Nephrectomy

10 min read Last updated April 8, 2026

Surgical approach

  • Indications: renal cell carcinoma (radical/partial), non-functioning kidney (stones/infection), trauma, living donor
  • Approaches
    • Open: flank incision (retroperitoneal) or subcostal/chevron/midline (transperitoneal); may involve rib resection
    • Laparoscopic/robotic: transperitoneal (most common) or retroperitoneoscopic; pneumoperitoneum and steep lateral tilt
    • Partial nephrectomy: tumour excision with renal hilar clamping (warm ischaemia) ± collecting system repair
    • Radical nephrectomy: kidney + Gerota’s fascia ± adrenal ± lymph nodes; early ligation of renal artery/vein
    • Donor nephrectomy: meticulous haemostasis, preservation of ureter/renal vessels; often laparoscopic with extraction incision
  • Key intraoperative events
    • Positioning: lateral decubitus (kidney rest), flexed table; risk of pressure/nerve injury
    • Pneumoperitoneum (lap/robot): reduced venous return, increased SVR, CO2 absorption; potential reduced renal perfusion/urine output
    • Hilar dissection/clamping: potential major haemorrhage; partial nephrectomy warm ischaemia time critical
    • Specimen extraction: transient haemodynamic changes; pain increases with extraction incision

Anaesthetic management

  • Type of anaesthesia
    • General anaesthesia is standard for open and laparoscopic/robotic nephrectomy
    • Regional/neuraxial: thoracic epidural (open) or intrathecal opioid; truncal blocks (TAP/QL/ESP) as alternatives
  • Airway
    • Cuffed ETT recommended (lateral position, pneumoperitoneum, potential long duration); SGA generally inappropriate
  • Duration
    • Laparoscopic/robotic: typically 2–4 h (longer if complex/obese/adhesions)
    • Open: typically 2–3.5 h; longer if IVC thrombus/lymphadenectomy/major reconstruction
  • How painful?
    • Open flank/subcostal: severe (rib resection/intercostal nerve trauma common); high opioid requirement without regional
    • Laparoscopic/robotic: moderate; pain from port sites + extraction incision; shoulder tip pain possible
  • Monitoring/lines (risk-stratified)
    • Standard monitoring for low-risk laparoscopic cases; consider arterial line for major blood loss risk, CKD, significant CV disease, or partial nephrectomy with clamp/ischaemia concerns
    • Large-bore IV access; group & save/crossmatch depending on approach and tumour stage (higher for open/IVC thrombus/partial)
    • Urinary catheter usually required (hourly output; protect remaining kidney); temperature monitoring and active warming

Preoperative assessment

  • Assess renal function and reserve
    • Baseline creatinine/eGFR, urinalysis/proteinuria; trend over time; identify solitary kidney/obstructive uropathy
    • Medication review: ACEi/ARB, diuretics, NSAIDs, metformin, nephrotoxins; plan perioperative management
  • Comorbidity profile
    • CKD: anaemia, platelet dysfunction/uraemia, electrolyte/acid-base issues, fluid sensitivity
    • Hypertension and cardiovascular disease common; consider functional capacity and need for further cardiac assessment
    • Malignancy: paraneoplastic effects (anaemia, hypercalcaemia), cachexia; VTE risk
  • Investigations (typical)
    • FBC (anaemia), U&E/creatinine, coagulation if indicated, calcium (RCC), ECG ± CXR; consider G&S/crossmatch
    • Imaging review: tumour size, venous involvement (renal vein/IVC thrombus), planned approach (open vs lap), partial vs radical
  • Optimisation
    • Correct anaemia where possible; manage BP; treat infection; consider prehabilitation and smoking cessation
    • Discuss postoperative renal risk: AKI, need for dialysis (rare but higher in CKD/solitary kidney/partial with ischaemia)

Intraoperative anaesthetic technique

  • Induction and maintenance
    • Balanced GA with volatile or TIVA; neuromuscular blockade usually required (especially robotic) to facilitate ventilation and surgical exposure
    • Ventilation: lung-protective strategy; adjust for pneumoperitoneum (higher airway pressures, permissive mild hypercapnia if appropriate)
  • Positioning and pressure care (lateral decubitus)
    • Secure patient (beanbag/straps), check ETT position after turning; protect eyes; ensure dependent arm not overstretched
    • Pad pressure points: axillary roll, peroneal nerve at fibular head, brachial plexus; avoid excessive table flexion if possible
    • Risks: pressure neuropraxia, rhabdomyolysis (obese/long cases), compartment syndrome (rare)
  • Fluid and haemodynamic management
    • Aim: maintain renal perfusion while avoiding overload (especially CKD); use balanced crystalloid; consider goal-directed therapy in major cases
    • Urine output may fall with pneumoperitoneum or renal hilar clamping; treat the patient (MAP/perfusion), not urine output alone
    • Vasopressors (e.g., noradrenaline) may be appropriate to maintain MAP rather than excessive fluids; avoid prolonged hypotension
  • Renal protection principles
    • Avoid nephrotoxins (NSAIDs in CKD/solitary kidney), avoid hypovolaemia and hypotension, maintain oxygenation, treat sepsis promptly
    • Diuretics (furosemide/mannitol) are not routine renal-protective strategies; may be used by surgeon in partial nephrectomy protocols but evidence for outcome benefit is limited
  • Analgesia
    • Open: thoracic epidural (e.g., T7–T10) or intrathecal opioid + multimodal; consider catheter techniques (paravertebral/ESP) if epidural unsuitable
    • Lap/robot: multimodal (paracetamol ± NSAID if appropriate), opioids, local infiltration; consider TAP/QL blocks (especially for extraction incision)
    • Consider ketamine/lidocaine infusion in opioid-tolerant patients; gabapentinoids with caution (sedation, renal dosing)
  • Antiemesis and ERAS
    • High PONV risk with laparoscopy/opiates: multimodal prophylaxis (e.g., dexamethasone + ondansetron ± droperidol) unless contraindicated
    • Maintain normothermia, early mobilisation, early enteral intake where appropriate; avoid excessive opioids

Blood loss and transfusion considerations

  • Bleeding risk varies
    • Higher: open radical nephrectomy, large tumours, venous involvement (renal vein/IVC thrombus), partial nephrectomy (parenchymal bleeding), redo surgery
    • Lower: uncomplicated laparoscopic radical nephrectomy
  • Preparation
    • Group & save for low-risk; crossmatch for open/partial/large tumour; consider cell salvage (malignancy: generally acceptable with leucocyte depletion filter per local policy)
    • Have major haemorrhage protocol awareness; ensure rapid infusion capability in high-risk cases

Postoperative care

  • Destination
    • Ward for uncomplicated lap cases; HDU/ICU for major open surgery, significant comorbidity, major blood loss, IVC thrombus cases, or epidural with high risk
  • Renal monitoring
    • Strict fluid balance, U&E/creatinine, avoid nephrotoxins, dose-adjust renally cleared drugs; anticipate transient creatinine rise after nephrectomy
  • Analgesia continuation
    • Epidural management (sensory level, haemodynamics, anticoagulation timing); alternative PCA if epidural not used
  • Respiratory and VTE prophylaxis
    • Incentive spirometry, early mobilisation; pharmacological + mechanical VTE prophylaxis (malignancy increases risk) per local guidance

Key complications (anaesthetic relevance)

  • Acute kidney injury (AKI)
    • Risk factors: pre-existing CKD, solitary kidney, hypotension, sepsis, nephrotoxins, major haemorrhage, prolonged warm ischaemia (partial nephrectomy)
  • Haemorrhage
    • Renal hilum/IVC injury; concealed bleeding retroperitoneally; watch for sudden hypotension/tachycardia and falling Hb
  • Respiratory complications
    • Atelectasis, pneumonia; pneumothorax/pleural breach (flank approach, rib resection) → raised airway pressures, hypoxia
  • Thromboembolism
    • Cancer + major pelvic/abdominal surgery; consider extended prophylaxis depending on local policy and risk
  • Position-related injury
    • Brachial plexus/peroneal neuropathy, pressure sores, corneal abrasion; rhabdomyolysis in prolonged lateral position
You are anaesthetising a patient for laparoscopic radical nephrectomy. Outline your anaesthetic plan including monitoring, analgesia and fluid strategy.

Structure: preop risks → technique/monitoring → positioning/ventilation → fluids/renal protection → analgesia/PONV → postop destination.

  • GA with cuffed ETT; controlled ventilation; muscle relaxation (esp. robotic)
  • Monitoring: standard; add arterial line if significant CV disease/CKD/expected blood loss; temp monitoring and active warming
  • Access: 2 wide-bore IV cannulae; G&S ± crossmatch depending on tumour/approach; consider cell salvage per policy
  • Positioning: lateral decubitus; secure patient; protect pressure points; re-check ETT after turning
  • Ventilation: adjust for pneumoperitoneum (higher airway pressures, EtCO2 rise); consider recruitment/PEEP; avoid excessive hypercapnia in raised ICP/pulm HTN
  • Fluids: balanced crystalloid; avoid both hypovolaemia and overload; consider goal-directed therapy; maintain MAP with vasopressors rather than large fluid boluses when appropriate
  • Renal protection: avoid nephrotoxins; avoid prolonged hypotension; interpret low urine output in context of pneumoperitoneum
  • Analgesia: multimodal; consider TAP/QL block + local infiltration; opioid PCA if needed; NSAID only if renal function and surgical team agree
  • PONV prophylaxis: multimodal; consider dexamethasone + 5HT3 antagonist ± droperidol
  • Postop: monitor renal function and fluid balance; VTE prophylaxis; consider HDU if high-risk/major blood loss
How does pneumoperitoneum affect physiology and what are the anaesthetic implications in nephrectomy?

Think: cardiovascular, respiratory, renal, neuro; then practical management.

  • Cardiovascular: ↑ intra-abdominal pressure → ↓ venous return (preload), ↑ SVR; CO may fall; vagal responses during insufflation possible
  • Respiratory: ↓ compliance, ↑ airway pressures, V/Q mismatch/atelectasis; CO2 absorption → ↑ PaCO2/EtCO2
  • Renal: ↓ renal blood flow/GFR and urine output (pressure + neurohumoral); oliguria common and not necessarily hypovolaemia
  • Management: ensure adequate depth/analgesia at insufflation; adjust ventilation (increase minute ventilation), use PEEP/recruitment; maintain MAP (vasopressors if needed); avoid fluid overload chasing urine output
A patient is planned for partial nephrectomy. What are the specific anaesthetic concerns compared with radical nephrectomy?

Partial nephrectomy adds renal ischaemia and parenchymal bleeding considerations; renal preservation is central.

  • Warm ischaemia time during hilar clamping: avoid hypotension/hypoxia; anticipate clamp/unclamp haemodynamic changes
  • Higher bleeding risk from renal parenchyma; ensure robust IV access, consider arterial line and crossmatch
  • Renal protection: meticulous haemodynamic stability; avoid nephrotoxins; consider goal-directed fluid therapy
  • Discuss with surgeon: expected clamp duration, use of mannitol/diuretics, need for controlled hypotension (generally avoid if renal preservation priority)
Open flank nephrectomy is planned. Describe your analgesic options and how you would choose between them.

Compare epidural vs intrathecal opioid vs paravertebral/ESP/QL vs systemic multimodal; consider contraindications and resources.

  • Thoracic epidural (T7–T10): excellent dynamic analgesia, opioid-sparing; risks: hypotension, failure, epidural haematoma/infection; consider in major open surgery
  • Intrathecal opioid (e.g., diamorphine/morphine): simpler, good early analgesia; risks: pruritus, nausea, respiratory depression (esp. CKD/OSA), limited duration
  • Paravertebral/ESP catheter: unilateral analgesia, less hypotension than epidural; variable evidence and operator dependent
  • QL/TAP blocks: may help incision pain; less reliable for deep flank pain; useful adjuncts
  • Systemic: paracetamol, opioids (PCA), ketamine/lidocaine infusions; NSAIDs only if renal function acceptable and agreed
  • Choice factors: anticoagulation, haemodynamic reserve, CKD/OSA, expected pain severity, availability of acute pain service, patient preference
During open nephrectomy the patient becomes suddenly hypotensive. Give a differential diagnosis and immediate management.

Use an A-E approach; think haemorrhage first but consider position/ventilation/anaesthetic causes.

  • Immediate actions: call for help, inform surgeon, increase FiO2, check pulse/ECG, confirm BP trace/cuff, assess depth/volatile, check ventilation and airway pressures
  • Haemorrhage (renal hilum/IVC): look for surgical field bleeding, suction volume, falling Hb; activate massive haemorrhage protocol if needed; rapid transfusion, TXA per protocol
  • IVC compression/traction or venous air embolism (rare): sudden hypotension ± drop EtCO2; manage with surgeon (flood field), 100% O2, aspirate via CVC if present, supportive vasopressors
  • Anaphylaxis: bronchospasm, rash, hypotension; treat with adrenaline and fluids; stop trigger
  • Tension pneumothorax/pleural breach (flank): rising airway pressures, hypoxia, hypotension; decompress and arrange chest drain
  • Cardiac events: arrhythmia/MI; treat per ALS/ACLS; consider arterial line and ABG
What are the causes of low urine output during nephrectomy and how would you manage it?

Differentiate physiological (pneumoperitoneum/clamping) from pathological (hypovolaemia/AKI/obstruction).

  • Common causes: pneumoperitoneum-related reduced renal perfusion; renal hilar clamping (partial); anaesthetic-induced hypotension; hypovolaemia/bleeding; obstruction/kinked catheter
  • Assess: MAP, HR, blood loss, fluid balance, airway pressures/EtCO2, catheter patency; consider ABG/lactate if concerned
  • Treat: optimise MAP (vasopressor if needed), correct hypovolaemia if present, reduce pneumoperitoneum pressure if feasible, ensure catheter patent; avoid reflex diuretic use without addressing perfusion
Discuss perioperative drug choices in a patient with CKD undergoing nephrectomy.

Cover induction/maintenance, analgesics, antibiotics, anticoagulants, and dose adjustments.

  • Induction agents: usual doses often acceptable; titrate to effect (reduced protein binding/uraemia may increase free fraction of some drugs)
  • Muscle relaxants: prefer agents independent of renal excretion (atracurium/cisatracurium); be cautious with prolonged effects of renally excreted drugs
  • Opioids: fentanyl/alfentanil suitable; morphine metabolites accumulate (risk respiratory depression); oxycodone accumulates; consider remifentanil intraop with planned postop strategy
  • NSAIDs: avoid or use cautiously (especially solitary kidney/CKD) due to AKI risk and impaired renal autoregulation
  • Antibiotics: adjust dosing for renally cleared agents; avoid nephrotoxic combinations where possible (e.g., aminoglycosides) unless clearly indicated
  • Anticoagulation: consider renal dosing for LMWH/DOACs; coordinate with neuraxial techniques timing
A living kidney donor is listed for laparoscopic donor nephrectomy. What additional considerations apply?

Healthy patient but ethical imperative to minimise harm; focus on safety, PONV, pain, and renal protection of remaining kidney.

  • Enhanced consent: discuss risks (bleeding, conversion to open, pain, VTE, rare need for transfusion) and postoperative renal implications
  • Renal protection: avoid hypotension and nephrotoxins; careful fluid strategy; ensure good postoperative hydration plan
  • Analgesia and PONV: multimodal with regional blocks; aggressive PONV prophylaxis to facilitate early mobilisation and oral intake
  • VTE prophylaxis and early mobilisation; consider psychological support and expectations
What complications are specific to the lateral position and how do you prevent them?

Think nerves, eyes, pressure, ventilation/perfusion, and access issues.

  • Nerve injuries: brachial plexus, ulnar, radial, common peroneal; prevent with neutral alignment, padding, avoid excessive abduction, axillary roll
  • Pressure injuries: dependent shoulder/hip, pressure sores; prevent with padding and frequent checks
  • Eye injury: corneal abrasion, rare ischaemic optic neuropathy in long cases; tape eyes, avoid pressure on globe, maintain perfusion
  • Airway/line displacement after turning; re-confirm ETT depth, breath sounds, and line security

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