Laparoscopic Radical Nephrectomy

Patient phenotype

Renal cell carcinoma. Age 50-75. Often: smoker, HTN, sometimes paraneoplastic syndrome (anemia, hypercalcemia, polycythemia). Lateral decubitus, kidney rest position.

Procedure

Lateral decubitus with kidney rest elevated. 4-5 ports, mobilize kidney, ligate renal artery + vein + ureter, en-bloc dissection if extensive disease. ~2-4 hours.

Anesthetic plan

GETA. Standard but: lateral position concerns + insufflation effects. A-line if cardiac comorbidity. Multimodal analgesia. Most extubate at end.

Setup

·Standard ASA + Foley + temp
·A-line (especially if HTN or cardiac concern)
·Two PIVs
·OG tube
·Type & screen 2 units (vascular ligation risk)
·Lateral decub padding + axillary roll + table flex (kidney rest)
·Forced air warmer

Biggest concerns by phase

Pre-op

Paraneoplastic syndromes + comorbidity

RCC paraneoplastic: anemia, hypercalcemia, polycythemia, HTN, AA amyloidosis, fever. Pre-op labs: CBC, BMP (Ca), coags. HTN may need optimization + arterial line. Smokers: pulm function + smoking cessation.

Induction

Standard induction + RSI if reflux

Standard induction. Insufflation + lateral position = potential aspiration risk; modified RSI if GERD.

Intra-op

Lateral decub + kidney rest + insufflation

Lateral decub: axillary roll, dependent arm forward, leg pillow. Kidney rest elevates flank — drops venous return. Insufflation 12-15 mmHg adds. Hypotension common at start of insufflation in lateral.

Intra-op

Renal vein injury → IVC tear catastrophic

Renal vein very short on right (drains directly to IVC). Injury can extend to IVC. Sudden massive bleeding possible. Type & screen active. Communicate any sudden hypotension to surgeon.

Intra-op

Tumor thrombus in IVC (rare but high stakes)

Some RCCs extend tumor thrombus into renal vein → IVC → RA. Pre-op imaging should identify. If present, may need cardiac surgery + bypass for thrombectomy. TEE intraop to monitor.

PACU

Postop: AKI in remaining kidney, pain, ileus

Remaining kidney now compensates. Watch creatinine. Pain: TAP block + multimodal. Ileus from manipulation; advance diet slowly. Discharge POD 2-4 typical.

Mock-defense scenarios

Practice answering these out loud. The probes show what an examiner is listening for.

Right radical nephrectomy, lateral decubitus + kidney rest. Mid-renal vein dissection, surgeon says 'tear, lots of bleeding from the vein, can't see.' BP drops to 70/40 in 30 sec. What's your plan?

What an examiner probes for

▹Activate massive transfusion
▹Confirm IV access patent + run blood
▹Communicate with surgeon — may need IVC clamp or open conversion
▹Vasopressor support
▹Anticipate: long resuscitation, IVC repair, possibly cardiac surgery if extends to RA

Sources

Miller's Ch 67
AUA Nephrectomy Guidelines

Anatomy reference

Sourced reference images. 4 matches for "kidney renal urinary".

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Education only — anesthetic plans vary by patient, institution, and provider judgment. Use as a starting point, not a substitute for clinical reasoning.