129 - Nephrectomy

Summary

Nephrectomy is a common urologic procedure indicated for malignancy, certain benign conditions of the kidney, and renal transplantation. While simple, radical, partial, donor nephrectomy, and nephroureterectomy all have common surgical steps, they each have unique complications.

Simple nephrectomy is indicated for benign but not trivial conditions. Indications include non-functioning kidneys (causing pain from congenital obstruction or urolithiasis), renovascular disease causing uncontrollable hypertension, benign symptomatic tumors (angiomyolipomas), trauma, or infectious diseases (xanthogranulomatous pyelonephritis, chronic or emphysematous pyelonephritis, and tuberculosis). The kidney is removed within Gerota's fascia along with a small amount of ureter. Patients who undergo nephrectomy for inflammatory conditions can be some of the most difficult to manage due to their medical comorbidities.

Donor nephrectomy is a simple procedure in which a healthy kidney (typically the left kidney because of increased vein length) is removed and transplanted as an allograft in a controlled, scheduled situation. The donor patients are healthy and have had extensive preoperative evaluations. Transplant nephrectomy is a simple nephrectomy in which the renal allograft is removed, usually for rejection complications.

Radical nephrectomy involves the removal of all structures within Gerota's fascia, which includes the ipsilateral, adrenal, kidney, and perirenal tissue. Adrenal sparing radical nephrectomy, especially for lower pole tumors, has become commonplace because of the low incidence of ipsilateral adrenal invasion or metastases. Most renal tumors are found incidentally by advanced radiologic imaging or during hematuria screening. Approximately 95% of enhancing renal masses are malignant; therefore, needle biopsy or pathologic proof before surgery is not routinely performed.