Kidney Resection

A kidney resection, also known as nephrectomy, is a surgical procedure that removes one of the two kidneys located at the back of the abdomen. The kidneys remove organic wastes and excess body fluid from the circulation to produce urine. A nephrectomy is a surgical procedure that includes removing a complete kidney from the body by a cut in the flank, the space between the ribcage and the hip. In a rare number of cases when cancer is suspected, a low or high cut, or an incision in the front of the abdomen, may be required, according to the tumor site.

If a person has impaired renal function or only has a single kidney, a partial nephrectomy, in which only a portion of the kidney is excised, may be performed in a low number of situations. A nephrectomy is typically performed to treat kidney cancer or a non-functioning kidney. A radical nephrectomy is performed in the case of kidney cancer. Radical nephrectomy involves removing the entire kidney, suprarenal gland, outer shell, adjacent fat, and associated veins in an effort to get rid the body of malignancy. A simple nephrectomy is performed on a non-functioning kidney caused by big stones, a limitation of blood flow, or aberrant kidney anatomy. Only the kidney is removed in a simple nephrectomy. To minimize repeated infections and the risk of serious morbidity as a result of infection, a simple nephrectomy is frequently performed.

In latest years, with the introduction and widespread use of abdomen Computed tomography scan and ultrasound imaging for a variety of abdomen and, on rare occasions, chest problems, the frequency of renal cell carcinoma has surged in asymptomatic individuals. Nowadays, more than half of all episodes of renal cell carcinoma are discovered by chance. These malignancies are usually smaller and earlier in stage, resulting in improved survival, recurrence, and metastatic percentages than renal cell carcinoma found in symptomatic patients. Symptomatic renal cell carcinoma manifests at a much higher stage and grade than accidentally detected tumors, and lesions are far more destructive, especially at later stages.

 

Relevant Anatomy

The kidneys are a pair of important organs positioned on either side of the spinal column and buried in the retroperitoneal connective tissue's intermediate layer. Both the kidneys and the suprarenal glands are enclosed by the perirenal fascia, commonly known as the Gerota fascia.

Renal cancers generally stay in this fascia and can be entirely removed by cutting the kidney and its accompanying fascia as a cohesive block. A single renal artery and vein reach the kidney medially through the renal hilum in the majority of people, however, numerous renal arteries are not unusual. The renal artery emerges from the aorta's lateral side, right below the superior mesenteric artery, and runs behind the renal vein. To feed the relevant renal parenchyma, the main renal artery separates into 3-5 segmental arteries. Because these segmental arteries are terminal arteries with no collateral branches, any lesion to the renal artery at any point causes a parenchymal infarct.

The renal parenchymal veins, unlike the renal arteries, readily connect among the various renal segments. On its lateral side, a single renal vein usually enters the inferior vena cava. Numerous renal arteries affect 22% of people unilaterally, but several renal veins are less prevalent. Above the kidney and posterolateral to the inferior vena cava is the right suprarenal gland. The main blood flow is the inferior phrenic artery, with branches from the aorta and renal artery. The venous drainage normally exits the apex of the gland and enters the dorsal surface of the inferior vena cava through a common vein on the right. This vein is small and delicate, and it is a frequent cause of hemorrhage after right adrenalectomy. Approximately 3.5 cm from the inferior vena cava and mostly opposite the gonadal vein, the left vein drains straight into the left renal vein. The left inferior phrenic vein, which normally connects with the adrenal vein but then travels medially and can be damaged during the separation of the gland's medial margin, is underappreciated.

The anterolateral aorta gives birth to the paired gonadal arteries, which are located below the renal vessels. A gonadal artery can occasionally originate above the level of the renal arteries from the ipsilateral renal artery or the aorta. The gonadal arteries flow anteriorly to the ureter on either side of their retroperitoneal path. In their inferior path, gonadal veins run parallel to the gonadal arteries, while superiorly, they are likely to be more lateral and adjacent to the ipsilateral ureter. The inferior side of the left renal vein is frequently entered perpendicularly by the left gonadal vein. The right gonadal vein empties obliquely below the position of the right adrenal vein into the right lateral portion of the inferior vena cava.

 

Renal Cell Carcinoma Epidemiology

Cysts make up the great proportion of renal masses detected by chance. In 24% of patients over the age of 40, an abdominal Computed tomography (CT) scanning indicates a simple kidney cyst. Kidney cysts are found in more than half of all men over the age of 50, according to some reports. When a patient has a kidney mass that is associated with gross hematuria, flank pain, or a palpable lump, the likelihood of the mass being renal cell carcinoma is about 51%. Other kidney masses, such as angiomyolipoma, kidney pelvic tumors, and other benign diseases, are quite infrequent in asymptomatic individuals, representing around 6% of all renal masses.

 

Renal Cell Carcinoma Etiology

A number of factors have been linked to a higher risk of renal cell carcinoma:

  • Obesity and smoking cigarettes are the most reliably confirmed causative risk factors for renal cell carcinoma, contributing to more than 32% and 19% of cases, respectively.
  • Hypertension is linked to a higher risk of renal cell carcinoma as an independent factor.
  • Analgesic usage was originally thought to be a more important cause than recent research suggests.
  • A 3- to 4-fold greater risk of renal cell carcinoma is linked to a family history of the disease. In less than 3% of cases of renal cell carcinoma, however, a familial tendency is discovered. The discovery of family members with a genetic disposition to the development of renal malignancies, such as von Hippel-Lindau, hereditary papillary renal carcinoma, Birt-Hogg-Dubé, and hereditary leiomyomatosis and renal cell cancer, has resulted in the identification of the various genes involved in these malignancies.

 

Kidney Resection Indications

For clinically resectable tumors, radical nephrectomy (total kidney resection) remains the operation of preference. After radical nephrectomy, 15-30% of patients with fully resected renal cell carcinoma experience relapse. In patients with metastatic disease, radical nephrectomy is also recommended as a palliative treatment in cases of persistent pain and bleeding as part of immunotherapy or the new chemotherapy strategy. As an adjuvant treatment, many patients are now managed with new FDA-approved tyrosine kinase inhibitors. In addition, various novel drugs for the treatment of metastatic renal cancer are now being tested in phase 2 and phase 3 trials. In terms of boosting the survival and delaying development, the findings so far have been positive.

Symptomatic cancer, a high Fuhrman grade of tumor, a high clinical stage, microvascular infiltration, and necrosis are all indicators of relapse. When compared to observation only, neither post-nephrectomy radiation treatment nor adjuvant interferon-alpha injection prevents relapse or improves overall survival rates in these patients. As a result, after radical nephrectomy for renal cell carcinoma, observation is still the mainstay of therapy.

 

Kidney Resection Contraindications

When a highly functional renal parenchyma must be maintained, such as in patients with bilateral renal cell carcinoma, renal cell carcinoma involving a solitary functioning kidney, chronic renal insufficiency; or unilateral renal cell carcinoma with a functioning contralateral kidney at risk for future impairment from intercurrent diseases, such as calculus disease, renal artery stenosis, diabetes, or hypertension, nephron-sparing surgery has proven to be an effective alternative to total kidney resection.  Novick was instrumental in the development of nephron-sparing surgery, demonstrating its safety and effectiveness, and establishing the optimum procedure.

Many trials have proven that nephron-sparing surgery is as successful as radical nephrectomy in treating patients with a single, small (less than 3 cm in diameter), unilateral, localized renal cell carcinoma. Even when the opposite kidney is healthy, nephron-sparing surgery is becoming more widely regarded as a successful treatment for small, selective, accidentally found cancers. According to recent research, nephron-sparing surgery can be used to treat tumors up to 6 cm in diameter, especially polar tumors that do not expand into the renal hilum.

The main downside of nephron-sparing surgery is the minor risk of local tumor recurrence in the remnant of the treated kidney due to undiagnosed microscopic multifocal renal cell carcinoma. An increased risk of hemorrhage and urine leakage is also linked to partial nephrectomy. Despite the greater rate of complications, preserving normal nephrons in the kidney lowers the chance of decreased kidney function and the difficulties that come with it.

The use of nephron-sparing surgery outnumbers radical nephrectomy in patients who get surgery, according to a study by Huang et al that analyzed trends and results in the therapy of small kidney tumors.

Laparoscopic partial nephrectomy is a relatively recent procedure that is becoming more popular. It has a shorter recovery time than an open partial nephrectomy. It is, however, linked to greater rates of positive margins, significant intraoperative consequences, and urologic problems. Patients with small exophytic lesions should have a laparoscopic partial nephrectomy done by an experienced laparoscopic urologist.

 

How is a Kidney Resection Performed?

For stage 1, 2, and certain stage 3 cancers, radical nephrectomy of the kidney is the recommended treatment.

The renal artery and vein are ligated, the kidney is removed outside the Gerota fascia, the ipsilateral adrenal gland is removed, and a full regional lymphadenectomy from the crus of the diaphragm to the aortic branching is performed.

Based on the size and location of the tumor as well as the patient's behavioral patterns, a transperitoneal cut or an extraperitoneal cut is used. In patients with supradiaphragmatic tumor thrombus formation, cardiopulmonary bypass with deep hypothermic circulatory arrest is done.

Individual preferences, rather than need, dictate the surgical method. A central cut is often employed at some hospitals, while the anterior subcostal, thoracoabdominal, and flank methods are favored in others. The majority of tumors can be removed by a transperitoneal subcostal cut.

The major benefit of the abdominal method is that it provides excellent exposure in the area of the renal artery. It's easier and quicker to make a vertical centerline cut. It also makes it easier to examine the rest of the abdominal tissues. A transverse cut allows for better exposure to the kidneys' lateral and superior portions, and a unilateral subcostal cut can be continued across the centerline as a chevron cut for optimum access of both kidneys, the aorta, and the inferior vena cava. The main disadvantage of the abdominal method is the slightly longer recovery time from ileus and intra-abdominal adhesions.

 

Preoperative Care

To avoid the negative effects of carbon dioxide absorption, the pulmonary and cardiac conditions must be adjusted prior to the procedure. You will be advised not to eat or drink for 8 hours prior to surgery, as well as shortly thereafter. The anesthesiologist may administer a pre-medication that causes you to become dry-mouthed and drowsy. Antibiotic prophylactic dose or cross-match formulations will be prescribed. The patient should be aware that high morbidity, an atypical body build, and prior abdominal surgery can all lead to the procedure's technical difficulty. Deep vein thrombosis prevention may be recommended for people who are at risk.

 

Operative Details

Nephrectomy is a fairly routine procedure that takes about 3-4 hours to complete. In most cases, a general anesthetic with a muscle relaxant is needed. The kidney is separated from surrounding tissues when the cut is created. The kidney's blood supply is identified and shut off, and the kidney, along with its encircling fat and associated veins, is excised. When hemostasis is established, the procedure is completed. Sutures and staples are used to seal the wound. To drain any wound oozing, a wound drain can be implanted. This is often put in place and remains in place for several days.

A catheter (a collection tube that collects urine from the bladder) is also inserted to check the remaining kidneys' urine output. The catheter is normally left in place for 1-2 days, or until you are able to move around. A stent, which is a tube-like structure that extends from the kidney to the bladder, may be used if you have had a partial nephrectomy. This aids in the recovery of the kidney. About 5-6 weeks following the surgery, it will be removed under local anesthesia.

 

Postoperative Care

Fasting, observation, painkillers and sedation, catheterization, drainage, antibacterial coverage, blood transfusion, and fluid therapy will all be administered as part of the postoperative treatment. There may be some oozing at the site of the wound. As usual, you can drink the first day following surgery and eat the second day. The drains and tubes are typically removed by the 2nd or 3rd day after the operation. After the operation, you may have to stay in the hospital for 3 to 7 days. Stitches and wound staples are often left in for 6 to 10 days. If skin stitches are needed, the patient will be given instructions on how to remove them.

 

Follow-up Period

When it is deemed acceptable, you will be discharged. You should follow the instructions for follow-up that were given to you when you were discharged. It normally takes 5 weeks to fully recuperate from surgery. Maintain a healthy level of activity by walking or doing other mild activities. At home, you will be allowed to eat and drink moderately. For up to five weeks or until the doctor advises, no heavy work, jogging, or gardening. You will be scheduled for a follow-up consultation with the doctor in 3 to 4 weeks to review the treatment options. If you experience any major side effects after being discharged, you should seek professional care at the closest Accident and Emergency Department. For examples: 

  • Signs of infection, such as increased erythema or warmth around the wound.
  • Profuse Bleeding
  • A great deal of pain

 

Kidney Resection Complications

Hemorrhage: Because the kidney is such a vascular organ, bleeding is a genuine possibility. The renal artery, anomalous arteries, and the inferior vena cava can all cause bleeding. When there is a tumor or inflammation, the risk is increased. Where applicable, methods such as acute normovolemic hemodilution and antifibrinolytic medications may be utilized to lessen the requirement for blood products. Cell Saver's utility for kidney tumors is questionable. Although further hemorrhage in the postoperative period is uncommon, it can necessitate a laparotomy. Due to a huge fresh resection region in the residual renal tissue, partial nephrectomy has a larger risk of blood loss than total nephrectomy. Blood clotting agents and the argon beam are two approaches that are often employed.

Problems with the heart: Preoperatively, the myocardial oxygen supply/demand balance should be maintained. It is necessary to examine the need for invasive monitoring. Shivering should be minimized after surgery, and pain management should be maximized. Postoperative discomfort can cause tachycardia, hypertension, greater oxygen consumption, and myocardial ischemia by triggering a stress reaction. If you've been taking beta-blockers or statins before, you should keep taking them. When it's time, anticoagulants for coronary artery stents should be restarted. Intensive care or telemetry should be considered.

Because the kidney is adjacent to the lungs, it is possible for the pleura or diaphragm to be damaged. This is frequently evident during an open procedure, and it is possible to fix it before the surgery is completed. However, especially during laparoscopic surgery, a higher degree of suspicion must be maintained. Any concerns about rapidly evolving difficult breathing and/or desaturation should be investigated thoroughly, and surgeons should be notified. With intermittent positive pressure ventilation, any pneumothorax can quickly escalate to a tension pneumothorax, causing severe cardiovascular instability. A chest x-ray is usually taken after surgery to rule out pneumothorax.

The carbon dioxide used to produce the pneumoperitoneum during laparoscopic surgery can cause substantial hypercarbia and acidosis, especially in longer surgeries. High intra-abdominal tension impedes venous return and compromises respiration, resulting in substantial hemodynamic changes.

The small or large bowel may be injured, needing primary closure or the creation of a colostomy.

 

Prognosis and Outcomes

Historically, tumor thrombus has extended into the inferior vena cava in 5-11% of individuals with renal cell carcinoma, and 2% have tumors affecting the right atrium. Interestingly, patients with resectable inferior vena cava expansion who do not have unresectable vena cava wall infiltration or lymph node metastasis have a prognosis that is similar to that of stage I disease. Aggressive surgical treatment is the only option for a possible cure in the absence of metastases.

Involved lymph nodes and metastases are poor indicators of survival. The 5-year survival rate for people with stage 4 cancer with distant metastases is less than 9%. If metastasis is identified before surgery, surgery is only recommended for palliation, admission into adjuvant therapy regimens, or potentially a single metastasis. Metastases discovered after surgery, particularly hepatic lesions, are linked to poor prognosis, and additional surgery in these patients should almost always be avoided. Sadly, after a thorough surgical removal, metastases are not uncommon. The most frequent cause of mortality in these patients is postsurgical metastatic renal cell carcinoma.

In 325 patients treated at New York University, survival rates were investigated in relation to the surgical stage, method of treatment, and pathological characterization of the underlying tumor. 25% of tumors were stage 1, 15.5% were stage 2, 28% were stage 3, and 31.5% were stage 4 at the initial diagnosis.

Patients with tumors restricted to the capsule had the highest 5-year and 10-year survival rates, according to the retrospective analysis. As the tumor spread to the perirenal fat or regional lymph nodes, survival rates dropped. Tumor migration into the renal vein did not have a substantial impact on 5-year survival rates but did reduce 10-year survival rates to 45 percent. Besides those managed with surgical extirpation of the secondary lesion, patients having metastases at the time of surgical excision had bad outcomes, irrespective of the site of metastases or kind of adjuvant therapy. An improved prognosis was linked to certain tumor features. Smaller than 6 cm in diameter, no infiltration of the collecting system, perirenal fat, or nearby lymph nodes, and a majority of clear or granular cells developing into an identifiable histological pattern were among the criteria.

 

Conclusion

For the treatment of kidney malignancies, radical nephrectomy has proven itself as the gold standard. Long-term follow-up has shown that open radical nephrectomy had a short patient hospitalization time and effective cancer management with no major difference in survival. When open and laparoscopic radical nephrectomies are compared, complication rates are reported to be 9.5% and 11%, respectively. Thus, in terms of overall survival without recurrence and early recovery, laparoscopic radical nephrectomy outperforms open radical nephrectomy.