Radical Nephrectomy
CHAD R. RITCH
SAM S. CHANG
MICHAEL S. COOKSON
Renal cell carcinoma (RCC) is the most common malignancy of the kidney and accounts for about 5% of all adult neoplasms in men and 3% in women. The estimated number of new cases of RCC in the United States in 2012 was 65,150 with a projected 13,680 deaths, and this incidence is expected to continue to increase as a result of the expanded use of radiographic imaging coupled with the aging population (1).
There has been an increase in incidence of RCC and a concomitant decrease in renal mass size and stage at presentation, likely related to the increased use of imaging. This shift in epidemiology has encouraged the American Urological Association (AUA) to develop guidelines specifically addressing the management of the clinical stage I renal mass (2). As such, several treatment options exist for select patients with incidentally discovered renal masses. However, radical nephrectomy remains the mainstay for curative treatment in the majority of patients. In fact, a recent randomized controlled trial by the European Organization for Research and Treatment of Cancer (EORTC 30904) has brought into question the survival benefit of partial nephrectomy for tumors <5 cm as compared to radical nephrectomy (3). Although these findings need to be corroborated, radical nephrectomy remains a standard treatment for most renal tumors to which other options should be compared.
The role of open radical nephrectomy in the management of RCC has changed somewhat over the last decade. Pure laparoscopic, hand-assisted laparoscopic, and robotic radical nephrectomy have emerged as less invasive alternatives to open surgery in the management of low- to moderate-volume (8 to 10 cm or smaller), localized RCCs without local invasion, renal vein involvement, or lymphadenopathy.
However, this has placed an increased emphasis on the performance of open radical nephrectomy in a higher percentage of patients who have either comorbid illnesses or advanced tumors that preclude a minimally invasive approach. Furthermore, the beneficial impact of cytoreductive nephrectomy has increased the clinical situations in which open radical nephrectomy may be performed in the setting of metastatic disease (4).
This chapter focuses on the open surgical approach for radical nephrectomy.
DIAGNOSIS
Typically, RCCs are characterized on computerized tomography (CT) scan by a solid parenchyma mass with a heterogeneous density and enhancement with IV contrast injection (between 15 and 40 Hounsfield units). However, despite modern imaging, some benign tumors and complex cysts may be indistinguishable from cancer and confirmed only after surgical excision or biopsy. As such, the use of percutaneous biopsy has increased in the diagnosis and management of some renal masses and is now included in the AUA guideline (2). Prior concerns of poor accuracy and needle tract seeding have been dismissed by contemporary reports demonstrating low false-negative rates and almost no reports of seeding (2).
Clinical staging in patients suspected of RCC usually includes a contrast-enhanced CT scan of the abdomen, which may include CT angiography as well as three-dimensional reconstructions, and magnetic resonance imaging (MRI) is used on occasion, depending on the clinical scenario.
INDICATIONS FOR SURGERY
The indication for radical nephrectomy is a clinically localized solid renal mass in a patient with a normal contralateral kidney. Patients with solitary kidneys, renal insufficiency, or bilateral renal masses should be considered candidates for nephron-sparing surgery. Partial nephrectomy is acceptable for T1 lesions in the “elective” setting (2). However, for larger lesions, radical nephrectomy remains the treatment of choice. A thorough preoperative history and physical examination should be performed before the procedure. If significant comorbidities are suspected, preoperative consultation with the appropriate physician is recommended. In an elective radical nephrectomy, the patient should be expected to physically withstand the operation, have a reasonable overall performance status, and have a 5-year life expectancy.
Routine lymphadenectomy remains controversial during radical nephrectomy. In fact, the recommendation against the role of routine lymphadenectomy at the time of radical nephrectomy is supported by data from a prospective, randomized controlled trial (EORTC 30881), which found a low incidence of lymph node metastases and no survival advantage with complete lymph node dissection (5). This study has been criticized for a low number of men at risk for nodal metastases but nevertheless adds support to this argument, and currently, lymphadenectomy is offered to selected high-risk individuals.
Radical nephrectomy in combination with immunotherapy for metastatic RCC (i.e., cytoreductive nephrectomy) has been demonstrated to improve survival among patients with metastatic RCC over immunotherapy alone (4,6). The tyrosine kinase inhibitor (TKI) class of medications has surpassed immunotherapy as the standard systemic therapy for metastatic disease (7). However, the concept of cytoreductive nephrectomy is still applied in the setting of TKI treatment for metastatic RCC. Accordingly, radical nephrectomy is offered to patients with a resectable primary tumor in the setting of metastatic disease as an initial treatment
strategy prior to systemic therapy. Radical nephrectomy may also be performed for palliation, such as for patients with intractable pain or life-threatening hemorrhage who fail conservative treatment despite the presence of metastases. The role of radical nephrectomy among patients with a solitary metastatic site is controversial; however, modest 5-year survival rates have been reported in selected patients, with best results reported in patients with solitary pulmonary metastases (8).
strategy prior to systemic therapy. Radical nephrectomy may also be performed for palliation, such as for patients with intractable pain or life-threatening hemorrhage who fail conservative treatment despite the presence of metastases. The role of radical nephrectomy among patients with a solitary metastatic site is controversial; however, modest 5-year survival rates have been reported in selected patients, with best results reported in patients with solitary pulmonary metastases (8).
Although local extension of primary RCC into the perinephric fat, vena cava, or ipsilateral adrenal gland may portend a worse prognosis, in the absence of metastatic disease, these factors alone should not dissuade the surgeon from attempting a radical nephrectomy. Similarly, regional lymphadenopathy should not exclude a patient from undergoing a radical nephrectomy. In addition, radical nephrectomy has been successfully performed in the setting of direct extension of the tumor into adjacent organs such as the liver, colon, spleen, pancreas, or psoas muscle. However, surgical removal in this setting is technically difficult and is associated with a higher morbidity and a potentially poor prognosis. Therefore, it should be attempted only after careful preparation and in cooperation with appropriate surgical consultants.
ALTERNATIVE THERAPY
Surgery remains the only effective and potentially curative form of therapy for primary RCC. Along this line, the main challenge to radical nephrectomy in the near future appears to be from more conservative surgical approaches, including nephron-sparing surgery and minimally invasive approaches. Retrospective series of elective partial nephrectomy, enucleation, and wedge resection have demonstrated equivalence in terms of cancer control and may afford potential advantages in terms of preserved renal function and quality of life in properly selected patients (9,10,11). However, results from EORTC 30904 demonstrated that overall survival was higher in patients undergoing radical nephrectomy (3).
Radical nephrectomy is also being performed through laparoscopic approaches, including hand-assisted techniques, which again have shown equivalent cancer control and significant advantages in terms of reduced pain, shorter convalescence, and improvements in quality of life (12).
 FIGURE 3.1 Types of incisions during radical nephrectomy. |
Open radical nephrectomy continues to play an important role in the management of RCC, and it is essential that any surgeon who employs minimally invasive techniques be well versed in its performance.
SURGICAL TECHNIQUE
There are a variety of factors that influence the choice of incision during radical nephrectomy. These include location of the affected kidney, tumor size and characteristics, body habitus, and physician preference. There are advantages and disadvantages to each incision, and it is important to be familiar with several approaches to the kidney as no one incision is appropriate in all settings. The most commonly used incisions for radical nephrectomy are the flank, thoracoabdominal, and transabdominal (subcostal or chevron) (Fig. 3.1).
Flank Incision
The flank approach can be advantageous for several reasons. First, it allows direct access to the retroperitoneum and kidney, and the entire procedure can often be performed in an extrapleural and extraperitoneal fashion. In addition, the incision is anatomic in that it follows the track of the intercostal nerves with minimal risk of denervation. However, in large tumors, tumors involving the upper pole, or situations where vena cava access is critical, a flank approach is often suboptimal. Although a flank approach may be performed through a subcostal incision, an 11th- or 12th-rib incision is superior for exposure of the upper pole and ipsilateral adrenal gland during radical nephrectomy.
The patient is positioned in the lateral decubitus position with the upper chest at about a 45-degree angle. An axillary roll is placed under the patient to cushion against pressure on the brachial plexus, and the elbows are padded to prevent ulnar nerve injury. The upper arm is draped across the body and placed on a Mayo stand or padded support. The lower leg is flexed at 90 degrees, and the upper leg is extended over one or two pillows. The kidney rest is raised and the table is flexed to elevate the flank and adjusted to make the flank horizontal to the floor. A beanbag or inflatable mattress may be helpful, and if utilized can be activated to further support the patient.
The patient is then padded and secured with wide adhesive tape and safety straps.
The patient is then padded and secured with wide adhesive tape and safety straps.
An 11th- or 12th-rib incision is made based on several factors, including the kidney position, the cephalad extent of the tumor, and the patient’s body habitus. A general rule is to incise over the rib so that, when extended medially, the incision will be over the renal hilum. The incision is then made off of the tip or over the rib from the posterior axillary line to the tip and extended medially as far as necessary, usually stopping short of the lateral border of the rectus abdominis (Fig. 3.2). The latissimus dorsi is divided, and the upper portion of the incision is carried down to the rib or near its tip. The incision is usually created between the ribs in the intercostal space, and additional exposure may be obtained by incising the costovertebral ligament. With larger tumors and depending on patient body habitus, a partial rib resection may be accomplished as shown in Figure 3.3. An Alexander periosteal elevator is used to deflect the periosteum from the bone to avoid injury to the intercostal bundle located under the inferior portion of the rib. A Doyen elevator is then used to strip the periosteum from the entire undersurface of the rib to be resected. Next, a rib cutter is used to divide the proximal segment of the rib. The posterior layer of the periosteum is then incised carefully, and the pleura is protected superiorly.
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