Historical Aspects

The first nephrectomies were probably performed serendipitously. Early reports of removal of large ovarian tumors indicate that the surgeon was
occasionally surprised to find the kidney included in the surgical specimen. Definitive renal surgery was first performed in 1869 by Gustav Simon,
who carried out a planned nephrectomy for treatment of a ureterovaginal fistula. The operation was preceded by extensive experimental
investigation of uninephrectomy in dogs to demonstrate that they could survive normally with only one kidney. This application of an experimental
model to a clinical problem was the forerunner of the method by which many current surgical procedures were developed.
In 1881, Morris was the first to perform nephrolithotomy in an otherwise healthy kidney, and he later defined the terms nephrolithiasis,
nephrolithotomy, nephrectomy, and nephrotomy. The first partial nephrectomy was performed in 1884 by Wells for removal of a perirenal
fibrolipoma. In 1887, Czerny was the first to use partial nephrectomy for excision of a renal neoplasm. Kuster performed the first successful
pyeloplasty (a dismembered procedure) in 1891 on the solitary kidney of a 13-year-old boy. In 1892, Fenger applied the Heineke-Mikulicz principle
for pyloric stenosis to ureteropelvic junction obstruction. In 1903, Zondek emphasized the importance of thorough knowledge of renal arterial
circulation when performing partial nephrectomy.
There was great controversy among early surgeons regarding the relative merits of retroperitoneal versus transperitoneal exposure of the kidney.
Kocher and Langham performed an anterior transperitoneal nephrectomy through a midline incision as early as 1878. A transverse abdominal
incision was employed in 1913 by Berg, who also mobilized the colon laterally to expose the great vessels and thus secure the renal pedicle with
greater safety. Berg was able to remove vena caval tumor thrombi through a cavotomy after control of the veins by vascular clamps. Rehn actually
reimplanted the contralateral renal vein after resecting the inferior vena cava (IVC) in 1922. However, the high incidence of peritonitis and other
abdominal complications led most urologists to adopt a retroperitoneal flank approach to the kidney during the first half of the 20th century. During
the late 1950s, the development of safe abdominal and vascular surgical techniques led to a revival of the anterior approach in patients
undergoing renal surgery (Culp and Winterringen, 1961; Poutasse, 1961).

Surgical Anatomy
The kidneys are paired vital organs located on either side of the vertebral column in the lumbar fossa of the retroperitoneal space. Each kidney is
surrounded by a layer of perinephric fat, which is, in turn, covered by a distinct fascial layer termed Gerota's fascia. Posteriorly, both kidneys lie on
the psoas major and quadratus lumborum muscles. They are also in relationship with the medial and lateral lumbocostal arches and the tendon of
the transverse abdominal muscle. Posteriorly and superiorly, the upper pole of each kidney is in contact with the diaphragm (Fig. 1021).
A small segment of the anterior medial surface of the right kidney is in contact with the right adrenal gland. However, the major anterior
relationships of the right kidney are with the liver, which overlies the upper two thirds of the anterior surface, and with the hepatic flexure of the
colon, which overlies the lower third. The second portion of the duodenum covers the right renal hilum.
A small segment of the anterior medial surface of the left kidney is also covered by the left adrenal gland. The major anterior relationships of the
left kidney are with the spleen, the body of the pancreas, the stomach, and the splenic flexure of the colon.
The kidney has four constant vascular segments, which are termed apical, anterior, posterior, and basilar (Boyce et al, 1967). The anterior
segment is the largest and extends beyond the midplane of the kidney onto the posterior surface. A true avascular line exists at the junction of the
anterior and posterior segments on the posterior surface of the kidney.
Each vascular segment of the kidney is supplied by one or more major arterial branches (Fig. 1022). Although the origin of the branches
supplying these segments may vary, the anatomic position of the segments is constant (Graves et al, 1954). All segmental arteries are end
arteries with no collateral circulation; therefore, when performing renal surgery, failure to preserve one of these branches leads to devitalization of
functioning renal tissue. Most individuals have a single main artery to each kidney originating from the lateral aspect of the aorta just below the
superior mesenteric artery (SMA). Multiple renal arteries occur unilaterally and bilaterally in 23% and 10% of the population, respectively.
The normal renal venous anatomy is depicted in Figure 1023. The left and right renal veins both terminate in the lateral aspect of the IVC. The
left renal vein is longer and has a thicker muscular layer than the right renal vein. These are the gonadal vein inferiorly, the left adrenal vein
superiorly, and one or two large lumbar veins posteriorly. There are no significant branches draining into the right renal vein. Multiple renal veins
are less common than multiple renal arteries.
The renal venous drainage system differs significantly from the arterial blood supply in that the intrarenal venous branches intercommunicate

freely among the various renal segments. Ligation of a branch of the renal vein, therefore, does not result in segmental infarction of the kidney
because collateral venous blood supply provides adequate drainage. This is important clinically because it enables one to obtain surgical access
to structures in the renal hilus by ligating and dividing small adjacent or overlying venous branches.
With regard to the intrarenal collecting system, there are 8 to 10 major calyces that open into the renal pelvis (Fig. 1024). The apical segment has
one major calyx that lies in the midfrontal plane and receives two minor calyces, which are lateral and medial. The basilar segment has a single
major calyx in the median plane and receives two minor calyces, which are anterior and posterior. There are three major calyces in the anterior
segment, which enter the renal pelvis at a 20-degree angle to the midfrontal plane, and three major calyces in the posterior segment that enter the
renal pelvis at a 75-degree angle to the midfrontal plane.

Preoperative Preparation
A thorough preoperative evaluation is important in patients undergoing renal surgery because of the special positions in which the patient may
have to be placed intraoperatively and the systemic disturbances that may occur secondary to renal infections and impairment of renal function.
Cardiorespiratory function is evaluated by eliciting any history of heart disease, chest pain, smoking, or respiratory distress on exertion. An
electrocardiogram, chest x-ray, and complete blood count should be obtained for all patients. The flank position with lateral flexion of the spine is
known to cause embarrassment of ventilatory capacity, and the venous return may be significantly diminished in this position, resulting in
hypotension. Therefore, alternatives to the flank approach should be used whenever possible in patients with a decreased pulmonary reserve.
Preoperative pulmonary function studies and blood gas analysis are mandatory in patients suspected of having impaired respiratory function. In
the event of impairment, use of an anterior surgical approach with the patient in the supine position is preferred.
Regardless of the surgical incision used, respiration may be seriously impaired postoperatively owing to transection of upper abdominal or flank
muscles and, occasionally, owing to removal of a rib. Also, the upper poles of the kidneys encroach on the undersurface of the diaphragm, and the
removal of a large upper pole renal mass may interfere temporarily with its function. Preoperative breathing exercises, alleviation of
bronchospasm, cessation of smoking, and evaluation of cardiopulmonary function are helpful in improving respiratory function and in preventing
postoperative cardiorespiratory problems.
Bleeding tendencies are assessed by examination of platelet function and coagulation factors. Patients should be questioned about excess
alcohol intake and ingestion of drugs, such as aspirin, that can influence blood clotting.
A thorough anatomic examination of the urinary tract should be made in all patients undergoing renal surgery. Available studies include
intravenous pyelography, cystoscopy, retrograde pyelography, ureteroscopy, cystourethrography, computed axial tomography, ultrasonography,
magnetic resonance imaging (MRI), renal arteriography, and renal venography. Three-dimensional volume-rendered computed tomography (CT)
is an accurate imaging modality for surgical planning before reconstructive renal surgery (Coll et al, 1999). These tests are reviewed in detail in the
chapter on radiology of the urinary tract, and their usefulness in evaluating patients for specific renal operations is described in subsequent
sections.
Overall, renal function is evaluated by estimation of the serum creatinine level and either endogenous creatinine clearance or iothalamate
glomerular filtration rate. Differential renal function can be assessed noninvasively with computed isotope renography using hippuric acid I 131 or
technetium 99. Hippuric acid I 131 is cleared by both glomeruli and tubules and is most useful for measuring unilateral renal dysfunction when
overall renal function is normal. Technetium chelated with diethylenetriamine pentaacetic acid (DTPA) is filtered only by the glomeruli and is thus
more helpful in assessing differential renal perfusion. Both these isotopes are excreted in the urine, and, in the presence of obstruction,
parenchymal concentration is obscured by the high concentration of isotope in the accumulated urine. Selective ureteral catheterization to
determine differential renal function is an invasive study that is rarely used.
Patients with either upper or lower urinary tract infection should receive organism-specific antibiotic therapy preoperatively. With suspected or
proven upper tract infection, at least 48 hours of antibiotic therapy is indicated before renal surgery. Severe bacteremia can occur during operation
on an infected kidney, with significant resulting morbidity and potential mortality.
Percutaneous embolization of the kidney is occasionally helpful before performing radical nephrectomy for large renal malignancies. The major
value of this adjunct procedure is for patients with an arterialized vena caval tumor thrombus or a medial extension of tumor that interferes with
early ligation of the renal artery. Absolute ethanol injected directly into the renal artery appears to be the most satisfactory therapy for
angioinfarction. Subsequent transient flank pain is common and often requires analgesic medication for control.
Patients are often concerned about how the removal of a kidney will affect their renal function. After nephrectomy for unilateral renal disease, the
opposite kidney undergoes compensatory hypertrophy, and the glomerular filtration rate is ultimately maintained at 75% of the normal value
(Aperia et al, 1977; Robitalle et al, 1985). Several long-term studies have shown no increase in hypertension or proteinuria, stable overall renal
function, and normal life expectancy after unilateral nephrectomy with a normal contralateral kidney (Kretschmer, 1943; Goldstein, 1956; Anderson
et al, 1968). This information should be shared with patients to alleviate their anxiety before surgery.

Intraoperative Renal Ischemia

Temporary occlusion of the renal artery is necessary for a variety of operations, such as partial nephrectomy, renal vascular reconstruction,
anatrophic nephrolithotomy, and repair of traumatic renal injury. In such cases, temporary arterial occlusion not only diminishes intraoperative
renal bleeding but also improves access to intrarenal structures by causing the kidney to contract and by reducing renal tissue turgor.
Performance of these operations requires an understanding of renal responses to warm ischemia and available methods of protecting the kidney
when the period of arterial occlusion exceeds that which may be safely tolerated.

Renal Tolerance to Warm Ischemia

Because renal metabolic activities are predominantly aerobic, the kidney is very susceptible to damage from warm ischemia. Almost immediately
after renal arterial occlusion, energy-rich adenosine triphosphates within the kidney cells begin to break down into monophosphate nucleotides to
provide the energy required for maintenance of structural and functional cellular integrity (Collste et al, 1971; Collins et al, 1977). When energy
sources have been depleted, cellular membrane transport mechanisms fail, causing an influx of salt and water, which ultimately results in severe
cellular edema and cell death.
The extent of renal damage after normothermic arterial occlusion depends on the duration of the ischemic insult. Canine studies have shown that
warm ischemic intervals of up to 30 minutes can be sustained with eventual full recovery of renal function (Ward, 1975). For periods of warm
ischemia beyond 30 minutes, there is generally significant, immediate functional loss, and late recovery of renal function is either
incomplete or absent. Histologically, renal ischemia is most damaging to the proximal tubular cells, which may show varying degrees of
necrosis and regeneration, whereas the glomeruli and blood vessels are generally spared.
Human tolerance to warm renal ischemia very closely parallels that seen in experimental canine observations, and, in general, 30 minutes is the
maximum tolerable period of arterial occlusion before permanent damage is sustained. In some clinical situations, this admonition may not apply,
and a longer period of ischemia may be safely tolerated. It is acknowledged that the solitary kidney is more resistant to ischemic damage than the
paired kidney, although precise limits have not been defined (Askari, 1982). Another situation that may enhance renal tolerance to temporary
arterial occlusion is the presence of an extensive collateral vascular supply. This is generally observed only in patients with renal arterial occlusive
disease (Schefft et al, 1980).
Another determinant of renal ischemic damage is the method employed to achieve vascular control of the kidney. Animal studies have
shown that functional impairment is least when the renal artery alone is continuously occluded. Continuous occlusion of the renal artery
and vein for an equivalent time interval is more damaging because it prevents retrograde perfusion of the kidney through the renal vein and may
also produce venous congestion of the kidney (Neely and Turner, 1959; Leary et al, 1963; Schirmer et al, 1966). Intermittent clamping of the renal
artery with short periods of recirculation is also more damaging than continuous arterial occlusion, possibly because of the release and trapping of
damaging vasoconstrictor agents within the kidney (Neely and Turner, 1959; Schirmer et al, 1966; Wilson et al, 1971; McLoughlin et al, 1978).
Animal studies have further demonstrated that the use of manual renal compression to control intraoperative hemorrhage is more deleterious than
simple arterial occlusion (Neely and Turner, 1959).

Prevention of Ischemic Renal Damage

Several general adjunctive measures should be employed in all patients undergoing operations that involve a period of temporary renal arterial
occlusion. These include generous preoperative and intraoperative hydration, prevention of hypotension during the period of anesthesia,
avoidance of unnecessary manipulation or traction on the renal artery, and intraoperative administration of mannitol. These measures help limit
postischemic renal injury by ensuring optimal perfusion with an absence of cortical vasospasm at the time of arterial occlusion, which allows
uniform restoration of blood flow throughout the kidney when the renal artery is unclamped. Mannitol is most effective when given 5 to 15 minutes
before arterial occlusion (Collins et al, 1980), and it is beneficial because it increases renal plasma flow, decreases intrarenal vascular resistance,
minimizes intracellular edema, and promotes an osmotic diuresis when renal circulation is restored (Nosowsky and Kaufman, 1963). Systemic or
regional heparinization before renal arterial occlusion is not necessary, unless there is existing small vessel or parenchymal renal disease.
When the anticipated period of intraoperative renal ischemia is longer than 30 minutes, additional specific protective measures are
indicated to prevent permanent damage to the kidney. Local hypothermia is the most effective and commonly employed method for protecting
the kidney from ischemic damage. Lowering renal temperature reduces energy-dependent metabolic activity of the cortical cells, with a resultant
decrease in both the consumption of oxygen and the breakdown of adenosine triphosphate (Harvey, 1959; Levy, 1959). The optimum temperature
for hypothermic in situ renal preservation is 15C, based on canine experiments conducted by Ward. In clinical renal surgery, it is difficult to
achieve uniform cooling to this level because of the temperature of adjacent tissues and the need to have a portion of the kidney exposed to
perform the operation. For practical reasons, a temperature of 20C to 25C is easier to maintain and represents a compromise that renders renal
surgery technically feasible while still allowing a renal-preservative effect. Both animal and human studies have shown that this level of
hypothermia provides complete renal protection from arterial occlusion of up to 3 hours (Wickham et al, 1967; Luttrop et al, 1976; Petersen et al,
1977; Wagenknecht et al, 1977; Marberger et al, 1978; Stubbs et al, 1978; Kyriakidis et al, 1979).

In situ renal hypothermia can be achieved with external surface cooling or perfusion of the kidney with a cold solution instilled into the renal artery.
These two methods are equally effective; however, the latter is an invasive technique that requires direct entry into the renal artery (Leary et al,
1963; Farcon et al, 1974; Kyriakidis et al, 1979; Abele et al, 1981). Surface cooling of the kidney is a simpler and more widely used method that
has been accomplished by a variety of techniques, such as surrounding the kidney with a cold solution (Mitchell, 1959) or applying an external
cooling device to the kidney (Cockett, 1961). These methods all require complete renal mobilization to achieve effective surface cooling.
Most urologists prefer ice-slush cooling for surface renal hypothermia because of its relative ease and simplicity. The mobilized kidney is
surrounded with a rubber sheet on which sterile ice slush is placed to completely immerse the kidney. An important caveat with this method is
to keep the entire kidney covered with ice for 10 to 15 minutes immediately after occluding the renal artery and before commencing the
renal operation. This amount of time is needed to obtain core renal cooling to a temperature (approximately 20C) that optimizes in situ renal
preservation. During performance of the renal operation, invariably, large portions of the kidney are no longer covered with ice slush, and, in the
absence of adequate prior core renal cooling, rapid rewarming and ischemic renal injury can occur. This technique is very effective for in situ renal
preservation. Stubbs and associates (1978) reported on 30 patients with a solitary kidney in whom anatrophic nephrolithotomy was performed with
ice-slush surface hypothermia; despite a mean renal artery clamp time of longer than 2 hours and as long as 4 hours in some cases, renal function
was completely preserved in all patients.
Another approach to in situ renal preservation that does not involve hypothermia is pretreatment with one or more pharmacologic agents to
prevent postischemic renal failure (Novick, 1983). Agents that have been tested include vasoactive drugs, membrane-stabilizing drugs, calcium
channel blockers, and agents that act to preserve or to replenish intracellular levels of adenosine triphosphate. A review of this field is beyond the
scope of this chapter. Experimental studies have shown that several of these agents can help to prevent postischemic renal failure. However, thus
far, no pharmacologic regimen has proved to be as effective as local hypothermia for ischemic intervals of 2 hours or more.

Surgical Approaches to the Kidney

Exposure of the kidney during surgery must be adequate to perform the operation and to deal with any possible complications. This is particularly
important in renal surgery because the kidney is deeply placed in the upper retroperitoneum with access limited by the lower ribs, liver, and
spleen. Injuries to large renal vessels may be difficult to control or to repair through small incisions, particularly in the presence of a large tumor or
inflamed perinephric tissues. Poor exposure renders the operation unnecessarily difficult and also leads to excessive retraction, with bruising of
the muscles and possible injury to the intercostal nerves, which can increase postoperative pain.
Factors to consider in selecting an appropriate incision for renal surgery include operation to be performed, underlying renal pathology,
previous operations, concurrent extrarenal pathology that requires another operation to be done simultaneously, need for bilateral renal
operations, and body habitus. Physical abnormalities in the patient, such as kyphoscoliosis or severe pulmonary disease, may also dictate that
certain approaches, such as the standard flank incision, not be used.
The kidney may be approached by four principal routes: an extraperitoneal flank approach, a dorsal lumbotomy, an abdominal incision, or a
thoracoabdominal incision. The indications, relative advantages, and technical performance of each approach are reviewed separately.

Flank Approach
This approach provides good access to the renal parenchyma and collecting system (Woodruff, 1955). It is an extraperitoneal approach and
involves minimal disturbance to other viscera. Contamination of the peritoneal cavity is avoided, and drainage of the perirenal space is readily
established. This approach is particularly useful in the obese patient because most of the panniculus falls forward, making this incision relatively
straightforward even in the very large person. The principal disadvantage of the flank incision is that exposure in the area of the renal
pedicle is not as good as with anterior transperitoneal approaches. In addition, the flank incision may prove unsuitable for the patient
with scoliosis or cardiorespiratory problems.
The most commonly used flank approach to the kidney is through the bed of the 11th or 12th rib (Hess, 1939; Hughes, 1949; Bodner and Briskin,
1950). The choice of rib depends on the position of the kidney and on whether the upper or lower pole is the site of disease. With a flank incision,
the midportion of the wound and the site of maximal exposure are in the midaxillary line. Access in the posterior part, at the neck of the rib, is
limited by the sacrospinalis muscle. The appropriate level of the incision is therefore best determined by drawing a horizontal line on the urogram
from the hilum of the kidney to the most lateral rib that it intersects (Fig. 1025). When access to the upper renal pole is required, the rib above is
selected.
The patient is placed in the lateral position after being anesthetized and having an endotracheal tube inserted. The back should be placed fairly
close to the edge of the operating table to ensure unimpeded access by the surgeon, and the patient should be positioned so that the tip of the
12th rib is over the kidney rest. The bottom leg is flexed to 90 degrees with the top leg straight to maintain stability. A pillow is placed between the
knees, and a sponge pad is placed under the axilla to prevent compression of the axillary vessels and nerves. The patient is secured in this
position with a wide adhesive tape passed over the greater trochanter and attached to the moveable portion of the table (Fig. 1026). The
extended upper arm can be supported on a padded Mayo stand, which is adjusted to the appropriate height to maintain the arm in a horizontal
position with the shoulder rotated slightly forward.

Flexion of the table and elevation of the kidney rest should be performed slowly and may be delayed until the surgeon is ready to make the skin
incision to minimize the time spent in this position. The flexion increases the space between the costal margin and the iliac crest and puts the flank
muscles and skin on tension. Care must be taken with patients who have stiff spines to ensure that their extremities remain in contact with the
table because their range of lateral flexion is limited. This position may not be well tolerated by elderly patients or by those with impaired
cardiopulmonary function because it results in decreased venous return owing to compression of the IVC and the dependent position of the legs. It
also limits aeration of the lung on the dependent side. It is important to determine the patient's blood pressure after she or he has been turned on
her or his side and again after the table has been flexed and the kidney rest elevated. The rest may have to be lowered and the table unflexed if
hypotension is observed.
The flank incision is made directly over the appropriate rib, beginning at the lateral border of the sacrospinal muscle (Fig. 1027). A left-sided 12th
rib incision is demonstrated in Figures 1027 to 10212. After the external oblique and latissimus dorsi muscles and the slips of the underlying
serratus inferior posterior muscles are divided (Fig. 1028), the periosteum over the rib is incised with a scalpel or by diathermy. The flat periosteal
elevator is used to reflect the periosteum off the rib (Fig. 1029). Mobilization of the periosteum is completed by separating it from the inner aspect
of the rib, using Doyen's periosteal elevator (Fig. 10210). The proximal end of the rib is then transected as far back as possible with the guillotine
rib resector. The retracted muscle mass is allowed to fall back over the sharp cut edge, protecting the operator from injury. The rib is grasped with
Kocher's clamp and is separated by sharp dissection from the muscles attached anteriorly to complete its removal.
When the 11th rib is resected, attention must be directed at the pleural reflection, which crosses its lower border at the junction of the anterior and
middle thirds and which occupies the posterior part of the wound as it lies on the lower fibers of the diaphragm. The pleura may be reflected
upward by sharply dividing the fascial attachments to the diaphragm. Alternatively, the lower fibers of the diaphragm can be detached from their
insertion into the posterior inner aspect of the 12th rib. This allows the lower diaphragm and pleura to be retracted upward, out of the wound.
An incision is now made through the periosteal bed of the rib to expose Gerota's fascia (Fig. 10211). The incision is completed anteriorly by
incising the lumbar fascia and inserting two fingers into the perinephric space to push the underlying peritoneum forward. The lateral peritoneal
reflection is peeled off the undersurface of the anterior abdominal wall and the transversalis fascia by sweeping it forward with the fingers. The
external and internal oblique muscles are divided by incising them sharply or with electrocautery while they are tented up over the two fingers
inserted below the transverse muscle (Fig. 10212). A little upward pressure controls bleeding from the severed vessels, allowing them to be
clamped or cauterized by the assistant. This should expose the intercostal neurovascular bundle as it courses forward and downward between the
internal oblique and transverse muscles. The transverse fibers of the transverse muscle may be split by blunt dissection below the nerve, allowing
it to fall away with the upper margin of the incision.
Finochietto's retractor is used to maintain the exposure. The blades of the retractor are placed over moistened gauze sponges to avoid breaking a
rib. The perinephric space is entered by incising Gerota's fascia posteriorly to avoid injury to the peritoneum. Care should be taken to avoid injury
to the iliohypogastric and ilioinguinal nerves as they emerge from behind the lateral border of the psoas muscle and pass down over the anterior
surface of the quadratus lumborum in the renal fossa.
The incision is closed by careful approximation of the corresponding muscle and fascial layers. To facilitate this, the kidney rest is lowered, and the
table is returned to the horizontal position. Care must be taken to avoid inclusion of any intercostal nerves or branches during closure of the
transversus muscle. Injection of 0.5% Marcaine into the fascial sheath around the intercostal nerves as they emerge from the intervertebral
foramina is helpful in diminishing postoperative pain and involuntary splinting of the lower chest. Drains are usually brought out posteriorly through
a separate stab incision below the wound.
Occasionally, a subcostal flank incision is indicated for surgery on the lower renal pole or upper ureter, insertion of a nephrostomy tube, or
drainage of a perinephric abscess. It has the disadvantage of being rather low in relation to the usual position of the kidney, which makes access
to the pedicle and renal pelvis more difficult. Exposure may be hampered by the iliac crest and subcostal nerve. The subcostal incision does not
have these disadvantages in children, in whom it provides good access to the kidney because the lower ribs are soft and easily displaced upward.
The subcostal incision is begun at the lateral border of the sacrospinalis muscle where it crosses the inferior edge of the 12th rib and is carried
forward about a fingerbreadth below the lower border of the last rib onto the anterior abdominal wall. The medial end of the incision is curved
slightly downward as it passes the midaxillary line to avoid the subcostal nerve and may be extended as far as the lateral border of the rectus
abdominis muscle. The extent of the incision is modified, depending on the location of the kidney and the nature of the disease.
With a subcostal incision, the latissimus dorsi muscle is divided in the posterior part of the wound to expose the posterior edge of the external
oblique muscle (Fig. 10213). The serratus inferior posterior muscles, arising from the lumbar fascia and inserting into the lower four ribs, are
divided in the posterior portion of the wound. The external oblique muscle is divided anteriorly. The fused layers of the lumbodorsal fascia are now
exposed, giving origin to the internal oblique and transverse muscles. After the internal oblique muscle is divided, the transverse muscle is
separated bluntly either above or below the subcostal nerve, depending on the course of the nerve in relation to the incision (Fig. 10214). Every
effort should be made to avoid injury to the intercostal nerves because this may cause persistent postoperative pain or bulging in the flank owing
to paresis of the denervated muscle. The lumbar fascia and the lateral border of the sacrospinal muscle may need to be incised to improve
exposure in the posterior part of the wound. Division of the costotransverse ligament as it passes up to the neck of the 12th rib allows the rib to be
retracted upward to further improve the exposure. The closure is as described for a flank incision.

Dorsal Lumbotomy
The dorsal lumbotomy incision is a useful approach for removal of a small kidney, for bilateral nephrectomy in patients with end-stage renal
disease, for open renal biopsy, for pyeloplasty, for pyelolithotomy, and for upper ureterolithotomy when the stone is firmly impacted (Novick, 1980).
This approach offers several advantages when performing these operations (Gardiner et al, 1979). Unlike the standard flank incision, no muscles
are transected, and access to the kidney is obtained by simply incising the posterior fascial layers. This approach is more rapid, provides strong
wound closure with less postoperative pain, and obviates anterolateral bulging of the abdomen that commonly results from flank incisions. With
detachment of the costovertebral ligament, the 12th rib can be retracted widely laterally, rendering resection of the rib unnecessary.
The dorsal lumbotomy approach is also advantageous in patients with prior abdominal or flank operations on the kidney because it permits
dissection of fresh tissue planes. The major disadvantage of dorsal lumbotomy is its limited access to the kidney and renal vessels, which
can pose a problem if there are intraoperative complications such as migration of a calculus or injury to major renal vessels with
bleeding.
When bilateral nephrectomy is done, the patient is placed in the prone position with the table flexed to increase the distance between the 12th rib
and the iliac crest. In this position, the patient is supported over the sternum and pubis so that there is free excursion of the anterior abdominal
wall to prevent embarrassment of respiration and venous return. For unilateral renal operations, the patient may be placed in the lateral position
with the table flexed to extend the lumbar region. In this position, a sandbag is placed between the abdomen and the table for support and to help
push the kidney posteriorly.
A vertical lumbar incision is made along the lateral margin of the sacrospinal muscle. The incision begins at the upper margin of the 12th rib
superiorly and follows a gentle lateral curve to the iliac crest inferiorly (Fig. 10215A). The incision is carried through the lumbodorsal fascia just
lateral to the sacrospinal and quadratus lumborum muscles, which are then retracted medially to approach the renal fossa (Fig. 10215B). The
transverse fascia is incised to expose the kidney contained within Gerota's fascia (Fig. 10215C). Exposure of the kidney is thus obtained without
transection of any muscle fibers. If additional superior exposure is needed, the costovertebral ligamentous attachment of the 12th rib is divided to
allow lateral and superior retraction of the rib (Fig. 10215D, E). The kidney can be mobilized and delivered down into the incision, provided that
the lower third of the kidney is located below the 12th rib on preoperative x-rays. However, for high-lying or enlarged kidneys, the dorsal
lumbotomy approach is cumbersome, and either a flank or an anterior incision provides better exposure. To close the incision, the retracted
muscles are allowed to return to their original position, and the lumbodorsal fascia is reapproximated.

Abdominal Incisions
The principal advantage of the abdominal approach is that exposure in the area of the renal pedicle is excellent. The principal
disadvantage is the somewhat longer period of postoperative ileus and the possible long-term complication of intra-abdominal
adhesions leading to bowel obstruction. The choice between a vertical or a transverse type of abdominal incision is determined by the patient's
anatomy and disease entity. A vertical incision is easier and quicker to perform and repair because it involves division of only the linea alba or the
anterior and posterior layers of the rectus sheet rather than several muscle layers. The vertical incision may be used in patients with a narrow
subcostal angle and is preferred in patients with renal injury because it allows better access for inspection of the remainder of the abdominal
contents for associated injuries. A transverse incision is preferable for patients with a wide subcostal angle and for exploration or removal of renal
mass lesions (Chute et al, 1967). This incision provides better access to the lateral and superior portion of the kidney. A unilateral subcostal
incision can be extended across the midline as a Chevron incision to provide excellent exposure of both kidneys along with the aorta and the IVC.
When an anterior subcostal incision is employed, the patient is in the supine position with a rolled sheet beneath the upper lumbar spine. The
incision begins approximately 1 to 2 fingerbreadths below the costal margin in the anterior axillary line and then extends with a gentle curve across
the midline, ending at the midportion of the opposite rectus muscle. The incision is carried through the subcutaneous tissues to the anterior fascia,
which is divided in the direction of the incision. In the lateral aspect of the incision, a portion of the latissimus dorsi muscle is divided. The external
oblique muscle is divided, exposing the fibers of the internal oblique muscle (Fig. 10216A). The rectus, internal oblique, and transverse
abdominal muscles are divided along with the posterior rectus sheath (Fig. 10216B, C). The peritoneal cavity is entered in the midline, and the
ligamentum teres is divided (Fig. 10216D).
The bilateral subcostal incision is performed as described for the unilateral incision, except that both sides are involved (Fig. 10217). It extends
from one anterior axillary line to the opposite anterior axillary line, with a gentle upward curve as it crosses the midline. This incision provides
better exposure of both kidneys than does a midline incision, particularly in obese patients with a wide subcostal angle. The disadvantage is that it
involves extensive transection of the abdominal wall musculature.
An extraperitoneal anterior subcostal approach may be useful to perform open renal biopsy or nephrectomy, particularly when there has been a
previous intra-abdominal procedure or when there is a possibility that the patient may require peritoneal dialysis postoperatively (Lyon, 1958). The
peritoneal cavity is not entered, thereby minimizing postoperative ileus and the chance of intra-abdominal complications. Reflection of the
peritoneum off theanterior abdominal wall may at times be difficult, and access to the renal pedicle may be less satisfactory than with a
transperitoneal incision.
The patient is placed in a semioblique position with a rolled sheet beneath the side in which the incision is to be made. The muscle layers are

divided as they are for a unilateral subcostal incision, except that the peritoneal cavity is not entered. The peritoneum is mobilized intact from the
undersurface of the lateral musculature and rectus sheath and is then retracted medially to expose the retroperitoneal space (Fig. 10218).
When a midline upper abdominal incision is employed, the patient is placed supine on the operating table with a rolled sheet beneath the upper
lumbar spine. The incision extends from the xiphoid to the umbilicus and can be extended around the umbilicus on either side if necessary. The
incision is carried down through the subcutaneous tissues to the linea alba, which is the midline fusion of the tendinous fibers of the anterior rectus
sheath. The linea alba is divided to expose the extraperitoneal fat and peritoneum, which is then entered (Fig. 10219).
A paramedian incision is another type of vertical abdominal incision that may be preferred, because the separate closure of the two layers of the
rectus sheath makes the wound more secure. The incision is made about 3 cm lateral to the midline to provide an adequate margin of rectus
sheath medially (Fig. 10220). The anterior sheath is divided and reflected medially off the underlying muscle by sharp division of the tendinous
intersections. The free medial edge of the muscle is retracted laterally to allow the posterior rectus sheath and peritoneum to be incised (Fig.
10221). An extraperitoneal approach to the kidney can also be made through a paramedian incision by carefully reflecting the peritoneum off the
posterior rectus sheath after it has been divided (Tessler et al, 1975).

Thoracoabdominal Incision
The thoracoabdominal approach is desirable for performing radical nephrectomy in patients with large tumors involving the upper
portion of the kidney (Clarke et al, 1958; Khoury, 1966; Middleton and Presto, 1973; Chute et al, 1976). It is particularly advantageous on the
right side, where the liver and its venous drainage into the upper vena cava can limit exposure and impair vascular control as the tumor mass is
being removed. There is less need for a thoracoabdominal incision on the left side because the spleen and pancreas can usually be readily
elevated away from the tumor mass. The thoracoabdominalincision optimizes exposure of the suprarenal area. Nevertheless, because it involves
additional operative time and greater potential pulmonary morbidity, I reserve this approach for patients in whom additional exposure over that
provided by an anterior subcostal incision is considered important to achieve complete and safe tumor removal.
The patient is placed in a semioblique position with a rolled sheet placed longitudinally beneath the flank. The lower leg is flexed and the upper
one is extended with a pillow beneath the legs. The pelvis assumes a more horizontal position, tilted only about 10 to 15 degrees, which allows
free access to the anterior abdominal wall. The incision is begun in the eighth or ninth intercostal space near the angle of the rib and is carried
across the costal margin to the midpoint of the opposite rectus muscle just above the umbilicus. The incision is carried down to the fascia, which is
divided in the direction of the incision ( Fig. 10222A). The latissimus dorsi, external oblique, rectus, and intercostal muscles are also divided in
the direction of the incision. The costal cartilage between the tips of the adjacent ribs is divided ( Fig. 10222B). The pleura in the posterior portion
of the incision is opened to obtain complete exposure of the diaphragm ( Fig. 10222C).
The diaphragmatic incision is begun at the periphery about 2 cm inside its attachment to the chest wall, with the incision then being carried around
circumferentially to the posterior aspect of the diaphragm ( Fig. 10222D). In doing this, there must be at least 2 or 3 cm of diaphragm left
attached to the rib cage to allow later reconstruction. By dividing the diaphragm in a circumferential manner from anterior to posterior, damage to
the phrenic nerve is avoided. This also creates a diaphragmatic flap that can be pushed into the chest to provide complete exposure of the liver,
which is then simply retracted upward ( Fig. 10222E). If further mobilization of the liver is needed, the right triangular ligament and coronary
ligament can be incised to mobilize the entire right lobe of the liver upward. This provides excellent additional exposure of the suprarenal vena
cava. Medial to the ribs, the internal oblique and transverse abdominal muscles are divided and the peritoneal cavity is entered. The colon and
duodenum are mobilized medially, and the liver is retracted upward to expose the kidney and great vessels ( Fig. 10222F).
At the completion of the procedure, the abdominal viscera are replaced in their anatomic position. The diaphragm is repaired with interrupted 20
silk mattress sutures with the knots tied on the undersurface. The chest wall is reapproximated by passing 00 polyglycolic sutures around the ribs
above and below. The sutures should be passed on a tapered needle to avoid cutting any vessels, with care taken to avoid the neurovascular
bundle. Before the pleura is closed, a 20-F chest tube is placed in the pleural cavity and brought out through a stab wound below the incision in
the posterior axillary line. The transected muscle and fascial layers are reapproximated separately. The chest tube is connected to an underwater
drain and is usually removed 24 to 48 hours postoperatively, provided that there is no persistent leakage of air and a chest x-ray shows
satisfactory lung expansion.

Simple Nephrectomy
Indications

Simple nephrectomy is indicated in patients with an irreversibly damaged kidney owing to symptomatic chronic infection, obstruction, calculus
disease, or severe traumatic injury. It is occasionally appropriate to remove a functioning kidney involved with one of these conditions when the
patient's age or general condition is too poor to permit a reconstructive operation and provided that the opposite kidney is normal. Nephrectomy
may also be indicated to treat renovascular hypertension owing to noncorrectable renal artery disease or severe unilateral parenchymal damage
from nephrosclerosis, pyelonephritis, reflux, or congenital dysplasia.
Simple nephrectomy can be performed through a variety of incisions. An extraperitoneal flank approach is usually preferable when the
kidney is chronically infected, when the patient is obese, or when multiple prior abdominal operations have been performed. A
subcapsular approach is indicated when severe perirenal inflammation or adhesions obscure anatomic relationships between the kidney and the
surrounding structures. A transperitoneal approach is preferable in patients who cannot tolerate the flank position, in end-stage renal disease
patients undergoing bilateral nephrectomy for polycystic kidney disease, and in cases of traumatic renal injury where early access to the pedicle is
necessary. The transperitoneal approach is also useful when multiple operations have been performed previously through the flank with resulting
dense adhesions around the kidney. Bilateral nephrectomy in patients with small end-stage kidneys can be done through a bilateral simultaneous
posterior approach (Novick, 1980).

Flank Approach
Once the perinephric space is entered, access to the kidney is obtained by incising Gerota's fascia on the lateral aspect of the kidney to avoid
injury to the overlying peritoneum ( Fig. 10223A). The plane of cleavage between the perinephric fat and the renal capsule is usually developed
easily. The kidney is mobilized by blunt dissection and, on the left side, the pancreas and duodenum are carefully reflected medially along with the
peritoneum. The ureter is identified during mobilization of the lower renal pole. It is preferable to divide the ureter after ligation of the pedicle to
avoid congestion of the kidney. The kidney is pulled downward, and the upper pole is dissected free. There is normally a separate compartment in
Gerota's fascia for the adrenal gland, which enables it to be readily separated from the upper pole.
The kidney is pulled laterally to identify the renal artery and vein, which are separated from surrounding fatty and lymphatic tissues by blunt
dissection ( Fig. 10223B). Whenever possible, it is preferable to secure the vessels individually away from the hilus, and the artery should always
be ligated first. The renal vein is usually visualized easily and is mobilized by ligating and dividing the gonadal, adrenal, and lumbar branches. The
vein can then be retracted to expose the artery, which lies posteriorly. Alternatively, the renal vein can be approached posteriorly by mobilizing the
kidney and retracting it up into the wound. The renal artery and vein are individually secured with 20 silk ligatures and are then divided ( Fig.
10223C). The ureter is clamped and divided, and the distal end is ligated with 20 chronic catgut to complete the nephrectomy ( Fig. 10223D).

Subcapsular Technique
Subcapsular nephrectomy is indicated when severe perirenal inflammation precludes satisfactory dissection between the kidney and the
surrounding structures (Kimbrough and Morse, 1953; Kittredge and Fridge, 1958). After the retroperitoneal space has been entered, the renal
capsule is identified, and a longitudinal incision is made over the lateral surface of the kidney (Fig. 10224A). Once the capsule has been entered,
a plane is developed between the renal parenchyma and the capsule over the entire surface of the kidney down to the level of the hilus (Fig.
10224B, C). The renal parenchyma is retracted laterally to expose the major renal vessels as they enter the hilus. Vascular branches are ligated
and transected as far laterally as possible to allow satisfactory proximal control of each branch (Fig. 10224D). The upper ureter is then ligated
and divided to complete the nephrectomy.

Transperitoneal Approach
In transperitoneal simple nephrectomy, a subcostal incision is made, and the peritoneal cavity is entered. On the left side, the colon, pancreas,
and spleen are reflected upward and medially to expose the left renal vein. A self-retaining ring retractor is useful to maintain exposure of the
surgical field (Fig. 10225A).
The renal vein and artery are mobilized, ligated, and transected (Fig. 10225B). The artery is occluded first to avoid excessive blood loss into the
kidney. The kidney is then mobilized laterally, superiorly, and inferiorly by sharp and blunt dissection. It is best to initiate the dissection laterally to
obtain maximum mobilization before approaching the posterior renal hilus where friable lumbar veins may be present (Fig. 10225C). In cases of
severe perirenal fibrosis, it may be necessary to remove some of the posterior psoas fascia together with the kidney. After complete renal
mobilization, the ureter is ligated and divided to complete the nephrectomy.

Radical Nephrectomy
Indications and Evaluation

Radical nephrectomy is the treatment of choice for patients with localized renal cell carcinoma (RCC) (Robson et al, 1969; Skinner et al,
1971). The preoperative evaluation of patients with RCC has changed considerably during the past 2 decades owing to the advent of new imaging
modalities such as ultrasonography, CT scanning, and MRI. In many patients, a complete preliminary evaluation can be performed using these
noninvasive modalities. Renal arteriography is no longer routinely necessary before radical nephrectomy. All patients should undergo a
metastatic evaluation including a chest x-ray, an abdominal CT scan, and, occasionally, a bone scan; the last is necessary only in patients with
bone pain or elevated serum alkaline phosphatase. Radical nephrectomy is occasionally done in patients with metastatic disease to palliate
severe associated local symptoms or to allow entry into a biologic response modifier treatment protocol, or concomitant with resection of a solitary
metastatic lesion.
Involvement of the IVC with RCC occurs in 4% to 10% of cases and renders the task of complete surgical excision more complicated (Schefft et
al, 1978). However, operative removal offers the only hope for cure and, when there are no metastases, an aggressive approach is justified. Fiveyear survival rates of 40% to 68% have been reported after complete surgical excision (Libertino et al, 1987; Neves and Zincke, 1987; Skinner et
al, 1989; Novick et al, 1990). The best results have been achieved when the tumor does not involve the perinephric fat and regional lymph nodes
(Cherrie et al, 1982). The cephalad extent of vena caval involvement is not prognostically important and, even with intra-atrial tumor thrombi,
extended cancer-free survival is possible after surgical treatment when there is no modal or distant metastasis (Glazer and Novick, 1996). In
planning the appropriate operative approach for tumor removal, it is essential for preoperative radiographic studies to define accurately the distal
limits of a vena caval tumor thrombus.
RCC involving the IVC should be suspected in patients who have lower extremity edema, a varicocele, dilated superficial abdominal veins,
proteinuria, pulmonary embolism, a right atrial mass, or nonfunction of the involved kidney. MRI is the preferred diagnostic study for demonstrating
both the presence and the distal extent of IVC involvement (Pritchett et al, 1987; Goldfarb et al, 1990). Transesophageal echocardiography (Fig.
10226) (Treiger et al, 1991; Glazer and Novick, 1997) and transabdominal color Doppler ultrasonography (McGahan et al, 1993) have also
proved to be useful diagnostic studies in this regard. Inferior vena cavography is reserved for patients in whom an MRI or ultrasound study is
either nondiagnostic or contraindicated. Renal arteriography is particularly helpful in patients with RCC involving the IVC because, in 35% to 40%
of cases, distinct arterialization of a tumor thrombus is observed. When this finding is present, preoperative embolization of the kidney often
causes shrinkage of the thrombus, which facilitates its intraoperative removal. When adjunctive cardiopulmonary bypass with deep hypothermic
circulatory arrest is considered, coronary angiography is also performed preoperatively (Belis et al, 1989; Novick et al, 1990). If significant
obstructing coronary lesions are found, these can be repaired simultaneously during cardiopulmonary bypass.

Standard Technique
Radical nephrectomy encompasses the basic principles of early ligation of the renal artery and vein, removal of the kidney outside Gerota's fascia,
removal of the ipsilateral adrenal gland, and performance of a complete regional lymphadenectomy from the crus of the diaphragm to the aortic
bifurcation (Robson et al, 1969). Perhaps the most important aspect of radical nephrectomy is removal of the kidney outside Gerota's
fascia because capsular invasion with perinephric fat involvement occurs in 25% of patients. It has been shown that removal of the
ipsilateral adrenal gland is not routinely necessary unless the malignancy either extensively involves the kidney or is located in the
upper portion of the kidney (Sagalowaky et al, 1994). Although lymphadenectomy allows for more accurate pathologic staging, its therapeutic
value remains controversial. Nevertheless, there may be a subset of patients with micrometastatic lymph node involvement who can benefit from
lymphadenectomy (Giuliani et al, 1990). The need for routine performance of a complete lymphadenectomy in all cases is unresolved, and there
remains a divergence of clinical practice among urologists with respect to this aspect of radical nephrectomy.
The surgical approach for radical nephrectomy is determined by the size and location of the tumor as well as by the habitus of the patient. The
operation is usually performed through a transperitoneal incision to allow abdominal exploration for metastatic disease and early access to the
renal vessels with minimal manipulation of the tumor. I prefer an extended subcostal or bilateral subcostal incision for most patients. A
thoracoabdominal incision is used for patients with large upper pole tumors (Fig. 10227). I occasionally employ an extraperitoneal
flank incision to perform radical nephrectomy in elderly or poor-risk patients with a small tumor.
When performing radical nephrectomy through a subcostal transperitoneal incision, a thorough exploration for metastatic disease is performed
after opening the abdominal cavity. On the left side, the colon is reflected medially to expose the great vessels. This is facilitated by division of the
splenocolic ligaments, which also helps to avoid excessive traction and injury to the spleen.
On the right side, the colon and duodenum are reflected medially to expose the vena cava and aorta (Fig. 10228).
The operation is initiated with dissection of the renal pedicle. On the right side, the renal vein is short, and care must be taken not to injure the
vena cava. The right renal artery may be mobilized either lateral to the vena cava or, with a large medial tumor, between the vena cava and the
aorta (Fig. 10229).
On the left side, the renal vein is quite long as it passes over the aorta. The vein is mobilized completely by ligating and dividing gonadal, adrenal,
and lumbar tributaries. The vein can then be retracted to posteriorly expose the artery, which is then mobilized toward the aorta (Fig. 10230). The
renal artery is ligated with 20 silk ligatures and divided, and the renal vein is then similarly managed (Fig. 10231).
The kidney is mobilized outside Gerota's fascia with blunt and sharp dissection as needed. The remaining vascular attachments are secured with

nonabsorbable sutures or metal clips. The ureter is then ligated and divided to complete the removal of the kidney and adrenal gland (Fig.
10232).
The classic radical nephrectomy procedure includes the performance of a complete regional lymphadenectomy. The lymph nodes can
be removed either en bloc with the kidney and adrenal gland or separately after the nephrectomy. Lymph node dissection is begun at the
crura of the diaphragm just below the origin of the SMA. There is a readily definable periadventitial plane close to the aorta that can be entered so
that the dissection may be carried along the aorta and onto the origin of the major vessels to remove all periaortic lymphatic tissue. Care must be
taken to avoid injury to the origins of the celiac artery and SMA superiorly as they arise from the anterior surface of the aorta. The dissection of the
periaortic and pericaval lymph nodes is then carried downward en bloc to the origin of the inferior mesenteric artery. The sympathetic ganglia and
nerves are removed together with the lymphatic tissue. The cisterna chyli is identified medial to the right crus, and entering lymphatic vessels are
secured to prevent the development of chylous ascites.
A thoracoabdominal incision is preferable when performing radical nephrectomy for a large upper pole tumor. This approach is
demonstrated in Figures 10233 to 10235 for a right-sided tumor. Once the liver has been retracted upward into the chest, the hepatic flexure of
the colon and the duodenum is reflected medially to expose the anterior surface of the kidney and great vessels (Fig. 10233). The renal artery is
secured with 20 silk ligatures and divided, and the renal vein is then similarly managed (Fig. 10234). The ureter and right gonadal vein are
ligated and divided, and the kidney is mobilized outside Gerota's fascia. Downward and lateral traction of the kidney exposes the superior vascular
attachments of the tumor and adrenal gland. Exposure of these vessels is also facilitated by medial retraction of the IVC (Fig. 10235). Care is
taken to preserve small hepatic venous branches entering the vena cava at the superior margin of the tumor mass. The tumor mass is then gently
separated from the undersurface of the liver to complete the resection.

Management of Retroperitoneal Hemorrhage

During performance of radical nephrectomy, intraoperative hemorrhage can occur from the IVC or its tributaries. The urologist should be familiar
with methods of preventing or controlling this problem. In most cases, vena caval hemorrhage is caused by the laceration or avulsion of large yet
fragile veins entering the vena cava at predictable locations.
Lumbar veins enter the posterolateral aspect of the vena cava at each vertebral level, and undue traction on the cava can result in their
avulsion with troublesome bleeding. To prevent this, care should be taken to retract the vena cava very gently with curved vein retractors
during its dissection; if additional mobilization is necessary, these veins should be dissected free from surrounding structures, ligated, and divided.
In ligating venous tributaries entering the vena cava, 30 to 40 suture material should be used, and the ligatures should not be tied too tightly
because this can cause shearing through the fragile venous wall with further hemorrhage. After the ligature has been applied, it should not be
pulled too tightly before the ends of the ligature are cut, again for fear of avulsing the entrance of the vein into the vena cava.
A second predictable bleeding site is the entry of the right gonadal vein into the anterolateral surface of the vena cava. This is an
extremely thin-walled vein, and excessive traction or mobilization of the cava at this level can lead to its avulsion, with resulting hemorrhage.
A third predictable site of bleeding lies at the level of the renal veins, where large lumbar veins often course posteriorly from the left
renal vein just lateral to the aorta or from the posterior aspect of the vena cava close to the entry of the right renal vein. Injudicious
mobilization of the renal veins, without consideration of these fragile and often large-caliber veins, can result in severe hemorrhage that may be
difficult to control.
A fourth predictable site of bleeding is at the level of the right adrenal vein that enters the IVC. This vein is large and friable, frequently lies
higher than the surgeon expects, and must be carefully dissected free from surrounding structures to avoid avulsion from the vena cava.
Finally, excessive vena caval hemorrhage can be prevented by careful dissection in proper tissue planes along the vena cava. This may be
difficult when tumor involves the vena cava, but usually a plane can be established along the vena caval wall that, if followed, allows safe and
relatively bloodless exposure. One should follow the general principle of isolating a relatively normal area of vena cava and working upward or
downward from that level to expose the diseased portion.
If inadvertent vena caval laceration or avulsion of entering veins occurs, control of hemorrhage can be accomplished by a variety of techniques.
Direct pressure on the site of bleeding gives immediate control until additional exposure can be gained, the field properly illuminated, and
additional suckers or retractors brought in if necessary. If the laceration involves the anterior or lateral caval wall and is of considerable length, it
can be readily controlled by applying a series of Allis clamps over the edges of the laceration in serial fashion. The edges of the laceration are then
oversewn with running 50 vascular suture material (Fig. 10236).
If avulsion of an entering lumbar vein is the cause of bleeding, the vena cava should be rolled medially, with digital compression above and below
the site of bleeding, until the posterolateral entry of the avulsed vein is exposed. This is then grasped with one or two Allis clamps, which can be
used as tractors to bring the avulsion into better view for oversewing with vascular suture material. Persistent bleeding can occur from the proximal
end of an avulsed lumbar vein, which may retract into the psoas muscle and be difficult to secure. This can be controlled in some cases by
grasping the end of the vein with a hemostat and then twisting the hemostat to bring the end of the vein into better view for suture ligation (Fig.
10237). If this is not possible, bleeding can be controlled by inserting a figure-of-eight 20 silk suture through the muscle overlying the vein.

Bleeding from large lumbar veins entering the posterior aspect of the left renal vein or the posterior wall of the vena cava near the entry of the right
renal vein can be particularly troublesome (Fig. 10238). Further mobilization of the vena cava and renal veins is often needed while compression
is maintained on the bleeding site. It may be necessary to apply a Satinsky side clamp across the entry of the renal vein, as well as a distal bulldog
clamp beyond the bleeding point in the renal vein, to control the hemorrhage and allow closure of the venous defect. Mobilization and gentle
rotation of the vena cava and/or the renal veins may also be necessary to gain optimal exposure. In this situation, as well, distal entry of the
lumbar vein into the posterior musculature can cause troublesome bleeding and must be controlled as described previously.

Radical Nephrectomy with Infrahepatic Vena Caval Involvement

There are four levels of vena caval involvement in RCC that are characterized according to the distal extent of the tumor thrombus (Fig. 10239).
A bilateral subcostal transperitoneal incision usually provides excellent exposure for performing radical nephrectomy and removing a
perirenal or infrahepatic IVC thrombus. For extremely large tumors involving the upper pole of the kidney, a thoracoabdominal incision
may alternatively be used. After the abdomen is entered, the colon is reflected medially, and a self-retaining ring retractor is inserted to maintain
exposure of the retroperitoneum ( Fig. 10240A, Fig. 10241). The renal artery and the ureter are ligated and divided, and the entire kidney is
mobilized outside Gerota's fascia, leaving the kidney attached by only the renal vein ( Fig. 10240B, C). During the initial dissection, care is taken
to avoid unnecessary manipulation of the renal vein and vena cava.
The vena cava is then completely dissected from surrounding structures above and below the renal vein, and the opposite renal vein is also
mobilized. It is essential to obtain exposure and control of the suprarenal vena cava above the level of the tumor thrombus. If necessary,
perforating veins to the caudate lobe of the liver are secured and divided to allow separation of the caudate lobe from the vena cava. This
maneuver can allow an additional 2 to 3 cm of vena cava to be exposed superiorly. The infrarenal vena cava is then occluded below the thrombus
with a Satinsky venous clamp, and the opposite renal vein is gently secured with a small bulldog vascular clamp. Finally, in preparation for tumor
thrombectomy, a curved Satinsky clamp is placed around the suprarenal vena cava above the level of the thrombus ( Fig. 10240D).
The anterior surface of the renal vein is then incised over the tumor thrombus, and the incision is continued posteriorly with scissors, passing just
beneath the thrombus ( Fig. 10240E). In most cases, there is no attachment of the thrombus to the wall of the vena cava. After the renal vein has
been circumscribed, gentle downward traction is exerted on the kidney to extract the tumor thrombus from the vena cava ( Fig. 10240F). After the
gross specimen is removed, the suprarenal vena caval clamp may be released temporarily as the anesthetist applies positive pulmonary pressure;
this maneuver can ensure that any small remaining fragments of thrombus are flushed free from the vena cava. When the tumor thrombectomy is
completed, the cavotomy incision is repaired with a continuous 50 vascular suture ( Fig. 10240G).
In occasional cases, there is direct caval invasion of the tumor at the level of the entrance of the renal vein and for varying distances. This requires
resection of a portion of the vena caval wall. Narrowing of the caval lumen by up to 50% does not adversely affect maintenance of caval patency.
If further narrowing appears likely, caval reconstruction can be performed with a free graft of pericardium.
In some patients, more extensive direct growth of tumor into the wall of the vena cava is found at surgery. The prognosis for these patients is
generally poor, particularly when hepatic venous tributaries are also involved, and the decision to proceed with radical surgical excision must be
carefully considered. Several important principles must be kept in mind when undertaking en bloc vena caval resection. Resection of the infrarenal
portion of the vena cava can usually be done safely, because an extensive collateral venous supply has developed in most cases. With right-sided
kidney tumors, resection of the suprarenal vena cava is also possible provided the left renal vein is ligated distal to the gonadal and adrenal
tributaries, which then provide collateral venous drainage from the left kidney. With left-sided kidney tumors, the suprarenal vena cava cannot be
resected safely owing to the paucity of collateral venous drainage from the right kidney. In such cases, right renal venous drainage can be
maintained by preserving a tumor-free strip of vena cava, augmented, if necessary, with a pericardial patch; alternatively, the right kidney can be
autotransplanted to the pelvis, or an interposition graft of saphenous vein may be placed from the right renal vein to the splenic, inferior
mesenteric, or portal vein (Fig. 10241).

Radical Nephrectomy with Intrahepatic or Suprahepatic Vena Caval Involvement

In patients with RCC and an intrahepatic or suprahepatic IVC thrombus, the difficulty of surgical excision is significantly increased. In such cases,
the operative technique must be modified because it is not possible to obtain subdiaphragmatic control of the vena cava above the tumor
thrombus. Several different surgical maneuvers have been used to provide adequate exposure, prevent severe bleeding, and achieve complete
tumor removal in this setting (Cummings et al, 1979; Novick, 1980; Foster et al, 1988; Skinner et al, 1989; Burt, 1991).
One technique for obtaining vascular control involves temporary occlusion of the suprahepatic intrapericardial portion of the IVC. To reduce
hepatic venous congestion and troublesome backbleeding, the porta hepatis and SMA are also temporarily occluded (Skinner et al, 1989). A
disadvantage of this approach is that occlusion of the latter vessels can be safely tolerated for only 20 minutes. This approach is also not
applicable in cases of tumor extension into the right atrium. At the Cleveland Clinic, the preferred approach is to employ cardiopulmonary
bypass with deep hypothermic circulatory arrest for most patients with complex supradiaphragmatic tumor thrombi and for all patients
with right atrial tumor thrombi (Marshall and Reitz, 1986). A favorable experience with this approach was reported in 43 patients (Novick et al,
1990), and a subsequent study showed excellent long-term cancer-free survival after its use in patients with right atrial thrombi (Glazer and
Novick, 1996). The relevant technical aspects are described subsequently.

A bilateral subcostal incision is used for the abdominal portion of the operation. After resectability is confirmed, a median sternotomy is made (Fig.
10242). Intraoperative monitoring is accomplished with an arterial line, a multiple-lumen central venous pressure catheter, and a pulmonary
artery catheter. Nasopharyngeal and bladder temperatures are monitored. Anesthesia is induced with fentanyl, sufentanil, or thiopental and is
maintained with a narcotic inhalation agent (Welch et al, 1989).
The kidney is completely mobilized outside Gerota's fascia with division of the renal artery and ureter, such that the kidney is left attached by only
the renal vein. The infrarenal vena cava and contralateral renal vein are also exposed. Extensive dissection and mobilization of the suprarenal
vena cava are not necessary with this approach. Adequate exposure is somewhat more difficult to achieve for a left renal tumor. Simultaneous
exposure of the vena cava on the right and the tumor on the left is not readily accomplished simply by reflecting the left colon medially. I have
dealt with this by transposing the mobilized left kidney anteriorly through a window in the mesentery of the left colon while leaving the renal vein
attached. This maneuver yields excellent exposure of the abdominal vena cava with the attached left renal vein and kidney. Precise retroperitoneal
hemostasis is essential before proceeding with cardiopulmonary bypass owing to the risk of bleeding associated with systemic heparinization.
The heart and great vessels are exposed through the median sternotomy. The patient is heparinized, ascending aortic and right atrial venous
cannulas are placed, and cardiopulmonary bypass is initiated (Fig. 10243). When the heart fibrillates, the aorta is clamped, and crystalloid
cardioplegic solution is infused. Under circulatory arrest, deep hypothermia is initiated by reducing arterial inflow blood temperature as low as
10C. The head and abdomen are packed in ice during the cooling process. After approximately 15 to 30 minutes, a core temperature of 18C to
20C is achieved.
At this point, flow through the perfusion machine is stopped, and 95% of the blood volume is drained into the pump with no flow to any organ.
The tumor thrombus can now be removed in an essentially bloodless operative field. An incision is made in the IVC at the entrance of the involved
renal vein, and the ostium is circumscribed. When the tumor extends into the right atrium, the atrium is opened at the same time (Fig. 10244A). If
possible, the tumor thrombus is removed intact with the kidney. Frequently, this step is not possible because of the friability of the thrombus and its
adherence to the vena caval wall. In such cases, piecemeal removal of the thrombus from above and below is necessary. Under deep
hypothermic circulatory arrest, the entire interior lumen of the vena cava can be directly inspected to ensure that all fragments of
thrombus are completely removed. Hypothermic circulatory arrest can be safely maintained for at least 40 minutes without incurring a cerebral
ischemic event (Svensson et al, 1993). In difficult cases, this interval can be extended either by maintenance of "trickle" blood flow at a rate of 5 to
10 mL/kg per minute (Mault et al, 1993) or by adjunctive retrograde cerebral perfusion (Pagano et al, 1995).
After complete removal of all tumor thrombus, the vena cava is closed with a continuous 50 vascular suture and the right atrium is closed (Fig.
10244B). As soon as the vena cava and right atrium have been repaired, rewarming of the patient is initiated. If coronary artery bypass grafting is
necessary, it is done during the rewarming period. Rewarming takes 20 to 45 minutes and is continued until a core temperature of approximately
37C is obtained. Cardiopulmonary bypass is then terminated. Decannulation takes place, and protamine sulfate is administered to reverse the
effects of the heparin. Platelets, fresh frozen plasma, desmopressin acetate, or a combination may be provided when coagulopathy is suspected.
Aprotinin has also proved effective in reversing the coagulopathy associated with cardiopulmonary bypass (Bidstrup et al, 1989) but may induce
thrombotic complications. Mediastinal chest tubes are placed, but the abdomen is not routinely drained.
In patients with nonadherent supradiaphragmatic vena caval tumor thrombi that do not extend into the right atrium, venovenous bypass
in the form of a caval-atrial shunt is a useful technique (Foster et al, 1988; Burt, 1991). In this approach, the intrapericardial vena cava,
infrarenal vena cava, and opposite renal vein are temporarily occluded. Cannulas are then inserted into the right atrium and infrarenal vena cava.
These cannulas are connected to a primed pump to maintain adequate flow from the vena cava to the right heart (Fig. 10245). This avoids the
obligatory hypotension associated with temporary occlusion alone of the intrapericardial and infrarenal vena cava. After venovenous bypass is
initiated, the abdominal vena cava is opened and the thrombus is removed. If bleeding from the hepatic veins is troublesome during extraction of
the thrombus, the porta hepatis may also be occluded (Pringle's maneuver). After the thrombus is removed, repair of the vena cava is performed
as previously described. This technique is simpler than cardiopulmonary bypass with hypothermic circulatory arrest but may entail more operative
bleeding.

Complications

After radical nephrectomy, postoperative complications occur in approximately 20% of patients, and the operative mortality rate is
approximately 2% (Swansonand Borges, 1983). Systemic complications may occur as after any surgical procedure. These include myocardial
infarction, cerebrovascular accident, congestive heart failure, pulmonary embolism, atelectasis, pneumonia, and thrombophlebitis. The incidence
of these problems can be reduced by adequate preoperative preparation, avoidance of intraoperative hypotension, appropriate blood and fluid
replacement, postoperative breathing exercises, early mobilization, and elastic support of the legs both during and after surgery.
An intraoperative gastrointestinal injury should always be checked for during the procedure, and lacerations should be repaired and
drained. Tears of the livers may be repaired with mattress sutures. Splenic injuries usually require splenectomy, although small lacerations may
be managed by application of Avitene or Oxycel. Injuries to the tail of the pancreas, which may occur with left radical nephrectomy, are best
managed by partial amputation.
A particularly distressing postoperative complication is the development of a pancreatic fistula owing to unrecognized intraoperative
injury to the pancreas. This is usually manifested in the immediate postoperative period with signs and symptoms of acute pancreatitis and
drainage of alkaline fluid from the incision. A CT scan of the abdomen demonstrates fluid collection in the retroperitoneum. Fluid draining from the
incision should be analyzed for pH and the presence of amylase. Treatment involves percutaneous or surgical drainage of the fluid
collection to avoid the development of a pancreatic pseudocyst or abscess (Zinner et al, 1974; Spirnak et al, 1984). Most fistulas close
spontaneously with the establishment of adequate drainage. Because the healing of a pancreatic fistula is usually a slow process, the patient is
also supported with hyperalimentation. Surgical closure by excising the fistulous tract and creating an anastomosis between the pancreas and a
Roux-en-Y limb of the jejunum is only occasionally necessary in patients with prolonged drainage.
Other gastrointestinal problems that may occur include a generalized ileus or a functional obstruction caused by a localized ileus of the colon
overlying the operated renal fossa. Oral feedings should not be given until adequate bowel sounds are present and the patient has passed flatus.
Nasogastric suction is used in more severe cases. When a prolonged period of ileus is anticipated, or if the patient is in a poor nutritional state,
parenteral hyperalimentation should be instituted.
Secondary hemorrhage may occur after radical nephrectomy and is manifested by pain, signs of shock, abdominal or flank swelling, and drainage
of blood through the incision or a drain site. Bleeding may be from the kidney or renal pedicle but is occasionally from an unrecognized injury to a
neighboring structure such as the spleen, the liver, or a mesenteric vessel. Patients should be given blood and fluid replacement as needed. In
most cases, it is best to reopen the wound, evacuate the hematoma, and secure the bleeding point. In the event of diffuse bleeding from a clotting
disorder, it may be necessary to temporarily pack the wound with gauze, which can then be gradually removed after 24 to 48 hours.
Pneumothorax may occur during thoracoabdominal or flank incisions. Pleural injuries are usually recognized immediately and repaired
with a running 30 or 40 chromic suture. Before complete closure of the incision, a red rubber catheter is inserted into the pleural cavity and a
purse-string suture is tied around the catheter. The anesthesiologist is then asked to hyperinflate the lungs. With hyperinflation and suction on the
catheter, air and fluid in the hemithorax are forced out through the red rubber catheter, which is then removed, and the purse-string suture is
secured. An alternative method is to place the distal end of the catheter in a basin of water. As the anesthesiologist hyperinflates the lung, air and
fluid are forced out of the pleural cavity through the red rubber catheter and into the basin of water. When the pleura is entered, a chest x-ray
should be obtained in the recovery room to ensure adequate re-expansion of the lung. Pneumothorax greater than 10%, tension pneumothorax, or
pneumothorax that is causing respiratory distress requires insertion of a chest tube.
Postoperative atelectasis is common in patients undergoing radical nephrectomy and is probably secondary to the positioning of the patient during
the procedure. This is a common cause of fever postoperatively and may be effectively treated with pulmonary physiotherapy, including deep
breathing, coughing, and incentive spirometry.
Infection is a common complication encountered in the postoperative period. Superficial wound infections are best managed by removal of skin
sutures or staples to allow for drainage. Deeper infections must be treated by the establishment of adequate drainage and the administration of
appropriate antibiotics when there are systemic manifestations of the infection. If the drainage is persistent and profuse, the possibility of a
retained foreign body or a fistulous communication with the intestine should be considered. Accumulations of lymph or serous fluid in the renal
fossa or pleura are best managed expectantly, unless they are causing respiratory embarrassment. Such accumulations may become infected or
may be complicated by bleeding if they are treated by needle aspiration.
Temporary renal insufficiency may develop postoperatively after ligation of the left renal vein in conjunction with right radical
nephrectomy and extension of a vena caval tumor thrombus (Clark, 1961; Pathak, 1971). Renal failure in this setting is probably
secondary to venous obstruction and usually resolves as drainage improves with the development of venous collateralis, although
temporary hemodialysis may occasionally be needed. It is always preferable, if possible, to preserve left renal venous drainage into the vena
cava to diminish the risk of this complication. As previously mentioned, ligation of the right renal vein leads to permanent and complete renal
failure.
When a flank incision is used to perform nephrectomy, an incisional hernia or bulge may occur postoperatively. The intracostal nerve lies
immediately below the corresponding rib between the internal oblique and the transverse abdominal muscles. At surgery, an effort should be
made to spare this nerve by dissecting both proximally and distally, enabling careful padding and retraction of the nerve out of the operative field,
because transection may lead to muscle denervation. Postoperatively, muscle denervation with flank bulging must be differentiated from a flank
incisional hernia, which is rare. With the latter, a fascial defect is usually palpable.

Partial Nephrectomy for Malignancy

Interest in partial nephrectomy, or nephron-sparing surgery, for RCC has been stimulated by advances in renal imaging, improved surgical
techniques, increasing numbers of incidentally discovered low-stage RCCs, and good long-term survival in patients undergoing this form of
treatment. Partial nephrectomy entails complete local resection of a renal tumor while leaving the largest possible amount of normal functioning
parenchyma in the involved kidney.
Accepted indications for partial nephrectomy include situations in which radical nephrectomy would render the patient anephric with
subsequent immediate need for dialysis. This encompasses patients with bilateral RCC or RCC involving a solitary functioning kidney.
The latter circumstance may be present owing to unilateral renal agenesis, prior removal of the contralateral kidney, or irreversible impairment of
contralateral renal function from a benign disorder. Another indication for partial nephrectomy is represented by patients with unilateral
RCC and a functioning opposite kidney, when the opposite kidney is affected by a condition that might threaten its future function, such
as calculus disease, chronic pyelonephritis, renal artery stenosis, ureteral reflux, or systemic diseases such as diabetes and
nephrosclerosis (Licht and Novick, 1994).
Studies have clarified the role of partial nephrectomy in patients with localized unilateral RCC and a normal contralateral kidney. These data
indicate that radical nephrectomy and partial nephrectomy provide equally effective curative treatment for patients who present with a
single, small (less than 4 cm), and clearly localized RCC (Butler et al, 1995; Lerner et al, 1996). The results of partial nephrectomy are less
satisfactory in patients with larger (more than 4 cm) or multiple localized RCCs, and radical nephrectomy remains the treatment of choice in such
cases when the opposite kidney is normal. The long-term renal functional advantage of partial nephrectomy with a normal opposite kidney
requires further study. Partial nephrectomy is also occasionally indicated in the management of patients with renal pelvic transitional cell
carcinoma of Wilms' tumor when preservation of functioning renal parenchyma is a clinically relevant consideration (Zincke and Neves, 1984;
Ziegelbaum et al, 1987).
The technical success rate with partial nephrectomy for RCC is excellent, and several large studies have reported 5-year cancer-specific
survival rates of 87% to 90% in such patients (Morgan and Zincke, 1990; Steinbach et al, 1992; Licht and Novick, 1994). These survival rates
are comparable to those obtained after radical nephrectomy, particularly for low-stage RCC. The major disadvantage of partial nephrectomy for
RCC is the risk of postoperative local tumor recurrence in the operated kidney, which has been observed in 4% to 6% of patients (Morgan and
Zincke, 1990; Steinbach et al, 1992; Licht and Novick, 1994). These local recurrences are most likely a manifestation of undetected microscopic
multifocal RCC in the renal remnant. The risk of local tumor recurrence after radical nephrectomy has not been studied, but it is presumably very
low.
A study from the Cleveland Clinic reviewed the results of partial nephrectomy for treatment of localized sporadic RCC in 485 patients. The mean
postoperative follow-up was 4 years (Hafez et al, 1999). The overall and cancer-specific 5-year patient survival rates in the series were 81% and
92%, respectively. Recurrent RCC developed postoperatively in 44 patients (9%) including 16 (3.2%) with local recurrence in the remnant kidney
and 28 (5.8%) with metastatic disease. These data confirm that partial nephrectomy provides effective therapy for patients with localized RCC
when preservation of renal function is a clinical consideration.
Evaluation of patients with RCC for partial nephrectomy should include preoperative testing to rule out locally extensive or metastatic
disease. For most patients, preoperative renal arteriography to delineate the intrarenal vasculature aids in excising the tumor with minimal blood
loss and damage to adjacent normal parenchyma. This test can be deferred in patients with small peripheral tumors. Selective renal venography is
performed in patients with large or centrally located tumors to evaluate for intrarenal venous thrombosis secondary to malignancy (Angermeier et
al, 1990). The latter, if present, implies a more advanced local tumor stage and also increases the technical complexity of tumor excision. Threedimensional volume rendered CT is a noninvasive imaging modality that can accurately depict the renal parenchymal and vascular
anatomy in a format familiar to urologic surgeons (Coll et al, 1999). The data integrate essential information from arteriography,
venography, excretory urography, and conventional two-dimensional CT into a single imaging modality and obviate the need for more
invasive imaging (Fig. 10246).
In patients with bilateral large synchronous RCCs, I usually approach the kidney most amenable to a partial nephrectomy first. Then,
approximately 1 month after a technically successful result has been documented, I perform radical nephrectomy or a second partial nephrectomy
on the opposite kidney. Staging surgery in this fashion obviates the need for temporary dialysis if ischemic renal failure occurs after nephronsparing excision of RCC. In patients with bilateral, small, synchronous RCCs, bilateral simultaneous partial nephrectomies are performed.
It is usually possible to perform partial nephrectomy for malignancy in situ by using an operative approach that optimizes exposure of
the kidney and by combining meticulous surgical technique with an understanding of the renal vascular anatomy in relation to the tumor.
Preoperative hydration and mannitol administration are important adjuncts to ensure optimal renal perfusion at operation. I employ an
extraperitoneal flank incision through the bed of the 11th or 12th rib for almost all these operations; I occasionally use a thoracoabdominal incision
for very large tumors involving the upper portion of the kidney. These incisions allow the surgeon to operate on the mobilized kidney almost at skin
level and provide excellent exposure of the peripheral renal vessels (Fig. 10247). With an anterior subcostal transperitoneal incision, the kidney is
invariably located in the depth of the wound, and the surgical exposure is simply not as good. Extracorporeal surgery is rarely necessary in these
patients today.
When in situ partial nephrectomy is performed for malignancy, the kidney is mobilized within Gerota's fascia while the perirenal fat around the

tumor is left intact.

102-1 For small, peripheral renal tumors, it is not necessary to control the renal artery. In most other cases, however, partial
nephrectomy is most effectively performed after temporary renal arterial occlusion. This measure not only limits intraoperative bleeding but also,
by reducing renal tissue turgor, improves access to intrarenal structures. When possible, it is helpful to leave the renal vein patent throughout the
operation. This measure decreases intraoperative renal ischemia and, by allowing venous backbleeding, facilitates hemostasis by enabling
identification of small, transected renal veins. In patients with centrally located tumors, it is necessary to occlude the renal vein temporarily to
minimize intraoperative bleeding from transected major venous branches.

102-2

When the renal circulation is temporarily interrupted, in situ renal hypothermia is used to protect against postischemic renal injury. Surface cooling
of the kidney with ice slush allows up to 3 hours of safe ischemia without permanent renal injury. An important caveat with this method is to keep
the entire kidney covered with ice slush for 10 to 15 minutes immediately after occluding the renal artery and before commencing the partial
102-3 This amount of time is needed to obtain core renal cooling to a temperature (approximately 20C) that
nephrectomy (see Fig. 10247).
optimizes in situ renal preservation. During excision of the tumor, invariably, large portions of the kidney are no longer covered with ice slush and,
in the absence of adequate prior renal cooling, rapid rewarming and ischemic renal injury can occur. Cooling by perfusion of the kidney with a cold
solution instilled via the renal artery is not recommended owing to the theoretical risk of tumor dissemination. Mannitol is given intravenously 5
to 10 minutes before temporary renal arterial occlusion. Systemic or regional anticoagulation to prevent intrarenal vascular thrombosis
is not necessary.
A variety of surgical techniques are available for performing partial nephrectomy in patients with malignancy (Novick, 1998). These
include simple enucleation, polar segmental nephrectomy, wedge resection, transverse resection, and extracorporeal partial
nephrectomy with renal autotransplantation. All these techniques require adherence to basic principles of early vascular control,
avoidance of ischemic renal damage, complete tumor excision with free margins, precise closure of the collecting system, careful
hemostasis, and closure or coverage of the renal defect with adjacent fat, fascia, peritoneum, or Oxycel. Whichever technique is
employed, the tumor is removed with a small surrounding margin of grossly normal renal parenchyma. Intraoperative ultrasonography
is very helpful in achieving accurate tumor localization, particularly for intrarenal lesions that are not visible or palpable from the
external surface of the kidney (see Fig. 10245A) (Assimos et al, 1991; Campbell et al, 1995) (Fig. 10248).
When performing a transverse resection of the upper part of the kidney, care must be taken to avoid injury to the posterior segmental
renal arterial branch, which may also occasionally supply the basilar renal segment (Fig. 10249). Preoperative selective renal
arteriography with oblique views is integral to identifying and preserving the posterior segmental artery at surgery and to thereby avoid
devascularizing a major portion of the healthy remnant kidney. Midrenal resections may also be particularly complicated because the arterial
supply comprises branches of anterior and posterior renal artery divisions, and the calyces often enter the same infundibula as those draining the
upper and lower poles.
Whatever nephron-sparing technique is used, the parenchyma around the tumor is divided with a combination of sharp and blunt dissection.
102-4 In many cases, the tumor extends deeply into the kidney, and the collecting system is entered. Often, renal arterial and venous branches
supplying the tumor can be identified as the parenchyma is being incised, and these should be directly suture-ligated at that time while they are
most visible (Fig. 10250).

102-5 Similarly, in many cases, direct entry into the collecting system may be avoided by isolating and ligating

major infundibula draining the tumor-bearing renal segment as the incision into the parenchyma is developed (see Fig. 10250).

102-5

After excision of the tumor, the remaining transected blood vessels on the renal surface are secured with figure-of-eight 40 chromic sutures.
Bleeding at this point is usually minimal, and the operative field can be kept satisfactorily clear by gentle suction during placement of hemostatic
sutures. Residual collecting system defects are similarly closed with interrupted or continuous 40 chromic sutures. At this point, with the renal
artery still clamped but with the renal vein open, the anesthesiologist is asked to hyperinflate the lungs and thereby raise the central and renal
venous pressures. This forces blood out through residual, unsecured, transected veins on the renal surface and thereby facilitates their detection
(Fig. 10251). Once identified, these veins are secured with interrupted figure-of-eight 40 chromic sutures. The argon beam coagulator is a
useful adjunct for achieving hemostasis on the transected peripheral renal surface.

102-6

In most cases, after the renal vasculature and the collecting system are secured, the kidney is closed on itself by approximating the
transected cortical margins with simple interrupted 30 chromic sutures after placement of a small piece of Oxycel at the base of the
defect.
102-7 This is an important additional hemostatic measure. When it is done, the suture line must be free of tension and the blood
vessels supplying the kidney must be free of significant angulation or kinking. After the renal defect is closed, the renal artery is unclamped, and
102-8 When the remnant kidney resides within a large retroperitoneal fossa, the kidney is fixed to the
circulation to the kidney is restored.
posterior musculature with interrupted 30 chromic sutures to prevent postoperative movement or rotation of the kidney, which may compromise
the blood supply (Fig. 10252). A retroperitoneal drain is always left in place for at least 7 days, and an intraoperative ureteral stent is placed only
when major reconstruction of the intrarenal collecting system has been performed.
In patients with RCC or transitional cell carcinoma, partial nephrectomy is contraindicated in the presence of lymph node metastasis,
because the prognosis for these patients is poor. Enlarged or suspicious-looking lymph nodes should be biopsied before initiating the renal
resection. When partial nephrectomy is performed, after excision of all gross tumor, absence of malignancy in the remaining portion of
the kidney should be verified intraoperatively by frozen-section examinations of biopsy specimens obtained at random from the renal
margin of excision. Such biopsies do not usually demonstrate residual tumor, but if they do, additional renal tissue must be excised.

Segmental Polar Nephrectomy

In patients with malignancy confined to the upper or lower pole of the kidney, partial nephrectomy can be performed by isolating and ligating the
segmental apical or basilar arterial branch while allowing unrepaired perfusion to the remainder of the kidney from the main renal artery. This
procedure is illustrated in Figure 10253 for a tumor confined to the apical vascular segment. The apical artery is dissected away from the
adjacent structures, ligated, and divided. Often, a corresponding venous branch is present, which is similarly ligated and divided. An ischemic line
of demarcation then generally appears on the surface of the kidney and outlines the segment to be excised. If this area is not obvious, a few
milliliters of methylene blue can be directly injected distally into the ligated apical artery to better outline the limits of the involved renal segment.
An incision is then made in the renal cortex at the line of demarcation, which should be several millimeters away from the visible edge of the
cancer. The parenchyma is divided by sharp and blunt dissection, and the polar segment is removed. In cases of malignancy, it is not possible to
preserve a strip of capsule beyond the parenchymal line of resection for use in closing the renal defect. When the collecting system and
vasculature have been repaired, the edges of the kidney are reapproximated as an additional hemostatic measure, using simple, interrupted 30
chromic sutures inserted through the capsule and a small amount of parenchyma. Before these sutures are tied, perirenal fat or Oxycel can be
inserted into the defect for inclusion in the renal closure.

Wedge Resection
Wedge resection is an appropriate technique for removing peripheral tumors on the surface of the kidney, particularly ones that are larger or are
not confined to either renal pole. Because these lesions often encompass more than one renal segment, and because this technique is generally
associated with heavier bleeding, it is best to perform wedge resection with temporary renal arterial occlusion and surface hypothermia.
In performing a wedge resection, the tumor is removed with a several-millimeter surrounding margin of grossly normal renal parenchyma (Fig.
10254). The parenchyma is divided by a combination of sharp and blunt dissection. Often, prominent intrarenal vessels are identified as the
parenchyma is being incised. These may be directly suture-ligated at the time, while they are most visible. After excision of the tumor, the
collecting system and vasculature are then repaired as needed. The renal defect can then be closed in one of two ways (see Fig. 10254). The
kidney may be closed on itself by approximating the transected cortical margins with simple interrupted 30 chromic sutures after placing a small
piece of Oxycel at the base of the defect. If this is done, there must be no tension on the suture line and no significant angulation or kinking of
blood vessels supplying the kidney. Alternatively, a portion of perirenal fat may simply be inserted into the base of the renal defect as a hemostatic
measure and sutured to the parenchymal margins with interrupted 40 chromic sutures. After closure or coverage of the renal defect, the renal
artery is unclamped, and circulation to the kidney is restored.

Major Transverse Resection

A transverse resection is done to remove large tumors that extensively involve the upper or lower portion of the kidney. This technique is
performed using surface hypothermia after temporary occlusion of the renal artery. Major branches of the renal artery and vein supplying the
tumor-bearing portion of the kidney are identified in the renal hilus, ligated, and divided (Fig. 10255A). If possible, this should be done before
temporarily occluding the renal artery to minimize the overall period of renal ischemia.
After the renal artery is occluded, the parenchyma is divided by blunt and sharp dissection, leaving a several-millimeter margin of grossly normal
tissue around the tumor (Fig. 10255B). Transected blood vessels on the renal surface are secured as previously described, and the hilus is
inspected carefully for remaining unligated segmental vessels. If possible, the renal defect is sutured together with one of the techniques
previously described (Fig. 10255C). If this suture cannot be placed without tension or without distorting the renal vessels, a piece of peritoneum
or perirenal fat is sutured in place to cover the defect.

Partial Nephrectomy for Central Tumors

For patients with central tumors, complete delineation of the renal arterial and venous supply is mandatory for surgical planning. As
stated, this information can now be obtained with three-dimensional CT scanning, and invasive vascular imaging studies are no longer
necessary (Coll et al, 1999). In patients with central tumors, partial nephrectomy is most effectively performed after temporary occlusion of the
renal artery and vein. Renal vein occlusion is important to minimize intraoperative bleeding from transected major venous branches. The renal
artery and vein are occluded separately with individual atraumatic vascular clamps.
During the preliminary dissection, the kidney is mobilized within Gerota's fascia while leaving intact the perirenal fat around the tumor. There may
be relatively little perirenal fat to preserve with central tumors that extend into the renal hilus. The tumor is mobilized and isolated as much as
possible by dissecting away adjacent segmental renal vessels that provide critical blood supply to the nontumor-bearing part of the kidney
that is to be preserved.
The differences between the renal arterial and venous circulations must be borne in mind and may be used to advantage in these
operations. Because all segmental arteries are end arteries with no collateral circulation, all branches supplying tumor-free parenchyma must be

preserved to avoid devitalization of functioning renal tissue. However, the renal venous drainage system is different, in that intrarenal venous
branches intercommunicate freely among the various renal segments. Therefore, ligation of a branch of the renal vein does not result in
segmental infarction of the kidney because collateral venous blood supply provides adequate drainage. This is important clinically because it
enables one to obtain safe surgical access to central tumors in the renal hilus by ligating and dividing small adjacent or overlying
venous branches. This allows the main renal vein to be completely mobilized and freely retracted in either direction to expose a central tumor
with no vascular compromise of uninvolved parenchyma (Fig. 10256). At this stage, small, segmental arterial branches that directly supply the
tumor can also be secured and divided. If the portion of kidney or tumor supplied by a segmental artery is not readily apparent, temporary
occlusion of the branch with a miniature vascular clamp can resolve this by enabling direct visualization of the ischemic supplied renal tissue.
When dissecting on the posterior renal surface, particular care must be taken to avoid injury to the posterior segmental renal arterial branch, which
has a variable location and may also occasionally supply the basilar renal segment; if this is the case, failure to identify and preserve this branch
can lead to devascularization of a major portion of the healthy remnant kidney.
The object of the preliminary dissection is to isolate the tumor and to secure as much of its direct blood supply as possible before clamping the
main renal artery and vein, so that overall warm renal ischemia time can be minimized. Intraoperative ultrasonography is also performed before
temporary renal vascular occlusion for the same reason. The primary value of this adjunctive imaging modality is for localization of intrarenal
tumors that are not visible or palpable from the external surface of the kidney. A prospective study demonstrated that intraoperative
ultrasonography is of limited value for detecting occult multicentric tumors in the kidney (Campbell et al, 1996).
After temporary occlusion of the renal artery and vein, the mobilized and isolated tumor is resected by incision of the attachment to the renal
parenchyma. Often, small renal arterial and venous branches supplying the tumor can be identified as the parenchyma is being incised, and these
should be directly suture-ligated at that time while they are most visible. While a surrounding margin of normal parenchyma should be removed
with the tumor, a wide margin of normal renal tissue is often not available for hilar tumors that may, in part, impinge directly on the central
collecting system. It is sufficient to remove these tumors with all adjacent renal sinus fat and with a 3- to 4-mm margin of surrounding normal
parenchyma where this is available.
In most cases, after securing the renal vessels and the collecting system, the kidney is closed on itself by approximating the transected cortical
margins with interrupted sutures as an additional hemostatic measure. When this is done, the parenchymal suture line must be free of tension and
the blood vessels supplying the kidney must be free of significant angulation or kinking. After closure of the renal defect, the renal artery is
unclamped, and circulation to the kidney is restored.

Simple Enucleation
Some RCCs are surrounded by a distinct pseudocapsule of fibrous tissue (Vermooten, 1950). The technique of simple enucleation implies
circumferential incision of the renal parenchyma around the tumors simply and rapidly at any location, often with no vascular occlusion and with
maximal preservation of normal parenchyma.
Initial reports indicated satisfactory short-term clinical results after enucleation, with good patient survival and low rate of local tumor recurrence
(Graham and Glenn, 1979; Jaeger et al, 1985). However, most studies suggested a higher risk of leaving residual malignancy in the kidney
when enucleation is performed (Rosenthal et al, 1984; Marshall et al, 1986; Blackley et al, 1988). These reports included several carefully done
histopathologic studies that demonstrated frequent microscopic tumor penetration of the pseudocapsule surrounding the neoplasm. These data
indicated that it is not always possible to be assured of complete tumor encapsulation before surgery. Local recurrence of tumor in the treated
kidney is a grave complication of partial nephrectomy for RCC, and every attempt should be made to prevent it. Therefore, it is my view that a
surrounding margin of normal parenchyma should be removed with the tumor whenever possible. This provides an added margin of safety against
the development of local tumor recurrence and, in most cases, does not appreciably increase the technical difficulty of the operation. The
technique of enucleation is currently employed only in occasional patients with von HippelLindau disease and multiple low-stage
encapsulated tumors involving both kidneys (Spencer et al, 1988).

Extracorporeal Partial Nephrectomy and Autotransplantation

Extracorporeal partial nephrectomy for RCC with autotransplantation of the renal remnant was initially described by several surgeons (Calne,
1973; Gittes and McCullough, 1975) as an approach to facilitate successful excision of large complex tumors involving the renal hilus.
Reconstruction of kidneys with RCC as well as renal artery disease may be facilitated with this approach (Campbell et al, 1993). The practical and
theoretical advantages of an extracorporeal approach include optimum exposure, a bloodless surgical field, the ability to perform a more precise
operation with maximum conservation of renal parenchyma, and greater protection of the kidney from prolonged ischemia. Disadvantages of
extracorporeal surgery include longer operative time with the need for vascular and ureteral anastomoses and increased risk of temporary and
permanent renal failure (Campbell et al, 1994); the latter presumably reflects a more severe intraoperative ischemic insult to the kidney. Whereas
some urologic surgeons have found that almost all patients undergoing partial nephrectomy for RCC can be managed satisfactorily in
situ (Novick et al, 1989), others have continued to recommend an extracorporeal approach for selected patients (Morgan and Zincke,
1990).
Extracorporeal partial nephrectomy and renal autotransplantation are generally performed through a single midline incision. The kidney is
mobilized and removed outside Gerota's fascia with ligation and division of the renal artery and vein as the last steps in the operation (Fig.

10257A). Immediately after dividing the renal vessels, the removed kidney is flushed with 500 mL of a chilled intracellular electrolyte solution and
is submerged in a basin of ice slush saline solution to maintain hypothermia. Under these conditions, if warm renal ischemia has been minimal, the
kidney can safely be preserved outside the body for as much time as needed to perform extracorporeal partial nephrectomy.
If possible, it is best to leave the ureter attached in such cases to preserve its distal collateral vascular supply, particularly with large
hilar or lower renal tumors in which complex excision may unavoidably compromise the blood supply to the pelvis, ureter, or both.
When this procedure is done, the extracorporeal operation is performed on the abdominal wall. If the ureter is left attached, it must be occluded
temporarily to prevent retrograde blood flow to the kidney when it is outside the body. Often, unless the patient is thin, working on the abdominal
wall with the ureter attached is cumbersome because of the tethering and restricted movement of the kidney. If these are observed, the ureter
should be divided and the kidney placed on a separate workbench. This practice provides better exposure for the extracorporeal operation, and,
as this is being done, a second surgical team can simultaneously prepare the iliac fossa for autotransplantation. If concern exists about the
adequacy of ureteral blood supply, the risk of postoperative urinary extravasation can be diminished by restoring urinary continuity through direct
anastomosis of the renal pelvis to the retained distal ureter.
Extracorporeal partial nephrectomy is performed with the flushed kidney preserved under surface hypothermia (Fig. 10257B). After the tumor has
been completely resected, the renal remnant may be reflushed or placed on the pulsatile perfusion unit to facilitate identification and suture ligation
of remaining potential bleeding points (Fig. 10257C). The kidney can be alternatively perfused through the renal artery and vein to ensure both
arterial and venous hemostasis. Because the flushing solution and perfusate lack clotting ability, there may continue to be some parenchymal
oozing, which can safely be ignored. If possible, the defect created by the partial nephrectomy is closed by suturing the kidney on itself to further
ensure a watertight repair (Fig. 10257D).
Autotransplantation into the iliac fossa is done, employing the same vascular technique as that for renal allotransplantation. Urinary continuity may
be restored with ureteroneocystostomy or pyeloureterostomy, leaving an internal ureteral stent in place. After autotransplantation, a Penrose drain
is positioned extraperitoneally in the iliac fossa away from the vascular anastomotic sites.

Complications
Complications of partial nephrectomy include hemorrhage, urinary fistula formation, ureteral obstruction, renal insufficiency, and
infection. Significant intraoperative bleeding can occur in patients who are undergoing partial nephrectomy. The need for early control and ready
access to the renal artery is emphasized. Postoperative hemorrhage may be self-limiting, if confined to the retroperitoneum, or it may be
associated with gross hematuria. The initial management of postoperative hemorrhage is expectant, with bed rest, serial hemoglobin and
hematocrit determinations, frequent monitoring of vital signs, and blood transfusions as needed. Angiography may be helpful in some patients to
localize actively bleeding segmental renal arteries, which may be controlled via angioinfarction. Severe intractable hemorrhage may necessitate reexploration with early control of the renal vessels and ligation of the active bleeding points.
Postoperative urinary flank drainage after a partial nephrectomy is common and usually resolves as the collecting system closes with
healing. Persistent drainage suggests the development of a urinary cutaneous fistula. This diagnosis can be confirmed by determination of the
creatinine level of the drainage fluid and by intravenous injection of indigo carmine with subsequent appearance of the dye in the drainage fluid.
The majority of urinary fistulas resolve spontaneously if there is no obstruction of urinary drainage from the involved renal unit. If the perirenal
space is not adequately drained, a urinoma or abscess may develop. An intravenous pyelogram or a retrograde pyelogram should be obtained to
rule out obstruction of the involved urinary collecting system. In the event of hydronephrosis or persistent urinary leakage, an internal ureteral stent
is placed. If this is not possible, a percutaneous nephrostomy may be inserted. Most urinary fistulas resolve spontaneously with proper
conservative management, although it may take several weeks in some cases. A second operation to close the urinary fistula is rarely necessary.
Ureteral obstruction can occur after partial nephrectomy because of postoperative bleeding into the collecting system with resulting
clot obstruction of the ureter and pelvis. This obstruction can lead to temporary extravasation of urine from the renal suture line. In most cases,
expectant management is appropriate and the obstruction resolves spontaneously with lysis of the clots. When urinary leakage is excessive, or in
the presence of intercurrent urinary infection, placement of an internal ureteral stent can help to maintain antegrade ureteral drainage.
Varying degrees of renal insufficiency often occur postoperatively when partial nephrectomy is performed in a patient with a solitary kidney. This
insufficiency is a consequence of both intraoperative renal ischemia and removal of some normal parenchyma along with the diseased
portion of the kidney. Such renal insufficiency is usually mild and resolves spontaneously with proper fluid and electrolyte
management. Also, in most cases, the remaining parenchyma undergoes compensatory hypertrophy that serves to further improve renal function.
Severe renal insufficiency may require temporary or permanent hemodialysis, and the patients should be aware of this possibility preoperatively.
Postoperative infections are usually self-limiting if the operative site is well drained and in the absence of existing untreated urinary infection at the
time of surgery. Unusual complications of partial nephrectomy include transient postoperative hypertension and aneurysm or arteriovenous fistula
in the remaining portion of the parenchyma (Snodgrass and Robinson, 1964; Rezvani et al, 1973).
A study detailed the incidence and clinical outcome of technical or renal-related complications occurring after 259 partial nephrectomies for renal
tumors at the Cleveland Clinic (Campbell et al, 1994). In the overall series, local or renal-related complications occurred after 78 operations
(30.1%). The incidence of complications was significantly less for operations performed after 1988 and significantly less for incidentally detected
versus suspected tumors. The most common complications were urinary fistula formation and acute renal failure. A urinary fistula occurred after
45 of 259 operations (17%). Significant predisposing factors for a urinary fistula included central tumor location, tumor smaller than 4 cm, need for

major reconstruction of the collecting system, and ex vivo surgery. Only one urinary fistula required open operative repair, whereas the remainder
resolved either spontaneously (n=30) or with endoscopic management (n=14).
Acute renal failure occurred after 30 of 115 operations (26%) performed on a solitary kidney. Significant predisposing factors for acute renal failure
were tumor larger than 7 cm, more than 50% parenchymal excision, longer than 60 minutes ischemia time, and ex vivo surgery. Acute renal
failure resolved completely in 25 patients, of whom 9 (8%) required temporary dialysis; 5 patients (4%) required permanent dialysis.
Overall, only eight complications (3.1%) required repeat open surgery for treatment, whereas all other complications resolved with nonintervention
or endourologic management. Surgical complications contributed to an adverse clinical outcome in only 7 patients (2.9%). These data indicate that
partial nephrectomy can be performed safely with preservation of renal function in most patients with renal tumors.

Postoperative Follow-Up
Patients who undergo nephron-sparing surgery for RCC are advised to return for initial follow-up 4 to 6 weeks postoperatively. At that time, a
serum creatinine measurement and intravenous pyelogram are obtained to document renal function and anatomy; in patients with impaired overall
renal function, a renal ultrasound study is obtained instead of an intravenous pyelogram.
A study from the Cleveland Clinic analyzed tumor recurrence patterns after partial nephrectomy in 327 patients with sporadic localized RCC
(Hafez et al, 1997). The purpose of this study was to develop appropriate guidelines for long-term surveillance after nephron-sparing surgery for
RCC. RCC occurred postoperatively in 38 patients (11.6%), including 13 patients (4.0%) who developed local tumor recurrence and 25 patients
(7.6%) who developed metastatic disease. The incidence of postoperative local tumor recurrence and metastatic disease, respectively, according
to initial pathologic tumor stage was as follows: 0% and 4.4% for stage T1 RCC, 2% and 5.3% for stage T2 RCC, 8.2% and 11.5% for stage T3a
RCC, and 10.6% and 14.9% for stage T3b RCC. The peak postoperative intervals for developing local tumor recurrence were 6 to 24 months (in
stage T3 RCC patients) and more than 48 months (in stage T2 RCC patients).
These data indicate that surveillance for recurrent malignancy after nephron-sparing surgery for RCC can be tailored according to the initial
pathologic tumor stage. All patients should be evaluated with medical history, physical examination, and selected blood studies on a yearly basis.
The latter should include serum calcium, alkaline phosphatase, liver function tests, blood urea nitrogen, serum creatinine, and electrolytes.
The need for postoperative radiographic surveillance studies varies according to the initial pathologic tumor (pT) stage. Patients who undergo
nephron-sparing surgery for pT1 RCC do not require radiographic imaging postoperatively in view of the very low risk of recurrent malignancy. A
yearly chest radiograph is recommended after nephron-sparing surgery for pT2 or pT3 RCC because the lung is the most common site of
postoperative metastasis in both groups. Abdominal or retroperitoneal tumor recurrence is uncommon in pT2 patients, particularly early after
nephron-sparing surgery, and these patients require only occasional follow-up abdominal CT scanning; I recommend that this be done every 2
years for this category. Patients with pT3 RCC have a higher risk of developing local tumor recurrence, particularly during the first 2 years after
nephron-sparing surgery, and they may benefit from more frequent follow-up abdominal CT scanning initially; I recommend that this be done every
6 months for 3 years and every 2 years thereafter. If a local recurrence is found without metastatic disease, either a second partial nephrectomy or
a total nephrectomy may be performed (Novick and Straffon, 1987).
It is also important to recognize that patients with less than one kidney are at higher risk for developing proteinuria, glomerular damage, and
impaired renal function as a result of glomerular hyperfiltration (Soloman et al, 1985; Foster et al, 1991). In one study, long-term renal function was
evaluated in 14 patients with a solitary kidney who underwent partial nephrectomy for localized malignancy (Novick et al, 1991). Preoperatively,
there was no clinical or histopathologic evidence of primary renal disease. Postoperative renal function remained stable in 12 patients, whereas 2
patients developed end-stage renal failure. A total of nine patients had proteinuria: low grade (less than 750 mg/day) in four patients and moderateto-severe (930 to 6740 mg/day) in five patients. A statistically significant association was found between more proteinuria and a reduced amount
of remaining renal tissue as well as a longer follow-up interval. A renal biopsy was done in four patients with moderate-to-severe proteinuria that,
in each case, showed focal segmental or global glomerulosclerosis.
These data suggest that patients with more than 50% reduction in overall renal mass are at the greatest risk for proteinuria,
glomerulopathy, and progressive renal failure. Structural or functional renal damage in such cases is usually antedated by the
appearance of proteinuria. Therefore, the follow-up of patients after partial nephrectomy in a solitary kidney should include a 24-hour
urinary protein determination in addition to the usual renal function and tumor surveillance studies. Patients who have proteinuria
(more than 150 mg/day) may be treated with a low-protein diet and a converting enzyme inhibitor agent, which appear to be beneficial in
preventing glomerulopathy caused by reduced renal mass (Meyer et al, 1985; Novick and Schreiber, 1995).

Partial Nephrectomy for Benign Disease

Partial nephrectomy is also indicated in selected patients with localized benign pathology of the kidney (Leach and Lieber, 1980). The indications
include (1) hydronephrosis with parenchymal atrophy or atrophic pyelonephritis in a duplicated renal segment; (2) calyceal diverticulum
complicated by infection or stones, or both; (3) calculus disease with obstruction of the lower pole calyx or segmental parenchyma disease with
impaired drainage (Papathanassiadis and Swinney, 1966; Bates et al, 1981); (4) renovascular hypertension owing to segmental parenchymal
damage or noncorrectable branch renal artery disease (Aoi et al, 1981; Parrott et al, 1984); (5) traumatic renal injury with irreversible damage to a
portion of the kidney (Gibson et al, 1982); and (6) removal of a benign renal tumor such as an angiomyolipoma or oncocytoma (Maatman et al,
1984).
The preoperative considerations are similar to those in patients undergoing partial nephrectomy for malignancy. In most cases, a vascular imaging
study should be performed to delineate the main and segmental renal arterial supplies. The same measures should be taken to minimize
intraoperative renal damage from ischemia. The preferred surgical approach is usually through an extraperitoneal flank incision, except in cases of
renal trauma, which are best approached anteriorly. The surgical techniques are similar to those described for malignant renal disease.
When performing an apical or basilar partial nephrectomy for benign disease, the segmental apical or basilar arterial branch is secured and the
parenchyma is divided at the ischemic line of demarcation, without the need for temporary renal arterial occlusion. More complex transverse or
wedge renal resections are best performed with temporary renal arterial occlusion and ice-slush surface hypothermia. When employing the
technique of transverse renal resection for a benign disorder, the renal capsule is excised and reflected off the diseased parenchyma for
subsequent use in covering the renal defect (Fig. 10258). The technical aspects of partial nephrectomy for benign disease are otherwise the
same as those described for malignancy, with adherence to the same basic principles of appropriate vascular control, avoidance of ischemic renal
damage, precise closure of the collecting system, careful hemostasis, and closure or coverage of the renal defect.

Heminephrectomy in Duplicated Collecting Systems

Because the indications for partial nephrectomy in this setting are usually hydronephrosis and parenchymal atrophy of one of the two segments,
the demarcation of the tissue to be removed is usually very evident. The atrophic parenchyma lining the dilated system can be further delineated
by blue pyelotubular backflow if the ureter is ligated and the affected collecting system is distended by blue dye under pressure. In such cases,
there is also often a dual arterial supply with distinct segmental branches to the upper and lower halves of the kidney. Segmental arterial and
venous branches to the diseased portion of the kidney are ligated and divided. After a strip of renal capsule is preserved, the parenchyma is
divided at the observed line of demarcation. There is usually minimal bleeding from the renal surface, and temporary occlusion of the arterial
supply to the nondiseased segment is often unnecessary. There should be no entry into the collecting system over the transected renal surface,
which is then closed or covered as described previously.

Renal Arterial Reconstruction

There are two main categories of renal artery disease, atherosclerosis and fibrous dysplasia, which account for approximately 80% and
20% of all such lesions, respectively. Other unusual causes of renal artery disease include arterial aneurysm, arteriovenous fistula,
neurofibromatosis, extrinsic obstruction of the renal artery, middle aortic syndrome, and renal artery thrombosis or embolism. Intervention may be
indicated in these disorders to treat associated hypertension, to preserve renal function, or to prevent rupture of an arterial aneurysm.
The role of surgical therapy in the management of these patients has changed for several reasons (Novick and McElroy, 1985). These
include the advent of percutaneous transluminal angioplasty (PTA) and stenting as alternative effective forms of treatment for certain
patients, the development of new and more effective techniques for surgical revascularization, and an enhanced appreciation of
advanced atherosclerotic renal artery disease as a correctable cause of renal failure. Surgical revascularization remains the treatment
of choice for patients with branch renal artery disease, with an ostial atherosclerotic lesion, with an arterial aneurysm, or in whom PTA
has been unsuccessful. Surgical revascularization continues to provide excellent long-term results in properly selected patients with renal artery
disease (Novick et al, 1987; Steinbach et al, 1997).
A variety of factors must be assessed in determining whether surgical treatment is appropriate for a given patient. These include the causal
relationship of renal vascular disease to hypertension, the adequacy of blood pressure control with medical therapy, the natural history of
untreated renal vascular disease with attention to the risk for renal function impairment, the medical condition of the patient, and the known results
of surgical therapy and other interventions such as PTA or renal artery stents.
Advances in surgical renovascular reconstruction have limited the role of total or partial nephrectomy in the management of patients
with renal artery disease. These operations are occasionally indicated in patients with renal infarction, severe arteriolar nephrosclerosis, severe
renal atrophy, and noncorrectable renovascular lesions. Nephrectomy may also be indicated in elderly, poorsurgical risk patients with a normal
contralateral kidney or after a failed revascularization procedure.

Indications for Treatment

Renovascular Hypertension
The coexistence of hypertension and renal artery disease does not always imply a causal relationship between the two. Renal artery
disease is far more common than renovascular hypertension. Classically, renovascular hypertension is a retrospective diagnosis rendered
when hypertension resolves after intervention to correct a renal artery lesion. The term now commonly refers to renin-mediated hypertension as a
result of renal artery disease. Clinical clues to suggest renovascular hypertension include age younger than 30 years or older than 50 years,
abrupt onset and short duration of hypertension, presence of extrarenal vascular disease, end-organ damage such as left ventricular hypertrophy
or high-grade hypertensive retinopathy, systolic-diastolic abdominal bruit, and deterioration of renal function in response to an angiotensinconverting enzyme inhibitor (ACEI). In patients who have a moderate clinical suggestion of renovascular hypertension, a number of noninvasive
tests have been developed that identify patients with renovascular hypertension and help predict the outcome of intervention treatment.
For patients with renovascular hypertension owing to fibrous dysplasia, candidacy for surgical intervention is guided by the specific
pathologic process, as determined by angiographic findings, and its associated natural history (Stewart et al, 1970). Medical management
of medial fibroplasia is the initial approach because loss of renal function from progressive obstruction is uncommon, and intervention is reserved
for those patients with difficult-to-control hypertension. Renal artery disease owing to intimal or perimedial fibroplasia is often associated
with progressive obstruction, which can result in ischemic renal atrophy. Therefore, early intervention is recommended to improve blood
pressure control and to preserve renal function.
The known results of PTA are important in assessing the need for surgery in patients with fibrous dysplasia. Technical and clinical success
rates with PTA for fibrous disease of the main renal artery are 90% to 95% and are no different from results obtainable with surgery
(Novick, 1994a, 1994b). Still, up to 30% of patients may present with branch disease or aneurysm that is not amenable to PTA. Surgery is then
reserved for patients with peripheral, complex branch disease or for those who have failed PTA.
Renal artery aneurysms may require repair if they result in significant hypertension or to prevent rupture when they are larger than 2 cm
and noncalcified (Novick, 1982). This is a particular concern in women of reproductive age because of the predisposition for rupture during
pregnancy.
For patients with atherosclerosis and RVH, the indications for intervention are more restrictive owing to the frequent presence of concomitant
extrarenal vascular disease. More vigorous attempts at medical management for this group are warranted. Surgical revascularization is reserved
for those patients whose hypertension cannot be satisfactorily controlled with mediation or when renal function becomes threatened by advanced
vascular disease. Whereas PTA is associated with a successful blood pressure result for nonostial atherosclerosis, the long-term
success rate with ostial lesions is poor owing to a higher incidence of restenosis (Novick, 1994a, 1994b). The results with endovascular
stenting for ostial lesions are better than those with PTA; however, surgical revascularization remains the definitive long-term therapy
for these patients (Steinbach et al, 1997).

Ischemic Nephropathy
Epidemiologic studies suggest that atherosclerotic renovascular disease is common in patients with generalized atherosclerosis obliterans
regardless of the presence of renovascular hypertension. The development of chronic renal insufficiency from atherosclerotic renal artery
disease, known as ischemic nephropathy, has become an important clinical issue that is separate and distinct from the problem of RVH.
Knowledge of the natural history of atherosclerotic renal artery disease permits identification of patients at risk for ischemic nephropathy
(Schreiber et al, 1984).
Those at highest risk are patients with high-grade stenosis (more than 75%) involving the entire renal mass (bilateral disease or disease
in a solitary kidney). Intervention in these patients is for the purpose of preservation of renal function. Many of these patients are older,
with diffuse extrarenal vascular disease and ostial renal artery disease. Clinical clues suggesting ischemic nephropathy include azotemia
(unexplained or associated with ACEI treatment), diminished renal size, and vascular disease in other sites (cerebrovascular disease, coronary
artery disease, or peripheral vascular disease).
In considering a patient for revascularization, a determination of the potential for renal salvage must be made (Novick, 1996a, 1996b). All testing in
this regard is aimed at identifying the presence of severe underlying renal parenchymal disease, in which case restoration of renal blood flow
would not result in recovery of renal function. Successful revascularization usually results when the affected kidney is larger than 9 cm and
demonstrates some evidence of function (usually assessed by isotopic renal scan). Total occlusion of the renal artery is not a contraindication for
repair because the viability of the kidney can be maintained by collateral circulation, which is demonstrable by angiography. Patients with mild-tomoderate renal dysfunction are acceptable surgical candidates; however, surgical revascularization is generally not worthwhile for
patients with advanced azotemia (serum creatinine more than 4 mg/dL) owing to the presence of significant underlying renal
parenchymal disease. An exception to this rule is the small number of patients with significant renal functional impairment and bilateral
total renal artery occlusion when one or both kidneys remain viable on the basis of collateral circulation. Such kidneys otherwise meet
criteria for revascularization (i.e., adequate size and with minimal parenchymal disease). Although such a presentation is uncommon, these
patients can have favorable outcomes with surgical revascularization. Finally, in equivocal cases, a renal biopsy is performed at the time of
revascularization. Preservation of the majority of glomeruli is the most important element of a favorable biopsy. Excessive glomerular hyalinization
precludes performance of surgical revascularization. Tubular atrophy, interstitial fibrosis, and arteriolar sclerosis are less important and do not
preclude consideration for revascularization.

Preoperative Considerations
Patients with atherosclerotic renal artery disease who are considered for surgical revascularization should undergo screening and
correction of significant associated extrarenal vascular disease, such as coronary and carotid disease. With aggressive treatment of
coexisting extrarenal vascular disease before surgical renal revascularization, perioperative morbidity and mortality can be minimized.
Before surgery, all patients require arteriography. For most patients, I use digital subtraction angiography with iodinated contrast material
because accurate anatomic information can be obtained with limited exposure to the contrast agent. In selected cases, carbon dioxide
angiography can be used, which eliminates the risk for contrast-related nephrotoxicity. In addition to anteroposterior views of the renal artery and
aorta, I routinely obtain a lateral aortogram, to assess the celiac artery, and a view of the lower thoracic aorta. These additional views are obtained
in anticipation of the use of extra-anatomic bypass procedures.
Many patients have bilateral disease, especially those with ischemic nephropathy. Because the morbidity of bilateral procedures is greater and
disease is frequently asymmetrical, I usually perform unilateral renal revascularization. In cases of renovascular hypertension, the more
extensively diseased artery is repaired, and for ischemic nephropathy, the larger kidney is repaired.
All patients undergoing surgical renal revascularization are hydrated well before surgery. Because renovascular hypertension is associated
with secondary hyperaldosteronism, potassium supplementation and monitoring of serum potassium levels are needed to guard against
hypokalemia. To further ensure optimal renal perfusion and an active diuresis intraoperatively, 12.5 g of mannitol is given intravenously
before commencing the operation; equivalent doses of mannitol are subsequently given before revascularization, immediately after
revascularization, and again in the recovery room.

Aortorenal Bypass
Although a variety of surgical revascularization techniques are available for treating patients with renal artery disease, aortorenal bypass with a
free graft of autogenous saphenous vein or hypogastric artery remains the preferred method in patients with a nondiseased abdominal
aorta (Straffon and Siegel, 1975; Novick et al, 1977a, 1977b; Stoney and Olofsson, 1988). Although an arterial autograft is theoretically
advantageous, use of the hypogastric artery as a bypass graft is limited by its short length and frequent involvement with atherosclerosis.
Therefore, the autogenous saphenous vein is most often employed, and excellent clinical results continue to be achieved with this type of bypass
graft. It is important to note that the gonadal vein should never be used as a renal artery bypass graft. This vein is extremely friable and may either
rupture postoperatively or undergo severe dilation. Currently, aortorenal bypass with a synthetic material is indicated only when an
autogenous vascular graft is not available, and polytetrafluoroethylene has become the synthetic graft of choice in such cases (Khauli et
al, 1984; Cormier et al, 1990).
To perform an aortorenal bypass on the right side, the kidney is exposed by reflecting the ascending colon medially and using Kocher's maneuver
on the duodenum (Fig. 10259). The liver and gallbladder are retracted upward, taking care to protect the hepatic ligament with its vessels and
common bile duct. Exposure of the right renal artery, right renal vein, IVC, and aorta is thereby obtained. The Buckwalter self-retaining ring
retractor is inserted to maintain exposure. Gerota's fascia is opened laterally to expose the surface of the kidney so that its color and consistency
may be observed.
The aorta is exposed from the level of the left renal vein to the inferior mesenteric artery, ligating overlying lymphatic vessels and lumbar
segmental branches as necessary to gain exposure. The proximal aspect of the right renal artery is exposed by mobilizing and retracting the vena
cava laterally and the left renal vein superiorly, carrying the dissection along the anterolateral aspect of the aortic wall until the renal artery origin is
encountered.
The distal two thirds of the main right renal artery are exposed by retracting the mobilized vena cava medially and the right renal vein superiorly.
To accomplish this, it is often necessary to secure and divide one or more lumbar veins entering the posterior aspect of the vena cava. There are
generally no significant tributaries of the right renal vein. After exposure of the right renal artery, it is then mobilized from its attached and
surrounding lymphatics and nerves. Small vessels and lymphatics are secured by light electrocautery or fine suture ligatures.
The bypass graft is placed along the lateral aortic wall to determine the best position for placement of the graft (Fig. 10260). At this point, the ring
retractor blades are relaxed to allow the aorta to return to its normal position and to prevent distortion of an otherwise well-placed graft after the
final retraction is released.
On the right side, it is important to bring the graft off the anterolateral aspect of the aortic wall to avoid kinking of the proximal anastomosis as the
graft passes in front of the vena cava. If the aortotomy is made too far anteriorly or posteriorly, the graft may kink, with subsequent development of
stenosis or thrombosis. On the left side, the graft may be placed directly off the lateral aspect of the aorta.
An end-to-side anastomosis of the bypass graft to the aorta is done first to minimize the time of renal ischemia (Fig. 10261). A DeBakey clamp is
placed to occlude the aorta, taking care to avoid compression of the mesenteric and contralateral renal arteries. In most cases, the lateral aortic

wall is only partially occluded, thereby preserving distal aortic flow and obviating the need for systemic heparinization. In some patients with a
small abdominal aorta (e.g., children, young females), better exposure is obtained by placing the DeBakey clamp completely across the aorta; this
maneuver totally interrupts aortic blood flow, and, in this event, systemic heparinization is initiated before aortic clamping.
An oval aortotomy is made on the anterolateral wall of the aorta. If significant atherosclerosis of the perirenal aorta is present, a local
endarterectomy is performed to remove atheromatous plaque from the region of the anastomosis.
The bypass graft is spatulated for a short distance and, if length permits, the apex of the spatulation is generally placed at the caudal end of the
aortotomy so that the graft can follow a gentle curve as it emerges from the aorta. If the aortotomy is located a significant distance below the distal
renal artery or if the graft is short, as on the side, then the apex is reversed cephalad to avoid kinking of the aortorenal bypass graft. Two corner
sutures of 60 silk are inserted 180 degrees apart to begin the anastomosis.
The anastomosis is performed with interrupted 60 arterial sutures, and the anterior wall of the anastomosis is completed first. The aorta is rotated
anteriorly to expose the posterior wall of the anastomosis, which is similarly completed with interrupted 60 arterial sutures. The graft is occluded
beyond its origin with a bulldog clamp, and the aortic clamp is gently released. An arterial leakage is corrected at this time with additional sutures
as needed. The bulldog clamp is intermittently released to ensure good blood flow and to flush the graft free of any atherosclerotic fragments. The
graft distal to the clamp is then irrigated with heparin solution.
The main renal artery is then mobilized in its entirety, if this has not already been done. The renal artery is ligated proximally, a bulldog clamp is
placed distally, and the diseased arterial segment is excised and sent for pathologic examination (Fig. 10262). Before the distal anastomosis is
performed, 10 mL of diluted heparin solution are instilled into the distal renal artery.
The bypass graft is brought anterior to the vena cava to lie in proximity to the distal renal artery. The graft is trimmed as necessary to allow a
tension-free end-to-end anastomosis with no redundancy in the length of the graft. The graft and distal renal artery are spatulated to create a wider
anastomosis, which minimizes the possibility of subsequent stenosis. The anastomosis is performed with 60 arterial sutures. Stay sutures, 180
degrees apart, are placed in the cephalic and caudal margins of the anastomosis. An end-to-end anastomosis of the graft to the renal artery is
preferred over an end-to-side technique because it provides better flow rates, is easier to perform, and allows removal of the diseased renal
arterial segment for pathologic study. The anastomosis is performed with interrupted 60 arterial sutures (Fig. 10263).
The proximal and distal bulldog clamps are released, and circulation to the kidney is restored. Adequate renal perfusion is verified by palpating the
pulse in the distal renal artery and by visually inspecting the renal surface. Arterial anastomotic leakage, if present, is controlled with Oxycel cotton
and/or additional 60 interrupted arterial sutures (Fig. 10264). Fig. 10265
Surgical revascularization is more complicated when the disease extends into the branches of the renal artery or when vascular
reconstruction is required for a kidney supplied by multiple renal arteries. When disease-free distal arterial branches occur outside the
renal hilus, aortorenal bypass operation can usually be done in situ. The size of the involved vessels is not a significant factor because, using
microvascular instruments and optical magnification, vessels as small as 1.5 mm in diameter can be repaired in situ. There are several variations
of the standard aortorenal bypass technique, which may be used to repair branch renal artery disease. Because the bypass graft must be
sufficiently long to reach the renal artery branches, an autogenous saphenous vein graft is the graft of choice in these cases.
In patients with disease involving two or more renal artery branches, I have found that aortorenal bypass with a branched vascular graft offers the
most useful and versatile technique for in situ vascular reconstruction (Fig. 10265) (Streem and Novick, 1982). These end-to-side anastomoses
are done with interrupted 70 arterial sutures and lead to creation of a multibranched graft that can be used to replace several diseased renal
artery branches. After insertion of the proximal graft into the aorta, direct end-to-end anastomosis of each graft branch to a renal artery branch is
done. During performance of each individual branch anastomosis, the remainder of the kidney continues to be perfused, and overall renal
ischemia is thus limited to the time required for completion of a single end-to-end anastomosis (approximately 15 to 20 minutes), which is an
important advantage.
Renal artery aneurysms have a variable presentation, and vascular involvement may be focal or diffuse (Poutasse, 1976; Novick, 1982). Saccular
aneurysms are the most commonly encountered type of renal artery aneurysm and are often located at the initial bifurcation or
trifurcation of the main renal artery. When the aneurysm is located outside the renal hilus, in situ excision may be done. If the renal artery wall
at the base of the aneurysm is intact, aneurysmectomy with either primary closure or patch angioplasty with a segment of saphenous vein can be
performed (Fig. 10266). If the entire circumference of the renal artery wall is diseased, then aortorenal bypass with a branched autogenous
vascular graft is done as described earlier (Ortenberg et al, 1983).

Alternative Bypass Techniques

In older patients with renal artery disease, involvement of the abdominal aorta with severe atherosclerosis, aneurysmal disease, or
dense fibrosis from a prior operation may render an aortorenal bypass or endarterectomy technically difficult and potentially hazardous
to perform. Simultaneous aortic replacement and renal revascularization are associated with operative mortality rates of 5% to 30% (Brewster et
al, 1976; Shahian et al, 1980; Dean et al, 1984; Tarazi et al, 1987) compared with rates of 2% to 6% (Novick et al, 1987; Libertino et al, 1992) for
renal revascularization without aortic replacement. Dean and associates (1984) analyzed various risk factors to identify patients at greatest risk
from a combined aortic and renal operation. The most significant risk factors were myocardial infarction, existing myocardial ischemia or
ventricular hypertrophy, a serum creatinine level higher than 3 mg/dL, diffuse peripheral vascular disease, and revascularization of both renal
arteries at the time of aortic replacement. Although operative mortality was 0% if none of these risk factors was present, it increased to 63% if
three or more were present. Therefore, simultaneous aortic replacement and renal revascularization should be considered only in patients
with a significant aortic aneurysm or symptomatic aortoiliac occlusive disease. In the absence of a definite indication for aortic replacement,
alternative bypass techniques are preferable because they can safely and effectively restore renal arterial blood flow while avoiding the
need for a more hazardous operation. These alternative bypass operations include hepatorenal bypass, splenorenal bypass, iliorenal bypass,
thoracic aortorenal bypass, and mesenterorenal bypass. The relative indications, surgical technique, and efficacy of these approaches are
reviewed here.
In considering patient eligibility for alternative visceral renal arterial bypass operations, the absence of occlusive disease involving the donor artery
must be verified by preliminary arteriography. Candidates for hepatorenal or splenorenal bypass must be evaluated with both
anteroposterior and lateral abdominal aortography to ensure that the celiac artery and its branches are unobstructed. Pelvic
arteriography is a requisite study in patients considered for an iliorenal bypass. If thoracic aortorenal revascularization is contemplated,
lower thoracic aortography must be obtained.
Surgical revascularization has been performed more often to preserve renal function in patients with ischemic nephropathy from
atherosclerotic renal artery disease. Such patients are generally older, with ostial renal artery lesions and diffuse atherosclerosis involving other
major abdominal vessels. Significant atherosclerotic occlusive disease involving the celiac and iliac arteries may preclude use of these vessels for
renal revascularization. Abdominal aortographic findings were reviewed in 254 patients with atherosclerotic renal artery disease to document the
prevalence of associated abdominal aortic and visceral arterial atherosclerosis (Fergany et al, 1995). All patients were evaluated with both
anteroposterior and lateral aortography. The renal, celiac, superior mesenteric, and common iliac arteries were evaluated for the presence and
severity of stenosis. The incidence of moderate (50% to 75%) or severe (more than 75%) visceral artery stenosis was determined in patients with
varying degrees of renal artery stenosis (Table 1021).
In the overall group of 254 patients with atherosclerotic renal artery stenosis, the incidence of significant celiac and iliac artery stenosis was 54%
and 50%, respectively. Patients with severe renal artery stenosis bilaterally or in a solitary kidney are of greatest interest because they compose
the most common candidate group for revascularization to preserve renal function. In this group, the incidence of significant celiac and iliac artery
stenosis was 59% and 58%, respectively. Patients with severe unilateral renal artery stenosis also occasionally require revascularization to treat
poorly controlled hypertension. In this group, the incidence of significant celiac and iliac stenosis was 52% and 30%, respectively (Fig. 10267). A
majority (75% to 81%) of patients in both of these groups had significant abdominal aortic atherosclerosis, which would preclude abdominal
aortorenal revascularization. These findings underscore the prevalence of celiac and iliac arterial occlusive disease in these patients, which, if
present, obviates use of these vessels for renal revascularization. The only other published study relevant to this issue is from Valentine and
colleagues (1991), who noted celiac artery stenosis in 17 of50 patients (34%) and with more than 50% renal artery stenosis and in 10 of 20 (50%)
with more than 75% renal artery stenosis.

Splenorenal Bypass
Splenorenal bypass is the preferred vascular reconstructive technique for patients with a troublesome aorta who require left renal
revascularization (Khauli et al, 1975; Brewster and Darling, 1979). Transposition of the splenic artery by retroduodenal passage for right renal
revascularization has been unsatisfactory and is not recommended. A requisite for performing splenorenal bypass is the demonstration on
preoperative aortography, with both anteroposterior and lateral views, of widely patent celiac and splenic arteries. The splenic artery must also be
carefully examined intraoperatively for intramural atheromatous disease, which may be minimally occlusive and therefore not apparent on
angiography, but significant nonetheless. This problem, which is more commonly observed in women than in men, also mitigates against use of
the splenic artery for renal revascularization.
The normal anatomic relationships of the splenic and renal vessels are shown in Figure 10268. To perform splenorenal bypass, an extended left
subcostal transperitoneal incision is made, and the left colon and duodenum are reflected medially. The plane between Gerota's fascia and the
pancreas is developed by blunt dissection, and the pancreas and spleen are gently retracted cephalad. The left renal vein is mobilized and
retracted inferiorly to expose the main left renal artery. The pancreas is gently retracted upward to permit access to the splenic vessels (Fig.
10269). The splenic artery may be palpated posterior and superior to the splenic vein, and that portion lying closest to the distal aspect of the
renal artery is chosen for mobilization. Small pancreatic arterial branches are divided and secured with fine silk sutures. The splenic artery may be
quite tortuous and should be mobilized proximally as close to the celiac artery as possible, where the vessel wall is thicker and the luminal
diameter larger.
After mobilization, the splenic artery is occluded proximally with a bulldog clamp, ligated distally with a 20 silk suture, and transected. It is not
necessary to remove the spleen, which receives adequate collateral supply from the short gastric and gastric epiploic vessels to maintain its
viability. After transection, the splenic artery is often observed to be in spasm with a considerably reduced luminal size. After irrigation of the lumen
with diluted heparin solution, the spasm can be relieved by gentle dilation of the splenic artery with graduated sounds. In general, there is no

significant disparity in the caliber of the splenic and renal arteries, and a direct end-to-end anastomosis is performed (Fig. 10270). I prefer this
type of anastomosis because it provides better flow, is easier to perform, and allows removal of the diseased arterial segment for pathologic study
(Fig. 10271). An alternative method for performing splenorenal bypass involves end-to-side anastomosis of the splenic artery to the distal
disease-free renal artery. I have employed this technique only in the unusual event of significant disparity in the caliber of the splenic and renal
arteries.
The advantages of the splenorenal bypass technique are that the operation is done well away from the aorta, that only a single vascular
anastomosis is necessary, and that revascularization is accomplished with an autogenous vascular graft. In properly selected patients,
splenorenal bypass is an excellent method for performing vascular reconstruction of the left kidney.

Hepatorenal Bypass
Hepatorenal bypass is the preferred vascular reconstructive technique for patients with a troublesome aorta who require right renal
revascularization. The hepatic circulation is ideally suited for a visceral right renal arterial bypass operation. The liver receives 28% of
the cardiac output in resting adults and is unique in having dual circulation from the portal vein and the hepatic artery, which contribute
80% and 20% of hepatic blood flow, respectively. Hepatic oxygenation is equally derived from these two circulations. It has been well
demonstrated that hepatic artery flow can be safely interrupted. When this occurs, hepatic function and morphology are maintained by
increased extraction of oxygen from portal venous blood and by rapid development of an extensive collateral arterial flow to the liver (Novick et al,
1979).
The hepatic artery arises from the celiac axis and runs anterior to the portal vein and to the left of the common bile duct. The first major branch is
the gastroduodenal artery, and thereafter the hepatic artery divides into its right and left branches. In considering a hepatorenal bypass operation,
one of the more clinically significant anatomic variations is origin of the right hepatic artery from the SMA, which occurs in about 12% of patients.
The left hepatic artery arises from the gastric artery in approximately 11.5% of patients.
In patients considered for a hepatorenal bypass operation, preoperative aortography with lateral views must demonstrate patent celiac and hepatic
arteries. In my experience, the hepatic artery is rarely involved with atherosclerosiscertainly less often than the splenic artery. Hepatorenal
bypass should also be undertaken only when preoperative biochemical screening reveals normal liver function. The most common method of
performing hepatorenal bypass is with an interposition saphenous vein graft anastomosed end-to-side to the common hepatic artery, just beyond
the gastroduodenal origin, and then end-to-end to the right renal artery (Fig. 10272). This technique preserves distal hepatic arterial flow and
thereby reduces the risk of ischemic liver damage.
In some patients, the common hepatic artery cannot be employed in this manner for hepatorenal revascularization, either because it is smaller
than the renal artery or because of an anatomic variation in which the right and left hepatic arterial branches have separate origins. In these
situations, the available major hepatic arteries are generally of insufficient caliber to maintain adequate blood flow to both the liver and the right
kidney. It is then preferable to perform end-to-end anastomosis of the common, right, or left hepatic arteries to the right renal artery (Fig. 10273)
(Novick and McElroy, 1985). In some patients, a direct tension-free anastomosis of these vessels can be done; otherwise, an interposition
saphenous vein graft is needed. Despite the resulting total or segmental hepatic dearterialization in these patients, postoperative liver function
studies have remained normal. However, the gallbladder is more susceptible to ischemic damage and may undergo necrosis when its
blood supply from the right hepatic artery is interrupted.
Strategies are available to avoid the complication of gallbladder ischemia in patients undergoing end-to-end hepatorenal revascularization. First,
when separate right and left hepatic arteries are present, the left hepatic artery should be used preferentially for anastomosis with the renal artery.
Second, if it is necessary to use the common or right hepatic arteries in this manner, an adjunctive cholecystectomy should be performed. A third
option is to perform end-to-end anastomosis of the gastroduodenal and renal arteries, with an interposition saphenous vein graft if necessary (Fig.
10274). However, the origin and course of the gastroduodenal artery must be such that proximal kinking does not occur when this vessel is
rotated toward the right kidney. It is also somewhat more difficult to mobilize an adequate length of this artery, and care must be taken to avoid
damage to the duodenum or pancreas. This technique is not as widely applicable as other methods of hepatorenal revascularization, but it does
offer the advantage of preserving hepatic arterial flow.
The results of hepatorenal bypass for right renal arterial occlusive disease have been excellent (Fig. 10275) and indicate that this is a safe and
effective operative approach in properly selected patients with a diseased abdominal aorta (Chibaro et al, 1984).

Thoracic Aortorenal Bypass

Use of the thoracic aorta for renal revascularization is a new surgical alternative for patients with significant abdominal aortic
atherosclerosis, celiac artery stenosis, and no primary indication to replace the abdominal aorta. The subdiaphragmatic supraceliac and
descending thoracic aorta are often relatively free of disease in such patients and can be used to achieve renal vascular reconstruction
with an interposition saphenous vein graft (Fry and Fry, 1989; Novick, 1994a, 1994b). Preoperative angiographic evaluation should include
views of the supraceliac and thoracic aorta to verify their disease-free status.
For left renal revascularization, I have employed the descending thoracic aorta as a donor site because I believe that it is more readily accessible
than the subdiaphragmatic supraceliac aorta (Fig. 10276). A left thoracoabdominal incision is made below the eighth rib and extended medially
across the midline. This incision provides excellent simultaneous exposure of the thoracic aorta and renal artery with no need for extensive
abdominal visceral mobilization. The left colon is reflected medially to expose the kidney and renal artery. The descending thoracic aorta is
exposed above the diaphragm and is partially occluded laterally with a DeBakey clamp. A small aortotomy is made, a reversed saphenous vein
graft is anastomosed end-to-side to the aorta, and the aortic clamp is then removed. During performance of the proximal anastomosis, distal aortic
flow is preserved and systemic heparinization is therefore not employed. A 2-cm incision is then made in the diaphragm just lateral to the aorta to
enlarge the hiatus. The saphenous vein graft is passed alongside the aorta, through the diaphragmatic hiatus, posterior to the pancreas, and into
the left retroperitoneum. End-to-end anastomosis of the vein graft and distal left renal artery is performed to complete the operation (Fig. 10277).
On the right side, the subdiaphragmatic supraceliac or lower thoracic aorta is equally accessible through an anterior bilateral subcostal incision.
The technique of thoracic aortorenal bypass is otherwise analogous to that described on the left side.
I reported my initial results with thoracic aortorenal bypass in 23 patients with hypertension, abdominal aortic atherosclerosis, and celiac artery
stenosis; in 21 patients, renal artery stenosis was present bilaterally or in a solitary kidney (Novick, 1994a, 1994b). There was one operative death
owing to myocardial infarction. Postoperatively, among the remaining 22 patients, hypertension was cured or improved in 19 (86%), and renal
function was stable or improved in 21 (95%).
Thoracic aortorenal revascularization is an attractive approach for several reasons. The thoracic aorta provides an excellent inflow source, and the
proximal end-to-side vein graft anastomosis yields an antegrade acute angle that is hemodynamically advantageous. Because the thoracic aorta is
only partially occluded during performance of the proximal anastomosis, distal aortic flow is preserved and systemic heparinization is unnecessary.
The potential morbidity of aortic cross-clamping, which includes the risk of spinal cord ischemia, is avoided. The period of renal ischemia is also
minimal and is limited to the time required for completion of the distal anastomosis, which is 15 to 20 minutes. Revascularization of the kidney is
achieved with an autogenous vascular graft, which is the optimal material for renal artery replacement. Finally, use of the invariably healthy
thoracic aorta minimizes the risk of peripheral embolization.

Iliorenal Bypass
Iliorenal bypass is an occasionally useful technique for revascularization in patients with severe aortic atherosclerosis, provided there
is satisfactory flow through the diseased aorta and absence of significant iliac disease (Novick and Banowsky, 1979). My approach is to
consider this operation only when a splenorenal, hepatorenal, or thoracic aortorenal bypass cannot be done. This preference is based on the fact
that aortic atherosclerosis may continue to progress in these patients, and, if so, this process is most likely to involve the intrarenal aorta. Such a
development might then compromise flow to a revascularized kidney whose blood supply is derived exclusively from one of the iliac arteries. The
suprarenal and supraceliac aorta are more often spared from progressive atherosclerosishence, my preference for bypass procedures
originating from these locations.
In general, iliorenal bypass is performed using the ipsilateral iliac artery because this simplifies exposure of the operative field (Fig. 10278). This
is a relatively minor consideration, and use of the contralateral common iliac artery is also satisfactory, particularly if it is less diseased than the
ipsilateral counterpart. Iliorenal bypass is performed through a midline transperitoneal incision after harvesting a long saphenous vein graft. The
colon is reflected medially to obtain simultaneous exposure of the ipsilateral common iliac and renal arteries. The common iliac artery is occluded
proximally and distally with bulldog clamps. An oval arteriotomy is made on the anterolateral aspect of the common iliac artery. The distal clamp is
temporarily released to enable 20 mL of diluted heparin solution to be instilled into the distal iliac and femoral arteries. Systemic heparinization is
not routinely employed.
The proximal end of the saphenous vein graft is spatulated, and the apex of the spatulation is placed at the cephalic end of the arteriotomy. Stay
sutures are placed in both cephalic and caudal margins of the anastomosis, which is then completed with interrupted 60 arterial sutures. A
bulldog clamp is placed across the proximal portion of the vein graft, and the iliac clamps are removed, restoring circulation to the lower extremity.
The saphenous vein graft follows a direct cephalad course toward the ipsilateral renal artery between the aorta medially and the ureter laterally.
An end-to-end anastomosis of the saphenous vein graft to the distal disease-free renal artery is then performed with interrupted 60 arterial
sutures. The graft is positioned to allow a tension-free distal anastomosis while avoiding angulation or kinking of the renal artery.

Mesenterorenal Bypass

In unusual cases, aortography reveals an enlarged SMA that may then be employed for visceral arterial bypass to either kidney (Fig.
10279 ). I have employed the superior mesenterorenal bypass technique in occasional patients with a troublesome aorta in whom a
bypass to the kidney from the celiac or iliac arteries was not possible (Khauli et al, 1985a, 1985b). The finding of an enlarged and widely
patent SMA is most often observed in patients with total occlusion of the infrarenal aorta. In such cases, the SMA has a wider caliber than
normal because it is supplying collateral vessels to areas ordinarily vascularized from the infrarenal aorta (i.e., large bowel, pelvis, and lower
extremities). Use of such an enlarged SMA for performance of a mesenterorenal bypass has been well tolerated, with no compromise of intestinal
blood flow. I have not used this approach in patients with normal-sized SMA and cannot comment on its efficacy in this setting.
To perform mesenterorenal bypass, the abdomen is entered through a midline incision. During revascularization of the left kidney, the descending
colon and splenic flexure are reflected medially, and a plan of dissection is developed between the pancreas and Gerota's fascia. Exposure of the
suprarenal aorta is obtained by gentle retraction of the pancreas and the first portion of jejunum cephalad, while the mesocolon is reflected
medially. If necessary, additional exposure may be obtained by mobilization and evisceration of the right colon and small bowel, as is done
commonly for retroperitoneal lymphadenectomy. The SMA can be palpated readily at its origin from the aorta approximately 1 to 2 cm above the
level of the renal arteries. The vessel lies against the neck of the pancreas as it courses between the neck and the uncinate process. The artery
then crosses the third part of the duodenum to enter the large bowel mesentery, where it lies posterior and to the left of the superior mesenteric
vein. The SMA is mobilized for a distance of 2 to 3 cm beyond its origin, where it is most accessible and without branches. The left renal artery
then is exposed and isolated similarly. A reversed segment of saphenous vein is anastomosed end-to-side to the lateral aspect of the SMA with
interrupted 60 vascular sutures. After completion of this anastomosis, which generally takes 15 to 20 minutes, blood flow through the SMA is
restored immediately, and the saphenous vein graft is occluded temporarily. End-to-end anastomosis of the vein graft to the left renal artery is then
done with interrupted 60 vascular sutures.
During revascularization of the right kidney, the ascending colon and duodenum are reflected medially to gain exposure of the aorta and right renal
artery. The ascending colon and small bowel are then rotated back to their normal position, and the SMA is palpated where it crosses the third
portion of the duodenum. The SMA is mobilized and isolated in this location for a distance of 3 to 4 cm. A saphenous vein graft is sutured end-toside to this portion of the SMA, and the graft is then passed through a tunnel in the root of the small bowel mesentery, after a gentle curve as it
crosses the third portion of the duodenum to enter the right retroperitoneum. End-to-end anastomosis of the graft to the right renal artery is
performed to complete the operation.

Extracorporeal Microvascular Branch Renal Artery Reconstruction

Vascular disease involving the branches of the renal artery is most often caused by one of the fibrous dysplasiasnamely, intimal,
medial, or perimedial fibroplasia. Other causes of branch disease include arterial aneurysm, arteriovenous malformation, Takayasu's
arteritis, neurofibromatosis, trauma, and, rarely, atherosclerosis. In such cases, the task of renovascular reconstruction is considerably more
complicated because it necessitates multiple vascular anastomoses to renal artery branches that may be difficult to expose and are small in
caliber. For these reasons, many patients in this category were formerly considered inoperable or candidates for total or partial nephrectomy.
However, technical advances have improved this outlook, and successful vascular reconstruction is now possible in most patients. This evolution
has primarily been due to the incorporation of microvascular and extracorporeal techniques into the armamentarium of the renovascular surgeon.
Branch renal artery lesions can often be repaired in situ with an aortorenal bypass when distal branches free of disease are present
outside the renal hilus (Novick, 1980). Extracorporeal branch arterial repair and autotransplantation are indicated primarily when
preoperative arteriography, with oblique views, demonstrates intrarenal extension of renovascular disease (Salvatierra et al, 1978;
Novick, 1981a, 1981b; Dubernard et al, 1985; Dean et al, 1986). The advantages of employing an extracorporeal surgical approach include
optimum exposure and illumination, bloodless surgical field, greater protection of the kidney from ischemia, and more facile employment of
microvascular techniques and optical magnification. Removing and flushing the kidney also cause it to contract in size, thereby enabling more
peripheral dissection in the renal sinus for mobilization of distal arterial branches. Finally, the completed branch anastomosis can be tested for
patency and integrity before autotransplantation.
In evaluating patients for extracorporeal revascularization and autotransplantation, preoperative renal and pelvic arteriography should
be performed to define renal arterial anatomy, to ensure disease-free iliac vessels, and to assess the hypogastric artery and its
branches for use as a reconstructive graft. Assuming the presence of a viable functioning kidney, the only absolute contraindication to this
approach is such severe aortoiliac vascular disease as to preclude renal autotransplantation. It is also best to avoid autotransplantation of kidneys
involved by severe renal parenchymal or small vessel disease. Such kidneys generally flush poorly after their removal, often leading to irreversible
ischemic damage and nonfunction.
Extracorporeal revascularization and autotransplantation are generally performed through an anterior subcostal transperitoneal incision combined
with a separate, lower-quadrant, transverse semilunar incision. For nonobese patients, a single midline incision extending from the xiphoid
process to the symphysis pubis may be used. The same intraoperative measures are taken as in live donor nephrectomy for allotransplantation to
ensure minimal renal ischemia and immediate function after revascularization. These measures include prevention of hypotension during
anesthesia, administration of mannitol, minimal surgical manipulation of the kidney, and rapid flushing and cooling of the kidney after its removal.
Systemic heparinization before nephrectomy is unnecessary.
Immediately after its removal, the kidney is flushed intra-arterially with 500 mL of a chilled intracellular electrolyte solution and is then submerged
in a basin of ice-slush saline to maintain hypothermia (Fig. 10280). The extracorporeal operation is completed under ice-slush surface
hypothermia, and, if there has been minimal warm renal ischemia, the kidney can be safely preserved in this manner for many more hours than

are needed to perform even the most complex renal repair. In performing extracorporeal revascularization, I have found it cumbersome to work on
the abdominal wall with the ureter attached. It is preferable to divide the ureter and place the kidney on a separate workbench. This provides better
exposure for the extracorporeal operation and allows a second surgical team to prepare the iliac fossa simultaneously. This approach is also
justified by the low incidence of complications after ureteroneocystostomy in renal allotransplantation.
Extracorporeal branch arterial reconstruction is performed with microvascular instruments, 70 to 90 suture material, and optical magnification
with loupes (3.5 or 6) or an operating microscope. The basic instruments required for microvascular surgery include a microneedle holder,
microscissors, fine jeweler's forceps, small vessel dilators, microvascular clamps, and a 10-mL syringe with a 27-gauge blunt needle for irrigation.
After removal and flushing of the kidney, and with maintenance of surface hypothermia, the renal artery branches are mobilized distally in the renal
sinus beyond the area of vascular disease (Fig. 10281). During this dissection, care is taken not to interfere with ureteral or renal pelvic blood
supply. When the diseased renal artery branches are completely exposed, an appropriate technique for vascular reconstruction is selected.
The optimal method for extracorporeal branch renal artery repair involves the use of a branched autogenous vascular graft (Novick, 1981a,
1981b). This technique permits separate end-to-end microvascular anastomosis of each graft branch to a distal renal artery branch (Fig. 10282).
A hypogastric arterial autograft is the preferred material for vascular reconstruction because this vessel may be obtained intact with several of its
branches (Fig. 10283).
Occasionally, the hypogastric artery is not suitable for use as a reconstructive graft because of atherosclerotic degeneration. When this occurs, a
long segment of saphenous vein can be harvested and, employing sequential end-to-side microvascular anastomoses, a branched graft can be
fashioned from this vessel. This branched graft is then used in a similar manner to achieve reconstruction of the diseased renal artery branches
(Fig. 10284).
Branched grafts of the hypogastric artery and saphenous vein may occasionally prove too large in caliber for anastomosis to small secondary or
tertiary renal arterial branches. In these cases, the inferior epigastric artery provides an excellent alternative free graft for extracorporeal
microvascular repair (Novick, 1981a, 1981b). This artery measures 1.5 to 2 mm in diameter, is rarely diseased, and coapts nicely in caliber and
thickness to small renal artery branches (Fig. 10285). The inferior epigastric artery may also be employed as a branched graft, either individually
or in conjunction with a segment of saphenous vein (Fig. 10286).
Although use of a branched autogenous vascular graft provides a simple, versatile, and effective method for branch renal arterial reconstruction,
other techniques are occasionally preferable, depending on the extent of vascular disease. In some patients with localized segmental intrarenal
branch lesions, there may be other arterial branches that either are uninvolved or have more proximally located vascular disease. Such branches
with longer disease-free distal segments may be anastomosed end-to-side, either into a larger arterial branch or into the reconstructive vascular
graft (Fig. 10287).
Occasionally, two distal arterial branches of similar diameter and free of disease are found adjacent to one another. When this occurs, the two
adjacent branches can be conjoined and then anastomosed end-to-end to a single limb of the branched graft (Fig. 10288).
Renal artery aneurysms have a variable presentation, and the method of extracorporeal repair is determined by whether renovascular involvement
is focal or diffuse. If the renal artery wall at the base of an aneurysm is intact, aneurysmectomy with patch angioplasty can be performed.
Aneurysms with short focal involvement of renal artery branches may also be simply resected with end-to-side branch reanastomosis or end-toside reimplantation into an adjacent branch. In other cases, with more extensive vascular disease, aneurysmectomy and revascularization with a
branched autogenous graft are indicated (Fig. 10289).
These extracorporeal vascular techniques are all performed with interrupted sutures, except for the conjoined anastomosis, for which a continuous
suture is used. When revascularizing multiple arterial branches, one must anticipate the position that the various branches will assume in relation
to one another on completion of the repair. Individual branch anastomoses are then done with careful attention to avoid subsequent malrotation,
angulation, or tension. In all cases, extracorporeal repair leads to creation of a single main renal artery so that autotransplantation may be
performed with one arterial anastomosis and no increase in revascularization time. When extracorporeal revascularization has been completed,
the kidney is either reflushed or placed on the hypothermic pulsatile perfusion unit to verify patency and integrity of the repaired branches. Renal
autotransplantation into the iliac fossa is then performed, with anastomosis of the renal vessels to the iliac vessels and restoration of urinary
continuity by ureteroneocystostomy.

Postoperative Care

Patients undergoing surgical renal revascularization may experience wide fluctuations in blood pressure in the early postoperative period, with
either hypotensive or hypertensive episodes that may predispose to graft thrombosis or bleeding from vascular anastomotic sites, respectively.
Therefore, these patients are placed in the intensive care unit for monitoring of central venous pressure, urine output, pulse rate, and serum levels
of hemoglobin and creatinine. During this period, diastolic blood pressure is maintained at approximately 90 mm Hg to ensure satisfactory renal
perfusion. If hypertensive episodes occur, they are managed with intravenous infusion of sodium nitroprusside. Within the first 24 hours
postoperatively, a technetium 99m renal scan is obtained to verify perfusion of the revascularized kidney. If clear evidence of perfusion is not
present, then arteriography should be done immediately to examine the repaired renal artery.
If the patient's condition is stable, the nasogastric tube, central venous line, arterial line, and urethral catheter are removed 48 hours
postoperatively, and intensive care monitoring is discontinued. Most patients are discharged from the hospital 1 week postoperatively. Subsequent
follow-up is performed by periodic evaluation of blood pressure and serum creatinine level and technetium 99m renal scanning.

Clinical Results
Experiences with alternative bypass techniques for renal revascularization at the Cleveland Clinic from January 1980 to December 1992 were
analyzed (Fergany et al, 1995). A total of 175 revascularization operations were performed in 171 patients. In all patients, alternative bypass
techniques were employed owing to severe abdominal aortic atherosclerosis or previous aortic surgery. The revascularization operations
comprised hepatorenal bypass (n=59), splenorenal bypass (n=54), iliorenal bypass (n=37), thoracic aortorenal bypass (n=23), renal
autotransplantation (n=1), and superior mesenterorenal bypass (n=1). Surgical renal revascularization was indicated to treat poorly controlled
hypertension in 13 patients and to treat ischemic nephropathy in 158 patients; all patients in the latter group had severe renal artery stenosis
bilaterally or in a solitary kidney.
There were five patient deaths within the first postoperative month for an overall operative mortality rate of 2.9%. Postoperative thrombosis of the
repaired renal artery occurred after 7 of 175 revascularization operations (4%). In the 13 patients with severe hypertension, the mean preoperative
blood pressure was 176/101 mm Hg, and the mean postoperative blood pressure was 142/78 mm Hg. The mean preoperative and postoperative
serum creatinine levels in this group were 1.2 mg/dL and 1 mg/dL, respectively.
In patients with ischemic nephropathy, postoperative renal function was improved in 41%, stable in 44%, and deteriorated in 15%. The
best results were obtained in patients with a preoperative serum creatinine level of less than 2 mg/dL; 90% experienced postoperative
improvement or stabilization of renal function. Although preservation of renal function was the predominant indication for intervention in the
ischemic nephropathy group, all these patients also had hypertension that was controlled with medical therapy. Postoperatively, hypertension was
cured in 14%, improved in 63%, and unchanged in 23%. The results of this study affirmed the efficacy of alternative bypass techniques for renal
revascularization when the prerequisite conditions for their use were present.
From 1976 to 1991, extracorporeal microvascular reconstruction and autotransplantation were performed in 66 patients with complex branch renal
artery disease at the Cleveland Clinic (Novick, 1996a, 1996b). This series included 50 females and 16 males ranging in age from 4 to 62 years.
Renovascular disease was caused by fibrous dysplasia in 42 patients, an arterial aneurysm in 13 patients, atherosclerosis in 7 patients, primary
dissection in 2 patients, arteriovenous fistula in 1 patient, and arteritis in 1 patient. Eighteen patients presented with branch disease in a solitary
kidney, 27 patients had bilateral renovascular disease, and 21 patients had unilateral branch disease with a normal contralateral kidney. Renal
revascularization was indicated to treat renovascular hypertension in 58 patients, to prevent rupture of an arterial aneurysm in 7 patients, and to
treat an asymptomatic arteriovenous fistula in 1 patient.
In the 66 patients who underwent extracorporeal branch reconstruction and autotransplantation (including one bilateral autotransplantation), a total
of 187 diseased renal artery branches were repaired (mean, 2.8 branches per operation). The period of cold renal ischemia needed to perform
extracorporeal microvascular repair ranged from 1 to 3.5 hours. All patients were studied postoperatively with isotope renography and, in many
cases, with arteriography as well. Postoperative follow-up in these cases ranged from 1 to 15 years. In 64 patients, branch arterial reconstruction
was technically successful, whereas 2 patients suffered postoperative occlusion of the repaired renal artery. Fortunately, in both of the latter
patients, a normal contralateral kidney was present. Currently, all 66 patients are normotensive, including 11 patients who continue to require lowdose antihypertensive medication. The current level of renal function is stable or improved in all patients. These results attest to the efficacy of
extracorporeal microvascular reconstruction in enabling revascularization with preservation of renal parenchyma to be achieved in patients with
complex branch arterial lesions.

Complications
Operative Mortality

Most patients with nonatherosclerotic lesions, such as fibrous dysplasia or aneurysm, are young and otherwise healthy. Therefore, the
risk of operative death in this group is minimal. However, several studies during the 1970s indicated significant operative mortality rates of 6%
to 10% in patients with atherosclerotic renal artery disease. These patients compose an older group and often have associated coronary,
cerebrovascular, and/or peripheral vascular disease. In the National Cooperative Study, coronary artery disease was the leading cause of
operative mortality after surgical treatment for atherosclerotic renal artery disease (Franklin et al, 1975). Other significant risk factors included
magnitude of the operation performed and presence of extracranial cerebrovascular disease.
Several policies have been adopted to reduce operative mortality after surgical revascularization in patients with atherosclerotic renal
artery disease. These include preliminary screening and correction of existing coronary or cerebrovascular occlusive disease,
avoidance of bilateral simultaneous renal operations, and reliance on methods of revascularization that avoid operation on a badly
diseased aorta. The impact of these policies at the Cleveland Clinic was evaluated in a review of surgical revascularization for renal artery
disease in 361 patients from 1975 to 1984 (Novick et al, 1987). The cause of renal artery disease was atherosclerosis in 241 patients and fibrous
dysplasia or an arterial aneurysm in 120 patients. The operative mortality rate was 21% and 0% in the former and latter groups, respectively.
These data indicate that when appropriate measures are taken, the risk of operative mortality after renal revascularization is small even in older
patients with generalized atherosclerosis.

Hypertension
Patients undergoing renal revascularization often experience hypertension postoperatively, even with technically satisfactory vascular repair. This
hypertension may be due to hypervolemia, vasoconstriction from total body hypothermia, poorly controlled incisional pain, or renal ischemia
sustained intraoperatively. Such blood pressure elevation may be quite severe immediately after surgery and, if not properly controlled, can
promote hemorrhage from fresh vascular anastomoses. Therefore, these patients are initially placed in an intensive care unit for monitoring the
central venous pressure, blood pressure, urine output, pulse rate, and serum levels of hemoglobin and creatinine. During this time, diastolic blood
pressure is maintained at 90 to 100 mm Hg to ensure satisfactory renal perfusion. I prefer to manage postoperative hypertension with continuous
intravenous infusion of sodium nitroprusside for the first 24 to 36 hours. At this time, if hypertension persists, maintenance therapy with oral agents
is initiated, and the nitroprusside infusion is gradually discontinued.
Approximately 50% of patients who are ultimately cured of hypertension by renal revascularization experience blood pressure elevation for a
period of time postoperatively. In fact, it is not uncommon for such hypertension to persist for several weeks after surgery before gradually
resolving. Of course, when this occurs, patency of the reconstructed renal artery must be confirmed with isotope renography and/or angiography.

Hemorrhage
Early hemorrhage after renal revascularization is generally a consequence of poor surgical technique. Bleeding from a vascular anastomotic site
can occur if it is under tension, if one or both of the anastomosed vessels are diseased, or if the vascular sutures have not been placed sufficiently
close together. Eversion of intima through the anastomosis may also predispose to hemorrhage and should be avoided.
Early hemorrhage may also be due to poor surgical hemostasis. This complication is most likely to occur because of unsecured collateral vessels
in the renal hilum; because of damage to the left adrenal gland, which is often closely apposed to the left renal artery; or because of inadequately
secured lumbar arteries that have been divided during aortic mobilization. When a saphenous vein bypass graft has been used, bleeding can
occur from avulsion of a ligature applied to one of the branches of the vein graft; this can be avoided by suture ligation of all such branches.
Factors that predispose to early postoperative hemorrhage include incomplete reversal of systemic heparinization, episode of hypertension, or
unrecognized coagulopathy. Mild bleeding that ceases spontaneously in an asymptomatic patient does not require reoperation. Such small
hematomas generally undergo complete reabsorption without sequelae, although extrinsic cicatricial stenosis of the repaired renal artery may
occasionally result. With severe or uncontrolled bleeding, immediate reoperation is indicated to evacuate the accumulated blood and secure
hemostasis.
In unusual cases, late hemorrhage can occur weeks, months, or even years after renal revascularization. This may be due to infection involving
the vascular suture line (Nerstrom and Engell, 1972; Szilagy et al, 1972), rupture of a noninfected false aneurysm at the anastomotic site into the
retroperitoneum or gastrointestinal tract (Moore and Hall, 1970), or erosion of a prosthetic bypass graft into the duodenum (Cerny et al, 1972). All
present as sudden catastrophic hemorrhage that requires immediate operation. Prosthetic graft erosion can be avoided at the original operation by
interposing peritoneum or omentum between such grafts and the duodenum or by placing the graft retrocaval on the right side. It is also
appropriate to state that prosthetic renal artery bypass grafts should be used only when an autogenous vascular graft is not available.

Renal Artery Thrombosis

Thrombosis of the repaired renal artery is an uncommon complication that occurs in less than 5% of patients undergoing
revascularization, generally within the first few days of surgery. Postoperative hypotension, a hypercoagulable state, and hypovolemia are
factors that predispose to this problem. Significant intrarenal arteriolar nephrosclerosis causes poor run-off, which can also lead to arterial
thrombosis. Nevertheless, arterial thrombosis is usually due to poor technical performance of revascularization and, in this regard, several points
deserve emphasis.
All the vessels used for anastomosis should be free of disease that may cause subsequent occlusion. Complete excision of all renal artery disease
is necessary. Occasionally, a local aortic endarterectomy is performed when an aortorenal bypass is done. All vascular anastomoses must be
done precisely, to avoid intraluminal intrusion of adventitia and trauma to the intima. The latter may result from improperly applied surgical forceps
or vascular clamps and is known to promote intraluminal platelet aggregation, fibrin deposition, and development of a thrombus. When an
endarterectomy is done, the resulting traumatized arterial surface can also predispose to thrombus formation.
If an intimal flap is present in the distal renal artery at revascularization, it must be tacked down with interrupted sutures to avoid intramural
dissection and occlusion after restoration of blood flow. End-to-end anastomosis of vessels that are more than 50% disparate in diameter should
also be avoided. This invariably leads to bunching of the smaller vessel and unfavorable hemodynamics that can lead eventually to thrombus
formation and vascular occlusion.
When performing a renal artery bypass procedure, the bypass graft must be properly placed to avoid angulation, kinking, or malignancy with the
renal artery. Figures 10290 and 10291 illustrate the most common errors in the positioning of an aortorenal bypass graft that can lead to
thrombosis or stenosis. These same considerations apply to all renal revascularization operations, especially extracorporeal branch repairs. In
these repairs, multiple renal arterial branch anastomoses are commonly done, and it is important to anticipate the position that the various
branches will assume in relation to one another on completion of the repair and after autotransplantation.
Embolization of an atheroma from a traumatized aorta into the kidney and external compression of the repaired artery by retroperitoneal fluid
collection are additional causes of postoperative thrombosis. Finally, although thrombosis is typically an early event, occlusion of an aortorenal
bypass graft can occur months or years later from progressive aortic atherosclerosis at the origin of the graft.
The diagnosis of renal artery thrombosis must be established almost immediately for salvage of the kidney to be possible. In some cases,
subtotally occlusive thrombus and/or extensive collateral renal arterial supply allow additional time to undertake successful intervention. The most
helpful clinical clues to postoperative thrombosis are persistent or sudden hypertension and elevated serum creatinine level. However, both of
these findings may initially be present with a patent vascular repair. Therefore, a radiographic renal imaging study should be routinely done within
the first 24 hours of surgery; and in this regard, I have found isotope renography with technetium to be an excellent noninvasive method. Because
I always perform direct end-to-end anastomosis of the bypass graft to the distal renal artery, renal uptake of isotope ensures patency of the
vascular repair. This study is less reliable if an end-to-side anastomosis of the bypass graft to the distal renal artery has been done. If isotope
renographic findings are equivocal and/or clinical suspicion for arterial thrombosis remains high, then angiography should be done immediately.
The traditional treatment for postoperative renal arterial thrombosis has been emergency surgical re-exploration with thrombectomy and/or graft
revision if the kidney is found to be viable. More commonly, the kidney is no longer viable, and a nephrectomy is done. Percutaneous low-dose
intra-arterial infusion of streptokinase is a new method that may be undertaken as an alternative to surgery (Berni et al, 1983; Cronan and
Dorfman, 1983; Dardik et al, 1984). Although successful clot lysis has been reported with this technique, there also appears to be an increased
risk of bleeding from hypofibrinogenemia. Percutaneous transcatheter thrombectomy has also been described as treatment for acute renal artery
thrombosis or embolism; however, this technique cannot be safely done in the presence of a fresh vascular anastomosis (Milan et al, 1978).
Systemic anticoagulation with heparin is not effective as primary therapy for postoperative arterial thrombosis but is a useful adjunctive measure
after surgical thrombectomy or intra-arterial streptokinase infusion.

Renal Artery Stenosis

The incidence of stenosis of a surgically reconstructed renal artery is less than 10% with current techniques, and this complication
typically occurs weeks, months, or even years after revascularization. Many of the causes are similar to those outlined for postoperative
thrombosis, such as faulty suture technique, intimal trauma, incomplete excision of primary vascular disease, wide disparity in vessel size,
dissection of a distal intimal flap created at surgery, and torsion, angulation, or kinking of the vessels. When an end-to-end vascular anastomosis
is performed, the likelihood of subsequent stenosis can be minimized by spatulating the ends of the two vessels to fashion a suture line that is
wider than the normal circumference of the renal artery. Tension on the vascular suture line can also cause narrowing in this area and should be
avoided. Finally, during procurement of a saphenous vein graft, care should be taken not to overdistend the vein or injudiciously dissect
periadventitial tissue, both of which may cause devascularization of the graft that leads to subsequent stenosis.
Other causes of late postoperative renal artery stenosis include diffuse subendothelial fibroplastic proliferation in saphenous vein grafts, neointimal
proliferation at the suture line of synthetic grafts, recurrent primary vascular disease, and obstruction from a valve in a segment of saphenous vein
(Dean et al, 1974). With the last cause, grafts should always be reversed so that blood flow is directed toward the cephalic end, which allows
venous valves to assume a neutral position. However, even when this is done, such valves may undergo fiberoptic contracture to produce a
weblike stenosis of the vein graft. This occurrence, although rare, suggests that a valveless segment of vein should be used, if possible.
All patients undergoing renal revascularization should be followed up at yearly intervals with blood pressure measurements,

determination of renal function, and isotope renography with technetium. Postoperative renal artery stenosis that is more than 70%
occlusive is invariably accompanied by an elevation in blood pressure and, not uncommonly, evidence of deteriorating renal function. When either
of these conditions is present, or if there is isotope renographic evidence of diminished renal perfusion, angiography should be done. Recurrent
arterial stenosis is most often located at a vascular suture line but may present anywhere along the course of the reconstruction renal arterial
supply. The therapeutic options are surgical reoperation of PTA. Because secondary revascularization in such cases is quite difficult and may lead
to nephrectomy, PTA is a reasonable initial approach to therapy if it is technically feasible.

Renal Artery Aneurysm

Long-term angiographic studies of patients who underwent aortorenal saphenous vein bypass revealed graft dilation in 25% to 52% of patients
and frank aneurysm formation in 5% to 8% of patients (Stanley et al, 1973; Dean et al, 1974). These findings have been observed more often in
children than in adults. The clinical significance of these abnormal-appearing vein grafts remains uncertain, because most of these patients
continue to be normotensive with excellent renal function. In some cases, graft dilation has been associated with a distal anastomotic stenosis,
suggesting the latter as a possible inciting factor (Fig. 10292). However, in other cases, similar dilation has been found with no evidence of
stenosis (Fig. 10293). This problem has only rarely been encountered with autogenous arterial grafts. It may be possible to prevent saphenous
vein graft dilation by more careful procurement and storage of the graft in chilled heparinized lactated Ringer irrigation or autologous blood to
prevent transmural ischemia. When severe aneurysmal dilation is present, or if graft expansion is associated with recurrent hypertension,
reoperation and attempted secondary revascularization are indicated.
Postoperative aneurysm formation has also been associated with use of the spermatic or ovarian veins for renal artery bypass surgery. These
veins are extremely friable, cannot withstand the stress of arterial pressure, and undergo severe dilation or frank rupture. Therefore, their use as
bypass grafts in arterial reconstruction is absolutely contraindicated.
After renal revascularization, a false aneurysm may develop at a vascular anastomotic site months or years later. Mycotic false aneurysms are
caused by deep wound infection involving the vascular suture line (Nerstrom and Engell, 1972). Contrary to a widely held impression, there is no
increased risk of infection with vascular silk sutures when they are used for anastomosis of autogenous vessels. Noninfected false aneurysms
have most often been associated with synthetic bypass grafts, because anastomoses of native vessels with these grafts never acquire significant
strength other than that determined by the suture line (Moore and Hall, 1970). For this reason, synthetic graft anastomoses should always be done
with a nonreabsorbable suture, such as polypropylene, rather than with silk, which loses its tensile strength over time. Infected or uninfected false
anastomotic aneurysms can rupture spontaneously and should be repaired as soon as the diagnosis is established.

Aortic Complications
During an aortorenal bypass operation, clamping and unclamping of the abdominal aorta is performed. When the aorta is involved with
atherosclerosis, this maneuver can cause dislodgment of plaque, resulting in aortic thrombosis and/or distal embolization. This occurrence can be
minimized by selecting the healthiest portion of the abdominal aorta for use in such operations. Intraoperative systemic heparinization also helps
prevent this problem. Ultimately, the most effective prevention is to avoid operation on the extensively diseased aorta by using alternative
techniques, such as hepatorenal or splenorenal bypass.
Whenever aortic surgery is undertaken, the peripheral pulses and lower extremities should always be examined before and immediately after
revascularization. If there is evidence of compromised peripheral circulation postoperatively, emergency transbrachial abdominal aortography
should be done. Immediate surgical thromboembolectomy is indicated to relieve aortic or major peripheral vascular occlusion. Minor discoloration
of the toes from cholesterol microemboli can be observed easily when good peripheral pulses are present. This problem generally resolves
spontaneously, and digital amputation is rarely necessary.
Clamping and unclamping of the aorta may also produce an intraluminal aortic dissection, especially if a local endarterectomy has been done. This
can be prevented by suturing down distal flaps of intima within the aorta when the lumen is exposed. This type of aortic dissection can cause
peripheral ischemia or may be entirely asymptomatic, in which case simple observation is sufficient.

Visceral Complications

Visceral-renal arterial bypass operations are indicated in patients with severe aortic disease and may be associated with specific complications.
When splenorenal bypass is done, splenic viability is maintained by collateral vascular supply from the short gastric and gastroepiploic arteries.
Nevertheless, a retractor-induced splenic laceration may be sustained during mobilization of the splenic artery, which necessitates performance of
an incidental splenectomy. In an initial series of splenorenal bypasses, this complication occurred in 5 of 32 cases (16%) (Novick et al, 1977a,
1977b). During mobilization of the splenic artery, the splenic vein, which is thin-walled and directly adjacent to the artery, may be inadvertently
damaged. Lacerations of the splenic vein are repaired with interrupted 50 vascular sutures. Injury to the pancreas, with resulting pancreatitis or
pseudocyst formation, is a potential complication of splenorenal bypass that I have not yet encountered.
In hepatorenal bypass, the common hepatic artery and its major branches can be mobilized quite readily without damaging the portal vein or
common bile duct. Hepatorenal bypass is usually done by end-to-side anastomosis of a saphenous vein graft to the common hepatic artery, which
allows preservation of distal hepatic arterial flow (Chibaro et al, 1984). However, in some cases, a direct end-to-end anastomosis of the hepatic
and right renal arteries is done, which produces complete hepatic dearterialization (Novick and McElroy, 1985). This is well tolerated by the liver
owing to the increased extraction of oxygen from portal venous blood and the fairly rapid development of collateral hepatic arterial flow. Thus,
although transient abnormalities in liver function parameters may occur, permanent hepatic damage has not yet been observed. However, the
gallbladder is more susceptible to ischemic damage and may undergo postoperative necrosis when its blood supply from the right hepatic artery is
interrupted. This problem can be avoided by performing an adjunctive cholecystectomy in patients whose blood flow through the common hepatic
artery is totally diverted to the kidney.
A bypass from the SMA to the kidney is occasionally an option in patients with severe aortic atherosclerosis (Khauli et al, 1985a, 1985b). Because
the SMA is the only source of blood supply to a large portion of the bowel, this operation may produce postoperative intestinal ischemia. Such
ischemia can be avoided by limiting this approach to patients with infrarenal aortic occlusion, in whom a significantly enlarged SMA is invariably
present.

Acute Renal Failure

Acute renal failure induced by ischemia is a potential complication of surgical revascularization that, fortunately, can be prevented in
most cases. Because all revascularization operations require temporary occlusion of the renal artery, it is important to understand renal
responses to warm ischemia. If the period of arterial occlusion exceeds that which may be safely tolerated, then specific renal preservation
measures are indicated.
In general, 30 minutes is the maximum period of arterial occlusion that the kidney can withstand before permanent damage is sustained
(Novick, 1983). In some clinical situations, this time may not apply, and a longer period of ischemia may be safely tolerated. It is acknowledged
that the solitary kidney is more resistant to ischemic damage than the paired kidney, although precise limits have not been defined. I reviewed the
outcome of renal revascularization in 43 patients with a solitary kidney in whom warm ischemic intervals ranged from 14 to 59 minutes and in
whom no specific renal protective measures were employed. In this series, there were no cases of acute renal failure postoperatively, which
indicated in many of these patients the ability of the solitary kidney to safely withstand periods of warm ischemia longer than 30 minutes (Askari et
al, 1982). Another situation that may enhance renal tolerance to temporary arterial occlusion is the presence of an extensive collateral vascular
supply, which is often observed in patients with renal arterial occlusive disease.
When postoperative acute renal failure occurs, it is generally manifested by a fall in urine output and a rise in serum creatinine level. Alternatively,
nonoliguric renal insufficiency may be observed. The cornerstone of therapy for such acute renal failure is judicious fluid management to ensure
normal extracellular volume and sodium content. In older patients, central venous pressure is not reliable for monitoring fluid replacement, and
pulmonary artery wedge pressure provides a more accurate measurement of left ventricular filling pressure. This information allows precise control
of the volume and rate of fluid infusion, so that maximum cardiac output can be achieved without inducing left ventricular decompensation. The
role of diuretic and vasoactive drug therapy for improving renal perfusion after ischemic injury is controversial. Furosemide administration appears
to be of value because it is known to increase renal blood flow by stimulating the release of intrarenal alprostadil, a potent dilator of the afferent
renal arterioles (Patak et al, 1975).

Miscellaneous Renal Operations

Open Renal Biopsy

Open renal biopsy may be necessary to establish a tissue diagnosis in patients with renal disease, to assess the severity of such disease, or to
evaluate the potential for salvable renal function in patients with a known correctable disorder who are candidates for a reconstructive operation.
Open biopsy is usually preferred over the percutaneous technique in patients with a solitary kidney, coagulopathy, atypical anatomy, or other
factors that may increase the risk of a closed biopsy. An open biopsy also provides more tissue for study and minimizes the potential for
complications such as arteriovenous fistula, perirenal hematoma, and gross hematuria.
An open renal biopsy may be performed through an extraperitoneal flank or posterior incision. General anesthesia is preferable; however, in a thin,
cooperative patient, local anesthesia may be employed. The right kidney is usually biopsied owing to its more caudal location.
After making the surgical incision, Gerota's fascia is opened and the lower pole of the kidney is exposed. An elliptical incision is made in the renal
capsule, which is usually 1 to 2 cm long and 0.5 to 1 cm wide (Fig. 10294A). The incision is deepened on either side with a scalpel and beveled
so that the final wedge depth includes an adequate segment of cortical tissue, usually 5 to 8 mm deep. Fine Metzenbaum scissors are used to
complete the transection of cortex at the bottom of the wedge, and the tissue is gently lifted out using the slightly spread scissor blades rather than
a forceps, which might crush the specimen (Fig. 10294B). Suction is avoided during this final maneuver to prevent loss of tissue into the suction
tip. This technique of elliptical wedge biopsy is preferred over open needle biopsy because bleeding is more readily controlled and more renal
tissue is obtained. The renal incision is closed with absorbable 20 or 30 sutures placed across the defect and gently tied over Oxycel (Fig.
10294C).

Surgery for Simple Renal Cysts

Simply renal cysts usually present as mass lesions and are often detected during renal imaging studies performed for unrelated reasons. A small
number of patients require exploration to distinguish between a cyst and an atypical tumor mass. Large renal cysts causing obstruction may also
occasionally require open surgical drainage with unroofing (Stanisic et al, 1977).
The preferred surgical approach for drainage of a renal cyst is through an extraperitoneal posterior, flank, or anterior incision, according to the
number and location of lesions. Gerota's fascia is opened, and the cystic lesion is exposed by dissection of perirenal fat from the cyst and adjacent
parenchyma (Fig. 10295A). The surrounding area is packed off, and cyst fluid is aspirated for diagnostic study. The cyst wall is then entered
sharply and is resected near its junction with normal parenchyma (Fig. 10295B). The base of the cyst cavity is inspected, and any suspicious
areas are biopsied with immediate frozen-section examination. After unroofing, the perimeter of the cyst wall is oversewn with an absorbable 30
or 40 continuous suture to achieve hemostasis (Fig. 10295C). Alternatively, the edge of the cyst wall may be cauterized and persistent bleeders
controlled with interrupted figure-of-eight absorbable sutures. Drainage is not required unless the cyst is infected.

Open Nephrostomy Insertion

Nephrostomy tube drainage is usually achieved by the percutaneous approach, but an open operation is occasionally necessary owing to difficult
anatomy or a minimally dilated upper urinary tract. Open nephrostomy insertion may also be performed intraoperatively during reconstructive
procedures such as pyeloplasty or ureterocalicostomy.
Primary nephrostomy insertion is usually performed through an extraperitoneal flank incision. After the kidney is mobilized, the renal pelvis is
exposed and opened. A Willscher nephrostomy tube, as illustrated in Figure 10296, is particularly simple to place because of a built-in malleable
stylet within a smoothly tapered sheath (Noble, 1989). The stylet of the catheter is passed through the pyelotomy and is then used to puncture the
cortex from within a calyx (Fig. 10296A). It is important to ensure that the nephrostomy is made near the convex border of the kidney and not in
the anterior or posterior surface, because this allows for better positioning of the tube and minimizes the risk of injury to large intrarenal vessels.
Usually, a 22-F or 24-F catheter is used. The Willscher tube has a flared portion with wide openings followed by a long tip, which may be used as
a splint through the ureteropelvic junction if necessary. The catheter is pulled through the cortex until the flared portion lies in good position within
the collecting system, usually in the pelvic calyx or a dependent calyx (Fig. 10296B). The nephrostomy tube is secured to the renal capsule with
a 30 absorbable purse-string suture. The pyelotomy is closed with 30 or 40 absorbable suture. The stylet of the nephrostomy tube is passed
through the flank muscles, subcutaneous tissue, and skin, with care taken to ensure proper alignment of the tube as it passes from the kidney to
the exterior. Heavy 20 skin sutures are inserted to secure the tube near the flank wall exit point to prevent inadvertent dislodgment. A Penrose
drain is placed near the pyelotomy site and brought out through a separate stab wound in the flank.
Ongoing care of a nephrostomy tube is important to prevent infection and to ensure unobstructed drainage. Periodic urine cultures are obtained,
and significant intercurrent urinary infection is appropriately treated. If the tube is dislodged within 7 to 10 days of its insertion, it may not be
possible to replace it through the tract, and a secondary procedure may be necessary. Even with the best of care, encrustations form around the
tube and require periodic tube replacement at 6- to 8-week intervals. This is usually readily performed under fluoroscopic guidance once a chronic
tract has been established.

Surgery for Polycystic Kidney Disease

Bilateral nephrectomy may be necessary in selected patients with end-stage renal failure from polycystic kidney disease who are candidates for
renal transplantation. Indications for bilateral nephrectomy in this setting include a history of significant bleeding or renal infection and massively
enlarged kidneys that may interfere with placement of an allograft in the pelvis. This operation is best performed through an anterior bilateral
subcostal or midline transperitoneal incision.
Occasionally, unilateral nephrectomy is required before the patient develops end-stage renal failure, when the polycystic kidney is a site of
complications such as infection, severe pain owing to bleeding or obstruction, or development of a tumor. Cyst puncture and unroofing of cysts
may be helpful when they obstruct the collecting system or cause flank pain (Lue et al, 1966). Multiple cyst punctures and unroofing of cysts
(Rovsing's operation) do not appear to improve renal function or prevent further deterioration (Milam et al, 1963). However, this
approach can provide long-term pain relief in symptomatic patients (Elzinga et al, 1993).

Isthmusectomy for Horseshoe Kidney

Horseshoe kidney occurs in about 1 in 700 individuals and is frequently associated with other urologic anomalies. The isthmus that joins the
kidneys usually lies anterior to the great vessels. Ureteral obstruction with hydronephrosis, some formation, or infection is the most common
problem with this condition and may require surgical treatment (Culp and Winterringen, 1955). In patients with ureteral or ureteropelvic junction
obstruction, division of the isthmus alone is insufficient, and appropriate correction of the obstruction is required; in such cases, isthmusectomy
may be a useful adjunctive measure to allow repositioning of the kidney and maintenance of an unobstructed upper urinary tract. Abdominal pain
in the absence of any demonstrable renal symptomatology is rarely due to the presence of polar fusion and is not an indication of isthmusectomy.
When surgery is performed on a horseshoe kidney, an anterior subcostal extraperitoneal approach is preferred. This provides good access to the
isthmus as well as to the pelvis and ureter, which are rotated anteriorly. Horseshoe kidneys are generally supplied by multiple renal vessels that, in
some cases, can enter the isthmus directly. The isthmus may be fibrous but often consists of parenchyma tissue. Isthmusectomy is performed by
mobilizing the isthmus from the great vessels, being careful to avoid injury to any anomalous vessels, and placing mattress sutures of 00 chromic
catgut through the parenchyma about 1 cm on either side of the line of section to control bleeding. The divided ends can be further oversewn with
sutures passed through the capsule of the cut edges. Two or three sutures through the divided isthmus and into the fascia overlying the muscles
of the posterior abdominal wall are used to fix the lower pole, which is rotated outward to allow room for the ureter to lie on the posterior abdominal
wall.

Local Excision of Renal Pelvic Tumor

In patients with localized transitional cell carcinoma of the renal pelvis, nephroureterectomy with a bladder cuff is the treatment of
choice. A nephron-sparing operation may be indicated in selected patients with low-grade, noninvasive malignancy present bilaterally
or in a solitary kidney to avoid the need for dialytic renal replacement therapy. A variety of conservative surgical approaches are available in
such cases, including open pyelotomy with tumor excision and fulguration, partial nephrectomy (Fig. 10297), and endourologic techniques with or
without adjunctive topical chemotherapy (Zincke and Neves, 1984; Huffman et al, 1985; Streem and Pontes, 1986; Smith et al, 1987; Ziegelbaum
et al, 1987; Vasavada et al, 1995). The last two approaches are reviewed elsewhere.
Open pyelotomy and tumor excision may be employed in patients with noninvasive transitional cell carcinoma confined to a portion of the renal
pelvis. Occasionally, small lesions involving an infundibulum may be accessible for this approach. This operation is performed through an
extraperitoneal flank incision after mobilization of the entire kidney within Gerota's fascia.
The upper ureter and renal pelvis are mobilized along the posterior renal aspect. Renal pelvic dissection is carried into the renal sinus, which often
also exposes one or more infundibula. Small vein or Gil-Vernet retractors are used to maintain this operative exposure (Fig. 10298A). The renal
pelvic incision is made to expose the tumor-bearing portion of the renal pelvis (Fig. 10298B). This incision may be extended into an infundibulum
if necessary. It is preferable to excise a full-thickness segment of the renal pelvis encompassing the tumor (Fig. 10298C). Frozen sections are
prepared to ensure that the resected margins are free of disease. An alternative approach is to sharply excise the tumor at its base while
preserving the integrity of the renal pelvic wall and to then fulgurate the base and surrounding area extensively. After excision of all gross tumor,
operative pyeloscopy is used to examine the intrarenal collecting system for any remaining lesions. The site of renal pelvic tumor excision is
repaired with 40 chromic suture (Fig. 10298D), and the pyelotomy incision is then similarly closed. A Penrose drain is placed near the
pyelotomy and brought out through a separate stab wound in the flank.

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