Partial Nephrectomy
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A nephrectomy is the surgical removal of a kidney, performed to treat a number of kidney diseases including kidney cancer. It is also done to remove a normal healthy kidney from a living or deceased donor, which is part of a kidney transplant procedure.


History

The first recorded nephrectomy was performed in 1861 by Erastus B. Wolcott in Wisconsin. The patient had had a large tumor and the operation was initially successful, but the patient died fifteen days later. The first planned nephrectomy was performed by the German surgeon
Gustav Simon Gustav Simon (2 August 1900– 18 December 1945) was a Nazi Party official who served as ''Gauleiter'' of Gau Moselland from 1931 to 1945 and, from 1940 until 1942, as Chief of Civil Administration in occupied Luxembourg. Early years Gustav S ...
on August 2, 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, including renal cell carcinoma, a non-functioning kidney (which may cause
high blood pressure Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
) 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 donor
kidney transplantation Kidney transplant or renal transplant is the organ transplant of a kidney into a patient with end-stage kidney disease (ESRD). Kidney transplant is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantati ...
. A nephroureterectomy is the removal of a kidney and the entire ureter and a small cuff of the bladder for
urothelial cancer Transitional cell carcinoma, also called urothelial carcinoma, is a type of cancer that typically occurs in the urinary system. It is the most common type of bladder cancer and cancer of the ureter, urethra, and urachus. It accounts for 95% of ...
of the kidney or ureter."Laparoscopic (keyhole) removal of the whole kidney and ureter: Information about your procedure from The British Association of Urological Surgeons (BAUS)
'' British Association of Urological Surgeons'', No. 17/063 (May 2017), pp. 1-8.


Procedure

The surgery is performed with the patient under general anesthesia. A kidney can be removed through an open incision or laparoscopically. For the open procedure, 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 laparoscopic approach utilizes three or four small (5–10 mm) cuts in the abdominal and flank area. The kidney is completely detached inside the body and then placed in a bag. One of the incisions is then expanded to remove the kidney for cancer operations. If the kidney is being removed for other causes, it can be morcellated and removed through the small incisions. Recently, this procedure is performed through a single incision in the patient's navel. This advanced technique is called single port laparoscopy. For some illnesses, there are alternatives today that do not require the extraction of a kidney. Such alternatives include renal embolization for those who are poor candidates for surgery, or partial nephrectomy if possible. Occasionally renal cell cancers can involve adjacent organs, including the IVC, the colon, the pancreas or the liver. If the cancer has not spread to distant sites, it may be safely and completely removed surgically via open or laparoscopic techniques.


Kidney donation

In January 2009, a woman who had previously had a
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...
was able to donate a kidney and have it removed through her vagina. The operation took place at
Johns Hopkins Medical Center The Johns Hopkins Hospital (JHH) is the teaching hospital and biomedical research facility of the Johns Hopkins School of Medicine, located in Baltimore, Maryland, U.S. It was founded in 1889 using money from a bequest of over $7 million (1873 m ...
. 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. This operation has also taken place at the Cleveland Clinic, which first performed transvaginal Nephrectomy. Living donation has a mortality risk of 0.03% during the procedure and seems to result in similar health outcomes to controls.


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 An electrolyte is a medium containing ions that is electrically conducting through the movement of those ions, but not conducting electrons. This includes most soluble salts, acids, and bases dissolved in a polar solvent, such as water. Upon dis ...
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. Patients who have had open surgery will have to stay in hospital longer than those who have had laparoscopic surgery. In long-term, a person with only one kidney ("solitary kidney") may be more prone to developing
chronic kidney disease Chronic kidney disease (CKD) is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years. Initially generally no symptoms are seen, but later symptoms may include leg swelling, feeling tired, vo ...
. A 2014 study suggested that lifelong risk of
chronic kidney disease Chronic kidney disease (CKD) is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years. Initially generally no symptoms are seen, but later symptoms may include leg swelling, feeling tired, vo ...
is several-fold higher in kidney donors, although the absolute risk is still very small. A 2017 article in the New England Journal of Medicine suggests that persons with only one kidney including those who have donated a kidney for transplantation or those whose kidney was removed for cancer, should avoid high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of
chronic kidney disease Chronic kidney disease (CKD) is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years. Initially generally no symptoms are seen, but later symptoms may include leg swelling, feeling tired, vo ...
.


Partial nephrectomy

Partial nephrectomy is the surgical removal of a kidney tumor along with a thin rim of normal kidney, with the two aims of curing the cancer and preserving as much normal kidney as possible.


History

Czerny first described a partial nephrectomy in 1890.Czerny HE (cited by Herczel E): Ueber nierenextirpation bietr. Klin Khirurg 1890;6:485. However, due to limited x-ray and imaging capabilities to find small kidney tumors and significant complications associated with early operations it was largely abandoned. More recently, with improved imaging, improved surgical techniques and increased kidney tumor detection, partial nephrectomy is performed more often.


Indications

A partial nephrectomy should be attempted when there is a kidney tumor in a solitary kidney, when there are kidney tumors in both kidneys, or when removing the entire kidney could result in kidney failure and the need for dialysis. Partial nephrectomy is also the standard of care for nearly all patients with small renal masses (<4 cm in size). Most renal masses between 4-7 centimeters can also be treated by partial nephrectomy if they are located in the proper position. Renal masses larger than 7 centimeters are generally treated with radical nephrectomy unless the tumor occurs in a solitary kidney, there are tumors on both sides or kidney function is bad. Patients who are told their tumors are too big or too hard for a partial nephrectomy may want to seek another opinion because surgeons who take care of many patients with kidney cancer are more often able to spare the kidney than those who only see a few cases.


Procedure

A partial nephrectomy is performed with a patient under general anesthesia as well. A partial nephrectomy can be performed through an open, laparoscopic or robotic approach. The patient is typically placed on the operating room bed lying on the side opposite the kidney tumor. The goal of the procedure is to remove the kidney tumor along with a thin rim of normal kidney tissue. Because the kidneys clean the blood, all blood eventually flows through the kidneys and 25% of it will go into the kidneys with each heart beat. In order to safely remove the kidney tumor, the blood flow to the kidney is often temporarily blocked off. The tumor is then cut out and the surgeon must sew the remaining kidney back together. Partial nephrectomy is often an alternative to complete, or radical, nephrectomy for renal cell cancer.


Complications

Patients who undergo partial nephrectomy experience complications around 15-25% of the time. The most common complications are bleeding, infection, and urinary leak.


Cancer control, quality of life, and survival

Partial nephrectomy offers the same chance of cure from the renal cell cancer as radical nephrectomy. This was confirmed in a recent meta-analysis. Partial nephrectomy has been shown to maintain kidney function better than total removal. There is some debate whether this preservation of kidney function leads to long-term benefits to the patient. Some studies have found that patients treated by partial nephrectomy live longer than patients who had their whole kidney removed. Other studies have found the opposite. Partial nephrectomy has been associated with better quality of life compared to radical nephrectomy.


See also

* Kidney donation * List of surgeries by type


References


External links


Drawings of the steps of the procedure



Explanation of the surgery, the risks and the recovery
{{Urologic surgical and other procedures Nephrology procedures Pediatric surgical procedures Surgical oncology Surgical removal procedures Urologic surgery