You are in: eMedicine Specialties > Urology > Surgery Nephrectomy, RadicalArticle Last Updated: Sep 28, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Richard A Santucci, MD, FACS, Associate Professor, Department of Urology, Wayne State University School of Medicine; Chief of Urology, Detroit Receiving Hospital Richard A Santucci is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology) Coauthor(s): Hosam S Al-Qudah, MD, Fellow in Genitourinary Oncology, H Lee Moffitt Cancer Center, University of South Florida Editors: Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center, Department of Urology, Manhattan; Professor and Vice Chairman, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: radical nephrectomy, simple nephrectomy, kidney disease, kidney resection, radical kidney surgery, renal cell carcinoma, RCC, localized renal cell carcinoma, renovascular hypertension, renal artery disease, parenchymal damage, nephrosclerosis, pyelonephritis, reflux dysplasia, congenital dysplasia of the kidney, congenital kidney dysplasia, renal dysplasia, kidney dysplasia, renal lesion, simple nephrectomy, renal cyst, renal cancer, renal cell cancer, irreversible kidney damage, calculus disease, nephron-sparing surgery, NSS, partial nephrectomy, laparoscopic partial nephrectomy INTRODUCTIONSection 2 of 12
  Nephrectomy has many indications, for both simple and radical approaches. A simple nephrectomy is indicated in patients with irreversible kidney damage due to symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury. Simple nephrectomy is also indicated to treat renovascular hypertension due to noncorrectable renal artery disease or severe unilateral parenchymal damage caused by nephrosclerosis, pyelonephritis, reflux dysplasia, or congenital dysplasia of the kidney. Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). In certain circumstances, radical nephrectomy is also indicated to treat locally advanced RCC and metastatic RCC. With the advent and increasingly mainstream use of abdominal CT scanning and ultrasound imaging in recent years, incidental detection of RCC has increased in asymptomatic patients. Currently, 15-72% of RCC cases are detected incidentally. These tumors tend to be smaller and of lower stage, resulting in better survival rates, lower recurrence rates, and lower metastasis rates than RCC detected in symptomatic patients. Symptomatic RCC presents at a significantly higher stage and grade, and tumors are substantially more aggressive than incidentally discovered lesions, particularly at later stages. History of the Procedure
FrequencyOverall, the vast majority of incidentally discovered renal masses are cysts. EtiologySeveral factors have been associated with increased risk of RCC.
ClinicalTraditionally, RCC is diagnosed after any or all of the classic triad of symptoms, ie, flank pain, palpable mass, and hematuria, have been investigated (see Image 1). However, with the increased use of imaging techniques over the past 2 decades, up to 72% of RCC cases are identified incidentally after investigation for unrelated abdominal pain or other nonurologic symptoms. Suspect involvement of the inferior vena cava in patients who have lower extremity edema, varicocele, dilated superficial abdominal veins, proteinuria, pulmonary embolism, a right atrial mass, or no function in the involved kidney. Lack of early warning signs characterizes RCC, resulting in a high proportion (one third) of patients with metastases at diagnosis. These patients face a dismal prognosis; the 5-year survival rate is less than 10% and the average survival is only 6-12 months. RCC is resistant to chemotherapy. Approximately 10-20% of patients with metastatic disease respond to immunotherapy with interleukin-2, interferon-alpha, or both. Sometimes, the response is durable.3 INDICATIONSSection 3 of 12
Radical nephrectomy remains the procedure of choice for surgically resectable lesions. Relapse occurs in 20-30% of patients with completely resected RCC after radical nephrectomy. Radical nephrectomy is also indicated in patients with metastatic disease as part of immunotherapy or the new chemotherapy protocol as a palliative procedure in cases of intractable pain and bleeding. Predictors of relapse include symptomatic disease, high Fuhrman grade of tumor, high pathological stage, microvascular invasion, and necrosis. In these patients, neither postnephrectomy radiation therapy nor adjuvant interferon-alpha administration delays relapse or increases overall survival rates compared with observation alone. Therefore, observation remains the standard of care following radical nephrectomy for renal cell cancer. RELEVANT ANATOMYSection 4 of 12
The kidneys are paired vital organs located on either side of the vertebral column and embedded in the intermediate stratum of retroperitoneal connective tissue. The perirenal fascia, also called the Gerota fascia, encloses both the kidneys and adrenal glands. Renal malignancies tend to remain within this fascia and can be excised completely by removing the kidney and its surrounding fascia as a single entity. In most individuals, a single renal artery and vein enters the kidney medially through the renal hilum, but multiple renal arteries are not uncommon. The renal artery arises from the lateral aspect of the aorta, just below the superior mesenteric artery, and passes behind the renal vein. The main renal artery then divides into 4-5 segmental vessels to supply the corresponding renal parenchyma. These segmental vessels are end arteries without collateral circulation; thus, any injury to the renal artery at any level results in infarction of the corresponding parenchyma. Unlike the renal arteries, the renal parenchymal veins intercommunicate freely among the various renal segments. Usually, a single renal vein joins the inferior vena cava on its lateral aspect. Multiple renal arteries occur unilaterally in 23% of the population, whereas multiple renal veins are less common. The right adrenal gland lies above the kidney posterolateral to the inferior vena cava. The inferior phrenic artery is the main blood supply, with additional branches from the aorta and renal artery. The venous drainage usually is through a common vein on the right, exiting the apex of the gland and entering the posterior surface of the inferior vena cava. This vein is short and fragile and is a common source of bleeding during right adrenalectomy. The left vein empties directly into the left renal vein approximately 3 cm from the inferior vena cava and often opposite to the gonadal vein. Not well-recognized is the left inferior phrenic vein, which typically communicates with the adrenal vein but then courses medially and can be injured during dissection of the medial edge of the gland. The paired gonadal arteries arise from the anterolateral aorta at a level somewhat below the renal vessels. Occasionally, a gonadal artery arises from the ipsilateral renal artery or from the aorta above the level of the renal vessels. In their retroperitoneal course, the gonadal arteries pass anteriorly to the ureter on either side. Gonadal veins parallel the gonadal arteries in their inferior course but, superiorly, tend to be more lateral and closer to the ipsilateral ureter. The left gonadal vein usually enters the inferior aspect of the left renal vein perpendicularly. The right gonadal vein usually drains obliquely into the right lateral aspect of the inferior vena cava, below the level of the right adrenal vein. CONTRAINDICATIONSSection 5 of 12
Nephron-sparing surgery (NSS) has become a successful alternative treatment to radical nephrectomy for RCC when a functioning renal parenchyma must be preserved, such as in patients with (1) bilateral RCC; (2) RCC involving a solitary functioning kidney; (3) chronic renal insufficiency; or (4) unilateral RCC with a functioning opposite kidney at risk for future impairment from an intercurrent disease, such as calculus disease, renal artery stenosis, diabetes, or nephrosclerosis. Several studies have confirmed that NSS provides curative treatment that is as equally effective as radical nephrectomy in patients who have a single, small (<4 cm in diameter), unilateral, localized RCC. NSS is also becoming increasingly recognized as effective treatment for small, select, incidentally discovered tumors, even when the contralateral kidney is normal. The major disadvantage of NSS is the small risk (1-6%) of local tumor recurrence due to undetected microscopic multifocal RCC in the remnant of the operated kidney. Partial nephrectomy is also associated with a higher risk of bleeding and urine leak. Laparoscopic partial nephrectomy is a new modality that is increasingly used. It offers faster convalescence than open partial nephrectomy. However, it is associated with a higher rates of positive margins, major intraoperative complications, and urologic complication rates. Laparoscopic partial nephrectomy should be preserved for patients with exophytic small tumors. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
TREATMENTSection 7 of 12
Medical therapyRadical nephrectomy has been the traditional approach to treating solid renal masses. However, not all solid renal masses are malignant. As the number of incidentally detected solid renal masses increases because of widespread radiographic imaging, the incidence of benign tumors appears to be increasing. In a prospective study of 106 solid renal masses treated with surgical resection, Dechet et al showed that 15 (14%) were benign.4 Oncocytomas compromised most masses, with an overall 10% incidence rate of solid renal masses. Given the high incidence of benign tumors, especially among solid renal masses 4 cm in diameter or smaller, radical nephrectomy seems excessive in all cases. However, identifying these cases preoperatively using radiographic imaging and/or fine-needle biopsy or aspiration is impossible. Link et al reviewed the results of 223 laparoscopic partial nephrectomies and found that only 66.4% of patients had renal cell cancer in the final pathology (mean tumor size, 2.6 cm).5 Some centers advocate intraoperative needle biopsy of these solid renal masses with immediate frozen-tissue sectioning to help identify patients who may benefit from NSS or radical nephrectomy if specific tumor histology can be determined. A urologist should seek a tissue diagnosis only if an indeterminate or solid lesion is found in a patient with known nonrenal cancer (ie, differential diagnosis of primary renal cancer vs a metastatic lesion). In this regard, an ultrasound-guided or CT-guided puncture or biopsy of the lesion is indicated. Surgical therapyRadical nephrectomy of the kidney is the treatment of choice for stage I, II, and some stage III tumors. Radical nephrectomy encompasses ligating the renal artery and vein, removing the kidney outside the Gerota fascia, removing the ipsilateral adrenal gland, and performing a complete regional lymphadenectomy from the crus of the diaphragm to the aortic bifurcation. The surgical approach includes either a transperitoneal incision (extended or bilateral subcostal and thoracoabdominal) or an extraperitoneal incision, depending on the size and location of the tumor and the patient's habitus. Cardiopulmonary bypass with deep hypothermic circulatory arrest is used is performed in patients with supradiaphragmatic tumor thrombi involvement. The surgical approach is guided more by individual preference than by necessity. In some institutions, a midline incision is commonly used, while, in others, the anterior subcostal, thoracoabdominal, and flank approaches are preferred. In general, most tumors are resectable through a transperitoneal subcostal incision. The principal advantage of the abdominal approach is that exposure in the area of the renal pedicle is excellent. A vertical midline incision is easier and quicker to perform. It also allows better access for inspection of the remainder of the abdominal contents. A transverse incision provides better access to the lateral and superior portion of the kidney, and a unilateral subcostal incision can be extended across the midline as a chevron incision to provide excellent exposure of both kidneys, the aorta, and the inferior vena cava. The principal disadvantage of the abdominal approach is the somewhat longer period of postoperative ileus and intra-abdominal adhesions. Removal of the adrenal gland has been advocated because the gland is enclosed within the Gerota fascia and because ipsilateral adrenal metastasis occurs in 2-10% of most reported series.6 The risk of adrenal metastasis is related to the malignant potential of the primary tumor and its size and position. The need for routine ipsilateral adrenalectomy currently is under debate. A new report of 247 patients with RCC showed that only 3% of patients had adrenal involvement; each case was diagnosed preoperatively with CT scanning.7 However, patients with large tumors or tumors high in the upper pole are probably better served with a standard radical nephrectomy that includes adrenalectomy. The role of regional lymphadenectomy in patients with localized kidney cancer is controversial. Because no widely effective treatments are available for metastatic RCC, proponents argue that if only small nodes are involved, regional lymphadenectomy may benefit a small number of patients. Extensive nodal involvement portends a poor prognosis. Patients with lymphatic metastasis commonly demonstrate synchronous or metachronous distant metastasis; thus, regional lymphadenectomy is of no benefit. Despite a lack of randomized controlled studies, current data suggest that some patients can benefit from regional lymphadenectomy, especially the subset of patients with micrometastatic lymph node involvement. Preoperative detailsIn addition to a good history and physical examination, certain tests are performed routinely prior to any major renal surgery. These include ECG, chest radiography, complete blood cell count, and electrolyte profile with BUN and creatinine levels. Preoperative pulmonary function testing and blood gas analysis are necessary in patients in whom impaired respiratory function is suspected. A flank position with lateral flexion of the spine can decrease ventilatory capacity and venous return, resulting in hypotension and hypoxia. Thus, an anterior surgical approach with the patient in the supine position is used in patients with significantly impaired respiratory function. Preoperative breathing exercises, alleviation of bronchospasm, and cessation of smoking help prevent postoperative cardiorespiratory problems. Patients should be asked about any use of alcohol or the ingestion of drugs or aspirin that may influence blood clotting. Prothrombin time, activated partial thromboplastin time, and a platelet count are used routinely to identify bleeding tendencies. The anatomy of the urinary tract is usually examined prior to any nephrectomy. These studies include intravenous pyelography, cystoscopy, retrograde pyelography, ureteroscopy, cystourethrography, CT scanning, ultrasonography, MRI, renal angiography, and renal venography. These tests reveal the location of the kidneys; any anatomic variations such as a duplicated ureter, horseshoe kidneys, or multiple arteries or veins; and associated pathology such as renal stones, transitional cell carcinomas of the bladder or ureter, and possible lesions of the contralateral (ie, remaining) kidney. CT scanning is the most cost-effective method of evaluating a suspected renal mass lesion and is currently the method of choice for detecting and staging renal carcinoma. Differential renal function is often assessed noninvasively with computerized isotope renography (renal scan) using radioactive iodine (iodine 131) or technetium-99m. Organism-specific antibiotic therapy is instituted at least 48 hours after surgery if the patient has evidence of an upper or lower urinary tract infection. Preoperative percutaneous embolization of the kidney is occasionally rendered for patients with an arterialized vena cava thrombus or if medial extension of the tumor interferes with early ligation of the renal artery. Angioinfarction commonly leads to transient flank pain, which requires analgesic medication. Intraoperative detailsAn anterior subcostal, thoracoabdominal, or flank approach is used depending on the size and location of the tumor and the habitus of the patient. An extraperitoneal flank approach is usually preferable when the kidney is chronically infected, when the patient is obese, or when multiple prior abdominal operations have been performed. A transperitoneal approach is preferable in patients who tolerate flank position, in patients with end-stage renal disease undergoing bilateral nephrectomy for polycystic kidney disease, and in patients with traumatic renal injuries in whom early access to the pedicle is necessary. The transperitoneal subcostal incision is used to resect most renal tumors because exposure to the great vessels through this approach is excellent. A large upper-pole tumor is best approached via the thoracoabdominal route. After the peritoneal cavity is entered, the intra-abdominal contents are inspected for any evidence of metastatic disease. The peritoneal reflection is incised along the line of Toldt, thus mobilizing the ascending and descending colon. The vena cava is used as a reference landmark with tumors of the right kidney. This vessel can be followed upward to the point where the left renal vein enters. Before dealing with the renal vessels, ligating and dissecting the gonadal vein at the point where it enters the vena cava is preferable. Then, the renal artery and vein are ligated and divided. The renal artery is ligated before the vein whenever possible, on either side. However, approaching the pedicle from the front, to ligate and divide the vein first, is sometimes easier. After this, the artery is readily exposed and quickly clamped and ligated. Downward and lateral traction of the kidney exposes the superior vascular attachments of the tumor and adrenal gland. Exposure of these vessels also is facilitated by medial retraction of the inferior vena cava. The right renal artery can be ligated in the aortocaval space. This is especially useful when regional lymphadenectomy is performed because the access to this space must be obtained anyway. Usually, the renal artery is ligated with two 2-0 nonabsorbable ligatures close to the aorta. A ligature is also placed in the distal end. The renal vein is palpated for any firmness that suggests a tumor thrombus. Short adrenal veins that empty directly into the side of the vena cava may also need ligature or hemostasis. Lumbar veins are usually not clipped because they may become displaced. Instead, a 0 silk ligature is passed on a right-angle clamp and tied. Oversewing the stumps of the renal artery and vein with 5-0 arterial silk may be prudent. Some surgeons prefer to doubly clamp the artery and vein separately and to divide it between clamps. After removing the specimen, the artery is tied with 1-0 synthetic absorbable suture (SAS) and reinforced with a second 1-0 SAS as a stick tie. The vein is ligated with a 1-0 SAS. Tumor extension into the renal vein usually is not problematic because the tumor thrombus can be milked back toward the kidney as the renal vein is ligated closer to the vena cava. Occasionally, a vascular clamp must be placed at the junction of the renal vein and inferior vena cava. Then, the renal vein is divided, the vein and thrombus resected, and the stump of the renal vein or caval incision is oversewn. Management of tumor thrombus within the inferior vena cava depends on the cephalad extent of the thrombus and the presence or absence of invasion into the inferior vena cava. Then, the Gerota fascia surrounding the kidney and adrenal gland is dissected away from the surrounding structures using sharp and blunt dissection, as needed. Lymphatic and sympathetic structures are ligated or clipped. The ureter and gonadal vein are mobilized bluntly to the level of bifurcation of the aorta and lifted into the wound. Each is clamped and ligated with 0 silk ligatures, leaving the proximal end long enough for later identification. The upper pole of the kidney is pulled down to expose the adrenal gland, and the connective tissue and peritoneal attachments are progressively divided. Starting the dissection laterally along the posterior body wall toward the crus of the diaphragm is easier. The cranial connections to the adrenal gland are divided carefully between clips. In 75% of cases, ipsilateral adrenalectomy is not required. For left-sided tumors, the splenocolic and lienophrenic attachments are divided to allow the spleen to be swung up out of the way; otherwise, the spleen may be injured during a left nephrectomy from an anterior approach. The kidney is removed from the retroperitoneum (see Image 3). Regional lymphadenectomy for RCC is controversial. The defect in the mesocolon is closed to prevent internal hernias. Drains are not used routinely for radical nephrectomy at the authors' institution. However, if the intraoperative blood pressure is low, later bleeding from spasmic small vessels is anticipated. Direct infiltration into the duodenum and the wall of the colon is rare. If the colon or the spleen is involved, consider removing the organ. If locally advanced tumors suspected of extension into either the colon or mesentery are present, patients should undergo a mechanical and antibiotic bowel preparation. Segmental colon resection and primary anastomosis should be possible in most cases. Invasion of the liver is uncommon because of the Glisson capsule, which forms a barrier. For invasion of the liver, perform right hepatectomy and right nephrectomy en bloc by controlling the hilar structures on the right side first. The mass then can be elevated to expose the vena cava to allow control of the hepatic veins. If the tail of the pancreas is involved from left-sided kidney cancer, perform simple resection of the tail of the pancreas and oversew the pancreatic duct, covering the resected area with greater omentum. Postoperative detailsMany postoperative complications, such as myocardial infarction, cerebrovascular accident, congestive heart failure, pulmonary embolism, atelectasis, pneumonia, and thrombophlebitis, can be reduced with adequate preoperative preparation, avoidance of intraoperative hypotension, appropriate blood and fluid replacement, postoperative breathing exercises, early mobilization, and elastic support of the legs, both during and after surgery. After nephrectomy for unilateral renal disease, the opposite normal kidney undergoes compensatory hypertrophy, and the glomerular filtration rate is ultimately maintained at 75% of the normal value. Normal life expectancy can be achieved after a unilateral nephrectomy with a normal contralateral kidney. COMPLICATIONSSection 8 of 12
Approximately 20% of patients undergoing radical nephrectomy develop postoperative complications, and the operative mortality rate is approximately 2%. Intraoperative complications include injury to any gastrointestinal organs (eg, liver, spleen, pancreas) or to any major blood vessels (eg, aorta, inferior vena cava). Pleural injuries can result in pneumothorax. Postoperative complications include secondary hemorrhage from the renal pedicle or any unrecognized injury, atelectasis, ileus, both superficial and deep wound infections, temporary or permanent renal failure, and incisional hernia. Other well-recognized systemic complications include myocardial infarction, congestive heart failure, pulmonary embolism, cerebrovascular accident, pneumonia, and thrombophlebitis. OUTCOME AND PROGNOSISSection 9 of 12
Historically, 4-10% of patients with RCC have tumor thrombus extending into the inferior vena cava, and 1% have tumor involving the right atrium. Surprisingly, the prognosis for patients with resectable inferior vena caval extension without unresected vena caval wall invasion or lymph node involvement approaches that of stage I cancer. In the absence of metastases, an aggressive surgical approach provides the only hope for a potential cure. Lymph node involvement and metastases are adverse predictors of survival. People with stage IV disease and with distant metastasis have a 5-year survival rate of less than 10%. If metastasis is discovered preoperatively, surgery is considered only for palliation, for entry into adjuvant treatment protocols, or, possibly, for a solitary metastasis. Metastases, particularly hepatic metastases, recognized at the time of surgery are associated with poor outcomes, and further surgery should probably be abandoned in these patients. Unfortunately, metastases after complete surgical resection is not uncommon. In these patients, postsurgical metastatic RCC is the most common cause of death. Survival rates in relationship with surgical stage, type of therapy, and pathologic characterization of the primary tumor were studied in 326 patients treated at Nephrectomy can ameliorate paraneoplastic syndromes, hemorrhaging, and tumor pain. Paraneoplastic syndromes associated with RCC include the following:
FUTURE AND CONTROVERSIESSection 10 of 12
Laparoscopy is gaining worldwide acceptance in the treatment of organ-confined renal cancer. Both laparoscopic radical nephrectomy and laparoscopic nephron-sparing procedures are viable alternatives to traditional open, radical, and partial nephrectomy surgeries. Advantages of laparoscopic radical nephrectomy over open nephrectomy include the following:
Laparoscopy appears to offer the same cancer control results as open surgery, with comparable disease-free survival at 5 years and, recently, at 10 years. Laparoscopic radical nephrectomy can be performed using the transperitoneal or the retroperitoneal approach. The retroperitoneal approach showed some benefit in quicker vascular control and less operative time. Both approaches are similar in terms of other patient outcomes. Although laparoscopic radical nephrectomy for organ-confined kidney cancer is now considered one standard of care, several reports concerning locally invasive kidney cancer treated laparoscopically show promising results. Now, the challenge for each urologist is to learn these new technologies if he or she wants to be part of this rapidly growing field. Renal ablative cryosurgery and radiofrequency are emerging as the newest techniques for treating locally confined renal cancer.9, 10 Limited experience has demonstrated their effectiveness in treating small peripherally located tumors, with minimum morbidity and a favorable outcome. These treatment modalities are still in their infancy, and clinical trials are currently underway to determine their long-term effectiveness. Sorafenib and sunitinib are vascular endothelial growth factor receptor inhibitors. They are now FDA-approved for treating metastatic renal cell cancer and have demonstrated promising initial results. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Sep 28, 2007 | ||||||||||||||||||||||||||
