirely after a partial nephrectomy and in anyone with one kidney — they are the commonest avoidable cause of a rising creatinine after this operation.
Creatinine and haemoglobin are checked on the first day and again over the next two. A creatinine that rises after a partial nephrectomy is usually a matter of fluid balance or medication rather than a surgical disaster, but obstruction and urine leak are excluded rather than assumed away. Clear watery fluid in the drain is tested rather than watched: if its creatinine is far above the blood level it is urine, the drain stays in, and a stent is arranged. The drain is never pulled out to see what happens.
The warning signs that bring us back quickly are a falling haemoglobin with a fast pulse and fullness in the flank, urine output dropping away, fever with a distended abdomen after the third day, breathlessness or leg swelling, and — in anyone with a single working kidney — a sudden fall in urine output, which is a same-day vascular emergency and not something to review in the morning. New back pain in someone known to have kidney cancer is imaged before they are made to walk, because deposits in the spine from this cancer weaken bone.
Discharge happens when the fever has settled, food is being tolerated, walking is independent, pain is controlled without the forbidden painkillers, and the creatinine is stable or falling — with that discharge eGFR written down as the new baseline everyone measures against afterwards. Before leaving, the histology appointment is booked, and where drug treatment after surgery is likely to be discussed, the oncology appointment is booked too. That window does not stay open indefinitely and it is regularly lost to a delayed referral.
One schedule watches the cancer and one watches the kidneys, and they are not the same schedule. The second is the one that gets dropped, usually the moment the cancer follow-up is discharged.
Cancer surveillance is scans of the chest and abdomen at intervals set by the stage, the grade and the features of the specimen — widely spaced for a small, low-grade, confined tumour, and close for tumours that had grown outside the kidney, involved nodes, showed aggressive dedifferentiation, or came out with an involved margin. After an ablation the scanning is tighter at the start, and any new enhancement inside the treated area is treated as recurrence until proved otherwise. One point is worth stating clearly: this cancer can come back late, sometimes beyond ten years, so nobody should be told at five years that they can stop thinking about it.
Kidney surveillance runs alongside it for everyone, permanently: creatinine, eGFR and urine protein at three months, at a year and then annually, with blood pressure and sugar reviewed at every visit and a kidney-physician referral if function falls below the agreed level or protein appears in the urine.
When kidney cancer is found with deposits elsewhere, drug treatment leads and surgery follows only where it helps. Removing the kidney is no longer routine in this situation, and doing it reflexively in a patient who is unwell delays the treatment that would have worked.
Surgery still has a place. Removing the kidney is offered to selected patients who are well, whose disease burden elsewhere is low, or whose own tumour is causing bleeding or pain. Removing a small number of deposits — particularly in the lung — in a fit patient remains a genuine route to long disease-free survival in this cancer and deserves active consideration rather than a reflexive dismissal. Where a course of drug treatment has worked well, removing the kidney afterwards is a reasonable plan in selected cases.
Dr Swati Shah I Robotic Uro Oncologist I Prostate, Kidney, Bladder Cancer specialist
Gota, Ahmedabad, Gujarat
Directions to the Gota clinic
Dr Swati Shah Uro Oncologist I Prostate, Bladder, Kidney Cancer I Robotic surgeon
Apollo Hospital, Bhat, Gandhinagar, Gujarat
Directions to Apollo Hospital, Bhat
Telephone and WhatsApp: +91 63590 11009
Dr Swati Shah consults at the Gota OPD in Ahmedabad and operates at Apollo Hospital, Bhat, Gandhinagar. Families travelling in from Saurashtra, north Gujarat and Rajasthan can usually complete the consultation, the kidney-function tests and the remaining staging scans in a single visit if they telephone ahead.
A tumour in the kidney can be taken out in two quite different ways: the tumour alone, leaving the kidney behind, or the whole kidney with it. The cancer is removed either way. What differs is how much working kidney you are left with for the rest of your life — and that is the decision this page is about. Call +91 63590 11009 WhatsApp Dr Swati Shah's team
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