Nephrectomy

What is it?

A nephrectomy is the surgical removal of a kidney, the organ that filters waste from the blood and produces urine. There are two kidneys, right and left. Each is about four to five inches long. They are located at the back of the abdomen, just below the diaphragm, behind the liver on the right and the spleen on the left. A portion of each kidney is protected by the lowest one or two ribs and by the muscles that cover the back and side of the body.

Depending on the reason for a nephrectomy, all or part of one kidney or both kidneys will be removed:

Partial nephrectomy: part of one kidney is removed
Simple nephrectomy: all of one kidney is removed
Radical nephrectomy: all of one kidney is removed, together with the neighboring adrenal gland (the adrenaline-producing gland that sits on top of the kidney) and neighboring lymph nodes
Bilateral nephrectomy: both kidneys are removed.

A nephrectomy can be done by conventional open surgery. For a simple nephrectomy, laparoscopic surgery is also available at a growing number of medical centers.

In a conventional open nephrectomy, the surgeon removes the kidney through a standard incision (surgical cut) between eight and 12 inches long. When possible, this incision is made in the side of the body to allow the surgeon access to the kidney while only minimally disturbing the abdominal organs. However, depending on the reason for the nephrectomy and the health of the patient, an incision may be made in the front of the abdomen or in the back.

In the laparoscopic procedure, four small incisions are made in the wall of the abdomen. The doctor uses a laparoscope (a rod-shaped instrument with a camera for viewing inside the body) to guide the surgical instruments and to free the kidney. If the kidney is being removed for donation, one incision must be enlarged to between 6 and 9 centimeters so that the kidney can be removed in one piece. Usually, this larger incision is next to the navel or, in women, along the bikini line in the lower abdomen.

Both conventional open nephrectomy and laparoscopic nephrectomy are done with the patient under general anesthesia, so that the patient is not awake during the procedure. Laparoscopic nephrectomy usually causes less pain during recovery than a conventional nephrectomy, and allows a quicker recovery and less obvious scarring. However, laparoscopic nephrectomy takes a longer time under anesthesia than an open nephrectomy, and requires a surgeon who is skilled in laparoscopy. A laparoscopic nephrectomy is not practical for people with significant scarring around the kidney or people who need a radical nephrectomy.

What it's used for

A nephrectomy may be used to remove a kidney for the following reasons:

The kidney has a cancer. This usually requires a radical nephrectomy.
The kidney has been damaged, and the damage causes recurring symptoms or problems (such as infection). Damage can be caused by infection, kidney stones, or cysts. Damage can also occur if urine builds up pressure due to a blockage somewhere in the urinary tract.
The patient has severe high blood pressure (hypertension) caused by renal artery stenosis. In this condition, a diseased artery results in damage to one kidney. Nephrectomy usually does not cure the high blood pressure in this illness, but it can make control of blood pressure more manageable.
Severe trauma, such as an automobile accident, has damaged the kidney beyond repair.
One person wishes to donate a kidney to another person.
A transplanted kidney has been rejected by the recipient's body and is not functioning. Surgery to remove this kidney is called an allograft nephrectomy, and is different surgically from removing the patient's own kidney.

Preparation

About one week before surgery, you will need to stop taking aspirin and other blood-thinning medications. Beginning at midnight on the night before surgery, you must not eat or drink anything. This reduces the risk of vomiting during surgery. As part of the general preparations for surgery, your doctor will review your allergies and medical and surgical histories. If you are a woman, and there is any chance that you might be pregnant, you must tell your doctor before surgery.

How it's done

The medical team inserts an intravenous (IV) line into one of your veins to deliver fluids and medications. You will receive general anesthesia.

Traditional surgical simple nephrectomy: When nephrectomy is done through an incision in your side, the procedure takes place on an angled operating table. You will lie on your side with your body bent sharply at the waist. This position stretches your side and it makes the kidney more accessible to the surgical team. The surgeon makes an angled incision through the skin and muscle of your side, either along the lower border of your ribs, or near your 11th or 12th rib. This incision typically extends from your spine, around your side, to the front of your abdomen. If necessary, a portion of one or two ribs will be removed to expose your kidney. Nearby organs are moved aside gently. The kidney's blood vessels and ureter are tied off and cut, and the kidney is lifted out of your body. The internal layers of the incision are closed with sutures; the upper layer of skin is closed with sutures or surgical staples. In some cases, a temporary drainage tube will be inserted to drain fluids from the wound. After surgery, you are moved to the recovery room, where you will be monitored for several hours until you are stable enough to return to your hospital room. After about 24 to 48 hours, the drainage tube is removed. You probably will remain in the hospital for five to seven days.
Radical nephrectomy: The procedure is similar to a simple nephrectomy, except that the incision often is made in the front of the abdomen, and it may even extend into the lower portion of the chest. Usually, this incision is larger than that for a simple nephrectomy, especially if the surgery is needed to remove a large tumor involving the upper portion of the kidney. In a radical nephrectomy, the neighboring lymph nodes and adrenal gland are removed together with the kidney.
Laparoscopic nephrectomy: A laparoscope and small surgical instruments are inserted into your abdomen through four small incisions (each incision is about 12 millimeters long). The surgeon uses a tiny camera on the laparoscope to guide the surgical instruments to detach your kidney from connecting blood vessels and your ureter. Toward the end of the procedure, one of the small incisions (usually one located just below the navel) is enlarged to allow the kidney to be lifted out of your body. Using surgical instruments, the surgeon maneuvers the edges of a soft sling underneath your kidney. By pulling on the edges of this sling, the surgeon can lift the kidney out through the incision. At the end of the procedure, the abdominal incisions are closed with sutures or surgical tape.

Follow-up

About one week after you return home from the hospital, you will visit your doctor for follow-up. At this visit, your doctor will check the healing of your incision and will tell you when you can resume your normal activities. For most people who have had conventional open surgery, full recovery takes about six weeks. When a surgeon does a laparoscopic nephrectomy, a person typically can return to work after about four weeks.

In most healthy people who have only one kidney removed, the remaining kidney can function well enough to handle the needs of the body. Life expectancy is normal. People who have both kidneys removed will need a kidney transplant or dialysis, a mechanical procedure that does the filtering work of the missing kidneys.

Risks

The risks of the procedures depend on the type of nephrectomy (simple, radical, bilateral, laparoscopic) and on the surgical approach (location of the incision). Some risks include:

injury to neighboring organs such as the intestines, liver, spleen, and pancreas
hemorrhage (bleeding), either inside the abdomen or from the surgical wound
an accidental cut or puncture into the chest cavity, causing a collapsed lung
a temporary decrease in lung function immediately after surgery
wound infection
temporary decrease in kidney function if only one kidney was removed
injury to nerves near the site of the incision
a hernia (bulge of bowel) causing a lump under the incision scar.