Approach - GETT. Anticipate placing an epidural if it is an open case and/or you anticipate high postoperative pain. Induction - Standard, but be cautious of hypotension - if there is tumor thrombus involvement in the inferior vena cava venous return is decreased, which will predispose the patient to hypotension during induction. Have a phenylephrine drip primed and ready. SSEP monitoring - Indicated for surgeries where blood flow to the spinal cord may be interrupted. Paralytics have no effect on SSEP monitoring, but typically need to keep inhalation agents at 0.5 MAC or less. Nitrous Oxide - Recommended to AVOID nitrous during the procedure, as it can result in bowel expansion and hinder surgeon visualization. Pain Management - Preoperatively placed continuous epidural analgesia is strongly recommended for open nephrectomies due to high postoperative pain scores. However, epidural local anesthesia administration may be postponed postoperatively to mitigate the risk of sympathectomy, which will potentiate the hypotensive effects of high blood loss. Lines/Drains - Be prepared for rapid, massive blood loss depending on vascular involvement of the tumor. Two peripheral IVs recommended with setup for rapid transfusion. Central line depending on patient condition as well as tumor position in relation to vascular structures (IJV central line preferably on left if IVC is involved). Arterial line for precise blood pressure monitoring and frequent lab draws. Foley catheter for assessment of adequate hydration (goal UOP > 0.5 mL/kg/hr). Positioning - Usually lateral flexed position with kidney rest. Hydration Considerations - Maintain adequate hydration to optimize blood flow to remaining kidney and prevent hypotension related to vena cava compression. CVP may not reflect intravascular volume accurately because venous return through the IVC may be impaired by tumor thrombi. Controlled Hypotension - Only brief periods of controlled hypotension should be used to reduce blood loss due to the potential of impairing the function in the contralateral kidney. Extra Equipment needed - beanbag, axillary roll, gel donut, securement straps or tape for arms, pillows/blankets for extremity support. Required Testing - EKG, CBC, CMP, PT/PTT, UA, Type & Cross. Typically have 2 units on stand-by. Blood Loss - Variable depending on the extent of vascular involvement of the tumor. The risk is HIGH (about 500 mLs), but typically is in the 200-300 mL range. Possible Complications - Risk of pneumothorax related to tumor location (signs: unstable hemodynamics, increases PIP, decreased SpO2), Circulatory failure as a result of complete occlusion of the vena cava by the tumor, Acute pulmonary embolization of tumor fragments intraoperatively, and reflex renal vasoconstriction in the unaffected kidney which can result in postoperative renal dysfunction
Radical nephrectomy removes the whole kidney, part of the ureter, the adrenal gland, and the surrounding fat tissue. Radical nephrectomies are performed as curative treatment for Renal Cell Carcinoma in 85-90% of cases. RCC is the most common malignancy of the kidney, and is refractory to chemotherapy and radiation therapy. It occurs more frequently in men. In 5-10% of these cases have vascular involvement of the tumor, which may extend into the renal vein, inferior vena cava, and right atrium (usually associated with right-sided RCC). History of chronic smoking, CAD, COPD, DM, and renal failure are typically associated with this patient population.
Open procedures are typically indicated if the tumor is larger (>10 cm) and more invasive into the renal tissue and surrounding structures. The incision may be anterior subcostal, flank, or midline, and ranges from 6-12 inches long. Many centers prefer a thoracoabdominal approach for large tumors, especially when a tumor thrombus is present, which allows for cardiopulmonary bypass. The kidney and perinephric fat are removed along with the surrounding (Gerota's) fascia and proximal 2/3 of the ureter. The renal artery and vein are ligated, Ipsilateral adrenal gland resection is now rare, since adrenal metastases only occurs in about 10% of these patients. Retroperitoneal lymph node dissection is typically performed in open cases as well.
References: Butterworth, J.F., Mackey, D.C., Wasnich, K.D. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed., pp. 679-680, 686-686). New York, NY: McGraw-Hill Education, LLC. Holt, N.F. (2018). Cancer. In R.L. Hines & K.E. Marshall (Ed.), Anesthesia and co-existing disease (7th ed., pp. 603). Philadelphia, PA: Elsevier, Inc. Jaffe, R.A.. (2014). Anesthesiologist's manual of surgical procedures (5th ed., pp 1392-1394). Philadelphia, PA: Wolters Kluwer Health. Morse, C.Y. (2018). Renal anatomy, physiology, pathophysiology, and anesthesia management. In J.J. Nagelhout & S. Elijah (Ed.), Nurse anesthesia (6th ed., pp. 707). St. Louis, MO: Elsevier, Inc. Richie, J. P. (2023). Definitive surgical management of renal cell carcinoma. UpToDate. https://www.uptodate.com/contents/definitive-surgical-management-of-renal-cell-carcinoma
