Anesthesia for Nephrectomy – Simple, Radical, and Laparoscopic


1. Introduction

Nephrectomy involves surgical removal of a kidney and may be performed for:

  • Benign conditions: PUJ obstruction, non-functioning kidney, chronic infection (→ simple nephrectomy)
  • Malignancy: Renal cell carcinoma (RCC) (→ radical nephrectomy)
  • Donor nephrectomy: For renal transplantation
  • Approach: Open or laparoscopic


🔍 2. Types of Nephrectomy

Type

Indication

Scope

Simple Nephrectomy

Non-malignant conditions (hydronephrosis, TB)

Kidney only

Radical Nephrectomy

Renal tumors (e.g., RCC)

Kidney, adrenal, perinephric fat, lymph nodes

Partial Nephrectomy

Tumors <4 cm, solitary kidney

Tumor with rim of normal parenchyma

Laparoscopic Nephrectomy

Minimally invasive for simple/donor nephrectomy

Transperitoneal or retroperitoneal



3. Preoperative Considerations

A. History & Examination

  • Assess renal function, comorbidities (HTN, DM), hydration status
  • Evaluate for anemia, electrolyte disturbances, or infection
  • For radical nephrectomy – oncologic assessment, CT scan, local invasion

B. Laboratory Investigations

  • RFTs: Serum creatinine, BUN
  • CBC: Anemia, infection
  • Coagulation: Risk of bleeding
  • Electrolytes: Na⁺, K⁺, Ca²⁺
  • Urine analysis & culture

C. Imaging

  • CT/MRI: For tumor extent and planning
  • Renal scan (DTPA/MAG3): To assess function of both kidneys

D. Optimization

  • Correct anemia and electrolytes
  • If infection present → antibiotics
  • In case of solitary kidney or CKD, involve nephrology preoperatively


 4. Anesthetic Technique

Both general anesthesia and regional techniques may be used depending on the approach and patient condition.

✅ General Anesthesia:

  • Preferred approach for open and laparoscopic nephrectomy

Standard Drugs:

  • Induction: Propofol or Etomidate (in poor EF), Fentanyl, Rocuronium
  • Maintenance: Oxygen + Air/Sevoflurane or TIVA, intermittent opioids
  • Muscle relaxant: Cisatracurium preferred in renal dysfunction


 5. Intraoperative Considerations

Parameter

Simple Nephrectomy

Radical Nephrectomy

Laparoscopic Nephrectomy

Positioning

Lateral decubitus

Lateral with kidney rest

Lateral decubitus

Monitoring

Standard + Arterial line (for radical)

Arterial line, ± CVP if major blood loss expected

Standard; arterial if needed

Analgesia

Regional block (e.g., ESP) or PCA

Epidural or TAP block

TAP block or wound infiltration

Blood loss

Minimal

Moderate to high (tumor invasion)

Minimal

Fluid balance

Maintain euvolemia

Monitor urine output, avoid overload

Restrict initially; liberalize post specimen removal

Pneumoperitoneum (Lap)

Not applicable

Not applicable

CO₂ insufflation → ↑PVR, ↓venous return, ↑PaCO₂



 6. Specific Concerns

🧱 Radical Nephrectomy:

  • Can involve large tumors, IVC thrombus, adrenalectomy
  • Risk of massive blood loss → type and crossmatch blood
  • Vascular control → possible hypotension
  • May need IVC clamping or CPB in extensive cases

💨 Laparoscopic Nephrectomy:

  • Pneumoperitoneum → ↑ PaCO₂ → need for controlled ventilation
  • Trendelenburg/reverse Trendelenburg affects venous return and cerebral perfusion
  • Gas embolism and subcutaneous emphysema are rare but serious


🩹 7. Postoperative Management

Aspect

Details

Pain Management

PCA opioids, epidural, or regional blocks (TAP, ESP, wound infiltration)

Fluid Balance

Monitor closely; avoid overload

Urine Output

Keep UO >0.5 mL/kg/hr

Complications

Bleeding, infection, ileus, renal failure (especially in solitary kidney)

Mobilization

Early ambulation → ↓ DVT risk




🧠 Key Viva/Exam Pearls

  • Q: Why avoid sevoflurane in CKD?
    Sevoflurane can release Compound A which is nephrotoxic, especially with low flow.
  • Q: Why is atracurium preferred in ESRD?
    It undergoes Hofmann elimination, independent of renal clearance.
  • Q: What are signs of CO₂ embolism in laparoscopic nephrectomy?
    Sudden ↓ EtCO₂, hypotension, “mill wheel” murmur, hypoxia.