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Nephrectomy
Removal of the kidney

Each year approximately 30,000 new cases of kidney cancer are diagnosed and over 10,000 die of the disease.

Anatomy and Physiology

The kidneys are a pair of bean shaped reddish-brown organs that lie on either side of the spinal column and just below the diaphragm. They are about 5 inches (12.5 cm.) long and 3 inches (7.5 cm.) wide (Figure 1)

Figure 1. Anatomy of the kidney. The upper portion of the kidney is cut away to expose the cortex, calyxes and renal pelvis. The renal artery and ureter enter and the renal vein leaves the kidney at the hilus. The adrenal gland rests on the upper pole of the kidney. © N. Gordon
  • On the medial (facing the spine) border the kidney is notched at the hilus, the point where the major artery to the kidney enters and vein leaves
  • The ureter also leaves from the hilus
  • The kidney is made up of over a million renal tubules (nephrons). All the nephrons together form the cortex . The nephrons filter the blood of waste products that pass into the urine
  • The urine passes from the nephrons into collecting tubes called calyxes and then into the renal pelvis (the dilated upper portion of the ureter) and into the ureter, which conducts the urine into the urinary bladder
    1. The wall of the renal pelvis and ureter are composed three layers. The inner layer called the mucosa is lined with cells called transitional cells
    2. The middle layer is composed of muscle
    3. The outer layer is composed of fibrous tissue and is called the adventitia
  • Two kidneys are not necessary for survival. In fact, less than one kidney is all that is necessary
  • On the upper surface of each kidney lies the adrenal gland, a small pyramid shaped tissue that produces steroid hormones and adrenaline
  • A capsule of thin tissue encloses each kidney
  • The renal fascia (Gerota's fascia) is a membrane layer that encloses the kidney and adrenal gland. It is separated from the capsule of the kidney by the perinephric space, which contains fat

Pathology

  • The types of kidney tumors are
  • Cancer that arises from the tubules of the cortex of the kidney and has been called renal cell carcinoma (cancer), hypernephroma or clear cell carcinoma (Figure 2)
Figure 2 - large renal cell carcinoma of the right kidney that has spread into the surrounding tissues. Courtesy S. Sadiq
  • Urothelial (transitional cell) carcinoma that arises from the renal pelvis and upper ureter
  • Renal adenoma from the cortex of the kidney but less than one inch in size. Some physicians believe these tumors may be benign but most physicians regard renal adenomas as small cancers Kidney cancer at first spreads locally then may invade blood vessels and lymphatics (thin walled channels that contain a watery fluid called lymph that drains into surrounding lymph nodes)
  • Once the cancer enters blood vessels or lymphatics, it may metastasize (go to other places in the body). Common sites of metastases are lung, lymph node, bone, adrenal gland, opposite kidney, brain, heart, spleen, bowel and skin.
  • Spread by lymph channels is usually first to the lymph nodes about the involved kidney, then to the retroperitoneal nodes (behind the abdomen) and then upwards to the nodes in the mediastinum (the area between the lungs)

History and Physical Examination

  • Factors that may cause renal cell carcinoma are
    1. Smoking tobacco
    2. Inherited abnormal gene
    3. Multiple cysts in the kidneys
    4. Long term kidney dialysis
    5. Kidney tumors are more common in males than females
  • Factors that may cause urothelial tumors
    1. These tumors are 2-3 times more common in males than females
    2. Occurs more often in the older age groups
    3. Aromatic hydrocarbons - occupations at risk include dyestuff, rubber, chemicals, construction, metals, leather and paint
    4. Cigarette smoking
    5. Coffee drinking, saccharin and phenacetin abuse
  • Signs and symptoms
    1. Blood in the urine
    2. Low back pain
    3. Lump in the abdomen (belly) or flank
    4. Weight loss
    5. Fever of unknown cause
    6. Tiredness
    7. Abdominal pain and cramping
    8. Muscle aches
    9. High blood pressure
    10. Distended veins in the legs (occurs when the inferior vena cava is invaded)
    11. Ankle swelling (occurs when the inferior vena cava is invaded)

Testing

  • Laboratory tests
    1. Blood in the urine
    2. Anemia (low red blood cells)
    3. Increased calcium in the blood
    4. Abnormal liver function tests (elevated bilirubin, increased alkaline phosphatase and decreased prothrombin)
  • Intravenous Urography (also called Intravenous Pyelogram or IVP). An iodine containing X-ray 'dye' that is injected into a vein (intravenous contrast) is removed by the kidney. The dye accumulates in the calyxes, renal pelvis, ureter and urinary bladder and outlines any abnormality in these areas
  • Abdominal Ultrasound. The transducer (sound producer and receiver) is placed over the kidney and a picture of the kidney and any abnormality is produced on a monitor screen
  • Computerized Tomography (CT scan). The combination of an X-ray beam and computer produces a picture of the kidney and any tumor. It can readily tell the difference between a kidney tumor and a benign kidney cyst. Accuracy of determining between benign and malignant tumors is improved by giving intravenous contrast before the scan (Figure 2)
  • Magnetic Resonance Imaging (MRI). The combination of a large magnet, radiofrequency waves and computer produce a picture of the kidney and any tumor. It is the best non invasive method of demonstrating blood vessels in and about the kidney
  • Arteriography. A catheter is placed under X-ray (fluoroscopic) control in the renal artery and contrast dye injected to outline the vessels in the kidney. Ninety-five percent of kidney tumors have an increased number of blood vessels. Arteriography may help the urologist (urologic surgeon) in planning tumor removal
  • Percutaneous Biopsy. A needle is placed through the skin and directed into the tumor using the CT scanner. A small biopsy of the tumor is taken for examination
  • Cystoscopy/Ureteroscopy. A lighted tube with fiber optics is placed into the urinary bladder and the urologist looks into the bladder. If there is blood in the urine, the urologist can tell from which kidney the blood comes. A smaller lighter tube may then be placed into the ureters and a tumor in the renal pelvis seen and biopsied (small piece of tissue taken for microscopic analysis)

Tumor Staging and Treatment

After review of all the tests, tumor staging helps the surgeon determine the extent of the tumor and is important in selecting the best treatment.

  • Staging of renal cell carcinoma
    1. The most common staging classification is
    • Stage I Tumor confined to the kidney
    • Stage II Invasion of perinephric fat but confined to renal fascia
    • Stage III
        • A. Invasion of renal vein or vena cava (major vein to the heart)
        • B. Metastasis to regional lymph nodes
        • C. Invasion of renal vein or vena cava and regional lymph nodes
    • Stage IV
        • A. Invasion of adjacent organs other than the adrenal gland
        • B. Distant metastases

TNM Classification and staging. Another method of staging renal cell carcinoma is the TNM classification which depends on whether the tumor has spread locally, into lymph nodes or metastasized

  • T stands for the renal cell tumor itself noting how large and especially how deeply the tumor extends from its origin
    • TX The primary tumor cannot be assessed (unable to be seen on testing)
    • T0 No evidence of a primary tumor (tumor arising in the kidney)
    • T1 Tumor is less than one inch (2.5 cm.) and limited to the kidney
    • T2 Tumor is greater than one inch and limited to the kidney
    • T3 The tumor extends into the veins or invades the adrenal gland or perinephric space but not through the renal fascia
      • T3a Tumor invades the adrenal gland or perinephric space but not beyond the renal fascia
      • T3b The tumor can be seen invading the renal veins below the diaphragm
      • T3c Tumor invades the vena cava above the diaphragm
    • T4 Tumor invades beyond the renal fascia
  • N stands for nodes (regional lymph nodes that may be invaded by tumor)
    • NX Regional lymph nodes cannot be assessed
    • N0 No regional lymph node metastasis
    • N1 Metastasis in a single lymph node, 2 cm. or less
    • N2 Metastasis in a single lymph node, more than 2 cm. but less than 5 cm.; or multiple lymph nodes, none of which is more than 5 cm. (2 inches)
    • N3 Metastasis in a lymph node more than 5cm.
  • M stands for metastasis or the spread of the cancer to other parts of the body
    • MX Distant metastasis cannot be assessed
    • M0 No distant metastasis
    • M1 Distant metastasis

TNM Stages for determining therapy contains the following combinations of T, N and M.

Stage I T1, N0, M0
Stage II T2, N0, M0
Stage III T1, N1, M0
 T2, N1, M0
 T3a, N0, M0
 T3a, N1, M0
 T3b, N0, M0
 T3b, N1, M0
 T3c, N0, M0
 T3c, N1, M0
Stage IV T4, any N, M0
 any T, N2, M0
 any T, N3, M0
 any T, any N, M1
  • Staging of cancer of the renal pelvis and ureter
    • Stage I No invasion of tumor into the wall
    • Stage II Invasion through the mucosa
    • Stage III Invasion through the muscle layer or into kidney tissue but not through the adventitia of the renal pelvis or ureter or through the kidney capsule
    • Stage IV The tumor extends through the adventitia of the renal pelvis or ureter pr through the renal capsule with or without involvement of nearby organs or lymph nodes
  • Treatment based on Stage
    • Stage I
      • Nephrectomy (kidney removal) is the accepted therapy for Stage I renal cancer. Removal may be simple in which only the kidney is removed or radical in which removal includes removal of the kidney, adrenal gland, perinephric fat, and renal fascia with or without removal of the nearby lymph nodes
    • Stage II
      • Radical nephrectomy is the treatment of choice. A more radical removal of lymph nodes is frequently carried out but this has not been definitively proven to be of value. Radiation therapy has frequently been given along with nephrectomy, however, there is no definite evidence that this improves outcome
    • Stage III
      • Radical nephrectomy is the treatment of choice. A more radical removal of lymph nodes is frequently carried out but this has not been definitively proven to be of value. Surgery includes the renal vein and portion of the vena cava as necessary. Radiation therapy has frequently been given along with nephrectomy, however, there is no definite evidence that this improves outcome. Chemotherapy may also be used
    • Stage IV
      • These patients are rarely cured. Nephrectomy and radiation are helpful in reducing symptoms due to the tumor. Spontaneous improvement occasionally occurs. In certain patients removal of a single or just a few metastases can significant improve survival. This appears best when the patient has had a nephrectomy and a long period free of tumor between the nephrectomy and the development of the metastasis. Chemotherapy may also be beneficial

Surgical Procedure

  • Radical Nephrectomy. This is the removal of the whole kidney from outside of the renal fascia including the fatty tissue around the kidney, attached adrenal gland and lymph nodes. This is the most common surgery performed for cancer of the kidney
    1. The surgery is carried out through either a bilateral subcostal or thoracoabdominal incision (Figure 3A). Usually the subcostal incision is used. The thoracoabdominal incision is preferred when the tumor is large and at the upper pole of the kidney
    2. After opening the abdomen, the colon is moved to expose the kidney (Figure 3B)
    3. Removal of the kidney begins with control of the renal artery and vein by tying these vessels with suture (Figure 3C)
    4. The kidney is then dissected from the surrounding tissues from outside of the renal fascia
    5. The ureter is then tied off and divided to allow removal of the kidney and adrenal gland (Figure 3D)
    6. The lymph nodes are then removed from the diaphragm to where the aorta (main artery in the body) divides into the arteries to the legs (Figure 3E)
    7. After removal, the incision is closed suture

     

Figure 3A - Surgical removal of the right kidney. Position of the bilateral subcostal and thoracoabdominal incisionsFigure 3B - The colon is moved to expose the kidney. Note the position of the aorta, inferior vena cava and lymph nodes. © N. Gordon
Figure 3C - The renal blood vessels are dissected free and tied off and cut. © N. GordonFigure 3D - After the renal fascia and kidney are freed up, the ureter is tied off and cut to remove the kidney. © N. Gordon
Figure 3E - The lymph nodes are then removed from the level of the diaphragm to the end of the aorta. © N. Gordon
  • Partial Nephrectomy. This is removal of only a part of the kidney. This is used when removal of the entire kidney would result in the patient requiring dialysis. This may occur if both kidneys have tumor or if the other kidney is not functioning. This procedure may also be used if the tumor is small (less than 1.5 inches or 4 cm.) and clearly separated from the majority of the kidney
    1. The approach is similar to that for radical nephrectomy
    2. The renal artery is temporarily clamped to reduce bleeding
    3. The tumor is then removed with a margin of normal tissue
    4. The calyxes and renal pelvis that have been cut through are carefully closed with suture
    5. The cut end of the kidney is covered with fat, fascia or peritoneum (the thin lining of the abdominal cavity)
    6. The clamp on the renal artery is removed and all bleeding is controlled
    7. The incision is then closed

Complications

  • Complications following radical nephrectomy occur in approximately 20% of patients and about 2% of patients die.
  • Complications of any surgery such as heart attack, heart failure, stroke, pneumonia, blood clots in the legs and pulmonary embolism (blood clot to the lungs)
  • Injury to the stomach, small bowel or large bowel
  • Tears of the liver
  • Injury to the spleen
  • Injury to the pancreas with pancreatitis
  • Bowel obstruction may occur
  • Ileus (temporary loss of bowel function)
  • Hemorrhage which may be severe
  • Pneumothorax (puncture of the lung)
  • Infection
  • Temporary loss of renal function of the other kidney
  • Incisional hernia (see hernia)

Other Treatment

  • Chemotherapy involves the use of drugs that attack cancer cells. This may be in the kidney or in metastases. Usually injected into a vein the
  • Radiation therapy. High-energy radiation (X-ray) is directed at the tumor or to metastases. Kidney cancer is not very sensitive to radiation
  • Immunotherapy is sometimes used for treating metastases. This works by increasing the bodies own immune system that fights infection to fight the cancer cells. Interleukin-2 and interferon-alpha have been used with some success. Sometimes Immunotherapy may be combined with chemotherapy

Postoperative Care

  • Following nephrectomy the patient's output of urine is monitored to be sure it is adequate
  • Function of the kidney is monitored with blood and urine tests to determine if it is satisfactory. An intravenous pyelogram (IVP) may also be done to monitor function
  • If kidney function is impaired, an ultrasound of the kidney may be obtained instead of an IVP
  • After discharge, the patient may be re-examined for evidence of tumor recurrence. This is usually done at six month intervals for 4-5 years and every year thereafter
  • There is some information that suggests that patients with less than one kidney functioning are at greater risk for developing further damage to the kidney with an increase of protein in the urine