Nephrectomy

 Definition

A nephrectomy is a surgical procedure for the removal of a kidney or section of a kidney.

Purpose

Nephrectomy, or kidney removal, is performed on patients with severe kidney damage from disease, injury, or congenital conditions. These include cancer of the kidney (renal cell carcinoma); polycystic kidney disease (a disease in which cysts, or sac-like structures, displace healthy kidney tissue); and serious kidney infections. It is also used to remove a healthy kidney from a donor for the purposes of kidney transplantation .

  According to the United Network for Organ Sharing (UNOS), 5,974 people underwent nephrectomy to become living kidney donors in 2001. The majority of these donors—43.9%—were between the ages of 35 and 49, and 58.8% were female. Related donors were more common than non-related donors, with full siblings being the most common relationship between living donor and kidney recipients (28.5% of living donors).

Description

Nephrectomy may involve removing a small portion of the kidney or the entire organ and surrounding tissues. In partial nephrectomy, only the diseased or infected portion of the kidney is removed. Radical nephrectomy involves removing the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney. A simple nephrectomy performed for living donor transplant purposes requires removal of the kidney and a section of the attached ureter.

Open nephrectomy

In a traditional, open nephrectomy, the kidney donor is administered general anesthesia and a 6–10 in (15.2–25.4 cm) incision through several layers of muscle is made on the side or front of the abdomen. The blood vessels connecting the kidney to the donor are cut and clamped, and the ureter is also cut between the bladder and kidney and clamped. Depending on the type of nephrectomy procedure being performed, the ureter, adrenal gland, and/or surrounding tissue may also be cut. The kidney is removed and the vessels and ureter are then tied off and the incision is sutured (sewn up). The surgical procedure can take up to three hours, depending on the type of nephrectomy being performed.

Laparoscopic nephrectomy

Laparoscopic nephrectomy is a form of minimally invasive surgery that utilizes instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are maneuvered through four small incisions in the abdomen, and carbon dioxide is pumped into the abdominal cavity to inflate it and improve visualization of the kidney. Once the kidney is isolated, it is secured in a bag and pulled through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than a traditional nephrectomy, preliminary studies have shown that it promotes a faster recovery time, shorter hospital stays, and less post-operative pain.
A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may also be used to remove the kidney. In the hand-assisted surgery, a small incision of 3–5 in (7.6–12.7 cm) is made in the patient's abdomen. The incision allows the surgeon to place his hand in the abdominal cavity using a special surgical glove that also maintains a seal for the inflation of the abdominal cavity with carbon dioxide. This technique gives the surgeon the benefit of using his hands to feel the kidney and related structures. The kidney is then removed by hand through the incision instead of with a bag.

Diagnosis/Preparation

Prior to surgery, blood samples will be taken from the patient to type and crossmatch in case transfusion is required during surgery. A catheter will also be inserted into the patient's bladder. The surgical procedure will be described to the patient, along with the possible risks.

Aftercare

Nephrectomy patients may experience considerable discomfort in the area of the incision. Patients may also experience numbness, caused by severed nerves, near or on the incision. Pain relievers are administered following the surgical procedure and during the recovery period on an as-needed basis. Although deep breathing and coughing may be painful due to the proximity of the incision to the diaphragm, breathing exercises are encouraged to prevent pneumonia. Patients should not drive an automobile for a minimum of two weeks.

Risks

Possible complications of a nephrectomy procedure include infection, bleeding (hemorrhage), and post-operative pneumonia. There is also the risk of kidney failure in a patient with impaired function or disease in the remaining kidney.

Normal results

Normal results of a nephrectomy are dependent on the purpose of the procedure and the type of nephrectomy performed. Immediately following the procedure, it is normal for patients to experience pain near the incision site, particularly when coughing or breathing deeply. Renal function of the patient is monitored carefully after surgery. If the remaining kidney is healthy, it will increase its functioning over time to compensate for the loss of the removed kidney.
Length of hospitalization depends on the type of nephrectomy procedure. Patients who have undergone a laparoscopic radical nephrectomy may be discharged two to four days after surgery. Traditional open nephrectomy patients are typically hospitalized for about a week. Recovery time will also vary, on average from three to six weeks.

Alternatives

Because the kidney is responsible for filtering wastes and fluid from the bloodstream, kidney function is critical to life. Nephrectomy candidates diagnosed with serious kidney disease, cancer, or infection usually have few treatment choices aside from this procedure. However, if kidney function is lost in the remaining kidney, the patient will require chronic dialysis treatments or transplantation of a healthy kidney to sustain life.

 NURSING CARE  OF CLIENT HAVING A NEPHRECTOMY

Perioperative Nursing Considerations

• The surgeon or anesthesiologist may request hypothermia measured during the procedure.
• Have all X-rays in the room.
• Verify with the blood bank the number of available units.
• Chest tube and drainage unit will be needed for a transthoracic approach.
• A suprapubic catheter and drainage unit may be used if nephroureterectomy is performed.
• When two incisions are used, the patient is repositioned. Additional instrument tray is necessary.
  •Discuss operative and postoperative expectations as indicated, including the location of the incision  and anticipated tubes, stents, and drains. Preoperative teaching about postoperative expectations reduces anxiety for the client and family during the early postoperative period

POSTOPERATIVE CARE

• Provide routine postoperative care •Frequently assess urine color, amount, and character, noting any hematuria, pyuria, or sediment. Promptly report oliguria or anuria, as well as changes in urine color or clarity.Preserving function of the remaining kidney is critical; frequent assessment allows early intervention for potential problems.

• Note the placement, status, and drainage from ureteral catheters, stents, nephrostomy  tubes, or drains. Label each  clearly. Maintain gravity drainage; irrigate only as ordered. Maintaining drainage tube patency is vital to prevent potential hydronephrosis. Bright bleeding or unexpected drainage may indicate a surgical complication. 
• Support the grieving process and adjustment to the loss of a kidney. Loss of a major organ leads to a body image change and grief response. When renal cancer is the underlying diagnosis,the client may also grieve the loss of health and potential loss of life. 

Provide the following home care instructions for the client and family.

• Teach the importance of protecting the remaining kidney by preventing UTI, renal calculi, and trauma. 
• Maintain a fluid intake of 2000 to 2500 mL per day. This important measure helps prevent dehydration and maintain good urine flow. 
• Gradually increase exercise to tolerance, avoiding heavylifting for a year after surgery. Participation in contact sports is not recommended to reduce the risk of injury to the remaining kidney. Lifting is avoided to allow full tissue healing. Trauma to the remaining kidney could seriously jeopardize renal function. 
• Teach care of the incision and any remaining drainage tubes, catheters, or stents. This routine postoperative instruction is vital to prepare the client for self-care and prevent complications. 
• Instruct to report signs and symptoms to the physician, including manifestations of UTI (dysuria, frequency, urgency, nocturia, cloudy, malodorous urine) or systemic infection (fever, general malaise, fatigue), redness, swelling, pain, or drainage from the incision or any catheter or drain tube site. 
• Prompt treatment of postoperative infection is vital to allow continued healing and prevent compromise of the remaining kidney.