Nephrectomy - radical, partial, and everything in between

Preoperative prep

Teeing up the patient

Consent

Robotic nephrectomy

Patient preparation

  1. Position patient in modified flank with iliac cret over break in bed (opens up abdominal space), lower leg bent and upper leg straight
  2. Secure patient at legs, hip, chest, and arms (usually use armboard), avoid pressure and excess tension on arms/legs
  3. Flex bed, test rotation to ensure no movement (minimize fall risk)
  4. Prep patient abdomen from costal margin + xiphoid down to pelvis

Port access

  1. With patient rotated towards side of surgery (makes abdomen horizontal), access abdomen with Verress needle and ensure adequate placement prior to insufflation
  2. Place 8mm port approximately 2-4 fingers lateral to umbilicus
  3. Rotate patient away from side of surgery, place further 8mm robot ports, usually 2 fingers superior to ASIS (4th arm), 2 fingers inferior to costal margin, and another port between the camera and ASIS port, along with assist port (12mm) and liver retractor if right sided surgery (3-5mm)
  4. Insert monopolar scissors (R hand), bipolar grasper (L hand), and graspers (4th arm)

Obtaining renal exposure

  1. Incise colonic attachments to drop colon medially, extend superiorly/inferiorly to obtain adequate access to renal hilum without colon being in the way
  2. Right side: identify duodenum and divide attachments to retract medially (Kocher maneuver), may need to incise attachments to liver and insert liver retractor (kidney often very superior under liver)
  3. Left side: avoid injury to spleen and pancreas, may need to divide splenorenal attachments to retract spleen medially
  4. Injuries to avoid: diaphragm, colon (retraction/cautery), duodenum (cautery), spleen, pancreas
  5. Expose far enough medially without passing too far over great vessels (do not need to expose directly)
  6. Identify approximate inferior border of kidney (can usually compress kidney and see it move within Gerota fascia)
  7. Create window inferior to kidney, retracting gonadal vessels medially (avoids avulsion), identify and retract ureter laterally, then identify psoas muscle and create space with perirenal fat retracted laterally, keep fascia covering psoas
  8. Enlarge window superiorly, then place 4th arm within window for retraction/exposure, pull kidney towards anteromedial abdominal wall
  9. Dissect the window moving superiorly, using combination of pillar formation, careful cautery in layers, adjusting 4th arm traction, and avoiding injury to major vessels until hilum is identified

Radical nephrectomy

  1. Once renal vessels identified, can staple off together or separate (renal artery first), ensure adequate window for stapler to enter
  2. Avoid stapling SMA (have concern if "renal" artery identified prior to identifying renal vein)
  3. Do not clip renal vessels (higher risk for dislodgement and postoperative bleeding)
  4. Track superiorly, need to clip or bipolar larger vessels around adrenal to avoid bleeding (faster than cautery)
  5. Divide kidney from lateral and inferior attachments, can staple across ureter and lower pole attachments to save time
  6. Place specimen in bag and secure strings
  7. Examine hilum site, place hemostatic agents

Partial nephrectomy

  1. Divide Gerota fascia and provide direct renal exposure
  2. Once kidney exposed, use ultrasound probe to identify mass and demarcate on outside with cautery
  3. Clamp renal artery with bulldog, renal vein clamping is optional, selective renal artery clamping is optional, start timer, consider increasing pressure from 15 to 20
  4. Dissect out renal mass with enucleation or surrounding rim of normal tissue (combine sharp and gentle blunt dissection), place mass in specimen bag and secure strings
  5. Use V-loc to oversew the tumor base (start with stitch going through capsule, then end by bringing out of capsul)
  6. Flash the renal artery to assess degree of active bleeding, if minimal can remove clamp, can place extra V-loc as needed
  7. Place vicryl stitch through renal capsule on either side of resection site (enter capsule far from cut edge, exit parenchyma close to cut edge), place surgicel bolster (x2) underneath stitch within resection site, then place hemoloc clips on either end of suture and cinch down to secure, examine for hemostasis
  8. Close Gerota fascia over resection site
  9. Place drain in space created between kidney and psoas

Extraction and closure

  1. Remove instruments and undock robot
  2. Examine port removal with direct visualization (can close extraction site first then remove ports)
  3. Enlarge 4th arm incision to extract specimen, usually extend laterally to avoid epigastrics
  4. Close fascia (anterior +/- posterior) with PDS 1 (no loop), check repeatedly for intestinal injury and holes in fascial closure
  5. Do not need to close fascia on ports unless > 10mm at midline
  6. Can close deep space with 3-0 vicryl
  7. Close ports with 4-0 monocryl, secure drain with nylon stitch, cover with dermabond

Differences for nephroureterectomy

  1. Position in modified flank to also be able to reposition in trendelenberg later
  2. Place gemcitabine in bladder to kill any tumor cells that get spilled into bladder
  3. Initially place ports in similar way to nephrectomy
  4. Perform nephrectomy similar to normal (use ureter to track up to hilum)
  5. Once kidney is freed, can double clip ureter and cut in between (using cautery to prevent spillage) and place kidney in endocatch bag
  6. Beneficial to perform lymph node dissection - retroperitoneal if mainly renal pelvis vs pelvic for ureteral tumors
  7. Track ureter inferiorly, try to avoid gonadal vessel injury (can sacrifice if necessary)
  8. Once unable to track farther, undock robot and redock with patient in trendelenberg and place new port on contralateral side for better access
  9. Track ureter as far inferiorly as possible
  10. Drop ipsilateral anterior bladder to expose space of Retzius, clip and cut bladder pedicle to expose ureteral insertion into bladder
  11. Drain gemcitabine, then incise anterior bladder wall, inspect bladder to ensure that entire ureter with orifice is completely resected
  12. Close cystotomy with running 3-0 V-loc x2 layers, then leak test
  13. Place ureter in separate endocatch bag
  14. Extract both specimens from midline assist port

Open nephrectomy

Transperitoneal (for large tumors)

  1. Place patient supine, place over break to open up abdomen
  2. Make subcostal incision ~3cm inferior to costal margin on ipsilateral side, can extend past midline or superiorly at midline if needed
  3. Incise fascia with ligasure device
  4. Identify colon and have assistant retract superiorly, incise attachments to free colon from kidney, also free duodenum if on right side
  5. Place bookwalter retractor (may need to place on slight angle) and place 4-5 retractors to keep intestines out of field
  6. Use pediatric Yankauer suction to bluntly dissect and right-angle clamp with cautery to sharply dissect through tissue
  7. Start laterally, come inferiorly and staple or clip ureter, can then come superiorly and posteriorly to help with retraction
  8. Identify and isolate hilum, staple vessels separately or together depending on situation
  9. Assess hemostasis, use floseal and surgicel to improve hemostasis
  10. Close fascia with #1 PDS x2 (meet in middle), close anterior and posterior layers separately, then close subcutaneous with 3-0 vicryl and skin with monocryl or staples

Retroperitoneal

  1. Place patient supine, place over break to open up abdomen
  2. Make incision starting at tip of 11th rib and go medially approximately 5-8cm
  3. Incise layers, can incise muscle with ligasure device
  4. Identify periteoneum and retract medially to avoid entry
  5. Identify kidney and surrounding fascia
  6. Place small Bookwalter ring, retract peritoneum and underlying intestines (use moist lap) and abdominal wall
  7. Take down lateral attachments, then track inferiorly, can staple or clip ureter
  8. Retract kidney laterally to assess hilum, can staple vessels separately or together depending on size and angle
  9. Last, take down superior and posterior attachments to completely remove kidney
  10. Assess hemostasis, use floseal and surgicel to improve hemostasis
  11. Close fascia with #1 PDS x2, then close subcutaneous with 3-0 vicryl and skin with monocryl or staples

Postoperative management

Normal postoperative course

Partial nephrectomy postoperative bleeding