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.
Preoperative patient preparation:
- Perioperative antibiotic prophylaxis, if risk factors for wound infection are present.
- Perioperative indwelling catheter
- Perioperative gastric tube for a transperitoneal approach
- Consider epidural anesthesia
- Supine position of the patients with mild hyperextension of the lumbar spine.
- Midline laparotomy or subcostal incision
- Incision of the line of Toldt and medial reflection of the colon
- On the left side: peritoneal incisions to mobilize the spleen.
- On the right side: division and ligation of the ligamentum teres hepatis to mobilize the liver. Medial reflection of the duodenum until the vena cava is completely visible (Kocher maneuver).
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).
- On the left side, the division and ligation of the testicular vein or ovarian vein is necessary, since the vein drains into the renal vein. The division is done below the inferior pole of the kidney. On the right side, the vein may be spared or it is ligated close to the vena cava.
- Division and ligation of the ureter at the crossing with the iliac vessels. The ureter is followed to the renal hilum, the dissection should stay close to the vena cava (right side) or aorta (left side).
- Identification and preparation of the renal vessels. Visible lymph nodes are removed and sent for pathologic examination.
- The renal artery is ligated.
- The renal vein divided between Overholt clamps, the vein should be secured with double (suture) ligation. After division of the renal vein, the renal artery is now better visible and is divided in the same technique as the vein near the aorta. If significant atherosclerosis leads to a brittle artery, the use of 2–3 clips suitable for large vessels is wise.
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.
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.
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).
Drainage of the retroperitoneum is often performed, but it is probably not necessary after uncomplicated radical nephrectomy.
Postoperative Care after Radical Nephrectomy
- Removal of the gastric tube after surgery, clear liquid diet immediately (sips at first), advanced to regular diet as tolerated
- Early mobilization
- Intensive respiratory therapy
- Thrombosis prophylaxis
- Laboratory tests (hemoglobin, creatinine)
- Wound checks.
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.
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.
Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.
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
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