eMedicine Specialties > Urology > Surgery

Nephrectomy, Radical: Workup

Author: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Coauthor(s): Hosam S Al-Qudah, MD, Consultant Urologist, Department of General Surgery, Saad Specialist Hospital, Al-Khobar, Saudi Arabia
Contributor Information and Disclosures

Updated: Nov 24, 2009

Workup

Laboratory Studies

  • All patients should undergo a general and metastatic evaluation prior to considering radical nephrectomy. This includes urine analysis, complete blood cell count, kidney function tests, liver function tests, serum calcium assessment, and bleeding profile, as required.

Imaging Studies

  • For patients with bone pain or elevated serum alkaline phosphatase levels, a bone scan is also sometimes required, along with chest radiography and abdominal CT scanning.
  • If involvement of the inferior vena cava is suspected, MRI is performed to demonstrate the presence and the distal extent of inferior vena caval involvement.
  • CT scanning is an important part of the presurgical evaluation of the renal tumor. It yields good accuracy in evaluating the tumor size, location, and any invasion of renal collecting system or perirenal fat. The anatomy of the contralateral kidney is also evaluated. CT scan correctly reveals renal vein involvement in 82-95% of cases and vena caval involvement in 95-100% of cases. If the status of the veins is in doubt after CT scanning is performed, venography should be performed. Abdominal and pelvic CT scanning is performed with and without contrast unless the renal function is impaired or the patient has a contrast allergy. Chest CT scanning is performed for all cases in some centers. Other centers perform the study only when the chest radiography findings are abnormal or when the patient has respiratory symptoms.

  • CT finding of the patient in Image 1 that confirm...

    CT finding of the patient in Image 1 that confirms a huge right renal mass.

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    CT finding of the patient in Image 1 that confirm...

    CT finding of the patient in Image 1 that confirms a huge right renal mass.

  • Renal arteriography, although no longer routinely necessary before performing radical nephrectomy, is useful in showing arterialization of a tumor thrombus. However, arteriography may be supplanted by magnetic resonance angiography (MRA) and the even newer CT angiography techniques.
  • Transesophageal echocardiography can be used to assess vena caval tumor thrombi. It is accurate but invasive and costly and has no diagnostic advantage over MRI in the preoperative evaluation of these patients.5

Other Tests

  • A renal isotope scan is needed when the contralateral kidney appears smaller or is atrophied because this may change the management approach to partial nephrectomy in some patients.

Diagnostic Procedures

  • If a thrombus is present, preoperative embolization of the kidney often shrinks the thrombus, facilitating intraoperative removal. However, not all the centers embolize the kidney to shrink the thrombus. Perform embolization the day before or the same day of the surgery so that postembolization renal inflammation does not complicate the nephrectomy. Embolization may also be performed in some patients who are not fit enough for surgery and who have extensive bleeding. Recently, Subramanian et al (2009) reported on their 17-year experience with embolization. Of the patients in the report, 135 underwent embolization and 95 underwent surgery without embolization. They concluded that embolization does not provide any measurable benefit in reducing blood loss. Moreover, it was associated with increased major perioperative complications and mortality.6

More on Nephrectomy, Radical

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Workup: Nephrectomy, Radical
Treatment: Nephrectomy, Radical
Follow-up: Nephrectomy, Radical
Multimedia: Nephrectomy, Radical
References
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References

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Further Reading

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Keywords

radical nephrectomy, simple nephrectomy, kidney disease, kidney resection, radical kidney surgery, renal cell carcinoma, RCC, localized renal cell carcinoma, renovascular hypertension, renal artery disease, parenchymal damage, nephrosclerosis, pyelonephritis, reflux dysplasia, congenital dysplasia of the kidney, congenital kidney dysplasia, renal dysplasia, kidney dysplasia, renal lesion, simple nephrectomy, renal cyst, renal cancer, renal cell cancer, irreversible kidney damage, calculus disease, nephron-sparing surgery, NSS, partial nephrectomy, laparoscopic partial nephrectomy

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Contributor Information and Disclosures

Author

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Coauthor(s)

Hosam S Al-Qudah, MD, Consultant Urologist, Department of General Surgery, Saad Specialist Hospital, Al-Khobar, Saudi Arabia
Disclosure: Nothing to disclose.

Medical Editor

Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center; Professor and Vice Chairman, Department of Urology, New York Medical College
Michael Grasso, MD is a member of the following medical societies: American Medical Association, American Urological Association, California Medical Association, and Endourological Society
Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine
Martin I Resnick, MD † is a member of the following medical societies: American College of Surgeons, American Federation for Medical Research, American Institute of Ultrasound in Medicine, American Medical Association, American Society for Bone and Mineral Research, American Society for Reproductive Medicine, American Society of Andrology, American Surgical Association, American Urological Association, Association for Academic Surgery, Endocrine Society, National Kidney Foundation, Ohio Urological Society, and Pan American Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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