What is the preferred surgical approach for radical nephrectomy?

Updated: Feb 05, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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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.

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