- Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Nephrectomy has many indications, for both simple and radical approaches.
A simple nephrectomy is indicated in patients with irreversible kidney damage due to symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury. Simple nephrectomy is also indicated to treat renovascular hypertension due to noncorrectable renal artery disease or severe unilateral parenchymal damage caused by nephrosclerosis, pyelonephritis, reflux dysplasia, or congenital dysplasia of the kidney.
Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). In certain circumstances, radical nephrectomy is also indicated to treat locally advanced RCC and metastatic RCC.
With the advent and increasingly mainstream use of abdominal CT scanning and ultrasound imaging in recent years for various abdominal and, occasionally, chest complaints, incidental detection of RCC has increased in asymptomatic patients. Currently, more than 50% of RCC cases are detected incidentally. These tumors tend to be smaller and of lower stage, resulting in better survival rates, lower recurrence rates, and lower metastasis rates than RCC detected in symptomatic patients. Symptomatic RCC presents at a significantly higher stage and grade, and tumors are substantially more aggressive than incidentally discovered lesions, particularly at later stages.
History of the Procedure
See the list below:
1869: Gustav Simon performs the first planned nephrectomy for the treatment of ureterovaginal fistula.
1878: Kocher performs an anterior transperitoneal nephrectomy through a midline incision.
1881: Morris performs the first nephrolithotomy; he later defines the terms nephrolithiasis, nephrolithotomy, nephrectomy, and nephrotomy.
1884: Wells performs the first partial nephrectomy to remove a perirenal fibrolipoma.
1913: Berg uses a transverse abdominal incision for securing the renal pedicle to remove vena caval tumor thrombi through a cavotomy.
Early-to-mid 1900s: The retroperitoneal flank approach becomes preferred because of the lower incidence of peritonitis and other abdominal complications associated with the anterior approach.
1950s: The development of safe abdominal techniques leads to the revival of the anterior approach.
1963: Robson described radical nephrectomy and the improvement in survival with the procedure. 
1990: Clayman performs the first laparoscopic nephrectomy at Washington University.
Overall, the vast majority of incidentally discovered renal masses are cysts. Abdominal CT scanning reveals a simple renal cyst in 25% of patients older than 40 years. Others report the presence of renal cysts in more than 50% of men older than 50 years. When a patient presents with a renal mass in association with macroscopic hematuria, flank pain, or a palpable mass, the chance of the mass being renal cell cancer is approximately 50%. Other renal masses, specifically angiomyolipoma, renal pelvic tumors, and other benign lesions, all are relatively uncommon, accounting for approximately 5% of all renal masses among asymptomatic patients.
Several factors have been associated with increased risk of RCC.
Obesity and cigarette smoking are the most consistently established causal risk factors, accounting for more than 30% and 20% of renal cell cancers, respectively. 
Hypertension as an independent factor is associated with increased risk of RCC. 
Analgesic use was once considered to be a more significant etiology than recent reports have indicated. 
A family history of RCC is associated with a 2- to 3-fold increased risk of RCC. However, a familial predisposition is identified in less than 2% of RCC cases.  The identification of families with a predisposition to the development of renal neoplasms, including von Hippel-Lindau (VHL), hereditary papillary renal carcinoma (HPRC), Birt-Hogg-Dubé (BHD), and hereditary leiomyomatosis and renal cell cancer (HLRCC), has enabled the identification of the different genes for these cancers. 
Traditionally, RCC is diagnosed after any or all of the classic triad of symptoms, ie, flank pain, palpable mass, and hematuria, have been investigated (see image below). However, with the increased use of imaging techniques over the past 2 decades, up to 72% of RCC cases are identified incidentally after investigation for unrelated abdominal pain or other non-urologic symptoms.
Presenting symptoms may be related to bleeding in the tumor, resulting in stretching of the renal capsule and pain. Bleeding into the collecting system also causes pain due to clot formation and ureteral obstruction. Local invasion and clot extension into the vena cava is suspected in patients presenting with lower extremity edema, varicocele, dilated superficial abdominal veins, proteinuria, pulmonary embolism, a right atrial mass, or no function in the involved kidney.
Lack of early warning signs characterizes RCC, resulting in a high proportion (one third) of patients with metastases at diagnosis. These patients face a dismal prognosis; the 5-year survival rate is less than 10% and the average survival is only 6-12 months. Weight loss, fever, and night sweats may suggest metastasis.
Radical nephrectomy remains the procedure of choice for surgically resectable lesions. Relapse occurs in 20-30% of patients with completely resected RCC after radical nephrectomy. Radical nephrectomy is also indicated in patients with metastatic disease as part of immunotherapy or the new chemotherapy protocol as a palliative procedure in cases of intractable pain and bleeding. Many cases are now treated with new FDA-approved tyrosine kinase inhibitors as adjuvant therapy. In addition, several new medications are now in phase II and phase III trials for the management of metastatic renal cancer. Results so far have been promising in terms of improving survival and delaying progression.
Predictors of relapse include symptomatic disease, high Fuhrman grade of tumor, high pathological stage, microvascular invasion, and necrosis. In these patients, neither postnephrectomy radiation therapy nor adjuvant interferon-alpha administration delays relapse or increases overall survival rates compared with observation alone. Therefore, observation remains the standard of care following radical nephrectomy for renal cell cancer.
The kidneys are paired vital organs located on either side of the vertebral column and embedded in the intermediate stratum of retroperitoneal connective tissue. The perirenal fascia, also called the Gerota fascia, encloses both the kidneys and adrenal glands.
Renal malignancies tend to remain within this fascia and can be excised completely by removing the kidney and its surrounding fascia as a single entity. In most individuals, a single renal artery and vein enters the kidney medially through the renal hilum, but multiple renal arteries are not uncommon.
The renal artery arises from the lateral aspect of the aorta, just below the superior mesenteric artery, and passes behind the renal vein. The main renal artery then divides into 4-5 segmental vessels to supply the corresponding renal parenchyma. These segmental vessels are end arteries without collateral circulation; thus, any injury to the renal artery at any level results in infarction of the corresponding parenchyma.
Unlike the renal arteries, the renal parenchymal veins intercommunicate freely among the various renal segments. Usually, a single renal vein joins the inferior vena cava on its lateral aspect. Multiple renal arteries occur unilaterally in 23% of the population, whereas multiple renal veins are less common.
The right adrenal gland lies above the kidney posterolateral to the inferior vena cava. The inferior phrenic artery is the main blood supply, with additional branches from the aorta and renal artery. The venous drainage usually is through a common vein on the right, exiting the apex of the gland and entering the posterior surface of the inferior vena cava. This vein is short and fragile and is a common source of bleeding during right adrenalectomy. The left vein empties directly into the left renal vein approximately 3 cm from the inferior vena cava and often opposite to the gonadal vein. Not well-recognized is the left inferior phrenic vein, which typically communicates with the adrenal vein but then courses medially and can be injured during dissection of the medial edge of the gland.
The paired gonadal arteries arise from the anterolateral aorta at a level somewhat below the renal vessels. Occasionally, a gonadal artery arises from the ipsilateral renal artery or from the aorta above the level of the renal vessels. In their retroperitoneal course, the gonadal arteries pass anteriorly to the ureter on either side. Gonadal veins parallel the gonadal arteries in their inferior course but, superiorly, tend to be more lateral and closer to the ipsilateral ureter. The left gonadal vein usually enters the inferior aspect of the left renal vein perpendicularly. The right gonadal vein usually drains obliquely into the right lateral aspect of the inferior vena cava, below the level of the right adrenal vein.
Nephron-sparing surgery (NSS) has become a successful alternative treatment to radical nephrectomy for RCC when a functioning renal parenchyma must be preserved, such as in patients with (1) bilateral RCC; (2) RCC involving a solitary functioning kidney; (3) chronic renal insufficiency; or (4) unilateral RCC with a functioning opposite kidney at risk for future impairment from an intercurrent disease, such as calculus disease, renal artery stenosis, diabetes, hypertension, or nephrosclerosis. Novick played an important role in establishing NSS, proving its efficacy and safety, and describing the ideal technique.
Several studies have confirmed that NSS provides curative treatment that is as equally effective as radical nephrectomy in patients who have a single, small (< 4 cm in diameter), unilateral, localized RCC. NSS is also becoming increasingly recognized as effective treatment for small, select, incidentally discovered tumors, even when the contralateral kidney is normal. Recent reports suggest using NSS for tumors up to 7 cm in diameter, particularly for polar tumors that do not extend into the renal hilum.
The major disadvantage of NSS is the small risk (1-6%) of local tumor recurrence due to undetected microscopic multifocal RCC in the remnant of the operated kidney. Partial nephrectomy is also associated with a higher risk of bleeding and urine leak. Despite this higher complication rate, saving the normal nephrons in the kidney reduces the risk of impaired kidney function and its associated complications.
A study by Huang et al that described trends and outcomes in the management of small kidney cancers reported that the use of nephron-sparing surgery exceeds radical nephrectomy in patients who receive surgery.
Laparoscopic partial nephrectomy is a new modality that is increasingly used. It offers faster convalescence than open partial nephrectomy. However, it is associated with a higher rates of positive margins, major intraoperative complications, and urologic complication rates. Laparoscopic partial nephrectomy should be reserved for patients with small exophytic tumors and should be performed by a well-trained laparoscopic urologist.
Robson CJ. Radical nephrectomy for renal cell carcinoma. J Urol. 1963 Jan. 89:37-42. [Medline].
Lipworth L, Tarone RE, McLaughlin JK. The epidemiology of renal cell carcinoma. J Urol. 2006 Dec. 176(6 Pt 1):2353-8. [Medline].
Sudarshan S, Linehan WM. Genetic basis of cancer of the kidney. Semin Oncol. 2006 Oct. 33(5):544-51. [Medline].
Novick AC, Stewart BH, Straffon RA, Banowsky LH. Partial nephrectomy in the treatment of renal adenocarcinoma. J Urol. 1977 Dec. 118(6):932-6. [Medline].
Huang WC, Atoria CL, Bjurlin M, Pinheiro LC, Russo P, Lowrance WT, et al. Management of Small Kidney Cancers in the New Millennium: Contemporary Trends and Outcomes in a Population-Based Cohort. JAMA Surg. 2015 Jul. 150 (7):664-72. [Medline].
Glazer A, Novick AC. Preoperative transesophageal echocardiography for assessment of vena caval tumor thrombi: a comparative study with venacavography and magnetic resonance imaging. Urology. 1997 Jan. 49(1):32-4. [Medline].
Subramanian VS, Stephenson AJ, Goldfarb DA, Fergany AF, Novick AC, Krishnamurthi V. Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi. Urology. 2009 Jul. 74(1):154-9. [Medline].
Dechet CB, Sebo T, Farrow G, Blute ML, Engen DE, Zincke H. Prospective analysis of intraoperative frozen needle biopsy of solid renal masses in adults. J Urol. 1999 Oct. 162(4):1282-4; discussion 1284-5. [Medline].
Link RE, Bhayani SB, Allaf ME, et al. Exploring the learning curve, pathological outcomes and perioperative morbidity of laparoscopic partial nephrectomy performed for renal mass. J Urol. 2005 May. 173(5):1690-4. [Medline].
Antonelli A, Cozzoli A, Simeone C, et al. Surgical treatment of adrenal metastasis from renal cell carcinoma: a single-centre experience of 45 patients. BJU Int. 2006 Mar. 97(3):505-8. [Medline].
Yokoyama H, Tanaka M. Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: is ipsilateral adrenalectomy indispensable during radical nephrectomy?. BJU Int. 2005 Mar. 95(4):526-9. [Medline].
Bianchi M, Gandaglia G, Trinh QD, Hansen J, Becker A, Abdollah F, et al. A population-based competing-risks analysis of survival after nephrectomy for renal cell carcinoma. Urol Oncol. 2013 Sep 17. [Medline].
Golimbu M, Joshi P, Sperber A, Tessler A, Al-Askari S, Morales P. Renal cell carcinoma: survival and prognostic factors. Urology. 1986 Apr. 27(4):291-301. [Medline].
Oh JJ, Byun SS, Lee SE, Hong SK, Lee ES, Kim HH, et al. Partial nephrectomy versus radical nephrectomy for non-metastatic pathological T3a renal cell carcinoma: A multi-institutional comparative analysis. Int J Urol. 2013 Sep 30. [Medline].
Kim SP, Thompson RH, Boorjian SA, Weight CJ, Han LC, Murad MH, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis. J Urol. 2012 Jul. 188(1):51-7. [Medline].
Emara A, Kommu S, Hindley R, Barber N. Robotic Partial Nephrectomy versus Laparoscopic Guided Cryoablation for the Small Renal Mass: redefining the minimally invasive gold standard. BJU Int. 2013 May 23. [Medline].
Romao RL, Weber B, Gerstle JT, Grant R, Pippi Salle JL, Bägli DJ, et al. Comparison between laparoscopic and open radical nephrectomy for the treatment of primary renal tumors in children: single-center experience over a 5-year period. J Pediatr Urol. 2014 Jun. 10 (3):488-94. [Medline].
Hegarty NJ, Gill IS, Desai MM, Remer EM, O'Malley CM, Kaouk JH. Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation. Urology. 2006 Jul. 68(1 Suppl):7-13. [Medline].
Kaouk JH, Aron M, Rewcastle JC, Gill IS. Cryotherapy: clinical end points and their experimental foundations. Urology. 2006 Jul. 68(1 Suppl):38-44. [Medline].
Atwell TD, Farrell MA, Leibovich BC, Callstrom MR, Chow GK, Blute ML. Percutaneous renal cryoablation: experience treating 115 tumors. J Urol. 2008 Jun. 179(6):2136-40; discussion 2140-1. [Medline].
Clayman RV, Surya V, Miller RP, Reinke DB, Fraley EE. Pursuit of the renal mass. Is ultrasound enough?. Am J Med. 1984 Aug. 77(2):218-23. [Medline].
Cookson MS. Radical Nephrectomy. Graham Jr SD, Glenn JF, eds. Glenn's Urologic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1998. 61-72.
Cooney MM, Remick SC, Vogelzang NJ. Promising systemic therapy for renal cell carcinoma. Curr Treat Options Oncol. 2005 Sep. 6(5):357-65. [Medline].
Desai MM, Strzempkowski B, Matin SF, et al. Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. J Urol. 2005 Jan. 173(1):38-41. [Medline].
Finley DS, Beck S, Box G, Chu W, Deane L, Vajgrt DJ. Percutaneous and laparoscopic cryoablation of small renal masses. J Urol. 2008 Aug. 180(2):492-8; discussion 498. [Medline].
Flaherty KT, Fuchs CS, Colditz GA, et al. A prospective study of body mass index, hypertension, and smoking and the risk of renal cell carcinoma (United States). Cancer Causes Control. 2005 Nov. 16(9):1099-106. [Medline].
Gill IS, Clayman RV, McDougall EM. Advances in urological laparoscopy. J Urol. 1995 Oct. 154(4):1275-94. [Medline].
Gill IS, McClennan BL, Kerbl K, Carbone JM, Wick M, Clayman RV. Adrenal involvement from renal cell carcinoma: predictive value of computerized tomography. J Urol. 1994 Oct. 152(4):1082-5. [Medline].
Giuliani L, Giberti C, Martorana G, Rovida S. Radical extensive surgery for renal cell carcinoma: long-term results and prognostic factors. J Urol. 1990 Mar. 143(3):468-73; discussion 473-4. [Medline].
Harryman OA, Davenport K, Keoghane S, Keeley FX, Timoney AG. A comparative study of quality of life issues relating to open versus laparoscopic nephrectomy: a prospective pragmatic study. J Urol. 2009 Mar. 181(3):998-1003; discussion 1003. [Medline].
Hinman F. 1998. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 853-1056.
Ishikawa I, Honda R, Yamada Y, Kakuma T. Renal cell carcinoma detected by screening shows better patient survival than that detected following symptoms in dialysis patients. Ther Apher Dial. 2004 Dec. 8(6):468-73. [Medline].
Jacobsohn KM, Wood CG. Adjuvant therapy for renal cell carcinoma. Semin Oncol. 2006 Oct. 33(5):576-82. [Medline].
Jennings SB, Linehan WM. Renal, Perirenal, and Ureteral Neoplasms. Gillenwater JJ, Grayhack JT, Howards SS, Ducket JW. Adult and Pediatric Urology. 3rd ed. St. Louis: Mo: Mosby; 1996. 643-94.
Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. Walsh PC, Vaughan Jr D, Wein AJ, Retik AB, Zorab R. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998. Vol 1: 49-88.
Kjaer M, Frederiksen PL, Engelholm SA. Postoperative radiotherapy in stage II and III renal adenocarcinoma. A randomized trial by the Copenhagen Renal Cancer Study Group. Int J Radiat Oncol Biol Phys. 1987 May. 13(5):665-72. [Medline].
Luciani LG, Cestari R, Tallarigo C. Incidental renal cell carcinoma-age and stage characterization and clinical implications: study of 1092 patients (1982-1997). Urology. 2000 Jul. 56(1):58-62. [Medline].
Malaeb BS, Martin DJ, Littooy FN, et al. The utility of screening renal ultrasonography: identifying renal cell carcinoma in an elderly asymptomatic population. BJU Int. 2005 May. 95(7):977-81. [Medline].
McLaughlin JK, Lipworth L, Tarone RE. Epidemiologic aspects of renal cell carcinoma. Semin Oncol. 2006 Oct. 33(5):527-33. [Medline].
Mevorach RA, Segal AJ, Tersegno ME, Frank IN. Renal cell carcinoma: incidental diagnosis and natural history: review of 235 cases. Urology. 1992 Jun. 39(6):519-22. [Medline].
Novick AC. Partial nephrectomy for renal cell carcinoma. Urol Clin North Am. 1987 May. 14(2):419-33. [Medline].
Novick AC, Streem SB. Surgery of the kidney. Walsh PC, Vaughan Jr D, Wein AJ, Retik AB, Zorab R, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998. Vol 3: 2973-3051.
O'Malley RL, Godoy G, Kanofsky JA, Taneja SS. The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol. 2009 May. 181(5):2009-17. [Medline].
Ono Y, Hattori R, Gotoh M, Yoshino Y, Yoshikawa Y, Kamihira O. Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?. Curr Opin Urol. 2005 Mar. 15(2):75-8. [Medline].
Parmar S, Rademaker AW, Fung BB, Kozlowski JM, Kuzel TM. Implications of therapy choice on overall survival in metastatic renal cell carcinoma: a single institution experience. Med Oncol. 2005. 22(4):399-405. [Medline].
Peycelon M, Hupertan V, Comperat E, Renard-Penna R, Vaessen C, Conort P. Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol. 2009 Jan. 181(1):35-41. [Medline].
Pizzocaro G, Piva L, Costa A. Adjuvant interferon to radical nephrectomy in Robson's stage II and III renal cell cancer, a multicenter randomized study with some biological evaluations. Proc Am Soc Clin Oncol. 1997. 16:318A.
Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol. 1969 Mar. 101(3):297-301. [Medline].
Rodriguez A, Sexton WJ. Management of locally advanced renal cell carcinoma. Cancer Control. 2006 Jul. 13(3):199-210. [Medline].
Rodriguez R, Chan DY, Bishoff JT, et al. Renal ablative cryosurgery in selected patients with peripheral renal masses. Urology. 2000 Jan. 55(1):25-30. [Medline].
Simmons MN, Weight CJ, Gill IS. Laparoscopic radical versus partial nephrectomy for tumors >4 cm: intermediate-term oncologic and functional outcomes. Urology. 2009 May. 73(5):1077-82. [Medline].
Sorbellini M, Kattan MW, Snyder ME, et al. A postoperative prognostic nomogram predicting recurrence for patients with conventional clear cell renal cell carcinoma. J Urol. 2005 Jan. 173(1):48-51. [Medline].
Steinberg AP, Finelli A, Desai MM, et al. Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors. J Urol. 2004 Dec. 172(6 Pt 1):2172-6. [Medline].
Tosaka A, Ohya K, Yamada K, et al. Incidence and properties of renal masses and asymptomatic renal cell carcinoma detected by abdominal ultrasonography. J Urol. 1990 Nov. 144(5):1097-9. [Medline].
Tsui KH, Shvarts O, Smith RB, Figlin R, de Kernion JB, Belldegrun A. Renal cell carcinoma: prognostic significance of incidentally detected tumors. J Urol. 2000 Feb. 163(2):426-30. [Medline].
Varkarakis IM, Bhayani SB, Allaf ME, Inagaki T, Gonzalgo ML, Jarrett TW. Laparoscopic-assisted nephrectomy with inferior vena cava tumor thrombectomy: preliminary results. Urology. 2004 Nov. 64(5):925-9. [Medline].
Wagner JR, Walther MM, Linehan WM, White DE, Rosenberg SA, Yang JC. Interleukin-2 based immunotherapy for metastatic renal cell carcinoma with the kidney in place. J Urol. 1999 Jul. 162(1):43-5. [Medline].
Zeman RK, Cronan JJ, Rosenfield AT, Lynch JH, Jaffe MH, Clark LR. Renal cell carcinoma: dynamic thin-section CT assessment of vascular invasion and tumor vascularity. Radiology. 1988 May. 167(2):393-6. [Medline].