In Radical Nephrectomy the Kidney is removed with its covering Gerota's fascia, Adrenal gland, Ureter and surrounding peri-renal lymph nodes. The indication for radical nephrectomy are renal tumors, renal cell carcinomas and metastatic renal cell carcinomas (for spontaneous regression of the tumor as reported in some cases).
There are three approaches to the kidney for radical Nephrectomy
- Flank approach - the advantages include the dissection of the kidney from all the sides making the control of the hilum and vessels easy with better control of the bleeding from the neo-vascularization of the surrounding tissue. Disadvantages include the surgery on major vessels (vena-cava) in case there is infiltration / tumor thrombus into the renal vein or vena cava.
- Midline approach - in this the hilum of the kidney is controlled first with the dissection of the major vessels first. The advantages are that this incision is useful for the excision of vena caval thrombus / tumor invasion of renal vein or vena cava. Disadvantages are include that the kidney can be approached only from front and not from all sides as in flank approach.
- Laparoscopic approach - which again can be either trans-peritoneal or retro-peritoneal depending on the preference and experience of the surgeon.
Below is the video of the left radical nephrectomy of renal cell carcinoma of left kidney with tumor embolus of the left renal vein. The surgery was done from the modified left flank incision from the 10th inter-costal space. The modification is the opening up of the diaphragm at lateral end of the incision and peritoneum at the medial end of the incision. The diaphragm is opened to create more space for spreading of the ribs and the peritoneum is opened for the easy dissection of the colon and easy control of the renal vessels.
Left Radical Nephrectomy by modified flank incision