When Is Surgery Recommended for Kidney Cancer?
This article forms part of Dr Deanne Soares’ urologic cancer education series, providing evidence-based guidance on the diagnosis, treatment and recovery pathways for urological cancers.
One of the most important — and often under-discussed — questions in kidney cancer care is not how surgery should be performed, but whether surgery is needed at all, and if so, when.
For many patients, being told they have a kidney mass creates an understandable sense of urgency. Cancer is a confronting word, and the instinctive response is often to remove the problem as quickly as possible. For referring clinicians, the challenge is balancing timely action with appropriate restraint.
In contemporary kidney cancer management, surgery is a powerful and effective tool — but it is not always the first or only step. Decisions about surveillance, timing, and type of surgery depend on tumour behaviour, patient health, and long-term risk rather than reflex.
This article explains when surgery is recommended for kidney cancer in real clinical practice, and just as importantly, when it may be reasonable to wait, monitor, or reconsider.
Patient summary
Key points to know:
• Not all kidney cancers require immediate surgery
• Some small tumours can be safely monitored
• Decisions depend on tumour behaviour and overall health
• Surgery should be timed to maximise benefit, not urgency
• Careful selection improves long-term outcomes
Kidney cancer is not a single disease
Kidney cancer encompasses a spectrum of conditions with very different behaviours. Some tumours grow slowly over years. Others are more aggressive and require prompt intervention.
Imaging has improved dramatically, but radiology alone cannot always predict biological behaviour with certainty. As a result, kidney cancer management relies on risk stratification, not assumptions.
Key factors that influence recommendations include:
tumour size and growth rate
imaging characteristics suggestive of aggressiveness
location and anatomical complexity
patient age, comorbidities and kidney function
the presence or absence of symptoms
The aim is to intervene when surgery is likely to improve outcomes — not simply because a tumour exists.
When surveillance is appropriate
Small renal masses
Many kidney tumours detected today are found incidentally during imaging for unrelated reasons. A significant proportion of these are small, slow-growing lesions.
For selected patients, particularly those with:
tumours under approximately 4 cm
favourable imaging features
slow or negligible growth on serial imaging
significant medical comorbidities
limited life expectancy
active surveillance may be appropriate.
Surveillance does not mean ignoring the tumour. It involves structured imaging at defined intervals, careful monitoring for growth or change, and a clear plan to intervene if behaviour becomes concerning.
This approach avoids exposing patients to surgical risk when the likelihood of benefit is low.
The role of biopsy in decision-making
Renal mass biopsy can sometimes help clarify the nature of a tumour, but it is not required in every case.
Biopsy may be considered when:
imaging is indeterminate
results would meaningfully influence management
surveillance is being strongly considered
non-surgical options are under discussion
However, biopsy has limitations. Sampling error is possible, and a benign result does not always eliminate uncertainty. Biopsy findings must be interpreted in the context of imaging and clinical judgement.
When surgery is clearly recommended
Tumour growth or concerning features
Surgery is generally recommended when a tumour demonstrates:
sustained or accelerating growth
imaging features suspicious for aggressive behaviour
invasion beyond the kidney
involvement of surrounding structures
In these cases, the risk of progression outweighs the risks of surgery.
Symptomatic tumours
Symptoms such as pain, bleeding, or obstruction often indicate a need for intervention. While many kidney cancers are asymptomatic, symptoms suggest local effects that may worsen without treatment.
Higher-risk disease
Tumours that are larger, centrally located, or demonstrate high-risk features on imaging typically warrant surgical management, assuming the patient is medically fit.
Timing matters: surgery is not always urgent, but delay is not neutral
One of the most nuanced aspects of kidney cancer care is timing.
Not all cancers require immediate surgery, but prolonged delay in the presence of concerning features can compromise outcomes. The art lies in distinguishing between:
appropriate observation, and
unnecessary postponement
This distinction depends on careful follow-up, not passive waiting.
In experienced practice, timing decisions are revisited repeatedly as new information emerges.
Patient factors: fitness for surgery is part of the decision
Surgery should not be recommended in isolation from the patient’s broader health.
Important considerations include:
cardiovascular fitness
pulmonary reserve
baseline kidney function
diabetes and vascular disease
previous abdominal or renal surgery
In some patients, optimising medical conditions before surgery improves safety and outcomes. In others, the risks of surgery may outweigh potential oncological benefit.
This is where judgement matters most.
The role of experience and subspecialisation
Managing kidney cancer safely requires comfort with a range of scenarios — including knowing when not to operate.
In practice, this level of restraint is most reliably achieved by surgeons who routinely manage kidney cancer and are accustomed to balancing oncological risk with long-term health considerations. Experience does not eliminate uncertainty, but it supports sound decisions when imaging, biology, or patient factors sit in grey zones.
Robotic surgery: enabling precision, not dictating decisions
Robotic surgery has expanded the ability to tailor surgical approaches, particularly for partial nephrectomy and anatomically complex tumours.
In experienced hands, robotic surgery can:
facilitate precise tumour excision
support kidney preservation when appropriate
reduce recovery burden for selected patients
However, the availability of technology should never be the reason surgery is recommended. The decision to operate comes first; the technique follows.
Multidisciplinary input and shared decision-making
In contemporary Australian practice, higher-risk or ambiguous kidney tumours are best assessed within a multidisciplinary setting, where urologists, radiologists, oncologists and, when appropriate, nephrologists can weigh tumour behaviour, anatomy and patient factors together.
For higher-risk kidney cancers, decisions are often best made within a multidisciplinary framework involving urologists, radiologists, oncologists and, when appropriate, nephrologists.
Equally important is shared decision-making with patients and their families. Understanding values, tolerance for risk, and long-term priorities ensures that recommendations align with what matters most to the individual.
What patients often misunderstand
Several misconceptions arise repeatedly:
that all cancers require immediate surgery
that surveillance is “doing nothing”
that delaying surgery always worsens outcomes
that surgery is curative in all circumstances
Clear explanation early reduces anxiety and prevents rushed decisions driven by fear rather than evidence.
For patients and families: questions worth asking
Helpful questions include:
What is the behaviour of my tumour so far?
What are the risks of surveillance versus surgery for me?
How will we monitor for change if we wait?
What would prompt a recommendation to operate?
How does my overall health influence the plan?
There is value in understanding why surgery is recommended — or not.
For referring clinicians
GPs and referring specialists play a critical role in:
framing surveillance as an active strategy
reinforcing that restraint can be appropriate care
supporting patients through uncertainty
assisting with long-term health optimisation
Good kidney cancer care is longitudinal, not episodic.
Conclusion: surgery is recommended when it improves outcomes
Surgery for kidney cancer is recommended when it is likely to meaningfully improve cancer control or prevent future harm — not simply because a tumour exists.
Appropriate restraint is not hesitation. It is deliberate, evidence-based care.
When surgery is required, timing and approach should be individualised. When surveillance is appropriate, it should be structured and intentional. In both scenarios, thoughtful judgement protects patients from unnecessary intervention while preserving the ability to act decisively when needed.
That balance — between action and restraint — is at the heart of good kidney cancer care.
About the author:
Dr Deanne Soares is a Melbourne-based urologist with a subspecialty focus in robotic prostate, kidney and bladder cancer surgery, offering advanced minimally invasive cancer care.
