Urology: Nephrectomy

Nephrectomy

Definitions

  • Partial Nephrectomy: Resection of a Portion of the Kidney
  • Simple Nephrectomy: Resection of a Kidney
  • Radical Nephrectomy: Resection of the Kidney, Adrenal Gland, Gerota’s Fascia & Regional LN

Approaches

  • Open Surgery
    • Flank Approaches – Accessed Through the Retroperitoneum & Avoid Entry into the Peritoneal Cavity, Great for Exposure of Proximal Ureter & Kidney, Poor Access to Renal Hilum
      • Subcostal Flank
      • Supracostal Flank (Above 11th or 12th Rib)
    • Dorsal Lumbotomy – Accessed from the Back in a Prone Position, Does Not Require any Muscle Transection Making Lower Morbidity but Has Poor Exposure of the Hilum
    • Thoracoabdominal Approach – Accessed Through Both the Abdomen & Thorax for Large Tumors, Superior Tumors or Tumors with Venous Extension
    • Anterior Approaches:
      • Anterior Midline
      • Anterior Subcostal
  • Minimally Invasive Surgery
    • Transperitoneal
      • *The Most Traditional & Commonly Used MIS Approach
    • Retroperitoneal
    • Hand-Assisted
    • Robotic
    • Laparoscopic Single-Site Surgery (LESS)
    • Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Laparoscopic Transperitoneal Procedure

  • Position: Lateral Decubitus (Ipsilateral Side Up)
  • Place Ports
  • Renal Exposure:
    • Left Kidney:
      • Reflect Colon Medially
        • Requires Incision Along the Line of Toldt
      • Divide Splenocolic Ligament
        • Avoid Splenic Injury
      • Divide Colo-Renal Attachments
        • Should Separate Between the Mesenteric Fat (Bright Yellow) & Gerota’s Fat (Pale Yellow)
    • Right Kidney:
      • Use a Liver Retractor to Retract the Liver Superiorly
      • Reflect Colon Medially
        • Requires Incision Along the Line of Toldt
      • Divide Colo-Renal Attachments
        • Avoid Thermal Injury to the Duodenum
        • Should Separate Between the Mesenteric Fat (Bright Yellow) & Gerota’s Fat (Pale Yellow)
      • May Require Lateral Dissection of the Duodenum (Kocher Maneuver) to Fully Expose the Medial Aspect
  • Ureter Dissection:
    • Identify the Ureter & Gonadal Vessels
      • Along the Psoas Muscle Inferior to the Kidney
    • Elevate the Ureter & Sweep Gonadal Vessels Medially
    • Continue Dissection Up to the Kidney
      • Avoid Injury to the Cutaneous Nerves Over the Psoas Muscle
  • Renal Hilum Dissection:
    • Adequately Expose the Renal Vein & Artery
    • May Require Clips/Division of Accessory Venous Branches
  • Divide Hilar Structures:
    • Divide the Renal Artery
      • Artery Divided First to Decrease Size of Primary Tumor, Limit Tumor Engorgement & Possible Rupture/Upstaging
    • Divide the Renal Vein
  • Mobilize the Kidney
    • Dissect the Upper Pole While Preserving the Adrenal Gland
    • Divide the Ureter
    • Divide All Remaining Attachments
  • Remove the Kidney
    • Options:
      • Intact Through a Pfannenstiel Incision or an Extended Trocar Site Incision
      • Piecemeal After Morcellation in an Extraction Bag
  • Close Incisions