Surgeon contemplates lymph node network in kidney cancer surgery.

Rethinking Kidney Cancer Surgery: Is Less Really More?

Jordan Keane in Health & Wellness December 2025 • 5 min read.

"A critical look at when removing lymph nodes during kidney cancer surgery is beneficial, and when it might be doing more harm than good."

Cytoreductive nephrectomy (CN) is a complex surgical procedure performed under challenging circumstances. For years, it's been a standard approach, particularly in the immunotherapy era, based on the idea that removing as much of the cancer as possible improves survival. However, recent prospective studies are prompting experts to reconsider the extent of surgery needed, specifically whether routine lymph node removal (lymphadenectomy or LND) is always necessary during CN.

In a recent study published in the CUAJ, Patel and colleagues delved into this issue using data from the Surveillance, Epidemiology, and End Results (SEER) registry. Their findings challenge the conventional approach, suggesting that LND may not provide a therapeutic advantage in all cases. This has sparked a critical conversation within the medical community about tailoring surgical strategies to individual patient needs.

The study paints a detailed picture of metastatic kidney cancer treatment, considering the interplay between CN, LND, and patient outcomes. While survival rates for patients with newly diagnosed M1 (metastatic) disease remain less than a year on average, improvements have been observed over time. The association of CN with extended survival is noted, with consideration of potential selection biases in administrative data. What's particularly interesting is the suggestion that extensive node dissection doesn't necessarily improve survival, and in some cases, may even be linked to decreased overall and disease-specific survival.

Lymph Node Removal: When Does It Help?

Surgeon contemplates lymph node network in kidney cancer surgery.

The role of lymph node removal in kidney cancer surgery has been a topic of debate for years. The recent SEER registry study adds fuel to this discussion by suggesting that LND may not always be beneficial. This aligns with other studies that have questioned the value of routine LND during CN. One study by Trinh et al., also using SEER data, found that nodal disease worsened survival, with incremental declines observed with increased node burden.

Researchers at the Mayo Clinic analyzed 305 CN patients, a significant 62% of whom underwent LND. Their findings indicated no benefit from LND, even in patients with clinically node-positive disease. Through propensity-score groupings and analysis, they found no advantage to LND in cNO patients at high risk for occult node metastasis. These findings challenge the long-held belief that removing lymph nodes during CN improves outcomes.

No Universal Benefit: Studies consistently show that routine lymph node dissection (LND) doesn't improve survival rates in all kidney cancer patients undergoing cytoreductive nephrectomy (CN).
Potential Harm: In some cases, LND may be associated with decreased overall and disease-specific survival, suggesting it could be doing more harm than good.
Node-Negative Patients: Clinically node-negative patients, in particular, don't seem to benefit from LND.
Aggressive Disease: Patients with high-volume metastases or adverse prognostic factors are unlikely to benefit from LND, indicating that the procedure may not be effective in these advanced cases.

While these studies cast doubt on the routine use of LND, it's important to consider the potential reasons behind these findings. It's possible that the extent of tumor removal, rather than the lymph node dissection itself, is the key factor influencing survival. In other words, the best outcomes from CN may be achieved when a significant portion (≥90%) of the disease burden is removed with surgery, regardless of whether lymph nodes are also removed.

Tailoring the Surgical Approach: A Path Forward

So, what does this mean for surgeons treating patients with kidney cancer? It seems clear that a one-size-fits-all approach to lymph node removal is no longer appropriate. Clinically node-negative patients are unlikely to benefit from LND, and patients with high-volume metastases or numerous adverse prognostic factors may also be spared this procedure.

However, navigating the setting of small-volume, easily resectable node metastasis remains a challenge. While there is likely little harm from excising paracaval or para-aortic nodes in concert with the hilar dissection, the benefits are backed by intuition rather than data. On one side, leaving accessible disease behind feels unpalatable, and some with limited metastatic burden beyond the retroperitoneum may survive far beyond the median; it would seem unfair to leave cancer behind.

Ultimately, the decision to perform LND should be based on a careful assessment of the individual patient's risk factors, the extent of their disease, and the potential benefits and harms of the procedure. As research continues to evolve, robust prospective data to answer this question is unlikely forthcoming. Patients facing CN are in peril and we want to do something to help. Studies like this help to resolve where our efforts are best laid and when isn't actually more.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.5489/cuaj.4252, Alternate LINK

Title: Rethinking Lymph Node Metastasis And Cytoreductive Nephrectomy

Subject: Urology

Journal: Canadian Urological Association Journal

Publisher: Canadian Urological Association Journal

Authors: Michael Leveridge

Published: 2016-12-15

Everything You Need To Know

What is cytoreductive nephrectomy (CN)?

Cytoreductive nephrectomy (CN) is a surgical procedure where a surgeon removes as much of the kidney cancer as possible. This procedure has been a standard approach. The practice involves removing the cancerous kidney and, in some cases, removing the surrounding lymph nodes to prevent the cancer from spreading. It's an approach based on the idea that removing as much cancer as possible improves survival. The implication is that CN is a complex surgery performed under difficult conditions and is a key element in the treatment of metastatic kidney cancer.

Why is lymph node removal (LND) during cytoreductive nephrectomy (CN) being reconsidered?

The role of lymph node removal (lymphadenectomy or LND) is a topic of debate, specifically during cytoreductive nephrectomy (CN). Recent studies suggest that LND doesn't always improve survival rates. The study by Patel and colleagues using data from the SEER registry suggests that LND may not provide a therapeutic advantage in all cases. Some studies indicate potential harm, where LND may be associated with decreased survival. The significance is that surgeons are reconsidering whether routine LND is always necessary. The implications are that the surgical approach is being tailored to individual patient needs and not a one-size-fits-all approach.

Do patients with clinically node-negative disease benefit from lymph node removal (LND) during cytoreductive nephrectomy (CN)?

Patients with clinically node-negative disease do not seem to benefit from lymph node removal (LND) during cytoreductive nephrectomy (CN). Through analysis, no advantage to LND was found. This suggests that the routine removal of lymph nodes may not be necessary in all cases. This is significant because it challenges the long-held belief that removing lymph nodes during CN improves outcomes. The implication of this is that clinicians and surgeons may need to reevaluate the approach to kidney cancer surgery and tailor it to the individual patient.

Who may not benefit from lymph node removal (LND) during cytoreductive nephrectomy (CN)?

Studies suggest that patients with high-volume metastases or numerous adverse prognostic factors are unlikely to benefit from lymph node removal (LND) during cytoreductive nephrectomy (CN). This means that in advanced cases, LND may not be effective. In other words, the extent of tumor removal may be more important than LND itself. The significance is that not all patients need to undergo LND. This is a step toward tailoring the surgical approach. The implication is that surgeons are moving away from a one-size-fits-all approach, especially for patients with more advanced stages of the disease.

What does it mean to tailor the surgical approach in kidney cancer treatment?

The SEER registry study and others indicate that tailoring the surgical approach is essential when treating kidney cancer. Considering the interplay between cytoreductive nephrectomy (CN), lymph node removal (LND), and patient outcomes is important. This means that the surgeon should assess the individual needs of the patient. The significance of this is that it's no longer appropriate to use LND in all cases. The implication is that the focus is on the extent of tumor removal and tailoring the surgical plan to the individual patient, with the goal of improving patient outcomes.