Radical nephrectomy for renal tumors

Radical Nephrectomy Surgery in India

What is radical nephrectomy?

Nephrectomy (kidney removal): Radical nephrectomy for renal tumors is the gold standard treatment for cell carcinomas for the patients when they cannot get the partial nephrectomy. During the treatment, the kidney is removed along with the adipose capsule, regional lymph nodes, and gerota’s fascia.

The techniques accepted for radical nephrectomy are

  • Laparoscopic nephrectomy
  • Transperitoneal nephrectomy
  • Lumbar nephrectomy
  • Thoracoabdominal nephrectomy

What are the contraindications for radical nephrectomy?

The radical nephrectomy should not be performed if partial nephrectomy can be done. This should be specially kept in mind for patients with renal insufficiency, single kidney, hereditary renal cell cancer, or bilateral renal cell cancer.

What are the surgical options?

  • Perioperative antibiotic prophylaxis, if the risk for wound infection is present.
  • Perioperative gastric tube for a transperitoneal approach
  • Perioperative indwelling catheter
  • Opting for epidural anesthesiaPre
  • operative patient preparation

Transperitoneal Approach

  • Patients with a supine position with mild hyperextension of the lumbar spine.
  • Midline laparotomy or subcostal incision
  • On the left side: peritoneal incisions to mobilize the spleen.
  • The incision of the line of Toldt and colon has a medial reflection.

On the right side: ligamentum teres hepatis division and ligation to mobilize the liver. Medial reflection of the duodenum until there is the visibility of vena cava.

Flank Approach

Lateral decubitus position of the patient for a flank incision, the operation room table is flexed.To spare the subcostal nerve the dissection of the is between 11th and 12th rib. The layer between the psoas muscle and gerota’s fascia is done with blunt dissection. Till the time, the renal vein is identified, the peritoneum is dissected off the gerota’s fascia

Hilar Preparation

  • The vein gets drained into the renal vein, so ligation and division of the ovarian and testicular veins are important on the left side. The division is done on the kidney inferior pole. The ligated close to the vena cava or vein may be spared on the right side.
  • Ureter ligation and division are done at the crossing with the iliac vessels. The dissection needs to be done close to the aorta or close to the vena cava.
  • It is important to check the renal artery anomalies. The renal vessels need to be prepared and identified correctly. The lymph nodes which are present should be removed and then sent for pathological examination.

The renal vein needs to be secured with double ligation and it is divided between Overholt clamps. With the division, it makes it clear to see the artery properly and the same method is used to divide the vein near the aorta. For the large vessels, around 2 to 3 clips can be used.

Management of venous tumor thrombus:

The entire kidney is mobilized and the division of the renal artery is done. No special measurement is needed for the small thrombi renal vein

Postoperative Care following Radical Nephrectomy

  • Removal of the gastric tube after surgery, clear liquid diet immediately, advanced to a regular diet as needed.
  • Laboratory tests
  • Early mobilization
  • Intensive respiratory therapy
  • Wound checks
  • Thrombosis prophylaxis

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