Partial Nephrectomy

PARTIAL nephrectomy: how it’s performed (2011-2015):

Partials vs. Radicals Nephrectomies

Partial nephrectomy is also referred to as "nephron-sparing surgery" or "kidney-sparing surgery."  During partial nephrectomy the surgeon removes the tumor and saves the kidney.

Should I have the entire kidney removed and be safe?

Not necessarily! A number of studies show that a successful partial nephrectomy removes the tumor successfully and achieves cure rates similar to radical nephrectomy (or total kidney removal).  This is well-established for tumors < 4cm and there is emerging research suggesting that the same is true for larger tumors.  An experienced surgeon can look at the CT or MRI scan and make an assessment regarding the feasibility and safety of a partial nephrectomy.

What are the benefits of partial nephrectomy?

The major advantage is the preservation of kidney function.  For some patients who already have chronic kidney disease, these is of paramount importance to stay off dialysis. In general, patients who have worse kidney function are more likely to develop heart disease and die from it than patients with normal kidney function.

Who is the ideal partial nephrectomy patient?

First and foremost, the tumor must be in a location that would make a partial nephrectomy feasible and safe.  Experienced surgeons specializing in partial nephrectomy have the best chance at removing difficult tumors successfully.  There are a number of additional ideal patient and tumor characteristics:

  • Small kidney tumors (<4cm): It is now believed to be the standard of care to spare the kidney for all small kidney tumors.  This is because most small tumors are amenable to partial nephrectomy and most small tumors are not dangerous – losing a kidney would have worse consequences for most patients!  However, just because you have a small tumor does not mean you can undergo partial nephrectomy.  Tumor location is a major determinant of the safety of partial nephrectomy. 
  • Solitary Kidney: sparing a solitary kidney is essential to avoid dialysis in a patient with only one kidney.
  • Chronic kidney disease: (or a patient suffering from kidney failure) If this patient loses a kidney he/she are more likely to require dialysis—which will result in a worsened quality (and potentially quantity) of life.
  • Risk factors for kidney failure:  The most common reasons patients have poor kidney function today are diabetes and high blood pressure.  Having these conditions means you may already have worse kidney function than you think.  Saving the kidney will maintain a better kidney function and prevent kidney failure in the future.
  • Tumors in both kidneys:  Saving one or both kidneys will help this patient avoid kidney failure as well.
  • Any patient in whom the tumor can be safely removed via partial nephrectomy.  Since we do not know what the future may bring, saving the kidney is usually preferable.  Again for certain patients this may not be desirable and a discussion with an expert urologist is necessary.
How is a partial nephrectomy performed?

The kidneys receive approximately 1/4th of the bodies blood flow any given minute.  Safely performing a partial nephrectomy involves temporarily stopping the blood flow to the kidney (see Ischemia Time below), removing the tumor and reconstructing the kidney

Partial nephrectomy can be performed through an open incision or using robotic technology.  There are advantages and disadvantages to each approach.  The key points are removing the entire tumor and sparing the kidney safely

In general, the robotic approach yields smaller incisions, less postoperative pain,
and a shorter hospital stay.

The open surgical technique utilizes a small incision, allows cooling of the kidney
(important for patients with kidney disease) and may be ideal for patients with complex tumors. 
Our open technique DOES NOT routinely involve removing a rib.

Our commitment is to provide the best care with the most minimally invasive approach while maximizing safety and effectiveness. The kidney cancer experts at Johns Hopkins are skilled in both approaches and will decide the best approach with you.

Are there any complications that can occur unique to a partial nephrectomy?

The two major complications from this surgery include bleeding and urine leak.  Historically, the complication rate from partial nephrectomy is about 25%.  Partial nephrectomies performed at Johns Hopkins have a less than 10% rate of complications

What is "ischemia time" and what do I need to know about it?

Ischemia time refers to the amount of time that the surgeon temporarily blocks the blood vessels going into the kidney.  Stopping blood flow to the kidney (or any organ) can cause an "ischemic injury" leading to temporary or permanent loss of kidney function.  It is essential to block the vessels to allow for removal of the tumor in a bloodless field which allows the surgeon to see well, remove the entire tumor and keep the operation safe.  Occasionally the surgeon can cut the tumor without blocking the vessels (“NO or ZERO ISCHEMIA”).  A shorter ischemia time is desirable and we aim to have the tumor removed and the kidney reconstructed within 30 minutes.  However, longer ischemia times are acceptable in patients with excellent kidney function and two kidneys.  If a prolonged ischemia time is predicted (for instance in a larger or more complex tumor) or if a patient has a solitary kidney, ice can be used to cool the kidney and protect against injury related