Nephrectomy is the surgical procedure of removing a kidney or section of a kidney.
Description
Nephrectomy may involve removing a small portion of the kidney or the entire organ and surrounding tissues. In partial nephrectomy, only the diseased or infected portion of the kidney is removed. Radical nephrectomy involves removing the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney. A simple nephrectomy performed for transplant purposes requires removal of the kidney and a section of the attached ureter. A similar procedure is used to harvest cadaver kidneys, although both kidneys are typically removed at once (bilateral nephrectomy) and blood and cell samples for tissue typing are also taken.
The nephrectomy patient is administered general anesthesia and the surgeon makes an incision on the side or front of the abdomen. Muscle, fat, and tissue are cut away to reveal the kidney. The blood vessels connecting the kidney to the circulation are cut and clamped. Depending on the type of nephrectomy procedure being performed, the ureter, adrenal gland, and/or surrounding tissue may also be cut. The vessels and the ureter in the patient are then tied off and the incision is sewn up (sutured). The surgical procedure can take up to three hours, depending on the type of nephrectomy being performed.
Laparoscopic nephrectomy is a form of minimally-invasive surgery that utilizes instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are maneuvered through four small incisions in the abdomen. Once the kidney is freed, it is secured in a bag and pulled through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than a traditional nephrectomy, preliminary studies have shown that it promotes a faster recovery time, shorter hospital stays, and less post-operative pain for kidney donors.
Who Performs the Procedure and Where Is It Performed?
If nephrectomy is required for the purpose of kidney donation, it will be performed by a transplant surgeon in one of over 200 UNOS-approved hospitals nationwide. For patients with renal cell carcinoma, nephrectomy surgery is typically performed in a hospital setting by a surgeon specializing in urologic oncology.
Questions to Ask the Doctor
How many procedures of this type have you performed, and what are your success rates?
Will my nephrectomy surgery be performed with a laparoscopic or an open technique?
Will my nephrectomy be partial or radical, and what are the risks involved with my particular surgery?
What will my recovery time be after the procedure?
What are the chances that the transplant will be successful? (For those undergoing a nephrectomy to donate a kidney.)
What are the odds of success, and will I require adjunctive treatment such as chemotherapy or immunotherapy? (For those undergoing a nephrectomy to treat kidney cancer.)
To remove a kidney in an open procedure, an incision is made below the ribcage (A). The kidney is exposed (B) and connections to blood vessels and the ureter are severed (C). The kidney is removed in one piece (D). (Illustration by GGS Inc.)
Definition
A nephrectomy is a surgical procedure for the removal of a kidney or section of a kidney.
Purpose
Nephrectomy, or kidney removal, is performed on patients with severe kidney damage from disease, injury, or congenital conditions. These include cancer of the kidney (renal cell carcinoma); polycystic kidney disease (a disease in which cysts, or sac-like structures, displace healthy kidney tissue); and serious kidney infections. It is also used to remove a healthy kidney from a donor for the purposes of kidney transplantation.
Demographics
The HCUP Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality (AHRQ) reports that 46,130 patients underwent partial or radical nephrectomy surgery for non-transplant-related indications in the United States in 2000. Patients with kidney cancer accounted for over half of those procedures. The American Cancer Society projects that an estimated 31,900 new cases of renal cell carcinoma will occur in the United States in 2003.
According to the United Network for Organ Sharing (UNOS), 5,974 people underwent nephrectomy to become living kidney donors in 2001. The majority of these donors—43.9%—were between the ages of 35 and 49, and 58.8% were female. Related donors were more common than non-related donors, with full siblings being the most common relationship between living donor and kidney recipients (28.5% of living donors).
Description
Nephrectomy may involve removing a small portion of the kidney or the entire organ and surrounding tissues. In partial nephrectomy, only the diseased or infected portion of the kidney is removed. Radical nephrectomy involves removing the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney. A simple nephrectomy performed for living donor transplant purposes requires removal of the kidney and a section of the attached ureter.
Open Nephrectomy
In a traditional, open nephrectomy, the kidney donor is administered general anesthesia and a 6–10 in (15.2–25.4 cm) incision through several layers of muscle is made on the side or front of the abdomen. The blood vessels connecting the kidney to the donor are cut and clamped, and the ureter is also cut between the bladder and kidney and clamped. Depending on the type of nephrectomy procedure being performed, the ureter, adrenal gland, and/or surrounding tissue may also be cut. The kidney is removed and the vessels and ureter are then tied off and the incision is sutured (sewn up). The surgical procedure can take up to three hours, depending on the type of nephrectomy being performed.
Laparoscopic Nephrectomy
Laparoscopic nephrectomy is a form of minimally invasive surgery that utilizes instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are maneuvered through four small incisions in the abdomen, and carbon dioxide is pumped into the abdominal cavity to inflate it and improve visualization of the kidney. Once the kidney is isolated, it is secured in a bag and pulled through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than a traditional nephrectomy, preliminary studies have shown that it promotes a faster recovery time, shorter hospital stays, and less post-operative pain.
A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may also be used to remove the kidney. In the hand-assisted surgery, a small incision of 3–5 in (7.6–12.7 cm) is made in the patient's abdomen. The incision allows the surgeon to place his hand in the abdominal cavity using a special surgical glove that also maintains a seal for the inflation of the abdominal cavity with carbon dioxide. This technique gives the surgeon the benefit of using his hands to feel the kidney and related structures. The kidney is then removed by hand through the incision instead of with a bag.
Diagnosis/Preparation
Prior to surgery, blood samples will be taken from the patient to type and crossmatch in case transfusion is required during surgery. A catheter will also be inserted into the patient's bladder. The surgical procedure will be described to the patient, along with the possible risks.
Aftercare
Nephrectomy patients may experience considerable discomfort in the area of the incision. Patients may also experience numbness, caused by severed nerves, near or on the incision. Pain relievers are administered following the surgical procedure and during the recovery period on an as-needed basis. Although deep breathing and coughing may be painful due to the proximity of the incision to the diaphragm, breathing exercises are encouraged to prevent pneumonia. Patients should not drive an automobile for a minimum of two weeks.
Risks
Possible complications of a nephrectomy procedure include infection, bleeding (hemorrhage), and post-operative pneumonia. There is also the risk of kidney failure in a patient with impaired function or disease in the remaining kidney.
Normal Results
Normal results of a nephrectomy are dependent on the purpose of the procedure and the type of nephrectomy performed. Immediately following the procedure, it is normal for patients to experience pain near the incision site, particularly when coughing or breathing deeply. Renal function of the patient is monitored carefully after surgery. If the remaining kidney is healthy, it will increase its functioning over time to compensate for the loss of the removed kidney.
Length of hospitalization depends on the type of nephrectomy procedure. Patients who have undergone a laparoscopic radical nephrectomy may be discharged two to four days after surgery. Traditional open nephrectomy patients are typically hospitalized for about a week. Recovery time will also vary, on average from three to six weeks.
Morbidity and Mortality Rates
Survival rates for living kidney donors undergoing nephrectomy are excellent; mortality rates are only 0.03%—or three deaths for every 10,000 donors. Many of the risks involved are the same as for any surgical procedure: risk of infection, hemorrhage, blood clot, or allergic reaction to anesthesia.
For patients undergoing nephrectomy as a treatment for renal cell carcinoma, survival rates depend on several factors, including the stage of the cancer and the patient's overall health history. According to the American Cancer Society, the five-year survival rate for patients with stage I renal cell carcinoma is 90–100%, while the five-year survival rate for stage II kidney cancer is 65–75%. Stage III and IV cancers have metastasized, or spread, beyond the kidney and have a lower survival rate, 40–70% for stage III and less than 10% for stage IV. Chemotherapy, radiation, and/or immunotherapy may also be required for these patients.
Alternatives
Because the kidney is responsible for filtering wastes and fluid from the bloodstream, kidney function is critical to life. Nephrectomy candidates diagnosed with serious kidney disease, cancer, or infection usually have few treatment choices aside from this procedure. However, if kidney function is lost in the remaining kidney, the patient will require chronic dialysis treatments or transplantation of a healthy kidney to sustain life.
Resources
Books
Cameron, J. S. Kidney Failure: The Facts. New York: Oxford University Press, 1999.
Parker, James and Philip Parker, eds. The 2002 Official PatientSourcebook on Renal Cell Cancer. San Diego: Icon Health Publications, 2002.
Periodicals
Johnson, Kate. "Laparoscopy is Big Hit With Living Donors." Family Practice News 31 (January 2001): 12.
National Kidney Foundation. 30 East 33rd St., Suite 1100, New York, NY 10016. (800) 622-9010. http://www.kidney.org.
United Network for Organ Sharing (UNOS). 700 North 4th St., Richmond, VA 23219. (888) 894-6361. UNOS Transplant Connection: http://www.transplantliving.org.
Surgical removal of a kidney. The procedure is indicated when chronic disease or severe injury produces irreparable damage to the renal cells. Tumors, multiple cysts and congenital anomalies may also necessitate removal of a kidney. A single healthy kidney can carry on the functions formerly performed by both kidneys.
The first successful nephrectomy was performed by the German surgeon Gustav Simon on August 2nd, 1869 in Heidelberg. Simon practiced the operation beforehand in animal experiments. He proved that one healthy kidney can be sufficient for urine excretion in humans.
Indications
There are various indications for this procedure, such as renal cell carcinoma, a non-functioning kidney (which may cause high blood pressure) and a congenitally small kidney (in which the kidney is swelling, causing it to press on nerves which can cause pain in unrelated areas such as the back). Nephrectomy for renal cell carcinoma is rapidly being modified to allow partial removal of the kidney. Nephrectomy is also performed for the purpose of living donorkidney transplantation.
Procedure
The surgery is performed with the patient under general anesthesia. The surgeon makes an incision in the side of the abdomen to reach the kidney. Depending on circumstances, the incision can also be made midline. The ureter and blood vessels are disconnected, and the kidney is then removed. The surgery can be done as open surgery, with one incision, or as a laparoscopic procedure, with three or four small cuts in the abdominal and flank area. Recently, this procedure is performed through a single incision in the patient's belly-button. This advanced technique is called as Single Port Access Surgery.
In January 2009, a woman who had previously had a hysterectomy was able to donate a kidney and have it removed through her vagina. The operation took place at Johns Hopkins Medical Center. This is the first time a healthy kidney has been removed via this method, though it has been done in the past for nephrectomies carried out due to pathology. Removing organs through orifices prevents some of the pain of an incision and the need for a cosmetically unappealing larger scar. Any advance which leads to a decrease in pain and scarring has the potential to boost donor numbers.[1] This operation also has taken place at the Cleveland Clinic.
For some illnesses, there are alternatives today that do not require the extraction of a kidney. Such alternatives include renal embolization[2] for those who are poor candidates for surgery, or partial nephrectomy if possible.
After Care
Pain medication is often given to the patient after the surgery because of pain at the site of the incision. An IV with fluids is administered. Electrolyte balance and fluids are carefully monitored, because these are the functions of the kidneys. It is possible that the remaining kidney does not take over all functionality. A patient has to stay in the hospital between 2 and 7 days depending on the procedure and complications.
