Radical nephrectomy is the standard operation for renal masses that are not amenable to nephron-sparing surgery. The principle is en bloc removal of the kidney with its surrounding perinephric fat inside Gerota's fascia, with early vascular control. It can be performed open, laparoscopically, or robotically — choice depends on tumour size and complexity, the presence of venous tumour thrombus, and the surgeon's experience.
Indications
- Renal masses where partial nephrectomy is not technically feasible (central or hilar tumours, complex anatomy, multiple tumours within one kidney that cannot be safely excised together).
- cT2 disease and selected cT3 disease.
- Renal vein or IVC tumour thrombus — the operation is combined with thrombectomy.
- Large tumours where the residual renal parenchyma after partial would be insufficient.
- Symptomatic or destroyed kidney where preservation offers no benefit (cytoreductive nephrectomy in selected metastatic disease).
Contraindications
Absolute
- Untreated coagulopathy.
- Untreated systemic infection or sepsis.
Relative
- Solitary kidney or significant baseline CKD — partial nephrectomy or ablation should be reconsidered.
- Bilateral synchronous disease — partial on at least one side is preferred.
- Severe cardiopulmonary disease precluding general anaesthesia or pneumoperitoneum.
- Prior extensive abdominal surgery — relative for transperitoneal approaches; retroperitoneal or open may be preferable.
Preoperative Workup
- Imaging: contrast-enhanced CT or MRI with dedicated renal mass protocol. Define tumour size, location, vascular anatomy, lymphadenopathy, and the upper extent of any venous tumour thrombus.
- Chest imaging: CT chest for staging.
- Bloods: CBC, renal function, LFTs, coagulation, group and screen (cross-match if tumour thrombus or large tumour).
- Cardiac assessment if IVC thrombus extends above the diaphragm (anaesthetic plan may include cardiopulmonary bypass).
- Preoperative renal-artery embolization is occasionally used for a large or locally advanced tumour to reduce blood loss, ease dissection (tissue-plane oedema), allow ligating the renal vein before the artery, and shrink an arterialised tumour thrombus; ~75% develop a self-limited post-infarction syndrome (flank pain, fever, nausea).
- Functional assessment: split renal function (DMSA or split GFR on CT) when residual function in the contralateral kidney is in question.
- Consent: discuss conversion, transfusion, bowel or vascular injury, splenic injury (left side), pneumothorax, prolonged ileus, postoperative AKI, and need for adrenalectomy.
Positioning
- Open flank approach: full lateral decubitus over the contralateral side, table flexed at the iliac crest. Operative side up. Axillary roll under the dependent axilla. Arms supported. Bony prominences padded.
- Open transperitoneal (anterior): supine, sometimes with a small bump under the ipsilateral flank.
- Laparoscopic / robotic transperitoneal: modified lateral decubitus, flank up, table flexed. Camera and working ports placed along the lateral abdomen, assistant port in the midline.
The table flex opens the space between the costal margin and the iliac crest and is one of the most under-appreciated aspects of patient setup.
Surgical Steps
The steps below describe the transperitoneal approach, which is the most commonly used; the principles are the same for retroperitoneal and open flank approaches.
- Establish access and pneumoperitoneum. For robotic / laparoscopic, place the camera port first, insufflate, then place the working and assistant ports under direct vision.
- Mobilise the colon medially by incising the white line of Toldt along the descending or ascending colon. On the right, take down the hepatic flexure. On the left, mobilise the splenic flexure and divide the splenorenal ligament so the spleen falls medially.
- Identify the ureter and gonadal vessels in the retroperitoneum. Use these as landmarks to lift the lower pole of the kidney anteriorly.
- Develop the plane between Gerota's fascia and the psoas muscle, working from inferior to superior.
- Dissect the renal hilum. Identify the renal vein first (more anterior). On the left, divide the lumbar, gonadal, and adrenal vein tributaries to reach the renal artery posterior to the vein.
- Ligate the renal artery first, then the renal vein. Polymer clips and an endoscopic vascular stapler are standard; large vessels may require a stapler with vascular load. Always confirm both vessels are isolated and pulseless before division.
- Mobilise the upper pole off the diaphragm and posterior body wall. Decide on adrenal sparing — preserve the adrenal unless the tumour is at the upper pole with imaging suggesting adrenal involvement.
- Divide the ureter low (close to the pelvic brim) and complete the specimen mobilisation within Gerota's fascia.
- Specimen retrieval: place the specimen in a retrieval bag. For laparoscopic / robotic, extend a port site or perform a low Pfannenstiel for intact extraction (mandatory if a tissue diagnosis from intact specimen is needed). Morcellation is not acceptable for malignant tissue.
- Inspect haemostasis at the renal bed, hilum, and along the entire dissection. Look at the adrenal bed, the spleen (left side), the duodenum (right side), and the bowel mesentery.
- Close: fascia under direct vision, skin per standard.
IVC Tumour Thrombectomy
A renal-vein or IVC tumour thrombus (graded by the Mayo level system) is resected en bloc with the kidney, and the level dictates the vascular control required. Start heparin once a thrombus is detected, and use transoesophageal echocardiography for level II–IV thrombi (risk of intraoperative detachment). Involve vascular surgery for level II–III and cardiothoracic surgery for level III–IV; preoperative angioembolization can shrink a large thrombus.
| Level | Cranial extent | Vascular control |
|---|---|---|
| 0 | Confined to the renal vein | Radical nephrectomy alone |
| I | ≤2 cm above the renal-vein ostium | IVC milking, partial occlusion (Satinsky clamp), ostial cavotomy |
| II | Below the hepatic veins | Full IVC mobilisation with sequential clamping (caudal IVC → contralateral renal vein → cephalad IVC) and lumbar-vein control; infrahepatic cavotomy |
| III | Hepatic veins to diaphragm | Liver mobilisation and suprahepatic clamping, often with a Pringle manoeuvre (porta-hepatis clamp → total hepatic vascular occlusion), or veno-venous bypass |
| IV | Above the diaphragm (into the atrium) | Cardiopulmonary bypass with deep hypothermic circulatory arrest, right atriotomy |
When the thrombus invades the caval wall, resect the involved cava to negative margins (± grafting/reconstruction). Most level I thrombi are partially occlusive and non-adherent, needing little IVC dissection.
Key Anatomical Landmarks
- Gerota's fascia — the perinephric fascia that envelops the kidney, perinephric fat, and adrenal. The plane between Gerota's and the surrounding structures (psoas posteriorly, peritoneum anteriorly) is the dissection plane. En bloc resection inside Gerota's is the oncologic principle.
- Renal hilum — anterior to posterior: vein, artery, pelvis (mnemonic VAP). On the right, the renal vein is short and drains directly into the IVC. On the left, the renal vein is long, crosses anterior to the aorta, and receives the gonadal, adrenal, and lumbar veins. Left vein tributaries are the first traps for the trainee.
- Adrenal gland — sits superomedial to the upper pole. Right adrenal vein is short and drains directly into the IVC. Left adrenal vein drains into the left renal vein. Preserve the adrenal unless the tumour involves it.
- Duodenum — the second part lies anterior to the right kidney; kocherise to expose the IVC and right renal hilum.
- Pancreatic tail and spleen — lie anterior to the left upper pole. The splenorenal ligament must be taken down to safely mobilise the left kidney; the spleen is the most common collateral injury on the left.
- Lymphatic drainage — right kidney to paracaval and interaortocaval nodes; left kidney to para-aortic and preaortic nodes. Drives the field of any lymphadenectomy.
Complications
Intraoperative
- Vascular injury (renal vessels, IVC, aorta, lumbar veins).
- Adjacent organ injury — bowel, duodenum, pancreas, spleen (left), liver (right).
- Pleural injury and pneumothorax with upper-pole dissection.
- Diaphragmatic injury.
Early postoperative
- Haemorrhage (often from a hilar staple line or a missed lumbar vein).
- Pulmonary atelectasis and effusion, especially with subcostal incisions.
- Ileus.
- Acute kidney injury, particularly when contralateral function is impaired.
Late
- Incisional hernia, more common with flank incisions.
- Long-term CKD progression in patients with already-reduced contralateral function.
- Adrenal insufficiency is not expected after unilateral adrenalectomy if the contralateral adrenal is normal.
Postoperative Care
- Early extubation and standard postoperative monitoring on a surgical ward; ICU only for very large tumours, IVC thrombus, or significant intraoperative events.
- Pain control: regional or opioid-sparing regimens; ERAS pathways reduce length of stay.
- Early mobilisation from the evening of surgery.
- Diet advance as tolerated; ileus is usually short for laparoscopic / robotic cases.
- DVT prophylaxis with sequential compression devices and chemical prophylaxis per institutional protocol.
- Drain only if specifically indicated (urine leak risk, oozing); routine drains are not required.
- Monitor renal function and urine output; expect a transient creatinine rise.
- Histology review at the multidisciplinary meeting drives adjuvant treatment decisions.
Tips & Pitfalls
- Always isolate both vessels before dividing either. The most common avoidable disaster is dividing what was thought to be the artery and finding it was the vein, or hitting an aberrant lumbar branch.
- Watch the left adrenal and gonadal veins — they are the source of most "where is that bleeding coming from" moments on the left renal vein.
- Avoid traction on the spleen. Mobilise the splenic flexure and divide the splenorenal ligament early so the spleen rolls medially without you needing to retract it directly.
- Kocherise generously on the right — exposure of the IVC and right renal hilum is much safer with the duodenum reflected.
- For tumour thrombus, control the IVC above and below first. Lumbar veins draining into the IVC are easy to overlook and bleed briskly.
- Don't sacrifice the adrenal unless imaging or intraoperative findings justify it. Routine adrenalectomy adds morbidity without benefit.
- Specimen extraction site matters. A Pfannenstiel gives the best cosmesis and lowest hernia rate for large specimens; avoid extending a port site if you can avoid it.
- If you are not making progress within 30 minutes of a planned manoeuvre, change tactic. Persistence in the wrong plane causes injury.
Key Exam Points
- Indicated for large (>cT1b) or centrally located renal tumours not amenable to partial nephrectomy, or when partial is technically unsafe.
- Always isolate both renal vessels before dividing either — most common avoidable disaster is misidentifying artery vs vein.
- Left side: watch the adrenal vein (into renal vein), gonadal vein, and lumbar branches; right side: Kocherise generously to expose the IVC.
- Routine adrenalectomy is not indicated unless imaging or intraoperative findings suggest adrenal involvement.
- For tumour thrombus, control the IVC above and below before mobilising; lumbar veins bleed briskly when overlooked.
- Pfannenstiel extraction gives the best cosmesis and lowest hernia rate for large specimens.
- Routine drains are not required; place only if specifically indicated.
- Expect a transient creatinine rise postoperatively; monitor renal function.
- DVT prophylaxis with SCDs and chemical prophylaxis per institutional protocol.
- Histology review at the multidisciplinary meeting drives adjuvant treatment decisions.