Nephrectomy, Total and Partial

There are three possible ways that a total or partial nephrectomy may be done:

• Open surgery – A small cut (a couple of centimeters wide) is made in the upper belly or near the ribs. The skin is pulled aside so the surgeon can see and work directly on the child. This is usually done in young babies.
• Laparoscopic surgery – Several tiny cuts (a few millimeters wide) are made in the abdomen. The surgeon holds long, thin instruments with tools and a camera inside the tiny holes and operates using these, from the outside of the belly.
• Robotic surgery – Several tiny cuts (several millimeters wide) are made in the abdomen. The surgeon uses a computer to control the robotic arms, which move small tools underneath the skin to do the operation. This is also called robot-assisted laparoscopic surgery.

A nephrectomy is done when it is safer to remove the damaged kidney (or part of it) than to keep it in the body.

Children may need part or all of a kidney removed for a number of reasons. In most cases, there is a problem with the kidney that keeps it from working well. This leads to repeat urinary tract infections (UTIs), pain, kidney stones or other problems. Over time, symptoms can get worse. In addition, the damage can spread to healthy parts of the kidney or lead to a dangerous infection called sepsis. If the kidney swells due to a blockage, it can cause pain or other symptoms and may also start to push on other organs, which can affect how well those organs work. These blockages can often be fixed. However, if the kidney is not working well and is not easily fixed, it may be a better option to remove it if the child has a normal kidney on the other side.  

It is not uncommon for children to not have any symptoms with some forms of kidney disease or swelling of the kidney. Many children are diagnosed with a kidney problem before they are born, when a swollen kidney (called hydronephrosis) is found on an ultrasound. After they are born, other tests will be done to learn how well the kidney is working.

A total or partial nephrectomy may be needed for the following conditions:

• Atrophic or dysplastic kidney – The kidney is small and does not work well or make urine as it should. It may also cause issues with blood pressure.
• Reflux nephropathy – Urine leaves the kidney but then flows backward into the kidney when the child pees (reflux). This can cause infections and damage the kidney over time. In some cases, this can keep the kidney from working well even after the reflux has stopped on its own or has been corrected with surgery.
• Cancer – A tumor or cancerous cells in the kidney pose a danger to other areas of the body and need to be taken out. Tumors can also block urine and destroy healthy kidney cells.
• Kidney malfunction – The kidney has stopped working well. If other treatments do not work and the kidney may be more harmful in the body than out, it may be removed.
• Kidney injury or trauma – Physical injury has damaged the kidney and it cannot be saved.
• Anatomic abnormality – Something did not develop correctly in the kidney or urine tubes. For example, a urine tube at birth drains somewhere other than the bladder (ectopic) and does not work well enough to attach it to the bladder instead.
  • Renal dysplasia or multicystic dysplastic kidney – a birth defect in which the kidney does not develop normally and makes little or no urine. Instead, the tissue of the kidney contains small sacs of fluid called cysts instead of normal cells that make urine. These cysts often shrivel up over time and go away, but if this does not happen, removal of the kidney may be needed.

No matter the underlying condition, the doctor will look at your child’s total picture of health. They will consider how well the other kidney is working, how well the damaged kidney works, and what the risks are for your child for a partial versus total nephrectomy.

Once a problem is diagnosed and the doctor says surgery is needed, your child will be scheduled for the operation. Unless your child has a kidney removed because of trauma, nephrectomy is not an emergency surgery.

A nurse from Nationwide Children’s will call 1-3 days before the operation to give instructions and the exact time of the surgery. The nurse will let you know when to arrive, when your child needs to stop eating or drinking, and any other information you need to know for the operation. A partial or total nephrectomy requires at least one overnight stay at the hospital, even for minimally invasive operations.

1. Your child will be put to sleep using medicine (general anesthesia). A bladder catheter will be put in place after they go to sleep to measure the urine made during the surgery. It will be left in place overnight.
2. Your child will receive at least one dose of antibiotics to help lower the chance of an infection.
3. If your child has a partial nephrectomy, a stent (a small plastic tube) may be placed in the remaining urine tube during the procedure. The stent will stay in place until removal at a later date. This will help the urine tube stay healthy during and after the operation. This may require another brief outpatient procedure to remove the stent.
4. The surgery will last about 2-4 hours. A surgery nurse will call you from time to time to let you know how your child is doing.
5. In the recovery room, your child will be woken up from anesthesia and monitored closely for a period of time. If there are no signs of a problem, he or she will be given pain medicine if needed and will stay in a recovery room at the hospital for a day or two before going home.

If your child receives a stent, you will have to return to the hospital in 4-6 weeks. It will be removed under general anesthesia, but your child should be able to go home that same day. The surgeon will go through your child’s normal anatomy to remove it – there will not be any cuts. Imaging after surgery may include an ultrasound to check the health of the remaining kidney

You can also expect the following after partial or total nephrectomy:

• The skin is usually closed with internal, absorbable stitches and skin glue. These disappear on their own and don’t require any special removal or care.
• Your child can begin bathing and showering normally after 2 or 3 days
• Your child can usually return to normal activity in 2 weeks.
• The site of the cut may be sore for a few days or weeks.
• Some children have discomfort or a little pain from the stent for some of all of the time it is in place. If your child has a stent, he or she should not play contact sports until it is removed.
• If your child has a stent, they may have some blood in their urine until the stent is removed.

You should call the doctor or seek medical attention for your child after partial or total nephrectomy if your child:

• Has a fever of 101° F or higher any time before the scheduled follow-up visit
• Passes blood clots in the urine that make it difficult to pee
• Complains of severe pain in the belly, side or back that isn’t helped by the pain medicine they are given at discharge
• Has vomiting and cannot eat or drink normally
• Has symptoms of a urinary tract infection (UTI)

When a kidney doesn’t work well, it can cause pain, infections, kidney stones, and other problems, such as high blood pressure. Children with poor kidney function also have to be monitored frequently, meaning lots of time at the hospital for uncomfortable tests and imaging. When nephrectomy is successful, it can reduce the chances your child will have pain, infection, and kidney stones, and spare your child frequent monitoring and testing moving forward. It may also control their blood pressure.

A nephrectomy has all of the general risks of surgery, such as infection at the site of the cuts, bleeding, swelling, inflammation, and reaction to the anesthesia.

In addition, partial nephrectomy carries the risk of urine leaking into the body after surgery and irritating other tissue. There is also a risk of blood loss and injury to other organs during the operation. If there is a problem with the surgery or other complications later on, there is a chance that another surgery may be needed. With a partial nephrectomy, there is also the risk of some bleeding after surgery while your child is hospitalized.

• Why is nephrectomy needed?
• Is it possible to preserve part of the kidney and the urine tube?
• What alternative treatment options are available?
• What would happen if the surgery were not done?
• What is the best plan for follow-up care and imaging?
• When and how will you know that the surgery worked?
• What surgical technique does the doctor recommend, and why?
• What will kidney removal mean for your child’s long-term health?
• What can you expect before and during the surgery?

When your child needs a total or partial nephrectomy, our physicians understand that the situation is unique. Our staff and surgeons will work carefully to tailor the procedure to your child’s needs. Whenever possible, your child’s healthy tissue will be preserved so that he or she can keep two functioning kidneys.

At Nationwide Children’s, our surgeons perform minimally invasive surgery whenever possible so that children have smaller scars, less pain, and a swifter recovery. In some cases, the scars may even be hidden by the belly button and underwear. One approach that is used in some cases is called HIdES (hidden incision endoscopic surgery), which can reduce the visibility of your child’s scars.

When undergoing nephrectomy at Nationwide Children’s, your child has access to world-class care by surgeons and anesthesiologists who specialize in pediatric procedures. They operate using the most advanced equipment and instruments specifically designed for children whenever possible. Their expertise at assessing each child’s unique needs ensures that your child’s experience is customized, caring, and appropriate.