Nephrectomy

Definition

• The surgical removal of a kidney (partial or total).
• A nephrectomy may be performed for many reasons, including hydronephrosis, pyelonephritis, renal atrophy, renal artery stenosis, trauma, and tumors of the kidney and uterus.
• If a major portion of the ureter is also excised, the procedure is termed a Nephroureterectomy.

Positioning

• Lateral lumbar frank or transthoracic with affected side up.

Incision Site

• Flank (posterior axillary line, beneath the twelfth rib to suprapubic area).

Packs/ Drapes

• Laparotomy pack with transverse Lap sheet
• Extra drape sheets
• Towels

Instrumentation

• Major procedure tray
• Kidney tray
• Thoracotomy tray with vascular clamps
• Hemoclips
• Internal stapling instruments

Supplies/ Equipment

• Positioning aids
• Basin set
• Blades
• Suction
• Needle counter
• Asepto syringe
• Hemoclips
• Dissector sponges
• Penrose drains
• Closed-wound drainage
• Chest tube and drainage unit
• Suprapubic catheter
• Solutions
• Medications
• Sutures

Procedure Overview

1. A curved incision is made across the flank, and the fascia and muscle tissues are divided with a dissecting scissors or cautery.
2. Occasionally a rib must be sacrificed to gain access to the retroperitoneal space.
3. If a rib is to be taken, periosteal elevators and rib shears should be available.
4. The kidney and ureters are mobilized. The ureter is divided and the distal end ligated.
5. For malignant disease, a radical nephrectomy is performed. On the right side, the duodenum is protected with moist Lap sponges.
6. The vascular pedicle is transected and lymph node-bearing tissue is excised.
7. Gerota’s fascia is dissected from surrounding tissue; the ureter is divided and the kidney and surrounding fat, adrenal gland, and fascia are removed en bloc.
8. If a flank incision is being used, a second lower flank or inguinal incision is used to expose the distal ureter extraperitoneally.
9. The distal ureter is dissected free of surrounding tissues and a small cuff or bladder is excised with the intramural portion of the ureter.
10. The bladder incision is repaired; a suprapubic cystostomy catheter may be placed, and the distal ureter and bladder cuff are delivered into the flank wound and removed with the kidney.
11. The flank incision may be closed with or without drainage, in separate layers.
12. For trauma and some presentations of calculus disease involving only a portion of the kidney, a partial nephrectomy may be performed.

Perioperative Nursing Considerations

1. The surgeon or anesthesiologist may request hypothermia measured during the procedure.
2. Have all X-rays in the room.
3. Verify with the blood bank the number of available units.
4. Chest tube and drainage unit will be needed for a transthoracic approach.
5. A suprapubic catheter and drainage unit may be used if nephroureterectomy is performed.
6. When two incisions are used, the patient is repositioned. Additional instrument tray is necessary.