This edited transcript accompanies a previously recorded educational consultation with Dr. Hyung Kim. Professional actors portray the patients. Punctuation, paragraphing, speaker labels, and clear caption errors have been edited for readability; repetitive filler has been removed. It is not a word-for-word transcript. Timestamps link to the recording. Recommendations and numerical estimates reflect the recorded example and should not be applied to an individual patient.
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0:09 — Understanding the kidney mass
Dr. Kim: What have you been told so far about the growth on your kidney?
Patient: I have written some things down. Will I be in a lot of pain after surgery?
Dr. Kim: Before we talk about surgery, let me ask a few questions and explain what we are dealing with. I believe you will need surgery, but I think we will be able to fully treat this growth. You had a CT scan of your abdomen. Were you having pain? Is that why your doctor ordered it?
Patient: Yes. The pain was a little mysterious, but it became chronic, and I felt it was time to find out what it was about.
Dr. Kim: Your pain may not be related to this mass. It prompted the imaging, and we are fortunate to have found the tumor, but the tumor may not have caused the pain. Let me draw a picture. The tumor is on your left kidney. It is solid on the CT scan, has a blood supply, and is about five centimeters in size.
Patient: It protrudes like that?
Dr. Kim: Yes, it comes out of your kidney like this.
2:05 — Could the mass be cancer?
Dr. Kim: Based on its appearance on the CT scan, I would estimate an 80% chance that this is cancer.
Patient: So it could be malignant?
Dr. Kim: Yes. A cancer is malignant and has the potential to shorten your life. As long as it has not spread to other parts of your body, it can still be treatable and potentially curable. We have images of your chest, abdomen, and pelvis, and there is no sign of spread. We would be doing surgery with the goal of completely treating and curing you.
2:54 — Whether a biopsy would change treatment
Dr. Kim: With a growth in other parts of the body, such as the colon or breast, the first step is usually a biopsy. A small tissue sample is taken, and a pathologist examines it under a microscope.
Patient: Is that invasive?
Dr. Kim: It is a simple outpatient procedure. With a renal mass, however, we do not perform biopsies in many cases. A biopsy may miss the tumor, although that is uncommon. Even if the needle enters the tumor, it may sample normal tissue or necrotic, meaning dead, tissue, and the pathologist may not be able to make a diagnosis.
If the pathologist finds cancer, we would treat it. If no cancerous cells are found, there may still be cancer that the biopsy did not detect. That is called a false negative. In this recording, I describe a false-negative rate of about 10%.
If I told a healthy person that the biopsy was negative but that cancer could still be present, that person might still want the tumor treated.
If a positive and a negative biopsy would lead us to the same treatment, the biopsy may not change what we do. There are circumstances in which I recommend a biopsy, but given your health and activity level, I do not think it would be necessary in your case.
5:02 — Observation and removal of the whole kidney
Dr. Kim: Let us talk about the options. I will write them down for you. One option is observation without immediate treatment. Repeat imaging, perhaps in six months, can show how quickly the mass is growing and how it behaves. If it is unchanged, we might wait a year before the next study.
However, as a mass gets bigger, the risk that it is cancer and that it might spread and become incurable increases. Given your age, good overall health, and the size of this mass, I do not think observation is the best choice for you, but it is an option.
Another option is removal of the entire kidney, called a radical nephrectomy.
Patient: So I would have half of my renal system?
Dr. Kim: That is right. With one healthy kidney on the other side, you can live a normal life. People donate a kidney to friends or family members who are on dialysis. Your blood tests and imaging suggest that your right kidney is healthy. However, I do not think we need to remove your entire left kidney.
6:55 — Partial nephrectomy and kidney function
Dr. Kim: Another option is a partial nephrectomy. We remove the mass and a small margin of normal kidney to make sure the entire tumor is removed. That is the procedure I think makes the most sense for you.
Patient: Does the kidney regenerate?
Dr. Kim: If we remove part of the kidney, it does not necessarily regenerate. You would still have about 80% of the kidney on that side after surgery.
Patient: So that amount of renal function would be fine on that side?
Dr. Kim: Yes.
7:47 — Ablation as another option
Dr. Kim: Another option is ablation. We put a needle through the skin into the mass and use intense heat or cold to destroy the tissue without removing it. Heating is referred to as radiofrequency ablation; freezing is referred to as cryoablation.
These are less invasive treatments that can be performed in radiology. The needles are placed through the skin under local anesthesia, and the treatment can be an outpatient procedure. These options work best for tumors smaller than three centimeters, so ablation would not be my first choice for a five-centimeter tumor.
Patient: So size is critical?
Dr. Kim: Size is critical. Ablation also has a higher recurrence rate, so tumor may still be present after treatment. It requires more intensive follow-up with CT scans or MRI. For a younger, healthier patient with a larger mass like this, I think partial nephrectomy is the best option.
9:21 — Laparoscopic and robotic surgery
Dr. Kim: We would perform the surgery laparoscopically. In the past, we used a large incision, called an open procedure. Now we can operate through small, keyhole-sized openings using laparoscopic or robotic surgery.
Patient: I had something similar on both knees.
Dr. Kim: The idea is similar: we put a camera inside and use long instruments with small graspers. You will be asleep during this operation.
Whether we perform this laparoscopically or robotically, the incisions are about the same size. With laparoscopy, the surgeon holds the instruments. With robotic surgery, the robot holds them, and the surgeon controls their movement. In this discussion, I describe recovery and outcomes as being about the same, so the surgeon should use the approach they are comfortable with. In your case, I would probably use a laparoscope without a robot.
11:11 — Hospital stay, recovery, and pain control
Patient: How long would the surgery take?
Dr. Kim: About three hours. You would stay overnight, and recovery would take about a month. Many working patients take a month off. Some people who need to return sooner are working within two weeks.
You may need narcotic pain medication for about three days. For about a month after surgery, I ask you not to lift more than about 30 pounds or do activities requiring more exertion than that. Most patient now use tylenol and motrin, with no need for narcotics.
You asked about pain. Our goal is for you to have no pain when you are lying or sitting still. You can expect soreness when you cough, move, or get out of bed. Pain pills take about 30 minutes to start working, so you may need to anticipate discomfort and take the prescribed medication before it builds up. You should be able to sleep comfortably.
13:02 — Risks of partial nephrectomy
Dr. Kim: The full name of the proposed procedure is a laparoscopic partial nephrectomy. There are risks you should understand. Any surgery carries a risk of bleeding and infection. The kidney filters blood and makes urine, so cutting into it can cause bleeding or a urine leak.
In this recording, I quote about a 4% risk of bleeding requiring a blood transfusion. Often the bleeding stops after a unit or two of blood, but in about half of those cases it persists and may require another invasive or surgical procedure. Bleeding can be internal or appear in the urine. We watch for both after surgery. I quote an infection risk of about 1%.
Urine normally drains down from the kidney. If it leaks from the repaired tumor bed, another procedure may be needed. In our experience described here, that happens in fewer than 1% of cases.
If we cut into the tumor rather than around it, some tumor may be left behind at the edge of the removed tissue. This is called a positive margin. In this recording, I quote a rate of about 2%, and it may require another operation.
There is also a risk of injury to nearby organs, which may require more surgery. I quote a risk of less than 1%.
15:39 — Conversion to a different operation
Dr. Kim: There is a risk of conversion. We might begin planning a partial nephrectomy but need to remove the entire kidney because of complex anatomy or scar tissue. We might also start laparoscopically but need to convert to an open procedure.
In this recording, I quote a conversion rate of about 1%. Conversion to open surgery would mean a longer hospital stay and recovery. A laparoscopic procedure might involve one day in the hospital, whereas an open operation might involve five days and a longer recovery at home.
16:41 — Pathology and possible additional treatment
Dr. Kim: At this point, I think that if we remove the mass and it turns out to be cancer, you may not need further treatment. However, if it is growing into the fat around the kidney, it would be a higher-stage tumor. The pathologist may also find more aggressive features under the microscope.
In this older recording, I discuss sunitinib as a possible additional therapy for a more aggressive cancer. It is not traditional chemotherapy; it is an antiangiogenic therapy that interferes with the formation of blood vessels needed for tumor growth. The idea is to reduce the risk of microscopic cancer cells growing and the cancer recurring. More modern therapies include pembrolizumab with or without belzutifan.
I do not want to worry you by considering every possibility, but I do want you to know that pathology after surgery can provide new information that affects whether additional treatment might help.
Patient: This has been thorough and informative. It helps establish a strategy.
Dr. Kim: Do you have other questions today?
Patient: I think you have answered them, including the ones I was most concerned about. The illustrations were helpful.
Dr. Kim: Let us stay in touch. It was a pleasure meeting you.