What Is a Radical Nephrectomy?

Radical total nephrectomy, also called total nephrectomy; total nephrectomy of kidney and ureter; full length nephrectomy, is a kind of urological operation.

Radical nephrectomy

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Radical total nephrectomy, also called total nephrectomy; total nephrectomy of kidney and ureter; full length nephrectomy, is a kind of urological operation.

Chinese name

Radical nephrectomy

Foreign name

Radical nephrectomy with radical nephrectomy

Classification

Urology / Kidney Surgery

Urology / Kidney Surgery / Surgical Treatment of Renal Tuberculosis

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The incidence of renal tuberculosis is the highest in male genitourinary tuberculosis, and the primary lesions are almost always in the lungs. According to statistics at home and abroad, 70.9% to 83.1% of the 20 to 40-year-olds are affected. Renal tuberculosis is a blood-borne infection, so there are more opportunities for simultaneous infection on both sides. However, during the development of the disease, the lesions on one side may be severe, while the lesions on the other side may develop slowly. If the patient's body resistance is reduced and the condition develops rapidly, it may manifest as bilateral lesions, accounting for about 10%. Most patients with mild contralateral lesions heal on their own, and the renal tuberculosis seen is unilateral. The incidence is almost equal on the left and right. The lesions tend to be more polar in the kidneys. In the early stage, tuberculosis nodules were not different from tuberculosis lesions in other tissues. Caseous necrosis often occurred in the central part of such nodules, and tuberculous granulation tissue was surrounding. 90% of the lesions were in the renal cortex, and gradually expanded, merged, and further developed, ruptured at the renal nipple, and then spread to the renal pelvis and calf mucosa. It is clinically renal tuberculosis when it spreads far away through the kidney calyx and the renal pelvis, or the bacteria spread to other parts or all of the kidney through the lymphatic vessels of the kidney. During the course of the disease, if the patient has strong anti-tuberculosis immunity, it is fibrosing or with calcium deposition. If it becomes caseous, ulcers will form tuberculous voids, which may be focal. Can also spread to the whole kidney to become tuberculous pus kidney. Due to tuberculosis and urine contamination, infiltration ulcers and fibrosis occur in the ureteric mucosa, submucosa, or the entire layer of the ureter; lesions involving the ureter, the cavity is rough and uneven, and the thickness of the lumen is uneven, and the entire ureter becomes a rigid cable The lumen may be blocked, accelerating kidney damage. If the kidneys are completely destroyed, no urine is secreted, and no tuberculosis bacteria enter the bladder at this time, most of these kidneys have calcified areas or are filled with casein-like substances. This is called "household kidney removal." Lesions spread to the bladder, initially causing mucosal congestion and edema, tuberculous nodules or ulcers. Clinically, there are obvious urinary urgency, dysuria, and hematuria. If the lesion further invades the muscle layer, causing fibrosis of the tissue, the bladder loses its stretching power, the capacity decreases, and a bladder contracture is formed. In other cases, it penetrates the bladder wall and forms a bladder vaginal fistula or bladder rectal fistula. Tuberculosis of the bladder can involve the ureteral orifice of the healthy side, causing hydronephrosis in the kidney and ureter, and severe renal impairment in severe cases.

The clinical manifestations of renal tuberculosis are mainly frequent urination, urgency, dysuria, hematuria, pyuria, and low back pain. The diagnosis is mainly based on urine tuberculosis, cystoscopy, and pyelography. The medical treatment of renal tuberculosis is mainly the application of anti-tuberculosis drugs. The principle of medication is combined use, which lasts for a sufficient period of treatment. Isoniazid and streptomycin are more commonly used for aminosalicylic acid, which has good efficacy and low toxicity. In recent years, rifampicin and ethambutol have been listed as relatively less toxic due to their higher efficacy and less toxicity. Into the drug of choice. The course of treatment is generally within 12 months, that is, the two-phase therapy of rifampicin and ethambutol (starting the intensive phase and then the consolidation phase). Early small lesions can often be cured, and even large lesions can sometimes be stable. The role of the condition as a preoperative preparation. The surgical treatment of renal tuberculosis is to clear the lesion and shorten the treatment time. Renal tuberculosis lesion removal, partial nephrectomy, nephrectomy, total nephrectomy of the kidney and ureter, surgical treatment of contralateral hydronephrosis, and surgical treatment of contracture bladder are performed according to the scope of the lesion and the degree of organ involvement and destruction. In recent years, the incidence of renal tuberculosis has increased, and it should be given sufficient attention.

Radical total ureterectomy is suitable for tuberculous abscesses. If the ipsilateral ureter is dilated and purulent due to lower stenosis or atresia, or if there are multiple stenosis and dilation in the entire segment, an abscess should be performed. The aim is to clear genitourinary tuberculosis, which is beneficial for postoperative treatment and prevention of sequelae.

1. Partial nephrectomy is performed after regular drug antituberculosis treatment.

2. Correct anemia and improve physical fitness.

3. Prepare blood 400 800ml.

4. The indwelling catheter continuously drains the bladder.

General anesthesia or epidural block anesthesia, supine position, sandbags or small pillows on the back and hips of the operation side, tilt the body position by 20-30 °.

1. The incision tangent runs from the tip of the 11th rib forward to the lateral edge of the rectus abdominis muscle, and then extends vertically downward to the upper part of the pubic symphysis, similar to a "7" -shaped incision. Outside the rectus muscle, cut the external oblique muscle and rectus abdomen sheath, cut the external oblique muscle along its fiber backward and obliquely, and cut the latissimus dorsi and part of the back fascia, straight up to the 12th The lower edge of the ribs. Straight down to the upper edge of the pubic symphysis, completely separate the rectus abdominis from the internal and external oblique muscles, and then cut the rectus abdominis sheath along the full length of the incision. It is bluntly separated from the deep peritoneum. Do not tear the peritoneum.

2. Separate the peritoneum from the abdominal wall muscle layer along the full length of the incision, and push it with the abdominal organs to the opposite side. Cover the deep retractor with gauze pads and retract it to expose the entire retroperitoneal space on one side. come out.

3. Push the retroperitoneal fat and the peritoneum forward, cut the Gaussian fascia as close as possible to the posterolateral side, and extend upward and downward to expand the lumbar fascial incision and push open the renal kidney fat. At this point, the kidney and the upper and middle ureters are exposed in the visual field.

4. Before freeing the kidney, generally free the diseased ureter, tie it with a cloth band and lift it up, so as not to squeeze the pus into the bladder, and then bluntly separate each side of the kidney with fingers and peel off the inner side of the kidney to After the peritoneum is separated, the renal blood vessels and renal pelvis are exposed in the visual field, which is clearer than that through a lumbar incision. Separate the back of the renal pedicle with your fingers, ligate once with a 7-0 silk thread, and then cut it with forceps. After the distal end of the renal blood vessel is sutured, the kidney is freed, and it can be raised out of the incision, and the ureter is separated downward one by one. When it reaches the level of the iliac blood vessel, several pelvic vessels are cut and ligated one by one. Pull up the ureter, see it into the bladder, clamp, cut, and sew, and completely remove the kidney and ureter.

5. The upper and lower rubber tubes are placed in the surgical department for drainage, and the abdominal incision is sutured.

1. Use 3 kinds of anti-tuberculosis drugs, intramuscular injection of streptomycin, oral combination of ramipine and rifampicin. Available medicine for 3 to 6 months. If there is residual TB disease in the urinary system or active tuberculosis outside the urinary system, continuous treatment with drugs for 6 to 12 months or longer is needed, and streptomycin can be stopped early.

2. Those with significant bladder irritation, indwelling catheter drainage after operation.

3. Use antibiotics for 1 week, strengthen supportive therapy, and improve nutritional status.

4. Rubber tube drainage was removed 3 to 5 days after surgery.

5. Female patients of childbearing period can only become pregnant after their condition is stable and the drug treatment is over.

6. In order to prevent abdominal distension, gastrointestinal decompression can be performed, and it should be removed after the intestinal motility is restored. The urinary catheter was indwelling and the rubber drainage tube was removed 3 to 5 days after the operation.

1. After the ureteral stump syndrome tuberculosis kidney is removed, if there are tuberculosis lesions in the remaining ureter, patients often feel lower abdominal pain, frequent urination, and dysuria. Urine tests repeatedly showed red and white cells, pus cells, and Mycobacterium tuberculosis. This may be due to the narrowing of the lower end of the ureter and the accumulation of pus in the stump of the ureter. Cystoscopy revealed congestion, edema, dilation, and pus flowing into the bladder around the ureteral stump. Stones or growing tumors may even form in the late cavity. In order to further clarify the diagnosis, a ureteral catheter can be inserted and a contrast radiograph can be injected to understand the nature of the lesion. Once the diagnosis is confirmed, a stump ureterectomy is feasible.

2. Intestinal fistula is often found after the intestinal wall was accidentally injured. The intestinal contents flow into the wound within a few days after operation, causing local infection and intestinal fistula formation.

Complicated colon fistulas can mostly heal themselves. If the fistula does not heal for a long time, a temporary colostomy can be performed at the proximal end, and at the same time, a lumbar incision is enlarged to allow local drainage and the fistula can often heal itself. If it still does not heal, an intestinal fistula and anastomosis are needed.

Duodenal fistula should be regarded as a serious complication. Nutrient deficiency and imbalance of water and electrolyte can occur due to large loss of intestinal fluid. Tissue necrosis and secondary infection can also occur due to intestinal fluid stimulation to local tissues. If found early, surgery can be performed to repair the fistula. If it has been for a long time and local inflammation is significant, fasting should be performed and intravenous hypertrophy should be performed. A porous rubber drainage tube was inserted from the wound for negative pressure drainage. Protect the surrounding skin with zinc oxide ointment to make the fistula heal gradually. At the same time, jejunostomy can be used for enduring fistula to ensure adequate nutrition, maintain water and electrolyte balance, enhance the body's resistance, and promote wound healing.

3. Due to infection around the residual renal pedicle in the wound sinus, necrotic tissue and silk foreign matter remain, and wounds with hematoma, kidney or renal pelvis tissue fragments can cause wound infection to form and become sinus. After the kidney is removed, as far as possible, the diseased peripheral renal adipose tissue is removed. Stop bleeding carefully, and place a rubber tube for drainage if necessary. If chronic sinus has been formed and is not cured for a long time, if necessary, perform sinus extraction and invasive surgery or sinus resection.

4. Renal arterial and venous fistulas often occur in patients with severe adhesion around the renal pedicle and after large block clamps. If the fistula is small and does not affect cardiovascular dynamics, continue clinical observation, otherwise the fistula should be closed again.