Balancing Cancer Control with Kidney Preservation

Children with bilateral Wilms tumor need surgery that addresses two priorities at once: removing cancer and preserving as much healthy kidney tissue as safely possible.

That balance drives a collaborative approach at Cincinnati Children’s, where Michael Daugherty, MD, MHI, a pediatric urologist, and Meera Kotagal, MD, MPH, a pediatric surgeon, work together on complex bilateral Wilms tumor cases. Most children enter care through the oncology team at Cincinnati Children’s. However, we also receive direct surgical referrals for children who are receiving chemotherapy at other hospitals. Either way, early referral gives us time to evaluate kidney-sparing options while chemotherapy is underway.

“Every part of the kidney that you can save makes a difference for patients’ long-term outcomes and kidney health,” Kotagal says.

Chemotherapy Protocol Guides the Surgical Timeline

Bilateral disease accounts for fewer than 10% of Wilms tumor cases. Under the Children’s Oncology Group protocol for bilateral Wilms tumor, patients receive at least six weeks of three-drug chemotherapy and often continue for up to 12 weeks before resection.

During this window, Daugherty and Kotagal review imaging together, develop operative plans with oncology and radiology, and present cases through the solid tumor board when appropriate.

Often, one kidney has a larger tumor and may require nephrectomy, while the other may be eligible for partial nephrectomy. But in select patients, the goal is even more ambitious: preserving both kidneys through a bilateral nephron-sparing approach. Achieving that outcome depends on detailed imaging review, multidisciplinary planning and careful surgical execution.

“By 12 weeks, the patient needs to be in the operating room,” Kotagal says. “When we know a child is coming, we can plan around both surgeons’ schedules and make sure we’re both available.”

That planning lays the foundation for one of the most important surgical decisions: how to remove every tumor while preserving as much healthy kidney tissue as safely possible.

Bilateral Wilms Tumor Creates Unique Surgical Considerations

For pediatric urologists, bilateral Wilms tumor presents a different set of surgical considerations than many kidney tumors. The team must weigh tumor biology, chemotherapy response, blood supply, the kidney’s drainage system and the possibility of postoperative radiation therapy.

Daugherty brings urologic expertise in partial nephrectomy and kidney reconstruction, while Kotagal brings surgical oncology expertise and experience operating around major abdominal blood vessels.

Radiology joins the team in the operating room to perform an ultrasound directly on the kidney. This helps localize the tumor, define its relationship to nearby structures and evaluate for additional lesions, guiding decisions in real time.

“We’re always thinking through the best approach with our radiologists and oncologists,” Kotagal says. “We want to maximize cancer outcomes and make sure kids live as long and as healthy as they can, while also keeping as much kidney as we can.”

Enucleation Requires Case-by-Case Discussion

Surgical technique may also affect treatment after surgery. In some cases, surgeons can enucleate the tumor, removing it along the tumor capsule. In others, the team may remove a small rim of normal kidney tissue around the tumor to create a clearer margin.

“In adult kidney cancer, enucleation is well established. You can cut out the tumor with its capsule and no margin of negative tissue, and that’s essentially considered a negative margin,” Daugherty says. “But for Wilms tumor, it’s not the same.”

That difference can shape conversations before and during surgery, especially when the team is considering whether margin status may affect postoperative radiation recommendations.

“We’ve been leaning toward less enucleation in select cases, leaving a small rim of normal kidney tissue when that may help the child avoid radiation afterward,” he adds. “It’s individualized, and we’ve become more intentional about having those conversations for each child.”

When to Refer

Consider early consultation with Cincinnati Children’s for children with:

• Suspected or confirmed bilateral Wilms tumor
• Bilateral kidney masses or multifocal kidney tumors
• Syndromic risk factors for bilateral disease
• Complex anatomy on initial imaging
• Questions about kidney-sparing surgery after chemotherapy

To learn more or refer a patient, email Michael Daugherty or Meera Kotagal.

(Published June 2026)

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