Resection Specimens

Simple nephrectomy, radical nephrectomy and partial nephrectomy. Laparoscopic nephrectomy is now feasible in experienced hands only.

Simple nephrectomy: is indicated in patients with an irreversibly damaged kidney because of symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury. It is also indicated to treat severe unilateral parenchymal damage from nephrosclerosis, pyelonephritis, reflux or congenital cystic dysplasia of the kidney.

Radical nephrectomy: is the treatment of choice for patients with renal cell carcinoma (RCC). Radical nephrectomy encompasses ligating the renal artery and vein, removing the kidney outside the Gerota's fascia, the ipsilateral adrenal gland, and performing a complete regional lymphadenectomy from the crus of the diaphragm to the aortic bifurcation. The surgical approach includes either a transperitoneal incision (extended or bilateral subcostal and tho-racoabdominal) or an extraperitoneal incision, depending on the size and location of the tumour and the patient's condition. The surgical approach is guided more by individual preference than by necessity.

Removal of the adrenal gland has been advocated because the gland is enclosed within Gerota's fascia and because ipsilateral adrenal metastasis occurs in 2-10% of most reported series. The risk of adrenal metastasis is related to the malignant potential of the primary tumour, its size and position. Patients with large tumours or tumours high in the upper pole probably are better served by a standard radical nephrectomy that includes adrenalectomy.

The role of regional lymphadenectomy in patients with localised kidney cancer is controversial. Because no widely effective treatments are available for metastatic RCC, regional lymphadenectomy may benefit a small number of patients. Extensive nodal involvement is associated with a poor prognosis.

Partial nephrectomy (nephron-sparing surgery (NSS)): recent advances in preoperative staging, specifically modern imaging techniques, and improvements in surgical techniques have made nephron-sparing surgery (NSS) an attractive alternative to nephrectomy in select patients. It allows for optimal surgical treatment and, at the same time, obviates overtreatment and nephron loss when possible. Indications include synchronous bilateral tumours, tumours in a solitary kidney, or the presence of a poorly functional contralateral kidney (e.g., chronic pyelonephritis). Recently, indications for NSS for RCC have been expanded to include a normal contralateral kidney in younger patients with an incidental, localised, single, small (< 4 cm) RCC.

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