Dr. med. Dirk Manski



 You are here: Urology Textbook > Surgery (procedures) > Radical nephrectomy


Radical Nephrectomy

Indications for radical nephrectomy

Radical nephrectomy is the gold standard for the treatment of large renal cell carcinomas, if partial nephrectomy is not feasible. Radical nephrectomy consists of the removal of the kidney together with the adipose capsule, Gerota's fascia and regional lymph nodes. The transperitoneal approach allows early control of the renal vessels, propagated by Robson (Robson et al, 1969). This dogma has never been studied prospectively and is doubted by many authors in the clinical significance (Mickisch et al, 2002). Accepted technical approaches of radical nephrectomy are transperitoneal nephrectomy, lumbar nephrectomy, laparoscopic nephrectomy or thoraco-abdominal nephrectomy (for large tumors with vena cava thrombus).

Contraindications for Radical Nephrectomy

Do not perform radical nephrectomy if partial nephrectomy is technical possible, especially in patients with single kidneys, renal insufficiency, bilateral renal cell cancer or hereditary renal cell cancer.

Surgical Technique

Preoperative patient preparation:

Transperitoneal approach:

Flank approach:

Lateral decubitus position of the patient for a flank incision, the operation room table is flexed. The dissection is done between the 11th and 12th rib to spare the subcostal nerve. Blunt dissection of the layer between Gerota's fascia and the psoas muscle is done. The peritoneum is dissected of the ventral portion of the Gerota’s fascia until the renal vein is identified. On the right side, the duodenum has to be dissected of the vena cava (Kocher maneuver).

Hilar preparation:

Mobilization of the kidney:

The kidney is mobilized outside the Gerota's fascia. Using blunt and sharp dissection, the adrenal gland is separated from the adipose capsule and left in-situ. Adrenalectomy is only necessary, if large tumours of the upper kidney pole are present.

Management of venous tumor thrombus:

The complete kidney has to be mobilized and the renal artery should be divided. Small thrombi of the renal vein or vena cava do not require any special measures: the renal vein ostium is clamped with a Satinsky clamp after the ligation of the renal artery. After nephrectomy the defect of the vena cava is closed with a running suture.

Management of infrahepatic tumor thrombi:

Proximal and distal to the tumor thrombus, the vena cava is clamped using Satinsky clamps. The contralateral renal vein is clamped. Visible lumbar veins are clipped. The vena cava is opened (e.g. by circumcising the renal vein) and the tumor thrombus can be completely extracted with the already mobilized kidney [figure infrahepatic tumor thrombus resection]. If the tumor thrombus invades the wall of the vena cava, resection of the caval wall and reconstruction of the IVC is necessary.


Radical nephrectomy with infrahepatic tumor thrombus resection: after clamping the vena cava and contralateral renal vein, the vena cava is opened and tumor thrombus extraction is possible. The defect of the inferior vena cava is closed with a running suture in two layers.
figure radical nephrectomy with infrahepatic tumor thrombus resection

Management of intrahepatic and suprahepatic tumor thrombi:

Intrahepatic tumor thrombi may be resected while the suprahepatic vena cava inferior and the porta hepatis is clamped. If the tumor thrombus extends into the right atrium, the use of a cardiopulmonary bypass is inevitable. The operation should be performed with the help of visceral and/or cardiac surgeons depending on the cranial extension of the tumor thrombus.

Regional lymphadenectomy:

Lymphadenectomy is not necessary for T1–2 tumors without suspicious lymph node enlargement, since no survival benefit could be demonstrated in a large EORTC study (Blom et al, 1999 and 2009). Some authors advocate on the basis of retrospective studies a lymphadenectomy if advanced tumors or enlarged lymph nodes are present. Lymphadenectomy is recommended from the crus of the diaphragm to the aortic bifurcation. For left-sided tumors the para-aortic lymph nodes are removed, for right-sided tumors the paracaval lymph nodes are removed, and regardless of the side the interaortocaval lymph nodes should be removed (Capitanio et al, 2011).

Drains:

Drainage of the retroperitoneum is often performed, but it is probably not necessary after uncomplicated radical nephrectomy.

Postoperative Care after Radical Nephrectomy

General measures:

Analgesia:

Analgesics according to the WHO ladder are prescribed, e.g. a combination of metamizol and tramadol. A peridural anesthesia facilitates postoperative pain management.

Complications of Radical Nephrectomy

Complications of radical nephrectomy can be seen in the table complications of radical and partial nephrectomy, the data is from randomized and retrospective studies.

Complications of radical and partial nephrectomy: (Corman et al, 2000) (Poppel et al, 2007).
Complication Radical nephrectomy Partial nephrectomy
Significant hemorrhage 1,1 % 3,4 %
Hemorrhage <0,5 l 96 % 87 %
Urinoma 0 % 4 %
Reintervention 2,4 % 4,4 %
Mortality 2 % 1,6 %

Risk of significant hemorrhage:

The risk of significant blood loss during radical nephrectomy is below 5%, the risk increases up to 35% if tumor thrombus is present.

Injury of neighboring organs:

Liver injury, splen injury (risk of splenectomy), paralytic ileus, injury of the bowel, peritonitis, injury of the pancreatic tail with fistula, pneumothorax, chylous fistula due to injury of intestinal lymphatic vessels.

General complications:

Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.

Mortality:

Mortality due to bleeding, cardiovascular diseases, arrhythmia, acute renal failure, pulmonary embolism is around 2%.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z





References

Blom u.a. 1999 BLOM, J. H. ; POPPEL, H. van ; MARECHAL, J. M. ; JACQMIN, D. ; SYLVESTER, R. ; SCHRODER, F. H. ; PRIJCK, L. de:
Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. EORTC Genitourinary Group.
In: Eur Urol
36 (1999), Nr. 6, S. 570–5

Blom, Jan H M; van Poppel, Hein; Maréchal, Jean M; Jacqmin, Didier; Schröder, Fritz H; de Prijck, Linda; Sylvester, Richard & E. O. R. T. C. Genitourinary Tract Cancer Group
Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881.
Eur Urol, 2009, 55, 28-34.


Capitanio, U.; Becker, F.; Blute, M. L.; Mulders, P.; Patard, J.; Russo, P.; Studer, U. E. & Poppel, H. V.
Lymph node dissection in renal cell carcinoma.
Eur Urol, 2011, 60, 1212-1220.

Corman u.a. 2000 CORMAN, J. M. ; PENSON, D. F. ; HUR, K. ; KHURI, S. F. ; DALEY, J. ; HENDERSON, W. ; KRIEGER, J. N.:
Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program.
In: BJU Int
86 (2000), Nov, Nr. 7, S. 782–789

Mickisch 2002 MICKISCH, G. H.:
Principles of nephrectomy for malignant disease.
In: BJU Int
89 (2002), Nr. 5, S. 488–95

Poppel u.a. 2007 POPPEL, Hendrik V. ; POZZO, Luigi D. ; ALBRECHT, Walter ; MATVEEV, Vsevolod ; BONO, Aldo ; BORKOWSKI, Andrzej ; MARECHAL, Jean-Marie ; KLOTZ, Laurence ; SKINNER, Eila ; KEANE, Thomas ; CLAESSENS, Ilse ; SYLVESTER, Richard ; RESEARCH for the European Organization for ; CANCER (EORTC), Treatment of ; CANADA CLINICAL TRIALS GROUP (NCIC CTG), National Cancer I. of ; (SWOG), Southwest Oncology G. ; EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) the:
A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective Nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.
In: Eur Urol
51 (2007), Jun, Nr. 6, S. 1606–1615

Robson u.a. 1969 ROBSON, C. J. ; CHURCHILL, B. M. ; ANDERSON, W.:
The results of radical nephrectomy for renal cell carcinoma.
In: J Urol
101 (1969), Nr. 3, S. 297–301

Robson u.a. 2002 ROBSON, C. J. ; CHURCHILL, B. M. ; ANDERSON, W.:
The results of radical nephrectomy for renal cell carcinoma. 1969.
In: J Urol
167 (2002), Nr. 2 Pt 2, S. 873–5; discussion 876–7


  Deutsche Version: Tumornephrektomie