Radical Nephrectomy

Radical nephrectomy is the standard operation for renal masses 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 surgeon experience; a transperitoneal laparoscopic/robotic approach is now standard for most localized tumours, with open repair reserved for very large or locally advanced disease. The management context (staging, partial-vs-radical selection, adjuvant therapy) is covered in the Kidney Cancer topic, and nephron-sparing surgery on the Partial Nephrectomy page; this page is the operative reference.

Indications

• A high-complexity tumour in a patient with no CKD/proteinuria and a normal contralateral kidney (expected eGFR > 45) — radical nephrectomy is the standard for cT2 and most cT3 disease.
• Renal masses where partial nephrectomy is not technically feasible (central or hilar tumours, complex anatomy, multiple tumours in one kidney that cannot be safely excised together), or where the residual parenchyma after partial would be insufficient.
• Consider radical over partial when cold ischaemia would exceed ~45 minutes, < 20% functional nephron would remain, the tumour is highly complex, or there is lymph-node involvement.
• Renal vein or IVC tumour thrombus — combined with thrombectomy.
• A symptomatic or non-functioning 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 — reconsider partial nephrectomy or ablation.
• 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; a retroperitoneal or open approach may be preferable.

Preoperative Workup

• Imaging: contrast-enhanced CT or MRI with a dedicated renal-mass protocol — define tumour size, location, vascular anatomy, lymphadenopathy, and the upper extent of any venous tumour thrombus (MRI best defines the cranial extent and should be imaged close to surgery).
• Chest imaging (CT) for staging.
• Bloods: CBC, renal function, LFTs, coagulation, group and screen (cross-match for tumour thrombus or a large tumour).
• Cardiac assessment if IVC thrombus extends above the diaphragm (the 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, 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 when contralateral function is in question.
• Prophylaxis and prep: a cephalosporin within 1 hour of incision; no special bowel prep is needed for laparoscopic renal surgery; sequential compression devices for all, with heparin 5000 IU subcutaneously before surgery in high-DVT-risk patients.
• Consent: conversion to open, transfusion, bowel/vascular/splenic injury (left), pneumothorax, prolonged ileus, postoperative AKI, and possible adrenalectomy.

Choosing the Approach

• Transperitoneal laparoscopic/robotic is the standard minimally invasive route — a large working space and familiar landmarks; accepted for T1–T3a tumours, even very large (> 20 cm) masses in experienced hands.
• Retroperitoneal laparoscopic suits prior transabdominal surgery or an infected kidney, but offers a smaller working space and fewer landmarks (mostly used for simple nephrectomy).
• Open is chosen for very large or locally advanced tumours, extensive lymphadenopathy, or IVC thrombus needing wide vascular access.

The open incision is selected for the pathology:

Incision	Best for	Notes
Midline transperitoneal	Trauma, IVC thrombus, bilateral disease, horseshoe kidney	Fast and familiar with early vascular control; limited renal exposure (the hilum sits high in the wound)
Anterior subcostal	Radical nephrectomy, smaller tumours	Extraperitoneal on the left, transperitoneal on the right; extends to a chevron or flank if exposure is inadequate
Chevron (bilateral subcostal)	Bilateral tumours or nephrectomies	Excellent bilateral upper-retroperitoneal exposure; a cephalad sternotomy extension (Mercedes) gives cardiac access
Modified thoracoabdominal (hockey-stick)	Radical nephrectomy + lymphadenectomy	Versatile and extraperitoneal; extends inferiorly to the pubis or laterally over the ribs
12th-rib supracostal (flank)	Large mass, IVC thrombus, retroperitoneal exposure	Excellent extraperitoneal access; risks pleural injury
Thoracoabdominal (9th rib; 7th–8th on the right)	Very large tumours, IVC thrombus above the hepatic veins	Opens the pleura (needs a chest tube); maximal upper exposure

Positioning

• Open flank: full lateral decubitus over the contralateral side, table flexed at the iliac crest, operative side up; axillary roll under the dependent axilla just above the nipple line; arms supported and bony prominences padded.
• Open anterior (transperitoneal): supine, table extended, ± a bump under the ipsilateral flank.
• Laparoscopic/robotic transperitoneal: a 70-degree semilateral decubitus with the iliac crest over the table break and the table flexed; the lower leg flexed 90°, an axillary roll caudal to the axilla, and the patient strapped to allow intraoperative table rotation. Place a urethral catheter and an orogastric tube to decompress the bladder and stomach (the latter helps the spleen fall medially on the left).

Table flex opens the space between the costal margin and iliac crest — one of the most under-appreciated parts of setup.

Open Radical Nephrectomy

Expose the retroperitoneum by mobilising the colon medially along the white line of Toldt, keeping the renal fascia intact for a complete, spillage-free resection. The dissection plane stays outside Gerota's fascia.

Right side (transperitoneal subcostal): incise the line of Toldt from the common iliac artery to the hepatic flexure and develop the anterior pararenal space; kocherise the duodenum (it is fragile — avoid electrocautery, use light bipolar if needed) to expose the IVC. Dissect the IVC to identify and loop the right renal vein, palpating it and the cava for tumour thrombus. The right renal artery lies deep and superior to the vein on the lateral IVC; if the hilum is encroached by tumour, control the artery in the interaortocaval space with a 2-0 silk ligature or large clip. Once the artery is ligated, the vein deflates and can be ligated (2-0 silk or a vascular staple load). Control lumbar veins with a 0-silk ligature on a right-angle clamp (not clips, which may displace or block a stapler). Protect the friable gonadal vein — its avulsion from the IVC is a common cause of nephrectomy haemorrhage. Beware the short right adrenal vein entering the IVC posterolaterally, high near the hepatic veins.

Left side (flank): develop the pararenal space and open the anterior renal fascia over the aorta to find the left renal vein; ligate its lumbar, adrenal, and gonadal tributaries with 3-0 silk (the lumbar branch is a common source of operative haemorrhage). The left renal artery arises from the lateral aorta deep to the vein — doubly ligate it with 2-0 silk; if the vein stays engorged after arterial control, suspect an accessory renal artery before dividing the vein.

Adrenal decision: preserve the ipsilateral adrenal unless imaging or exploration suggests involvement (CT has a 99.4% negative predictive value). Adrenal metastasis is uncommon overall (< 5%) but rises with stage and tumour location — highest with T4 disease (~45%) and upper-pole or diffuse tumours. If indicated, remove the gland en bloc within Gerota's fascia.

Laparoscopic / Robotic Radical Nephrectomy

Access and Ports

Establish pneumoperitoneum by the Veress (closed) or Hasson (open) technique. The Veress needle is placed 2 fingerbreadths superior and 2 fingerbreadths medial to the anterior superior iliac spine (at the linea semilunaris); confirm placement with the aspiration/saline-drop test, expecting an opening pressure < 10 mm Hg. Insufflate transiently to 15–20 mm Hg for trocar placement (no longer than 10 minutes), then drop to 12–15 mm Hg (or 10–12 mm Hg with valveless insufflation). A 10-mm, 30-degree lens is used. Typical ports: a camera trocar superior and lateral to the umbilicus (lateral to the rectus, avoiding the inferior epigastric vessels), a 12-mm lower-quadrant working trocar, an upper-quadrant working trocar ~1 cm below the costal margin, ± a 5-mm assistant port; for a right nephrectomy add a 5-mm subxiphoid port to retract the liver.

Colon Mobilisation and Hilar Dissection

Incise the white line of Toldt and reflect the colon medially, staying in the avascular areolar plane (the pale-yellow Gerota fat against the darker mesenteric fat) — best entered at the lower pole; deviation increases bleeding. On the left, divide the splenophrenic and splenorenal ligaments so the spleen, pancreatic tail, and colon fall medially; on the right, kocherise the duodenum off the IVC. Trace the gonadal vein (lateral to the gonadal, medial to the ureter, with the psoas as a landmark) to the renal vein. Dissect the renal vein circumferentially; the renal artery lies posterior to it (a vessel "anterior" to the left renal vein is usually the SMA, not the renal artery). On the left, secure the lumbar vein before the artery — torn, it retracts into the back muscles.

Vessel Ligation and Retrieval

Ligate the artery first, then the vein — at least five titanium clips (leaving ≥ 3 proximally) or a vascular stapler (never fired over clips); en bloc stapler division of the artery and vein together is also quick and safe once each is identified. Divide the upper-pole attachments, sparing or taking the adrenal as indicated (handle the adrenal minimally — it ruptures easily). Clip and divide the ureter, then entrap the specimen in a retrieval sack (Endo Catch / LapSac) and extract it intact through a Pfannenstiel, Gibson, or extended port-site incision. Morcellation is avoided for malignancy (it confounds staging). Drop the pneumoperitoneum to 5 mm Hg to check haemostasis (look for "rivulets" in pooled irrigant); close fascia for ≥ 10-mm and Hasson sites.

Retroperitoneal Approach

Access is a 2-cm incision off the 12th-rib tip; a balloon is inflated with 800 cc of air outside Gerota's fascia to create the space, then a 15-mm Hg pneumoretroperitoneum with a 30-degree lens. The psoas and Gerota's fascia are the orienting landmarks; the renal artery is found on the medial psoas margin and taken first. Relative contraindications include recent open retroperitoneal surgery or an intense inflammatory process (e.g. xanthogranulomatous pyelonephritis).

IVC Tumour Thrombectomy

RCC is the commonest cause of a secondary IVC tumour thrombus in adults; distinguishing tumour thrombus from bland thrombus (on MRI/CT) is critical for planning, and 45–70% are cured by radical nephrectomy with thrombectomy — even level IV thrombi. The thrombus (graded by the Mayo level system) is resected en bloc with the kidney, and the level dictates the vascular control. Start heparin once a thrombus is detected, use transoesophageal echocardiography for level II–IV thrombi (intraoperative detachment risk), and 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, 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). Most level I thrombi are partially occlusive and non-adherent, needing little IVC dissection. By setting: N+ → radical nephrectomy + lymph-node dissection; T3 → nephrectomy + thrombectomy; T4 → en-bloc resection of involved adjacent organs if feasible; unresectable → embolisation / neoadjuvant therapy.

Lymphadenectomy

Landing zones are interaortocaval (right) and para-aortic (left). EORTC 30881 showed no survival benefit in cN0 disease (only 4% were pN+), so lymphadenectomy is not routine for cN0; it is recommended for cN+ (staging/prognosis) and considered with high-risk features (size > 10 cm, grade 3–4, sarcomatoid, necrosis, extrarenal extension, or thrombus).

Key Anatomical Landmarks

• Gerota's fascia — envelops the kidney, perinephric fat, and adrenal; its anterior and posterior laminae fuse laterally as the lateroconal fascia and then with the peritoneum as the white line of Toldt. En bloc resection inside Gerota's is the oncologic principle.
• Renal hilum — anterior to posterior: vein, artery, pelvis (mnemonic VAP). The right renal vein is short and drains directly into the IVC; the left is long, crosses anterior to the aorta, and receives the gonadal, adrenal, and lumbar veins — the left vein tributaries are the first traps for the trainee.
• Adrenal gland — superomedial to the upper pole. The right adrenal vein is short and drains into the IVC; the left drains into the left renal vein.
• Duodenum — its second part overlies the right hilum; kocherise to expose the IVC.
• Pancreatic tail and spleen — lie anterior to the left upper pole; the splenorenal ligament must be taken to mobilise the left kidney, and the spleen is the commonest collateral injury on the left.
• Pleura — its inferior limit lies between the 10th and 12th ribs, so a supracostal or thoracoabdominal flank incision risks pleural entry.
• Lymphatic drainage — right kidney to paracaval/interaortocaval nodes; left to para-aortic/preaortic nodes.

Complications

Intraoperative

• Vascular injury (renal vessels, IVC, aorta, lumbar veins) — for venous bleeding, compress, transiently raise the pneumoperitoneum to 20 mm Hg, add a port, and clip or suture.
• Adjacent-organ injury — bowel, duodenum, pancreas, spleen (left), liver (right).
• Pleural injury/pneumothorax with upper-pole or supracostal dissection; diaphragmatic injury.

Gastrointestinal and vascular pitfalls (open)

• The IMA and IMV can be safely ligated (the IMV is the landmark for the Cattell-Braasch maneuver); the SMV must not be sacrificed — ligation causes splanchnic (mesenteric) hypertension syndrome with bowel ischaemia, so do not close the abdomen primarily (compartment syndrome).
• SMA or celiac ligation is catastrophic (predominantly in left nephrectomy) — call vascular surgery and repair with 6-0 Prolene.
• Liver/spleen — argon-beam or electrocautery (60–90 W), fibrin glue, and Surgicel for minor injury; splenorrhaphy/splenectomy for serious splenic injury.
• Duodenum — drain a small intramural haematoma but do not resect apparently non-viable bowel; close lacerations and cover with an omental flap and drain.
• Pancreas — fibrin glue and a drain for superficial injury; distal pancreatectomy for a tail injury. Pancreatic fistula occurs in ~20–25% — give octreotide 100–300 µg subcutaneously every 8 hours for 10 days.

Laparoscopic-specific

• Rhabdomyolysis (flank/buttock pain or weakness) — risk rises with exaggerated flexion, male sex, obesity, kidney-rest use, and long operative time.
• Occult bowel injury presents atypically as trocar-site pain with leukopenia (often afebrile, no acute abdomen) — image promptly, as these patients deteriorate quickly.
• Shoulder-tip pain (diaphragmatic irritation from residual CO₂) and subcutaneous emphysema (usually self-limited).

Postoperative

• Haemorrhage (often a hilar staple line or a missed lumbar vein); atelectasis/effusion; ileus; AKI when contralateral function is impaired.
• Incisional hernia (more common with flank incisions); long-term CKD progression. Adrenal insufficiency is not expected after unilateral adrenalectomy with a normal contralateral gland.

Postoperative Care

• Early extubation and standard ward monitoring; ICU only for very large tumours, IVC thrombus, or significant intraoperative events.
• Pain: 15–30 mg of ketorolac (Toradol) IV every 6 hours for up to 36 hours if renal function allows, minimising narcotics to avoid ileus; ERAS pathways shorten stay.
• Early mobilisation; clear liquids the evening of surgery, advancing to a normal diet after flatus.
• DVT prophylaxis with sequential compression devices and chemical prophylaxis until ambulatory.
• The urethral catheter is removed once the patient is mobile (usually POD 1); discharge is typically POD 2–3 for laparoscopic cases.
• Place a drain only if specifically indicated; routine drains are not required. Monitor renal function (expect a transient creatinine rise). Histology at the MDT drives adjuvant decisions.

Tips & Pitfalls

• Always isolate both vessels before dividing either. The classic avoidable disaster is dividing the vein thinking it is the artery, or hitting an aberrant lumbar branch — and seeing the "renal artery" before the renal vein on the left usually means you are on the SMA.
• Watch the left adrenal, gonadal, and lumbar veins — they cause most "where is that bleeding from" moments on the left renal vein.
• Avoid traction on the spleen — divide the splenorenal ligament early so it rolls medially.
• Kocherise generously on the right — IVC and right-hilar exposure is far safer with the duodenum reflected.
• For tumour thrombus, control the IVC above and below first; lumbar veins draining the cava are easy to overlook and bleed briskly.
• Preserve the gonadal vessels when feasible — dividing them causes transient orchalgia in ~5% of men.
• Don't sacrifice the adrenal unless imaging or operative findings justify it.
• Specimen extraction site matters — a Pfannenstiel gives the best cosmesis and lowest hernia rate; never morcellate malignant tissue.