Kidney Removal (Nephrectomy)

A nephrectomy is a surgical procedure to remove all or part of a kidney. The kidneys are vital organs, that work hard to filter waste from your blood, maintain fluid balance and produce hormones essential for blood pressure regulation and red blood cell production. When a kidney becomes severely diseased, damaged or cancerous, its removal may become a necessary step to protect your overall health.

The procedure can vary significantly depending on the specific reason for the removal and the extent of the kidney damage or disease. It is important to understand that while it involves a vital organ, the human body is remarkably adaptable, and many individuals live full and healthy lives with only one functioning kidney.

Reasons for a Nephrectomy

Kidney removal is typically performed for a range of medical conditions affecting the kidney's health and function. Kidney cancer is the most common reason for a nephrectomy.

• Kidney cancer: This is the primary indication for most nephrectomies. A kidney tumor, especially if it is large or aggressive, often necessitates the removal of the affected kidney. We frequently treat different types of renal tumors, such as renal cell carcinoma, this way.
• Severe kidney damage: We may remove a kidney if it has sustained irreversible damage due to a severe injury, such as from trauma, rendering it nonfunctional and potentially causing pain or infection.
• Noncancerous tumors: While less common than cancerous growths, large benign (noncancerous) kidney tumors can also necessitate removal if they cause symptoms, grow too large or interfere with kidney function.
• End-stage kidney disease: In some rare cases of end-stage kidney disease, we may remove a nonfunctional, chronically infected or severely symptomatic kidney, especially if it's contributing to high blood pressure or other complications.
• Severe kidney infections: Chronic, recurring infections that are resistant to other treatments and cause persistent pain or systemic illness might lead to a nephrectomy.
• Congenital anomalies: Birth defects that cause severe kidney malformation and impair function can also be a reason for removal, particularly if they pose a risk of infection or other complications.
• Kidney donation: In this unique scenario, we remove a healthy kidney from a living donor to be transplanted into a recipient suffering from kidney failure. This is a voluntary procedure aimed at saving another person's life and is a testament to the body's ability to function with one healthy kidney.

The decision to perform a nephrectomy is made after careful evaluation by a health care team, considering the patient's overall health, the specific condition of the kidney and potential risks and benefits.

Types of Nephrectomy Procedures

The type of nephrectomy recommended depends on the reason for the surgery, the size and location of any tumors and the patient's overall health. There are two main categories of nephrectomy: partial and radical, each performed using various surgical approaches.

Partial Nephrectomy (Nephron-Sparing Surgery)

A partial nephrectomy involves removing only the diseased or damaged part of the kidney, such as a kidney tumor, while preserving as much healthy kidney tissue as possible. We refer to this approach as nephron-sparing surgery because it aims to save the healthy filtering units (nephrons) of the kidney.

• Purpose: Primarily used for smaller kidney tumors or when preserving kidney function is critical, such as in patients who have only one kidney or who have pre-existing kidney disease.
• Benefits: By leaving healthy kidney tissue, it helps to maintain more overall kidney function, which can be beneficial for long-term health, especially regarding blood pressure control and avoiding future kidney issues.

Nephrectomy (Total Nephrectomy)

A radical nephrectomy involves the removal of the entire kidney.

• Purpose: Typically performed for larger kidney tumors, more aggressive cancers or when the entire kidney is severely damaged and nonfunctional due to other conditions like severe infection or injury.
• Considerations: While a radical nephrectomy removes the entire diseased kidney, the remaining healthy kidney is expected to compensate and take over the full filtering workload.

Surgical Approaches for Kidney Removal

Both partial and radical nephrectomies can be performed using different surgical techniques.

Laparoscopic Nephrectomy (Minimally Invasive Surgery)

This approach is widely used today due to its benefits for the patient. Laparoscopic surgery involves several small incisions (usually three to four) in the abdomen. A thin, lighted tube with a camera (laparoscope) is inserted through one incision, allowing the surgeon to view the internal organs on a monitor. Specialized instruments are then inserted through the other small incisions to perform the surgery.

• Advantages: Generally results in less post-operative pain, a shorter hospital stay, faster recovery time and smaller scars compared to open surgery.
• Robot-assisted laparoscopic surgery: A variation of laparoscopic surgery where the surgeon controls robotic arms to perform the procedure. This offers enhanced precision, dexterity and a magnified 3D view, which can be particularly beneficial for complex partial nephrectomies.

Open Nephrectomy

In an open nephrectomy, the surgeon makes a single, larger incision (typically 6 to 12 inches long) in the side or abdomen to directly access the kidney.

• Indications: This traditional approach may be necessary for very large kidney tumors, complex cases, severe kidney disease or when there is extensive scarring from previous surgeries. It may also be chosen if there are concerns about the spread of cancer that require a wider surgical field.
• Considerations: While it involves a larger incision and potentially a longer recovery, open surgery allows the surgeon direct visualization and manipulation of the tissues, which can be crucial for certain challenging cases.

The choice of surgical approach will be discussed in detail by your surgical team, considering the specifics of your condition and your overall health. Kidney donation surgeries are always minimally invasive (laparoscopic or robotic).

Preparing for Nephrectomy Surgery

Preparing for a nephrectomy is a crucial step that helps ensure the best possible outcome. Your health care team will provide detailed instructions, but generally, preparation involves several key areas.

• Medical evaluation: You will undergo a thorough medical evaluation, including blood tests, urine tests and imaging scans (like CT scans or MRIs) to assess your overall health, the condition of your kidneys and the extent of the disease. This helps the surgeon plan the procedure.
• Medication review: Discuss all medications, supplements and herbal remedies you are taking with your doctor. You may need to stop certain medications, especially blood thinners, a week or two before surgery to minimize the risk of bleeding.
• Anesthesia consultation: You will meet with an anesthesiologist to discuss the general anesthesia, which ensures you are asleep and feel no pain during the surgery. They will review your medical history to ensure the safest anesthetic plan.
• Fasting: You will be instructed not to eat or drink for several hours before the surgery, typically starting the night before, to prevent complications related to anesthesia.
• Hygiene: You may be asked to shower with a special antibacterial soap the night before or the morning of surgery to reduce the risk of infection.
• Arrangements: Plan for your recovery period in advance. Arrange for someone to drive you home from the hospital, assist with daily tasks and help with childcare or pet care if needed, especially during the initial recovery phase.

Addressing any questions or concerns you have with your health care team before the surgery is vital for your peace of mind and preparedness.

Kidney Removal: What Happens During Surgery?

Nephrectomy is considered a major surgery. While the specific steps can vary depending on the type of nephrectomy (partial vs. radical) and the surgical approach (laparoscopic vs. open), the general process follows a structured path.

1. Anesthesia: Once you arrive at the hospital, you will be prepared for surgery. Before the procedure begins, you will receive general anesthesia. This means you will be completely unconscious and feel no pain throughout the entire surgery. Anesthesia also includes medications to relax your muscles and manage pain during and after the operation.
2. Positioning and incision: The surgical team will carefully position you on the operating table, typically on your side for kidney access. The surgeon will then make the necessary incision(s).
   • For laparoscopic nephrectomy, several small incisions (usually less than an inch each) are made in the abdomen. A laparoscope, a thin tube with a camera, is inserted through one incision to provide a view of the surgical area on a monitor. Other small instruments are inserted through the remaining incisions.
   • For an open nephrectomy, a single larger incision is made in your side or abdomen, providing direct access to the kidney.
3. Kidney dissection: The surgeon carefully navigates through tissues to reach the kidney. Blood vessels supplying the kidney (renal artery and vein) and the ureter (the tube that carries urine from the kidney to the bladder) are identified and carefully clamped and cut. In a radical nephrectomy, the adrenal gland and surrounding lymph nodes may also be removed if indicated.
4. Kidney removal: Once the kidney (or the diseased portion in a partial nephrectomy) is completely detached, it is carefully removed from the body. In laparoscopic procedures, the kidney is often placed in a bag and removed through one of the slightly enlarged incisions or through a separate small incision.
5. Closure: After the kidney is removed and all bleeding is controlled, the surgeon closes the incisions with sutures or staples. A small drainage tube may be placed temporarily near the surgical site to collect any excess fluid, which is usually removed within a few days.

The duration of a nephrectomy can vary widely, typically ranging from 2 to 4 hours, depending on the complexity of the case, the specific type of nephrectomy and the surgical approach used. Throughout the procedure, a dedicated surgical team, including the surgeon, anesthesiologist and nurses, monitors your vital signs closely to ensure your safety.

Risks and Potential Complications of Nephrectomy

Like any major surgical procedure, nephrectomy carries potential risks and complications, although serious issues are rare. Your medical team will discuss these possibilities with you before the surgery. Common surgical risks include:

• Bleeding: There is a risk of significant bleeding during or after surgery, which may occasionally require a blood transfusion.
• Infection: Infection can occur at the incision site or internally. Antibiotics are often given before and after surgery to minimize this risk.
• Reaction to anesthesia: Some individuals may experience adverse reactions to general anesthesia, such as nausea, vomiting, headaches or, more rarely, serious allergic reactions or respiratory problems.
• Pain: Post-operative pain is expected, but it is managed with medication. 

Specific risks associated with kidney removal include:

• Injury to nearby organs: Although rare, surrounding organs like the bowels, spleen, liver or pancreas could be inadvertently injured during the procedure.
• Pneumothorax: In some cases, especially with open incisions near the chest cavity, there's a small risk of collapsing a lung (pneumothorax).
• Nerve damage: Temporary or permanent nerve damage can occur, leading to numbness, tingling or weakness in the leg or groin area.
• Hernia: There's a small risk of developing a hernia at the incision site, especially with larger incisions.
• Kidney failure (in the remaining kidney): While the remaining healthy kidney typically compensates, there's a small risk of its function being impaired, especially if it's already diseased or damaged. This could potentially lead to chronic kidney disease. Because people who are able to donate a kidney have excellent kidney function, the risk of developing end stage kidney disease is quite low (on average, 31 in 10,000 donors).
• High blood pressure: In some cases, especially if the remaining kidney is already compromised, individuals may experience new or worsening high blood pressure.
• Proteinuria: The presence of protein in the urine, which can be a sign of stress on the remaining kidney.

The medical team takes extensive precautions to minimize these risks. Choosing an experienced surgeon and following all pre- and post-operative instructions significantly reduces the likelihood of complications.

Recovery After Kidney Removal

Recovery from a nephrectomy is a gradual process that varies for each individual, influenced by the type of surgery (laparoscopic vs. open) and your overall health.

Immediate Post-Operative Period (Hospital Stay)

• Initial hours: You will wake up in a recovery room, where nurses will closely monitor your vital signs, pain level and any signs of complications. You will likely feel groggy from the general anesthesia.
• Pain management: Pain is a normal part of recovery. You will receive pain medication, which may be administered intravenously (IV) or orally, to keep you comfortable. It's important to communicate your pain level to your nurses so they can adjust your medication as needed.
• Drips and tubes: You may have several tubes, including an IV line for fluids and medication, a urinary catheter to drain urine from your bladder and possibly a small drainage tube near the incision site to collect fluid. These are typically removed within a few days.
• Early mobilization: The health care team will encourage you to get out of bed and walk short distances as soon as safely possible, usually within 24 hours. Early movement helps prevent complications like blood clots and aids in recovery.
• Diet progression: You'll likely start with clear liquids and gradually progress to a regular diet as your digestive system recovers.
• Hospital stay: The typical hospital stay for a minimally invasive, laparoscopic or robotic nephrectomy is 1 to 2 days, while an open nephrectomy (not minimally invasive) may require 5 to 7 days or longer. When patients have special indications (very large polycystic kidneys or large cancers) sometimes an open nephrectomy approach is best.

Home Recovery

Once discharged from the hospital, your recovery continues at home.

• Pain management: You will likely need pain medication for a period. Follow your doctor's instructions for dosage and duration. Over-the-counter pain relievers may be sufficient as your pain subsides.
• Activity restrictions: For several weeks, you will have restrictions on your physical activity. This generally includes:
• Lifting: Avoid lifting anything heavier than 10 pounds (about a gallon of milk) for 8 weeks to prevent strain on your abdominal muscles and incision.
• Strenuous activity: Refrain from strenuous exercise, heavy lifting or activities that put significant strain on your core for a period recommended by your surgeon, often 8 weeks for open surgery and 3 to 4 weeks for laparoscopic.
• Driving: You typically cannot drive while taking narcotic pain medication or until you are comfortable enough to safely operate a vehicle without discomfort or hesitation.
• Wound care: Keep your incision clean and dry. You'll receive specific instructions on how to care for it. Report any signs of infection (redness, swelling, pus, fever) to your doctor immediately.
• Fatigue: It's common to feel tired and low on energy for several weeks after surgery. Rest is crucial for healing.
• Diet: Generally, there are no strict dietary restrictions after kidney removal if your remaining kidney is healthy. Focus on a balanced, healthy diet. Hydration is key – drink plenty of water to support your remaining kidney. Discuss any specific dietary concerns with your doctor.
• Follow-up: You will have follow-up appointments with your surgeon to monitor your recovery, check your incision and assess your kidney function.

Return to Normal Activities

The full recovery period varies. For laparoscopic surgery, most people can return to light activities within 2 to 4 weeks and resume most normal activities within 4 to 6 weeks. For open surgery, full recovery and return to normal activities may take 6 to 12 weeks. Listen to your body and your doctor's advice. Gradual increases in activity are recommended.

Living With One Kidney (Post-Nephrectomy Life)

People who have one kidney removed can live a completely normal, healthy life. The human body is designed with a significant reserve capacity, and the remaining healthy kidney is typically able to compensate for the loss of the other.

Kidney Function and Compensation

When one kidney is removed, the remaining healthy kidney undergoes a process called compensatory hypertrophy, meaning it grows slightly larger and increases its filtering capacity. This adaptation allows it to perform the work that two kidneys once did. For many individuals, their remaining kidney can maintain adequate kidney function for their entire lives.

Lifestyle Adjustments and Side Effects

While life with one kidney is generally normal, there are some important considerations and lifestyle adjustments to ensure the long-term health of your remaining kidney.

• Hydration: Staying well-hydrated is paramount. Drinking plenty of water helps your remaining kidney efficiently filter waste.
• Healthy diet: Maintain a balanced, nutritious diet. While there are no strict restrictions for healthy individuals with one kidney, limiting excessive salt, processed foods and unhealthy fats is always beneficial for overall health.
• Regular exercise: Engage in regular, moderate physical activity.
• Blood pressure control: High blood pressure can put a strain on the kidney. Monitor your blood pressure regularly and manage it effectively with lifestyle changes and, if necessary, medication.
• Avoidance of certain medications: Be cautious with medications that can be harsh on the kidneys, such as certain over-the-counter pain relievers (NSAIDs like ibuprofen or naproxen) when used long-term or in high doses. Always consult your doctor or pharmacist.
• Contact sports: While not a universal rule, some doctors recommend avoiding high-impact contact sports (like football or martial arts) or wearing protective gear, particularly if there's a risk of direct trauma to the kidney area, to protect the single remaining kidney from injury. Discuss this with your health care team.
• Alcohol consumption: Can you drink alcohol after having a kidney removed? In general, moderate alcohol consumption is usually acceptable once fully recovered and cleared by your doctor. However, excessive or chronic alcohol intake can put a strain on the kidneys and should be avoided. Always follow your physician's guidance.
• Regular medical check-ups: Regular follow-up with your doctor is essential. They will monitor your kidney function through blood tests (e.g., creatinine levels to estimate glomerular filtration rate) and urine tests (e.g., for proteinuria, which indicates protein in the urine) to ensure your remaining kidney is functioning well.

Long-Term Outlook and Survival Rate

The life expectancy after nephrectomy is generally very good, particularly if the surgery was for a noncancerous condition or early-stage cancer that was completely removed. For kidney donation, there is no impact on life expectancy. For kidney cancer, the survival rate for kidney removal depends heavily on the stage and type of cancer at the time of diagnosis and surgery. Early detection and treatment significantly improve the prognosis. Your medical team can provide more specific information based on your individual diagnosis.

Most people who have a nephrectomy do not develop chronic kidney disease or kidney failure. However, regular monitoring of your kidney function is important, especially as you age, to detect any potential issues early.

The Difference Between a Nephrectomy and a Kidney Transplant

It's common to confuse a nephrectomy with a kidney transplant, but they are distinct procedures with opposite goals.

• Nephrectomy: This is the removal of a diseased, damaged or donated kidney from a patient's body. The purpose is to treat a condition by taking out the problematic kidney, or donate a healthy kidney to help another person.
• Kidney transplant: This is the placement of a healthy donor kidney into a recipient whose own kidneys have failed. The purpose is to provide a new, functioning kidney to a patient suffering from end-stage renal disease. The patient's native kidneys are usually left in place unless they are causing severe problems.