How is radical nephrectomy performed?

Updated: Feb 05, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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An 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 video below depicts an example of nephrectomy used to treat multicystic kidney.

Nephrectomy for multicystic kidney.

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 below). Regional lymphadenectomy for RCC is controversial. The defect in the mesocolon is closed to prevent internal hernias.

Renal tumor after surgical removal. Renal tumor after surgical removal.

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.

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