A nephrectomy is a surgery most commonly used to remove a kidney that has developed cancer, or is otherwise severely damaged or diseased. Depending on the severity of the condition, a urologist will remove part (partial nephrectomy) or all (radical nephrectomy) of the kidney, as well as some surrounding tissues and blood vessels. But not all kidneys that are removed via a nephrectomy are diseased. There are instances in which a donor offers up their healthy kidney so that it can be transplanted into a person with a malfunctioning kidney. This is called a donor nephrectomy.
Nephrectomy Approaches and Types
A nephrectomy is a major surgery, and it requires general anesthesia to put the patient under. How the operation proceeds depends on the approach taken, as well as the amount of kidney removed.
Approach
Open Nephrectomy
During an open nephrectomy, a wide incision (about 10 to 20 inches long) is made on the front or side of the patient's abdomen, often between the lower ribs. This method requires a large enough incision for the doctor to reach in and expose the kidney, by moving muscle, fat and other tissues out of the way. The blood vessels that connect to the kidney are then clamped and tied off. The surgeon then removes the entire kidney (or a portion of it), as well as additional tissues depending on the type of nephrectomy being performed. Once that's complete, stitches are used to close the incision.
Laparoscopic Nephrectomy
With this approach, a long, thin tube with a light source and camera at its tip (laparoscope) is inserted through one of several cuts made in the abdomen, as are surgical instruments. The laparoscope, in particular, helps the surgeon know where to guide the surgical instruments which, once passed through the incisions, are used to isolate and dissect the affected kidney. Towards the end of the operation, a two to three inch incision is made on the abdomen below the belt line. The kidney is placed in a plastic sack and removed whole through this incision. A tube is left in the body to allow fluid buildup to drain. This tube is left in place for about the first day. The other incisions are sewn up, and the final stitches are placed when the drainage tube is removed. If the surgeon encounters a problem accessing the kidney during laparoscopic surgery, or if during exploration it is noted that the entire kidney is unhealthy, he may resort to an open nephrectomy.
Robot-Assisted Surgery
Like laparoscopic nephrectomy, several small incisions are made in the abdomen so that a laparoscope and surgical tools can be passed through to remove part or all of the diseased kidney. The difference, however, is that with robot-assisted surgery, robotic arms carry out the procedure as the surgeon controls the extremities from a nearby console.
Types
There are different types of nephrectomy for an unhealthy kidney, and they are based on the amount of cutting and tissue removed. They include:
- Partial Nephrectomy: Usually done when a patient has only one kidney or poor kidney function, the surgeon removes only a portion of the affected kidney.
- Simple Nephrectomy: When a kidney functions poorly because of an abnormality, large kidney stones, or a lack of blood supply, the surgeon removes the kidney, but the adrenal gland that rests on top of the kidney is left in place. Also, the ureter is tied off.
- Radical Nephrectomy: Often used to treat kidney cancer, the surgeon takes out the entire kidney, as well as its surrounding fat. The ureter and/or the adrenal gland may also be removed.
- Donor Nephrectomy: A healthy kidney and ureter are removed and implanted in a person with a malfunctioning kidney.
Nephrectomy Indications
A nephrectomy may be needed, if the patient has:
- Kidney cancer
- Tissue damage or recurrent infection due to a staghorn calculus, a type of urinary tract stone
- Large, painful cysts
- Chronic infection coupled with kidney scarring and loss of kidney function
- A kidney injury that has led to uncontrolled bleeding
- Conditions, such as pyonephrosis and hydronephrosis, which can cause the kidney(s) to lose function
Nephrectomy Risks and Complications
Surgery always carries the risks of bleeding, allergic reaction and infection, but infection can be minimized if antibiotics are administered prior to the surgery.
Although rare, complications can occur during a nephrectomy procedure. They include:
- Organ or tissue damage due to the instruments used
- Long-term bowel inactivity
- Incisional hernia, which can develop within one to five years post-surgery
- Post-operative pneumonia
- Death
- Blood clots
- Rejection of the donor kidney, if one is transplanted
- Kidney failure or loss of function in the remaining, healthy kidney
Nephrectomy Recovery
The patient will spend several hours being closely monitored in an intensive care unit after a nephrectomy, but will likely stay in the hospital for several days. A urinary catheter will be placed for the first day after surgery to drain the bladder. Fluids and pain medication are administered intravenously, as may the individual's diet. Most patients can start eating regular food by the day after the surgery.
On the day of the surgery, the nursing staff will get the patient out of bed to move around. This helps to prevent blood clots from forming in the legs.
Oxygen may be given during the initial 24 hours following surgery, and the doctor may instruct the patient to use some simple breathing exercises for the first few weeks after the operation. This will prevent respiratory infections from developing. The patient may also be fatigued for several weeks after surgery and find themself getting tired more easily than normal. With slow and steady recovery, however, this will go away.
Nephrectomy Post-Treatment Care
Patients will be given prescription pain medication for the first few days after they leave the hospital. Over-the-counter medicine should be adequate for pain management after that. Showers are acceptable once home, but tub baths are off limits for at least the first two weeks. The incision sites should be patted dry immediately after getting out of the shower.
Driving should also be avoided for the first two weeks after surgery, but walking is encouraged to help with the recovery. Heavy lifting and exercise should be avoided for at least six weeks. The patient's activity level should start to increase after the first few weeks, with most able to go back to work within one month.
Dietary changes may also need to be made. If so, the physician will likely recommend that the patient refrain from adding salt to foods and avoid a high-protein diet. Extra salt and protein will put too much pressure on the one remaining kidney. Follow up examinations should be attended to ensure progress is being made and that complications do not present.
References:
Minimally invasive surgery: laparoscopic nephrectomy. (2014). James Buchanan Brady Urological Institute.
Albala DM, Morey AF, Gomella LG, & Stein JP. (2011). Nephrectomy. Oxford American Handbook of Urology. Oxford University Press
Park S, Pearle MS, Cadeddu JA, & Lotan Y. (2007). Laparoscopic and open partial nephrectomy: cost comparison with analysis of individual parameters. J Endourol.
