Radical nephrectomy (RN): removal of Gerota's fascia (containing kidney and perirenal fat), sometimes adrenal gland and regional lymph nodes if advanced cancer
Nephron sparing (NSS): Partial nx, enucleation, or ablation. Lower risk of chronic renal insufficiency. Use if renal mass ≤ 7 cm (eg T1, equal cancer-specific survival and better overall survival compared to RN), or need to preserve more GFR (solitary, poor renal function, b/l tumors). However PNx has more complications, higher local recurrence.
- Negative margin size doesn't impact prognosis - go for a close margin
- Positive margin - no gross residual tumor ≥ 85% of the time with low risk of recurrence and can do surveillance; otherwise do RN or repeat partial nx/ablation
- Ischemic time: cool to 15C x 15 min (provides up to 3 hrs of ischemia time)
- Common practice to give mannitol 12.5g before clamping renal artery - not reabsorbed by tubules so increases intratubular osmotic pressure and free water excretion -> theoretically decrease intravascular cellular swelling, increase blood flow, increase free radical scavenging after ischemia reperfusion injury - but little evidence to support its use
RENAL nephrometry score (rate difficulty of potential partial nephrectomy)
- 4-6 pts - low complexity
- 7-9 pts - moderate complexity
- 10-12 pts - high complexity
- Higher complexity - more likely to undergo radical vs. partial; open vs. lap; surgical intervention vs. surveillance
- Does not connote specific management strategies
| 1 pt | 2 pt | 3 pt | |
| Radius | ≤ 4 cm | 4-7 cm | ≥ 7 cm |
| Exophytic/endophytic | ≥ 50% exophytic | < 50% exophytic | 100% endophytic |
| Nearness to collecting system | ≥ 7 mm | 4-7 mm | ≤ 4 mm |
| Anterior or posterior | anterior, posterior, or neither (x) | ||
|
Location relative to renal poles (h) if touches main vessels |
entirely below inferior pole or above superior pole | crosses polar line | > 50% lies across polar line (a), or is entirely between polar lines (b), or crosses axial midline (c) |
Stanford nephrectomy positioning and steps
Laparoscopic nephrectomy
- Reflect the transverse colon medially, at the white line of Toldt/peritoneal reflection
- R - liver, duodenum (reflecting the duodenum is called 'Kocherising')
- L - spleen
- Dissect in that plane to release the kidney
- At the lower pole of the kidney, identify the gonadal artery, then the ureter posterior to it, and the psoas muscle most posteriorly
- Testicular artery can be ligated - testes receive collateral from cremasteric artery and deferential artery (vas deferens) - but some do have chronic testicular pain afterwards
- Bhayani tip - there is always a weakness in Gerota's fascia right over the ureter to identify it
- Divide the renal vein (anterior) and artery. Renal vessel anatomy can differ - check the contrast CT to know how many arteries/veins there are.
- Radical nephrectomy - divide the vessels
- Partial nephrectomy - clamp the renal artery with bulldog clamps to begin ischemic time, and cold dissect the tumor out.
- Finish dissecting and bag the kidney/tumor. Extend the lap port incision, remove, and close (interior oblique, exterior oblique, fat/skin).
Open nephrectomy incisions
- Large or bilateral tumors - anterior abdominal incisions
- Midline - earlier vascular control for trauma but less exposure of kidneys
- Subcostal/chevron
- Makuuchi - "L" or "J" incision, from 2cm below xiphoid to above umbilicus, and then to tip of ipsilateral 12th rib.
- Flank incisions for partial nephrectomy
- Typically from tip of 11th rib towards umbilicus, from mid axillary line to lateral rectus
- Neurovascular bundles run along the underside of ribs, between the interal oblique and transversus - cut superior to the rib
- Posterior pleura can extend to 10-12th ribs
- AUA University flank incision video
| POD 0 | Clears |
| POD 1 | Regular diet, discharge Chung - all partials have JP drain and need JP Cr before removal |