Position: Supine, Lateral, Jack-Knife
Time: 2-4 hours (long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes

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

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

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