NEPHRECTOMY

From Big Medical Encyclopedia

NEPHRECTOMY (Greek nephros a kidney + ektome excision, removal) — operation of removal of a kidney.

For the first time the NEPHRECTOMY is made by G. Simon in 1869 N. is one of often applied operations at operational treatment of diseases of kidneys and makes 30% of all interventions. The N can be carried out only in the presence anatomically and functionally full-fledged second kidney; depending on a run time it can be planned and emergency. Sometimes precedes a nephrectomy according to indications nephrotomy (see).

Indications

Planned N. is made at malignant new growths of a renal parenchyma, a polycavernous nephrophthisis (at preferential hemilesion), a tubercular pyonephrosis, an omelotvoreniya and calcification of a kidney, a calculous pyonephrosis, far come unilateral hydronephrotic transformation, an actinomycosis of a kidney, ksantogranulematozny pyelonephritis, reiovaskulyarny and nephrogenic hypertensia at the contracted kidney, big solitary cysts which led to an atrophy of body. The serious general condition and considerable anemia at patients with malignant new growths of kidneys dictate need of carrying out the corresponding preoperative preparation in the shortest terms.

The emergency NEPHRECTOMY is shown at crush of a kidney and life-threatening bleeding, a separation of a kidney from a vascular leg, acute purulent pyelonephritis with a multiple anthrax, to the life-threatening persistent massive hamaturia caused patol, process in a kidney.

At papillary cancer of a renal pelvis make a nephroureterectomy with a cystectomy in order to avoid implantation urinogenny innidiation. The nephroureterectomy is made also at tuberculosis if in a gleam of an ureter there are considerable curdled changes, and also at far come ureterohydronephrosis caused by occlusion of an ureter a stone or an obliteration of his lower part.

Removal of an upper half of a double kidney (geminefrektomiya) and an ureterectomy sometimes is made at an ectopia of the mouth of an ureter and often observable at this incontience of urine.

The bilateral nephrectomy is carried out at patients hron, a renal failure as a preliminary stage of preparation to to renal transplantation (see).

Contraindications: absence or funkts, insolvency of a contralateral kidney, a bilateral hydronephrosis or tuberculosis of kidneys with considerably the expressed destructive changes, active extrarenal tuberculosis in a phase of infiltrative flash, multiple tumoral metastasises in various bodies, a cancer cachexia, a serious illness of cardiovascular system.

A technique

Carry out the NEPHRECTOMY under anesthetic or under local anesthesia. Use lumbar extra-peritoneal, front transperitoneal and thoracoabdominal accesses to a kidney (see. Kidneys ). Technology of operation and the choice of operational approach depend on the nature of a disease and its localization.

Fig. 1. Diagrammatic representation of a subkapsulyarny nephrectomy: and — the kidney (1) is decapsulated, the fibrous capsule (2) otsloyen to hiluses renalis and is cut by a circular section; — the fibrous capsule (2) is dissect and displaced, renal vessels of KZ are naked).

It is most extended lumbar by N. After an exposure the kidney is allocated from iaranefralny cellulose and release her vascular leg. An ureter, previously having alloyed, cross in an average third. Renal vessels (an artery and a vein) press and cross. The kidney is deleted. The stump of a renal leg is tied up, and then in addition stitched and alloyed. In nek-ry cases, napr, at sharply expressed sclerosing paranephritis and especially a pedunkulita, resort to a subkapsulyarny nephrectomy according to Fedorov. The fibrous capsule is otslaivat in the stupid way from a renal parenchyma up to hiluses renalis and make a circular section of the fibrous capsule from within a knaruzha according to hiluses renalis in the direction of cellulose of a renal sine. It allows to allocate a vascular leg (fig. 1), to-ruyu then press terminals and alloy. Operation is finished with obligatory drainage of retroperitoneal space.

fig. 2. Diagrammatic representation of the initial stage of a transperitoneal nephrectomy: after a laparotomy the back leaf of a peritoneum (1) and a retroperitoneal fascia are cut (2); renal vessels (3) are allocated and under them the clip is brought; 4 — a kidney; 5 — a liver; 6 — a gall bladder; 7 — a duodenum.

Transperitoneal N. is shown at Vilms's tumor at children and an adenocarcinoma of a kidney at adults. After an exposure of renal vessels (fig. 2), the lower vena cava and an aorta make mobilization and an alloying of a renal artery in the beginning, and then veins. The kidney is deleted with the uniform block with iaranefralny cellulose and adjacent fastion. The retroperitoneal space is drained through counteropening by lower than XII edges in lumbar area. Recover seams an integrity of a back leaf of a peritoneum. The wound of an abdominal wall is taken in tightly.

Torakoabdominalny N. is shown at big tumors of a kidney and distribution of blastomatous process on renal and lower hollow to veins, and also during the involvement in process pericaval, paraortalny limf, nodes and the next bodies. After an exposure of a kidney of the technician of operation as well as at transperitoneal N. Udaliv a kidney, drain retroperitoneal space and take in a back leaf of a peritoneum and a diaphragm. The pleural cavity is also drained. The wound is taken in tightly. Torakoab-dominalny N.'s advantage is the wide exposure not only renal vessels, but also the lower vena cava and an aorta, and also a possibility of removal of a kidney the uniform block with perinephric cellulose and fastion.

Complications

the Most frequent and terrible complication — bleeding from vessels of a renal leg, the lower vena cava or from the injured adrenal gland. At damage of the lower vena cava the vascular seam is shown by an atraumatic needle (see. Vascular seam ). During the sliding of a ligature from a renal leg it is necessary to press the bleeding vessels a finger, to drain a wound from blood and to repeatedly impose a ligature. Bleeding from an adrenal gland is stopped underrunning of the place of damage by a blanket seam. At lumbar access the found inadvertent injuries of a pleura or a peritoneum take in. Rare complications of the postoperative period are intestinal fistulas (see). The best prevention of complications is correctly chosen access providing the width of operational access.

In the postoperative period it is necessary to create adequate completion of blood, to normalize water and electrolytic balance, to observe carefully for diuresis (see). In uncomplicated N.'s cases it is allowed to rise and go already next day after operation. At a smooth current of the postoperative period of patients write out on 15 — the 16th day with the subsequent observance of the sparing mode.

Outcomes

define Recovery of working capacity individually, depending on the nature of the disease which demanded a nephrectomy. The postoperative lethality averages 3 — 4%. 5-year survival after N. concerning an adenocarcinoma of a kidney of 32,3% — 43,3%. The best results are observed at patients with a renal adenocarcinoma, the Crimea the NEPHRECTOMY is carried out by torakoabdominal-ny access. At renal tuberculosis of 30% of patients perish in terms from 6 to 12 years from specific process in the remained kidney. At a nephrolithiasis 1 — 2% of patients later can have 1 — 2 years stones in the remained kidney.



Bibliography: Lopatkin N. A. Tumors of a kidney, in book: A wedge, an onkourologiya, under the editorship of E. B. Marinbakh, page 5, M., 1975, bibliogr.; Pytel Yu. A. also I-e Am scarlet in Yu. G. O a rational operative measure at a tumor of a kidney, Urol. and nefrol., No. 5, page 63, 1978; P y-t of e of l A. Ya. and Grishin M. A. Diseases of the only kidney, page 154, M., 1973, bibliogr.; Trapezni to the island and M. F. Tumors of kidneys, M., 1978, bibliogr.; I) e b 1 e d G. L’abord transtho-rac-ique du rein, Acta urol. belg., v. 38, p. 121, 1970; Mayor G. ZinggE. J. Urologic surgery, N. Y., 1976.


Yu. G. Alyaev.

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