Department of Urology

Nephrectomy- Partial and Robot Assisted

Overview

Kidney cancer, especially when confined to the kidney with no spread to other parts of the body (no metastases) is treated surgically.  The first major decision is whether the whole kidney must be removed (Radical Nephrectomy), or if only the part around the tumor can be removed (Partial Nephrectomy).  The next decision is whether the surgery can be performed laparoscopically, using smaller incisions and telescopic instruments.  Often, when performing a Laparoscopic Partial Nephrectomy, the robot is used to aid in removal of the tumor and with suturing the defect in the kidney where the tumor was removed.  When someone has metastatic kidney cancer, we may remove the kidney tumor as this can be associated with a better response to systemic therapy.

Description

Open Radical Nephrectomy

The procedure uses general anesthesia and we encourage patients to consider an epidural anesthetic for pain control.  Patients are placed either on their side or flat on their back.  The structures around the kidney are dissected away from the kidney and the blood vessels to and from the kidney along with the ureter draining urine down to the bladder are tied and divided.  The adrenal gland may be removed with the kidney and a lymph node dissection may be performed to evaluate for spread of the cancer to the lymph nodes.

Laparoscopic Radical Nephrectomy

The procedure uses general anesthesia and patients are placed on their side.  We fill the abdomen with carbon dioxide and make several small 1-centimeter incisions to place telescopic instruments into the abdomen. The structures around the kidney are dissected away from the kidney and the blood vessels to and from the kidney along with the ureter draining urine down to the bladder are tied and divided.  The adrenal gland may be removed with the kidney and a lymph node dissection may be performed to evaluate for spread of the cancer to the lymph nodes.  The kidney is removed through a small incision in the lower abdomen below the belly button.

Open Partial Nephrectomy

The procedure uses general anesthesia and we encourage patients to consider an epidural anesthetic for pain control.  Patients are placed either on their side or flat on their back.  The kidney is exposed and freed from surrounding structures and the tumor is identified.  Often, ultrasound is used to identify the location and depth of the tumor.  The blood flow to the kidney may be interrupted with a clamp.  The tumor is then removed with a margin of normal kidney tissue.  The defect is closed and a drain is often left in place to allow for monitoring for bleeding or a urine leak.

Laparoscopic/Robotic Partial Nephrectomy

The procedure uses general anesthesia and patients are placed on their side.  We fill the abdomen with carbon dioxide and make several small 1-centimeter incisions to place telescopic instruments into the abdomen.   The kidney is exposed and freed from surrounding structures and the tumor is identified.  Often, ultrasound is used to identify the location and depth of the tumor.  The blood flow to the kidney may be interrupted with a clamp.  The tumor is then removed with a margin of normal kidney tissue.  The defect is closed and a drain is often left in place to allow for monitoring for bleeding or a urine leak.

Preoperative Considerations

Surgical

Patients must understand the surgical risks of the procedure including bleeding, infection, injury to structures around the kidney including the liver, spleen, intestines, diaphragm, pancreas, blood vessels, and nerves, urine leak if a partial nephrectomy is performed, and wound complications including infections and hernia.  The decision to perform radical or partial nephrectomy using an open or laparoscopic approach depends upon the tumor size and location, the presence of any cancer thrombus in the renal vein or inferior vena cava, and the presence of metastatic disease.  A history or prior kidney procedures, prior abdominal operations, and obesity make kidney surgery more difficult.  Prior to kidney cancer surgery, patients may receive a bowel preparation as kidney surgery often involved mobilization of the intestines.

Medical

Most patients with kidney cancer are 40-70 years old, and thus, may have other medical problems that can increase the risk of medical complications of kidney cancer surgery, including heart attack, stroke, formation of leg clots (deep venous thrombosis) or movement of these clots to the lungs (pulmonary embolism), and death.  Patients with many medical conditions may need to be seen by the Medicine Consult service before surgery to make sure that no other procedures, such as heart stress tests, must be one before surgery.  The consult also ensures that the Medicine Consult service will follow along with your medical care after surgery.

Other

All patients receive antibiotics prior to the procedure and many patients will receive an injection of a blood thinning medication before surgery to try to prevent deep venous thrombosis.  We encourage patients having open kidney cancer surgery to consider epidural analgesia because this helps us manage your pain control after the operation.

Postoperative Care

Most patients undergoing kidney cancer surgery will go to a regular floor bed after surgery, although more complex patients, or patients with larger cancers may require admission to the intensive care unit.  After surgery, when patients are walking independently, eating a regular diet with normal bowel function, and able to tolerate their incisional pain with pain pills rather than the epidural analgesia or intravenous pain medications, they can be discharged home.  After open radical or partial nephrectomy, this usually occurs 3-7 days after surgery.  After laparoscopic radical or partial nephrectomy, this usually occurs 1-3 days after surgery.

Long Term Care

Patients diagnosed with kidney cancer must be on Surveillance to monitor for a recurrence of the cancer.  Surveillance usually involves regular physical examinations with blood tests and imaging studies.  The timing of the surveillance visits depends on the aggressiveness of the cancer, which is represented by the Stage and Grade of the kidney cancer.

Additional Reading

National Cancer Institute – Kidney Cancer

Physicians

John L. Gore, MD, MS
Jonathan Harper, MD
Daniel W. Lin, MD
Jonathan L. Wright, MD, MS