Indications

• Malignancy [renal cell carcinoma]
• TCC of ureter requiring nephro-ureterectomy
• Non-functioning kidney
• Chronic pyelonephritis

Possible approaches

1. Open
   • Anterior/Transperitoneal
   • Posterio-lateral/Retroperitoneal
2. Laparoscopic
   • Transperitoneal
   • Retroperitoneal 

Procedure (Right nephrectomy - Anterior/peritoneal approach)

1. CT scan + confirm presence of opposite kidney (otherwise you're in big shit) + mark side + consent
2. GA + supine
3. Kocher's subcostal incision
   • identify hepatic flexure, duodenum, gonadal vessels
   • Mobilise colon medially: display perinephric fat
4. Identify kidney (surrounded by paranephric fat), ligate vascular pedicle (prevents dislodging of tumour cells into circulation)
   • Identify vascular pedicle
   • Clamp renal artery
   • Palpate renal vein; ligate and divide
   • Divide renal artery
5. Mobilise kidney within fascia (Gerota's, surrounds perinephric fat)
6. Divide ureter at accessible point
7. Remove kidney with perinephric fascia intact
8. Place suction drain
9. Close wound in layers

Procedure - Posterio-lateral approach

1. Lateral decubitus position + renal bridge on operating table under contralateral loin.
2. Subcostal incision along line of 12th rib: Midline -> posterior axillary line (ie, quite large)
3. Divide layers: skin / lat dorsi / ext obl / int obl / quad lumb / > kidney

Laproscopic nephrectomy

• Dissect out
• Bring to surface
• Make skin incision to deliver

Complications

1. Early
   • Wound infection
   • Bleeding
   • Haemorrhage
   • General - DVT, Chest infection, PE
2. Late
   • Tumour reccurrence