Nephrectomy

Generality

Nephrectomy is the surgical operation of partial or total removal of one or both kidneys.

There are three types of nephrectomy: radical nephrectomy, partial nephrectomy and simple nephrectomy.

However, surgeons can also resort to the operation in question for a kidney transplant or in the presence of severe non-neoplastic kidney disease.

The operative modalities with which it is possible to carry out a nephrectomy are three: the "open-air" surgical procedure, the and the robot-assisted laparoscopic procedure.

At the end of the operation, hospitalization is foreseen, the duration of which depends on the type of intervention.

What is nephrectomy?

Nephrectomy is the partial or total removal of one or both kidneys.

When it is reserved for a single kidney, it takes the specific name of unilateral nephrectomy ; when instead it is reserved for both kidneys, it assumes the specific name of bilateral nephrectomy .

The word "nephrectomy" derives from the union of two terms of Greek origin: nephrós ( νεϕρός ) - which means "kidney" - and ectomy ( ἐκτομή ) - which means "resection", "removal".

Please note : readers are reminded that the presence of a kidney alone does not prevent a human being from leading a normal and healthy life.

TYPES

There are three different types of nephrectomy:

• Radical (or complete ) nephrectomy : it is the surgery to remove a kidney and some structures associated with it, such as the ureter, the adrenal gland and the surrounding fatty tissues.
• Partial nephrectomy : it is the surgical procedure of removal of a section of a kidney and of tissues adjacent to the removed section.
• Simple nephrectomy : it is the surgical operation to remove a kidney, saving the adrenal and other adjacent structures.

Obviously, all three types of nephrectomy can be unilateral or bilateral, depending on the needs.

uses

The conditions that require the intervention of nephrectomy are:

• The presence of kidney cancer;
• The presence of a non-neoplastic kidney disease, such that one or both kidneys are severely damaged;
• Donation of a kidney.

KIDNEY CANCER

Kidney cancer is the main reason for nephrectomy interventions.

The decision regarding the type of nephrectomy to be taken lies with the operating surgeon and depends on various parameters, including: staging the neoplasm, the patient's state of health and the position of the tumor mass.

NEFRECTOMY FOR THE PURPOSE OF DONATION

Nephrectomy for the purpose of donation is the surgical practice useful for living donor kidney transplants .

From an efficacy point of view, living donor kidney transplantation provides much better results than dead donor kidney transplantation.

An individual is a good candidate to donate one of his kidneys, when he has good kidney function, he does not suffer from hypertension and / or diabetes and does not have a family history of these two conditions just mentioned.

Preparation

A few days before the nephrectomy, the patient must undergo a series of medical checks - the so - called pre-operative examinations - and meet with the surgeon who will carry out the operation, to be informed of the characteristics and implications of the operation.

Some topics of discussion of the surgeon-patient meeting:

• Duration of the intervention;
• Allergies to drugs that could be used during or after the operation;
• Drugs taken by the patient for the treatment of other morbid conditions;
• Pharmacological therapies that it is good to interrupt in view of the nephrectomy (eg: anticoagulants, antiplatelet agents, NSAIDs etc.);
• Duration of admission;
• Characteristics of pre-operative fasting.

Procedure

Surgeons have the opportunity to perform the nephrectomy operation in at least three different ways:

• Through an "open-air" intervention → "open-air" nephrectomy .
• Through a laparoscopy operation → laparoscopic nephrectomy .
• Through a robotic laparoscopy operation → robot-assisted laparoscopic nephrectomy .

Shortly before the nephrectomy procedure begins, an anesthesiologist has the task of practicing general patient anesthesia ; subjected to general anesthesia, the latter falls asleep and remains unconscious for the entire duration of the operation.

NEFRECTOMIA "IN THE OPEN SKY"

"Open sky" nephrectomy involves making an incision of several centimeters on the abdomen or on the side where the kidney to be removed resides. Generally, the correct position is just below the rib cage.

This incision represents the opening through which the operating surgeon reaches and extracts the diseased or donated kidney to a recipient.

In most cases, in order to perform the organ extraction smoothly, it is essential to remove the last rib (obviously from the part where the kidney to be taken takes place).

Once the extraction is completed, the surgeon closes the incision through some stitches.

LAPAROSCOPIC NEFRECTOMY

Laparoscopy is a minimally invasive surgical technique, thanks to which surgeons can access an individual's abdominal cavity and pelvic cavity, through incisions that are decidedly smaller than those performed during traditional "open-air" surgery.

The most representative surgical instrument of laparoscopy is the so-called laparoscope . Similar to a drinking straw, the laparoscope is built to be inserted into the abdominal and pelvic cavities and to view the contents of the latter, thanks to a camera, a light and a connection with an external monitor.

Generally three in number, laparoscopic incisions allow the introduction not only of the laparoscope, but also of those surgical instruments necessary for the removal of an organ or part of it.

Compared to "open sky" nephrectomy, laparoscopic nephrectomy has the following advantages:

• Shorter recovery times;
• Shorter hospitalization;
• Smaller surgical incisions;
• Lower risk of post-operative complications.

ROBOT-ASSISTED LAPAROSCOPIC NEFRECTOMY

Robot-assisted laparoscopy nephrectomy is a laparoscopy nephrectomy, in which the operating surgeon uses a robotic instrument to perform kidney removal of interest.

This robotic instrument, which responds to the commands of a special console, is composed of an exploratory camera and a series of mechanical arms, which in effect replace the surgeon's hands.

Post-operative phase

At the end of the nephrectomy, hospitalization is always expected.

The duration of hospitalization varies depending on the type of nephrectomy and the mode of intervention: for laparoscopic nephrectomy operations, hospitalization may last one night; for "open" nephrectomy procedures, it can last up to 7 days.

During the hospitalization period, the medical staff applies a urinary catheter to the patient - for the expulsion of urine - and periodically monitors the vital parameters (pressure, heart rate, temperature, etc.).

For the discharge and above all the return home, it is good that the patient asks for the support of a relative or a close friend.

Risks and complications

Thanks to advances in surgical medicine, today's nephrectomy interventions are quite safe and low risk.

The most common complications are the classic ones of any major surgery procedure, namely:

• Infection development;
• Blood loss (bleeding) from incisions;
• "Post-operative pneumonia";
• Allergic reactions to anesthetics.

Among the less common complications, the reduced functionality of the remaining kidney deserves a mention (when, obviously, nephrectomy is unilateral).

DIALYSIS AND BILATERAL NEFRECTOMY

Patients undergoing bilateral nephrectomy require dialysis for the rest of their lives, just like those with severe renal insufficiency.

Results

The benefits of a nephrectomy depend on several factors, first of all the general state of health of the patient and the severity of the condition that required the intervention.

Regarding the most effective types of nephrectomy and at lower risk of complications, several studies have shown that partial nephrectomy is more associated with complete maintenance of renal function, compared to radical or simple nephrectomy (which, however, more often tend to precede a functional decline in the remaining kidney).

These studies are reliable, but it is important to remind the reader that some research has shown the exact opposite. Thus, the debate about the most effective type of nephrectomy is still widely open.