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🔪 NEPHRECTOMY — The Complete Master Guide

Easy Memory Hook: Think of nephrectomy types by HOW MUCH kidney is removed and WHY

• Radical = Remove ALL + surroundings (Cancer, aggressive)
• Simple = Remove ALL kidney only (Benign disease)
• Partial = Remove PART of kidney (Small tumors, save nephrons)
• Donor = Remove healthy kidney to GIVE to someone else

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🧠 THE BIG PICTURE — ONE-LINER EACH

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1️⃣ RADICAL NEPHRECTOMY

🎯 Definition

✅ Indications

• Renal cell carcinoma (RCC) — primary indication
• Large tumors (>7 cm, T2 stage)
• Tumor invading adrenal or perinephric fat
• Renal vein / IVC thrombus (extended radical)
• When partial nephrectomy is not feasible

🗂️ Types of Radical Nephrectomy

📐 Surgical Approaches

🔑 Key Clinical Points

• Gerota's fascia must be kept intact — do NOT breach it (prevents tumor spillage)
• Adrenal spared if imaging shows normal adrenal + upper pole tumor not involved
• Renal vein secured FIRST before artery (prevents renal engorgement)

  Actually: Artery ligated FIRST → then vein → prevents venous engorgement

• IVC thrombus levels (Neves classification):
  • Level I: Infrarenal IVC
  • Level II: Infrahepatic IVC
  • Level III: Retrohepatic IVC
  • Level IV: Supradiaphragmatic (requires cardiopulmonary bypass)
• Lymph node dissection is staging, not always therapeutic

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2️⃣ SIMPLE NEPHRECTOMY

🎯 Definition

✅ Indications (Benign — remember "CHPTR")

• Chronic pyelonephritis / xanthogranulomatous pyelonephritis
• Hydronephrosis (non-functioning kidney)
• Pyonephrosis
• Trauma (irreparable kidney)
• Renovascular hypertension (non-correctable stenosis)
• Also: Renal TB, polycystic kidney disease, calculus disease with destruction

🗂️ Types of Simple Nephrectomy

🔑 Key Clinical Points

• Subcapsular nephrectomy = capsule left behind; used when perirenal adhesions make dissection dangerous
• No need to remove adrenal gland or lymph nodes
• Gerota's fascia may be left — no oncologic concern
• Always confirm contralateral kidney function beforehand
• In xanthogranulomatous pyelonephritis: classic "bear paw" on CT; subcapsular approach preferred due to dense adhesions

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3️⃣ PARTIAL NEPHRECTOMY (Nephron-Sparing Surgery)

🎯 Definition

✅ Indications — Absolute vs Relative vs Elective

🗂️ Types of Partial Nephrectomy

🔑 Key Clinical Points — The "Trifecta" Goal

Trifecta of Partial Nephrectomy:

1. Negative surgical margins (no tumor at cut edge)
2. No urologic complications (urine leak, fistula)
3. Preserved renal function (warm ischemia <25 min)

• Warm ischemia time (WIT): Keep <25 minutes — prolonged WIT = nephron loss
• Cold ischemia: Ice slush used in open surgery if WIT expected >30 min
• RENAL nephrometry score guides complexity:
  • R = Radius (size)
  • E = Exophytic/endophytic
  • N = Nearness to collecting system
  • A = Anterior/posterior
  • L = Location (polar line)
• Renorrhaphy (closing the kidney) — use bolster sutures
• Urine leak is the most common complication (1–7%)
• Robotic partial nephrectomy = CT angiography beforehand for vascular mapping (as shown below)

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4️⃣ DONOR NEPHRECTOMY

🎯 Definition

✅ Indications

• Living related donor (LRD) — blood relative
• Living unrelated donor (LURD) — emotionally related (spouse, friend)
• Altruistic/anonymous donor

🗂️ Types of Donor Nephrectomy

🔑 Key Clinical Points (per Living Kidney Donors Guidelines, p.90)

• LEFT kidney preferred over right — longer renal vein = easier anastomosis for recipient
• Right kidney taken if: vascular anomaly on left, fibromuscular dysplasia, left is smaller
• Renal artery must be transfixed by suture ligature or anchor staple — NOT with nontransfixing clips (Weck Hem-o-lok clips are CONTRAINDICATED for renal artery)
• CT angiography mandatory before any donor nephrectomy (anatomy assessment)
• 3+ renal arteries → only experienced surgeon should operate
• Contraindications to donation:
  • Atherosclerotic disease of both renal artery orifices
  • Fibromuscular dysplasia of both renal arteries
  • Uncontrolled hypertension, DM, obesity
  • Solitary kidney
• Warm ischemia time must be minimized — kidney packed in cold preservative solution immediately
• Cold ischemia time for transplant ideally <24 hours

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🗃️ MASTER COMPARISON TABLE

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🔑 SURGICAL APPROACHES — ALL NEPHRECTOMIES

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⚡ HIGH-YIELD CLINICAL PEARLS (Exam Favorites)

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🧠 MEMORY AIDS

• Remove everything en bloc
• Adrenal included (usually)
• Diagnosis = RCC
• IVC thrombus managed by levels
• Cancer indication
• Artery first, then vein
• Lymph nodes for staging

• Solitary kidney = absolute indication
• Preserve >25% function
• Arteries mapped pre-op (CT angiography)
• RENAL score guides approach
• Exposed warm ischemia <25 min

• Left kidney preferred
• Experience required for 3+ arteries
• Forbid Hem-o-lok clips on artery
• Transfixing suture for renal artery

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