A radical nephrectomy is the complete removal of a kidney. The surgeon may also remove the adrenal gland and neighboring lymph nodes. We typically reserve this option in situations where a partial nephrectomy is not feasible or in situations where it is not advised. Typically a radical nephrectomy is performed for larger tumors or those that are more advanced. Sometimes total kidney removal can be helpful in patients with cancer that has already spread (metastatic). We advise a thorough evaluation by a team of experts to determine whether this is the best option for you.
If I need a total nephrectomy, can I still have it done laparoscopically?
The vast majority of kidney removals we perform are done via a minimally invasive method (laparoscopically or robotically). In fact, Johns Hopkins urologists have been performing these techniques longer than most institutions. Several key studies documenting the safety and efficacy of laparoscopic nephrectomy came out of our institution. The kidney is disconnected from the body using a few tiny incisions. It is then placed in a sealed bag and extracted from the body.
Can laparoscopic or robotic nephrectomy be performed on all patients?
Initially these minimally invasive techniques were reserved for patients with relatively small tumors. However, Johns Hopkins urologists recently reported the results of laparoscopic nephrectomy for large tumors (>7 cm in size).* Favorable perioperative and oncologic results were reported. In this study if a case was started laparoscopically for these challenging larger tumors, 95 percent of the time it was completed without having to convert to the open approach. Of course not all patients and not all tumors are ideal for the laparoscopic approach.
While we have reported excellent outcomes in patients with tumors invading into the kidney vein treated laparoscopically, most patients with vein or vena cava invasion will require open surgery. Additionally for patients with tumors larger than 20 cm or multiple prior abdominal procedures there may not be adequate working space to perform the procedure safely. Ultimately a surgeon who is experienced in both approaches will help make the optimal decision with you.
Any laparoscopic procedure may be converted to an open approach and as such a surgeon experienced in both approaches will maximize your chances at the best outcome.
*(Pierorazio PM, Patel HD, Feng T, Yohannan J, Hyams ES, Allaf ME. Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve.Urology. 2011 Oct;78(4):813-9. Epub 2011 Jul 29. )
#( Guzzo TJ, Schaeffer EM, McNeil BK, Pollock RA, Pavlovich CP, Allaf ME. Laparoscopic radical nephrectomy for patients with pathologic T3b renal-cell carcinoma: the Johns Hopkins experience. J Endourol. 2009 Jan;23(1):63-7
How is an open nephrectomy performed?
This procedure involves making an incision to remove the kidney. The incision is typically made in the flank (between the 10th and 11th ribs) but other incisions can be used. A subcostal, midline, or thoracoabdominal incision are all alternatives to the flank. Your surgeon will select the most optimal incision depending on patient and tumor specific factors.
Are the lymph nodes routinely removed during a nephrectomy procedure?
No is the short answer. They are always inspected but not necessarily removed. In a randomized trial from Europe in 2009*, it was shown that removing the lymph nodes did not help with added survival. It does however add to the time of the operation and the risk of complications. It remains that there are some patients who may benefit from removal of the lymph nodes. This is a good discussion to have with your surgeon. If for example the cancer appears contained within the kidney and there are a few enlarged lymph nodes next to the kidney and no other disease seen on imaging, it is advisable to remove those lymph nodes.
The reason is that a significant proportion of these lymph nodes are found to harbor inflammation and NOT cancer. This information surely would reassure the patient and change the predicted outcome in this case.
*(Blom JH, van Poppel H, Maréchal JM, Jacqmin D, Schröder FH, de Prijck L, Sylvester R; EORTC Genitourinary Tract Cancer Group. Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol. 2009 Jan;55(1):28-34. Epub 2008 Oct 1.)