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Radical Nephrectomy for Neoplasm
THE JOURNAL OF UROLOGY
Vol. 68, No. 1, July 1952 Printed in U.S.A.
RADICAL NEPHRECTOMY FOR NEOPLASM FREDERIC E. B. FOLEY AND (by invitation) WILLIAM P. MULVANEY, EDWARD J. RICHARDSON AND IRVING VICTOR
The behavior of malignant tumors wherever situated has dictated that surgical procedures for their removal be radical: extirpation of a peripheral segment of tissue along with neighboring lymph channels, lymph nodes, blood vessels and other structures to which the neoplasm may have extended even though there is no gross evidence of such extension. The radical mastectomy of Halsted for breast cancer is an example of this well founded surgical thinking and plan of operation. High amputation for small bone lesions is another. Hinman's radical operation for testicular neoplasm removes the spermatic fasiculus, spermatic vessels, retroperitoneal fat, lymph nodes and lymph channels. Total gastrectomy for small malignant lesions of the stomach has vindicated itself. These examples are enough to point out the thesis of this communication, though other analogous examples are obvious without mention. In dealing with malignant renal tumors the fundamental surgical principles of wide excision and removal of surrounding not grossly involved and apparently normal structures have not been followed. There have been some bizarre suggestions in this direction, such as opening the vena cava to extract from it neoplastic extensions into its lumen, which must be to no purpose. In a cursory way many writers have suggested that the perinephric fat be removed with the kidney, but make no suggestion as to how it should be done. The easy, simple and obvious removal of the immediately adjacent perinephric structures: the perinephric fat, renal fascial envelope, adrenal and vena cava from the renal veins downward to the bifurcation has never been urged. Most surgeons have been satisfied either to make the ordinary conservative nephrectomy with enucleation of the kidney from its surrounding fat or to remove also some of the perinephric fat by enucleation through the fat, but not including the pararenal fascia. All urologic surgeons of much experience have well realized that in a large proportion of cases of nephrectomy for renal neoplasm, some or all of the surrounding structures have been invaded and that this ordinary form of nephrectomy inevitably leaves parts of the neoplasm behind. This maldirection of surgical effort has persisted in face of the fact that almost no structure in the human anatomy, certainly no intra-abdominal organ, is better formed and related to surrounding structures than the kidney for easy radical removal along with all of the immediately surrounding structures to which the neoplasm may have extended. All urologic surgeons of much experience have made nephrectomy for neoplasm only to find upon examining the removed kidney that the plane of enucleation between the capsule and perinephric fat or through the fat went through an area of extension of the parenchymal growth into the fat. Recurrence within a year or two has substantiated the misgiving at the time of operation and has been another addition to the poor results of ordinary nephrectomy for neoplasm. Read at annual meeting, American Urological Association, Chicago, Ill. May 24, 1951. 39
40
FOLEY, MULVANEY, RICHARDSON AND VICTOR
Some years ago a new and radical form of nephrectomy for neoplasm was devised by one of us (F. E. B. F.) and has been in use by all of us. The preconceived form of operation was accurately planned, based on the behavior of renal tumors and on the anatomy of the kidney and its surrounding structures, particularly the renal fascia (O.T. fascia of Gerota). On several occasions the mass of tissue: kidney, perinephric fat, fascial envelope and adrenal removed by the form of radical nephrectomy to be described, has been examined with the finding of extension of the parenchymal growth into the surrounding structures. If permanent cure has been achieved in these cases it is due to this form of operation and the avoidance of ordinary conservative nephrectomy. Description and presentation of the new operation "Radical Nephrectomy for Neoplasm" at this time is prompted by a recent publication of Beare and McDonald1 and the urging of the junior authors (W. P. M., E. J. R., and I. V.) who have felt the report should not await statistical study to determine the results it achieves. For the purpose of determining the incidence of neoplastic invasion of the renal capsule and perineplffic fat by hypernephroma, Beare and McDonald made detailed gross and histologic examinations of 488 surgically removed kidneys containing hypernephroma. In 75 cases there was extension of the neoplasm to or into the renal capsule. In 268 cases the growth had gone beyond the renal capsule with invasion of the perinephric fat. In no case was neoplasm present in the fat without accompanying invasion of the renal capsule. It appeared, therefore, that involvement of perinephric fat occurs by direct extension and presumably does not occur by metastasis. The above observations point out that among 488 cases of renal hypernephroma, the neoplasm had extended beyond the kidney in 343 cases, which is more than 70 per cent of the cases. From this observation, the substantial quality of the report and from impression gained from our own experience and observations, this appears to be a conservative estimate of the percentage of extrarenal direct extension in cases of renal hypernephroma subjected to nephrectomy. Among the cases of renal capsule and perinephric fat involvement, Beare and McDonald found a smaller percentage of 5-year survivals than among the cases of neoplasms completely contained within the kidney. The statistical findings of Beare and McDonald, substantiated by our clinical experience, also point out that from the standpoints of complete eradication of the neoplasm and permanent cure, the ordinary form of "conservative" nephrectomy, with enucleation through the perinephric fat, must be ineffective in 70 per cent of cases of renal hypernephroma. Both sets of observations give clear indications for "radical nephrectomy for malignant neoplasm" and good warrant for presenting in a published report the form of radical nephrectomy devised several years ago, as mentioned above, along with a sufficiently detailed descrip1 Beare, ,J. R. and McDonald, J. R.: Involvement of the renal capsule in surgically removed hypernephroma: A gross and histopathologic study. J. Urol., 61: 857-861, 1949.
RADICAL NEPHRECTOMY
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tion of the method to encourage its use by others and with a view to promoting its widespread adoption. Before proceeding with preparation of this report describing a form of radical nephrectomy for neoplasm, search of the literature w-as made to find expressions bearing on the subject and to determine whether or not a similar or identical plan of operation had been previously described. To this end we have referred to all publications from 1896 to date with titles suggestive of bearing on this phase of the matter. In these publications we have been unable to find any comprehensive consideration of the anatomic relationships on which a truly radical nephrectomy must be founded, no detailed suggestion for taking advantage of these relationships and no adequately planned and described method of operation. However, the search did disclose a substantial number of vague comments on the importance of removing perinephric fat along with the kidney, but not even vague suggestion as to how this should be done. In 1916, Kretschmer2 advocated removal of the perinephric fat after nephrectomy for tuberculosis. In 1922, Fedoroff3 reported having attempted to remove the perinephric tissue after nephrectomy for hypemephroma had been made. In the same year Stevens 4 advised complete removal of the kidney, perinephric fat, suprarenal capsule, lymph vessels and glands en masse, but presented no anatomic considerations bearing on the suggestion and described no plan of operation for its accomplishment. In 1926, Vivian 5 made a similar suggestion. In 1929, Judd and Hand 6 recommended early ligation of the renal vascular pedicle and removal of the capsule and as much perinephric tissue as possible, but did not present a plan of operation. Mathe 7 in 1945 concluded that it would be well to remove the entire perinephric fat in cases of tumor and in certain cases of renal tuberculosis. In 1948, Cahill8 mentioned preliminary ligation of the vessels followed by removal of the kidney and perinephric fascia en masse. Cahill's mention of perinephric fascia removal is the only allusion we have been able to find to this anatomically and surgically important feature of the operation we have devised. Chute 9 in 1949, in describing the value of thoraco-abdominal incision for removal of renal tumors, urged early ligation of the vessels and removal of the perinephric fat, lymph nodes and areolar tissue around the pedicle en bloc with the tumor. Recently Sweetser10 described a method of operation for renal neoplasm which Kretschmer, H. L. et al.: Surg., Gynec. & Obst., 23: 391-395, 1916. Fedoroff, S. P.: Solid tumors of the kidney. Ztschr. f. Urol., 16: 9, 1922. Stevens, W. E.: Diagnosis and treatment of malignant tumors of the kidney. J. Urol., 10: 121-134, 1923. 5 Vivian, C. S.: Hypernephroma. Southwest. Med., 10: 7-9, 1926. 6 Judd, E. S. and Hand, J.P.: Hypernephroma. J. Urol., 22: 10-21, 1929. 7 Mathe,, C.: Evaluation of different types of nephrectomy; review of 247 cases. J. Urol., 53: 85-91, 1945. 8 Cahill, G.: Cancer of kidney, adrenal and testis. J.A.M.A., 138: 357-362, 1948. 9 Chute, R., Soutter, L. and Kerr, W. S., Jr.: Value of thoraco-abdominal incision in removal of kidney tumors. New Eng. J. Med., 241: 951-960, 1949. 10 Sweetser, T. H.: Surgery of retroperitoneal tumors. J. Urol., 57: 651-659, 1947. 2
3 4
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
took into account the need for something more radical than the usual form of nephrectomy. The features of the plan were directed toward overcoming the technical difficulties of extraperitoneal removal of kidneys much enlarged by neoplasm, early ligation of the pedicle and removal of perinephric fat. Particular emphasis was placed upon the form of extraperitoneal incision: the usual oblique flank incision plus addition of a limb extending from its anterior extremity at the border of the rectus muscle upward to the level of the xiphoid process. It is difficult to see that transperitoneal approach would add anything to the exposure and facility of this plan described by Sweetser. Sweetser recommended perinephric fat removal, but did not describe the anatomic considerations and dissection for its accomplishment. In cases of lower pole tumor, the growth may have extended to and become adherent to the vena cava. Separation of the growth from the vena cava by either sharp or blunt dissection would be hazardous and to no purpose because of failure to accomplish complete extirpation. In most such cases it is possible to mobilize the vena cava above and below the segment of invasion and remove this segment of vena cava en masse along with the renal mass. Ligation of the vena cava below the level of the renal veins may be made with relative impunity. The first recorded ligation was made in an animal in 1669 and was fatal. Some of the earliest ligations of the vena cava were made incident to its injury during nephrectomy. Kuster 11 in 1896 reported a case in which the inferior vena cava was injured and resected during nephrectomy. Death occurred 26 hours later. Pleasants 12 in a lengthy review of 8 cases of caval ligation or excision made previous to 1911 stated that death resulted in only two of the patients. All of these ligations were occasioned by caval injury during nephrectomy. In the modern treatment of thrombo-embolic disease, ligation of the inferior vena cava has become commonplace. Rents and exploratory incisions in the vena cava made during nephrectomy by contemporary surgeons are commonly reported and dealt with by repair or ligation. Donovan13 recently reported successful removal of a segment of vena cava measuring 1½inches with a neoplasm <_Jf the right kidney. We have ligated the inferior vena cava in 8 cases of vesical neoplasm prior to extensive electro-excision and massive electrocoagulation of the tumors and have eliminated pulmonary embolism completely. Side effects have been transient and not disabling. 14 Animal experiments are now in progress 15 which indicate that animals may survive ligation of the inferior vena cava above the level of the renal veins if preliminary ligation at a lower level is done to allow development of collateral circulation. Kuster, W.: Deutsche Chir., 3B: 1614-1618, 1896-1902. Pleasants, J. H.: Obstruction of inferior vena cava with a report of eighteen cases. Johns Hopkins Hosp. Rep. 16: 363-548, 1911. 13 Donovan, H.: A malignant right kidney removal at operation together with a short length of vena cava,. Brit. J. Ural., 17: 107, 1945. 14 Foley, F.E.B.: Urologists' Correspondence Club Letter, Feb. 1951. 15 Lespinaise, V.: Ligation of vena cava above the renal veins with or without nephrectomy. Quart. Bull. Northwestern Univ. Med. Sch., 21: 312-316, 1947. 11
12
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In the light of these facts, removal of a section of vena cava in right nephrectomy for neoplasm may well become a part of a radical plan of operation. RATIONALE OF RADICAL NEPHRECTOMY FOR RENAL NEOPLASM
The principle of radical wide excision of malignant neoplasm needs no special argument or vindication in the case of kidney tumors. The frequently appearing recommendation that "the perinephric fat should be removed with the kidney" indicates that in the surgical treatment of renal neoplasm there is vague agreement on the importance of this principle. But in none of the publications to which we have referred is adequate emphasis placed on the grave importance of this principle. Also we have been unable to find any detailed account of the anatomic considerations going with this principle and no description of a plan of operation or technique for its performance to make the principle truly effective. All of that is left vague. As description of an operation to be performed, it is grossly insufficient merely to say that "the perinephric fat should be removed with the kidney." The surgeon, particularly the young and inexperienced surgeon, looking for information on this subject will find no benefit from that. The literature and textbooks of urology abound in descriptions of the anatomic considerations, plans of operation and technique for their accomplishment in dealing with malignant neoplasm of other genito-urinary tract organs, particularly the testicle, prostate and bladder. So far as we have been able to determine, similar consideration has not been given to the anatomic considerations and surgical procedure for "radical" extirpation of malignant kidney tumors. Merely it is said that the nephrectomy should be accompanied by removal of the perinephric fat. Also it is sometimes pointed out that ligation of the renal vascular pedicle should be made early in the procedure before the kidney itself is disturbed and handled with the possibility of thus effecting dissemination. It has appeared to most writers that this latter desirable feature of the procedure is best accomplished by transperitoneal nephrectomy. We cannot share this view and will point out that by taking proper advantage of the anatomic relationships and following a well planned dissection, early ligation of the pedicle can be made as part of an extraperitoneal nephrectomy with no prior disturbance or handling of the kidney, with even greater facility and ease than it is accomplished by transperitoneal operation. Description of a well perfected and long practiced technique of operation which accomplishes radical wide excision of the tumor-containing kidney is the main burden of this paper. ANATOMIC CONSIDERATIONS AND TECHNIQUE OF RADICAL NEPHRECTOMY
The kidney, adrenal, upper part of the ureter, first portion of the renal lymph channels, adjacent lymph nodes, perinephric fat and vascular attachments of these structures and the spermatic (or ovarian) blood vessels are all contained in a fascia! envelope which -walls them off from surrounding structures. The fascia! envelope is readily separable from surrounding structures in clean cleavage planes permitting it to be removed intact along with its contents en masse.
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
The fascia! envelope referred to above is formed by the anterior and posterior layers of the renal fascia (O.T. fascia of Gerota). It will be clear from careful reference to the masterly Max Brodel illustration (figs. 1 and 2) that the renal fascial envelope contains all of the structures needing removal to promise cure. Any neoplasm which has extended beyond these fascial planes is hopeless. In our opinion a tumor which has extended beyo11d the renal capsule, but is still confined within these fascial planes may be
fa~cia Yensli~
(post.leaf)
Rel·ro
Frn. 1. Kidney, perinephric fat and renal blood vessels are completely enclosed in a fascial envelope formed by the anterior and posterior leaves of the fascia renalis (0.T. fascia of Gerota). Horizontal section. There is a clean cleavage plane between anterior leaf of fascia renalis and peritoneum and a similar cleavage plane between posterior leaf of fascia renalis and muscles of renal fossa. Kidney with its surrounding fat and fascial envelope may be completely separated from surrounding structures by blunt opening of these cleavage planes. (Kelly and Burnam: Diseases of the Kidneys, Ureters andB ladder, New York: D. Appleton Company, 1922, vol. 1.)
completely extirpated according to the method here described with some promise of permanent cure. In the radical nephrectomy here described and properly performed, particularly if there is normally abundant fat surrounding the kidney, the surgeon never sees the kidney any more than he sees the "cancer" in a properly made mastectomy for carcinoma of the breast. The plan of operation is based on the fact that both the anterior and posterior leaves of the renal fascia are readily separable from the structures against which they lie, with the same ease and facility with which the tunica vaginalis is separated from the dartos in excising a hydrocele. But if the operation is to be
RADICAL NEPHRECTOMY
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made as proposed and is to accomplish the radical en masseremoval contemplated, there must be strict adherence to its anatomic plan. METHOD OF OPERATION
Position of the patient is probably the most important technical detail of any kidney operation. Without proper position the procedure will be much impaired and beset by difficulties which may even defeat the plan of operation. The shoulder girdle and spine should be rotated forward away from the flank on the side
Fm. 2. Relationships of kidney, perinephric fat, adrenal and fascia renalis to surrounding structures are shown in sagittal section. (Kelly and Burnam: Diseases of the Kidneys, Ureters and Bladder. New York: D. Appleton Company, 1922, vol. 1.)
of operation. This enlarges the space between the twelfth rib and crest of the ilium. Maximal lateral flexion of the spine is effected by the kidney elevator of the operating table and contributes most to opening the "costal-iliac" space. A generous incision is a prime requirement. Such a procedure must not be handicapped by insufficient room and inadequate exposure. Beginning close to the spinous process of the tenth thoracic vertebra the incision is extended obliquely downward across the eleventh and twelfth ribs and is continued forward below and parallel to them obliquely across the abdomen to the edge of the
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
rectus muscle. The latissimus dorsi, external oblique and internal oblique muscles are divided in the line of incision exposing the lumbodorsal fascia. The latter is split parallel to its fibers with exposure of the underlying posterior leaf of the renal fascia (fig. 3). The peritoneum is stripped away from the undersurface of the transversalis muscle medialwards to the sheath of the rectus muscle. The split in the lumbodorsal fascia is continued forward in the transversalis muscle medialwards to the sheath of the rectus. With the peritoneum freed from the undersurface of the transversalis muscle the fibers of the transversalis may be widely retracted. In the anterior part of the incision the perietal paritoneum now forms the floor of the wound cavity.
FIG. 3. Lumbodorsal fascia has been incised parallel to its fibers exposing pararenal fascia (fascia renalis). Beginning of blunt opening of cleavage plane between this fascia and muscles on which it lies is shown. Next step will be blunt opening of cleavage plane between peritoneum and anterior layer of pararenal fascia (fascia renalis). Muscles covering costovertebral angle and costovertebral ligament will be divided giving wide exposure. (Foley: New methods for exposure of the kidney and nephropexy. Arch. Surg., 18: 1413-1426, 1929.)
The deep structures in the posterior angle of the incision are now divided: latissimus dorsi muscle, lumbodorsal fascia, costovertebral ligament, and, if need be, the edges of the quadratus lumborum and sacrospinalis muscles. Forceful upward retraction of the twelfth rib usually fractures it close to the vertebra and gives added room. If necessary, the twelfth, and additional ribs, may be removed to give the needed exposure, but is rarely required. In the posterior part of the incision the posterior leaf of the renal fascia forms the floor of the wound cavity. The procedure thus far has exposed a considerable posterolateral area of fascia! envelope containing the kidney and its immediately surrounding structures to be removed with it. At the lateral border of the kidney, the parietal peritoneum, already separated
RADICAL NEPHRECTOMY
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from the transversalis muscle, passes from the abdominal wall to the anterior surface of the kidney from which it is separated by the anterior leaf of renal fascia and perinephric fat. At this point the cleavage plane between the peritoneum and the anterior leaf of the renal fascia must be accurately identified. If need be, a small opening is made in the peritoneum to permit pulling away this single layer from the underlying renal fascia. Once this cleavage plane is entered, the peritoneum is peeled away from the renal fascia by blunt dissection medialwards over the anterior surface of the kidney to the vertebral bodies. Blunt opening of the cleavage plane is continued upward and downward thus exposing the fascial envelope covering the fat over the anterior surface of the adrenal, kidney and ureter.' ;, foscirr lumbo- ·. dor0a1 is
para· renaE:i
M.quudrntus lumboru.rn
Frn. 4. Blunt, separation of posterior layer of pararenal fascia (fascia renalis) from muscles of posterior abdominal wall is continued medial wards to vertebral bodies. (Foley, F. E. B.: Management of ureteral stone. J. A. !VI. A., 104: 1314-1317, 1935.J
vVith the parietal peritoneum, mesocolon and peritoneum-confined loops of bowel held medialwards, the anterior surface of the renal vascular pedicle should now be readily accessible for ligation. Or ligation may be postponed until the fascial envelope and its contents have been completely mobilized by separating the posterior leaf of the renal fascia from the muscles of the posterior abdominal wall, diaphragm and vertebral bodies. Starting again at the lateral border of the kidney, the kidney and perinephric fat covered by the posterior leaf of the renal fascia are retracted forward. The areolar tissue traversing the cleavage plane between the renal fascia andquadratus lumborum muscle will be put on the stretch and divided by blunt dissection (fig. 4). Continuing the blunt dissection medialwards and downwards the renal fascia is separated from the quadratus lumborum, iliopsoas and finally from the vertebral bodies along which the vena cava is exposed. Blunt· opening of this
48
FOLEY, MULVANEY, RICHARDSON AND VICTOR
cleavage plane is continued downward behind the ureter, which is separated from the muscles behind it along with the peri-ureteral fat. Continuing the blunt dissection upward the renal fascia separates from the diaphragm upward beyond the upper pole of the kidney. Above the upper pole of the kidney is a tent-like extension of the fused anterior and posterior leaves of the renal fasciae in which the adrenal is contained. The upward attachments of this tent of fascia may be more dense than to permit blunt separation and may require division with the scissors or scalpel. Finally the whole renal fascial envelope with its contained kidney and other structures has been completely mobilized and is ready for removal (fig. 5). Both
Fm. 5. Peritoneum has been separated from anterior layer of pararenal fascia (fascia renalis). Posterior layer of pararenal fascia (fascia renalis) has been separated from quadratus lumborum and iliopsoas muscles and lateral aspect of vertebral bodies medialwards almost to midline. Kidney enclosed in its fascial envelope and surrounding perinephric fat has been completely mobilized without kidney or its neoplasm having been uncovered. The plane of dissection has been peripheral to neoplasm. (Foley, F. E. B. : New methods for exposure of the kidney and nephropexy. Arch. Surg., 18: 1413-1426, 1929.)
anterior and posterior leaves of the renal fascia, where they cross the vertebral bodies, are very thin and will have been broken through leaving only the vascular pedicle and ureter as attachments. If the vascular pedicle was not ligated when first exposed by separating the peritoneum from the anterior leaf of the renal fascia, it is now doubly clamped and divided. The cut pedicle is twice ligated, with release of the proximal clamp as the first ligature is tied and release of the distal clamp as the second ligature is tied. Now the only remaining attachments are the ureter and spermatic (or ovarian) vein (fig. 6).
RADICAL NEPHRECTOMY
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The spermatic vein is divided and ligated followed by division and ligation of the ureter. If the renal tumor is not extensive, or is not located in the upper pole of the kidney, the adrenal need not be removed. In that case, the tent of renal fascia containing the adrenal is incised or bluntly divided along the line of renal-adrenal junction and the adrenal is separated from the kidney and left in place. The attachments of a lower pole tumor to the vena cava should not be disturbed. This segment of cava is excised between ligatures, one placed immediately below the renal vein, the other above the iliac bifurcation. The portion of
Fm. 6. Vascular pedicle has been divided and ligated. Tumor containing kidney, completely encased in its surrounding fat and fascial envelope, is held up out of wound in right hand of operator. Ureter and its surrounding fat are only remaining attachments. (Photograph at operation: Right radical nephrectomy for neoplasm.)
cava attached to the lower pole neoplasm is excised with the mass. The ureter is then doubly clamped, divided and ligated completing the radical nephrectomy. The nephrectomy has been made giving the kidney and its contained neoplasm the widest possible berth. The kidney itself has not been exposed and is completely surrounded by perinephric fat, the latter and the adrenal being contained in the fascial envelope. In the particular case in which the photographs illustrating this presentation were made, it was apparent when the removed kidney was shelled out of its fat that the lower pole neoplasm had extended beyond the capsule into the fat and that ordinary nephrectomy with enucleation in the cleavage plane between the capsule and fat would not have completely extirpated the neoplasm.
228 Lowry Bldg., St. Paul, Minn.
Vol. 68, No. 1, July 1952 Printed in U.S.A.
RADICAL NEPHRECTOMY FOR NEOPLASM FREDERIC E. B. FOLEY AND (by invitation) WILLIAM P. MULVANEY, EDWARD J. RICHARDSON AND IRVING VICTOR
The behavior of malignant tumors wherever situated has dictated that surgical procedures for their removal be radical: extirpation of a peripheral segment of tissue along with neighboring lymph channels, lymph nodes, blood vessels and other structures to which the neoplasm may have extended even though there is no gross evidence of such extension. The radical mastectomy of Halsted for breast cancer is an example of this well founded surgical thinking and plan of operation. High amputation for small bone lesions is another. Hinman's radical operation for testicular neoplasm removes the spermatic fasiculus, spermatic vessels, retroperitoneal fat, lymph nodes and lymph channels. Total gastrectomy for small malignant lesions of the stomach has vindicated itself. These examples are enough to point out the thesis of this communication, though other analogous examples are obvious without mention. In dealing with malignant renal tumors the fundamental surgical principles of wide excision and removal of surrounding not grossly involved and apparently normal structures have not been followed. There have been some bizarre suggestions in this direction, such as opening the vena cava to extract from it neoplastic extensions into its lumen, which must be to no purpose. In a cursory way many writers have suggested that the perinephric fat be removed with the kidney, but make no suggestion as to how it should be done. The easy, simple and obvious removal of the immediately adjacent perinephric structures: the perinephric fat, renal fascial envelope, adrenal and vena cava from the renal veins downward to the bifurcation has never been urged. Most surgeons have been satisfied either to make the ordinary conservative nephrectomy with enucleation of the kidney from its surrounding fat or to remove also some of the perinephric fat by enucleation through the fat, but not including the pararenal fascia. All urologic surgeons of much experience have well realized that in a large proportion of cases of nephrectomy for renal neoplasm, some or all of the surrounding structures have been invaded and that this ordinary form of nephrectomy inevitably leaves parts of the neoplasm behind. This maldirection of surgical effort has persisted in face of the fact that almost no structure in the human anatomy, certainly no intra-abdominal organ, is better formed and related to surrounding structures than the kidney for easy radical removal along with all of the immediately surrounding structures to which the neoplasm may have extended. All urologic surgeons of much experience have made nephrectomy for neoplasm only to find upon examining the removed kidney that the plane of enucleation between the capsule and perinephric fat or through the fat went through an area of extension of the parenchymal growth into the fat. Recurrence within a year or two has substantiated the misgiving at the time of operation and has been another addition to the poor results of ordinary nephrectomy for neoplasm. Read at annual meeting, American Urological Association, Chicago, Ill. May 24, 1951. 39
40
FOLEY, MULVANEY, RICHARDSON AND VICTOR
Some years ago a new and radical form of nephrectomy for neoplasm was devised by one of us (F. E. B. F.) and has been in use by all of us. The preconceived form of operation was accurately planned, based on the behavior of renal tumors and on the anatomy of the kidney and its surrounding structures, particularly the renal fascia (O.T. fascia of Gerota). On several occasions the mass of tissue: kidney, perinephric fat, fascial envelope and adrenal removed by the form of radical nephrectomy to be described, has been examined with the finding of extension of the parenchymal growth into the surrounding structures. If permanent cure has been achieved in these cases it is due to this form of operation and the avoidance of ordinary conservative nephrectomy. Description and presentation of the new operation "Radical Nephrectomy for Neoplasm" at this time is prompted by a recent publication of Beare and McDonald1 and the urging of the junior authors (W. P. M., E. J. R., and I. V.) who have felt the report should not await statistical study to determine the results it achieves. For the purpose of determining the incidence of neoplastic invasion of the renal capsule and perineplffic fat by hypernephroma, Beare and McDonald made detailed gross and histologic examinations of 488 surgically removed kidneys containing hypernephroma. In 75 cases there was extension of the neoplasm to or into the renal capsule. In 268 cases the growth had gone beyond the renal capsule with invasion of the perinephric fat. In no case was neoplasm present in the fat without accompanying invasion of the renal capsule. It appeared, therefore, that involvement of perinephric fat occurs by direct extension and presumably does not occur by metastasis. The above observations point out that among 488 cases of renal hypernephroma, the neoplasm had extended beyond the kidney in 343 cases, which is more than 70 per cent of the cases. From this observation, the substantial quality of the report and from impression gained from our own experience and observations, this appears to be a conservative estimate of the percentage of extrarenal direct extension in cases of renal hypernephroma subjected to nephrectomy. Among the cases of renal capsule and perinephric fat involvement, Beare and McDonald found a smaller percentage of 5-year survivals than among the cases of neoplasms completely contained within the kidney. The statistical findings of Beare and McDonald, substantiated by our clinical experience, also point out that from the standpoints of complete eradication of the neoplasm and permanent cure, the ordinary form of "conservative" nephrectomy, with enucleation through the perinephric fat, must be ineffective in 70 per cent of cases of renal hypernephroma. Both sets of observations give clear indications for "radical nephrectomy for malignant neoplasm" and good warrant for presenting in a published report the form of radical nephrectomy devised several years ago, as mentioned above, along with a sufficiently detailed descrip1 Beare, ,J. R. and McDonald, J. R.: Involvement of the renal capsule in surgically removed hypernephroma: A gross and histopathologic study. J. Urol., 61: 857-861, 1949.
RADICAL NEPHRECTOMY
41
tion of the method to encourage its use by others and with a view to promoting its widespread adoption. Before proceeding with preparation of this report describing a form of radical nephrectomy for neoplasm, search of the literature w-as made to find expressions bearing on the subject and to determine whether or not a similar or identical plan of operation had been previously described. To this end we have referred to all publications from 1896 to date with titles suggestive of bearing on this phase of the matter. In these publications we have been unable to find any comprehensive consideration of the anatomic relationships on which a truly radical nephrectomy must be founded, no detailed suggestion for taking advantage of these relationships and no adequately planned and described method of operation. However, the search did disclose a substantial number of vague comments on the importance of removing perinephric fat along with the kidney, but not even vague suggestion as to how this should be done. In 1916, Kretschmer2 advocated removal of the perinephric fat after nephrectomy for tuberculosis. In 1922, Fedoroff3 reported having attempted to remove the perinephric tissue after nephrectomy for hypemephroma had been made. In the same year Stevens 4 advised complete removal of the kidney, perinephric fat, suprarenal capsule, lymph vessels and glands en masse, but presented no anatomic considerations bearing on the suggestion and described no plan of operation for its accomplishment. In 1926, Vivian 5 made a similar suggestion. In 1929, Judd and Hand 6 recommended early ligation of the renal vascular pedicle and removal of the capsule and as much perinephric tissue as possible, but did not present a plan of operation. Mathe 7 in 1945 concluded that it would be well to remove the entire perinephric fat in cases of tumor and in certain cases of renal tuberculosis. In 1948, Cahill8 mentioned preliminary ligation of the vessels followed by removal of the kidney and perinephric fascia en masse. Cahill's mention of perinephric fascia removal is the only allusion we have been able to find to this anatomically and surgically important feature of the operation we have devised. Chute 9 in 1949, in describing the value of thoraco-abdominal incision for removal of renal tumors, urged early ligation of the vessels and removal of the perinephric fat, lymph nodes and areolar tissue around the pedicle en bloc with the tumor. Recently Sweetser10 described a method of operation for renal neoplasm which Kretschmer, H. L. et al.: Surg., Gynec. & Obst., 23: 391-395, 1916. Fedoroff, S. P.: Solid tumors of the kidney. Ztschr. f. Urol., 16: 9, 1922. Stevens, W. E.: Diagnosis and treatment of malignant tumors of the kidney. J. Urol., 10: 121-134, 1923. 5 Vivian, C. S.: Hypernephroma. Southwest. Med., 10: 7-9, 1926. 6 Judd, E. S. and Hand, J.P.: Hypernephroma. J. Urol., 22: 10-21, 1929. 7 Mathe,, C.: Evaluation of different types of nephrectomy; review of 247 cases. J. Urol., 53: 85-91, 1945. 8 Cahill, G.: Cancer of kidney, adrenal and testis. J.A.M.A., 138: 357-362, 1948. 9 Chute, R., Soutter, L. and Kerr, W. S., Jr.: Value of thoraco-abdominal incision in removal of kidney tumors. New Eng. J. Med., 241: 951-960, 1949. 10 Sweetser, T. H.: Surgery of retroperitoneal tumors. J. Urol., 57: 651-659, 1947. 2
3 4
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
took into account the need for something more radical than the usual form of nephrectomy. The features of the plan were directed toward overcoming the technical difficulties of extraperitoneal removal of kidneys much enlarged by neoplasm, early ligation of the pedicle and removal of perinephric fat. Particular emphasis was placed upon the form of extraperitoneal incision: the usual oblique flank incision plus addition of a limb extending from its anterior extremity at the border of the rectus muscle upward to the level of the xiphoid process. It is difficult to see that transperitoneal approach would add anything to the exposure and facility of this plan described by Sweetser. Sweetser recommended perinephric fat removal, but did not describe the anatomic considerations and dissection for its accomplishment. In cases of lower pole tumor, the growth may have extended to and become adherent to the vena cava. Separation of the growth from the vena cava by either sharp or blunt dissection would be hazardous and to no purpose because of failure to accomplish complete extirpation. In most such cases it is possible to mobilize the vena cava above and below the segment of invasion and remove this segment of vena cava en masse along with the renal mass. Ligation of the vena cava below the level of the renal veins may be made with relative impunity. The first recorded ligation was made in an animal in 1669 and was fatal. Some of the earliest ligations of the vena cava were made incident to its injury during nephrectomy. Kuster 11 in 1896 reported a case in which the inferior vena cava was injured and resected during nephrectomy. Death occurred 26 hours later. Pleasants 12 in a lengthy review of 8 cases of caval ligation or excision made previous to 1911 stated that death resulted in only two of the patients. All of these ligations were occasioned by caval injury during nephrectomy. In the modern treatment of thrombo-embolic disease, ligation of the inferior vena cava has become commonplace. Rents and exploratory incisions in the vena cava made during nephrectomy by contemporary surgeons are commonly reported and dealt with by repair or ligation. Donovan13 recently reported successful removal of a segment of vena cava measuring 1½inches with a neoplasm <_Jf the right kidney. We have ligated the inferior vena cava in 8 cases of vesical neoplasm prior to extensive electro-excision and massive electrocoagulation of the tumors and have eliminated pulmonary embolism completely. Side effects have been transient and not disabling. 14 Animal experiments are now in progress 15 which indicate that animals may survive ligation of the inferior vena cava above the level of the renal veins if preliminary ligation at a lower level is done to allow development of collateral circulation. Kuster, W.: Deutsche Chir., 3B: 1614-1618, 1896-1902. Pleasants, J. H.: Obstruction of inferior vena cava with a report of eighteen cases. Johns Hopkins Hosp. Rep. 16: 363-548, 1911. 13 Donovan, H.: A malignant right kidney removal at operation together with a short length of vena cava,. Brit. J. Ural., 17: 107, 1945. 14 Foley, F.E.B.: Urologists' Correspondence Club Letter, Feb. 1951. 15 Lespinaise, V.: Ligation of vena cava above the renal veins with or without nephrectomy. Quart. Bull. Northwestern Univ. Med. Sch., 21: 312-316, 1947. 11
12
RADICAL NEPHRECTOMY
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In the light of these facts, removal of a section of vena cava in right nephrectomy for neoplasm may well become a part of a radical plan of operation. RATIONALE OF RADICAL NEPHRECTOMY FOR RENAL NEOPLASM
The principle of radical wide excision of malignant neoplasm needs no special argument or vindication in the case of kidney tumors. The frequently appearing recommendation that "the perinephric fat should be removed with the kidney" indicates that in the surgical treatment of renal neoplasm there is vague agreement on the importance of this principle. But in none of the publications to which we have referred is adequate emphasis placed on the grave importance of this principle. Also we have been unable to find any detailed account of the anatomic considerations going with this principle and no description of a plan of operation or technique for its performance to make the principle truly effective. All of that is left vague. As description of an operation to be performed, it is grossly insufficient merely to say that "the perinephric fat should be removed with the kidney." The surgeon, particularly the young and inexperienced surgeon, looking for information on this subject will find no benefit from that. The literature and textbooks of urology abound in descriptions of the anatomic considerations, plans of operation and technique for their accomplishment in dealing with malignant neoplasm of other genito-urinary tract organs, particularly the testicle, prostate and bladder. So far as we have been able to determine, similar consideration has not been given to the anatomic considerations and surgical procedure for "radical" extirpation of malignant kidney tumors. Merely it is said that the nephrectomy should be accompanied by removal of the perinephric fat. Also it is sometimes pointed out that ligation of the renal vascular pedicle should be made early in the procedure before the kidney itself is disturbed and handled with the possibility of thus effecting dissemination. It has appeared to most writers that this latter desirable feature of the procedure is best accomplished by transperitoneal nephrectomy. We cannot share this view and will point out that by taking proper advantage of the anatomic relationships and following a well planned dissection, early ligation of the pedicle can be made as part of an extraperitoneal nephrectomy with no prior disturbance or handling of the kidney, with even greater facility and ease than it is accomplished by transperitoneal operation. Description of a well perfected and long practiced technique of operation which accomplishes radical wide excision of the tumor-containing kidney is the main burden of this paper. ANATOMIC CONSIDERATIONS AND TECHNIQUE OF RADICAL NEPHRECTOMY
The kidney, adrenal, upper part of the ureter, first portion of the renal lymph channels, adjacent lymph nodes, perinephric fat and vascular attachments of these structures and the spermatic (or ovarian) blood vessels are all contained in a fascia! envelope which -walls them off from surrounding structures. The fascia! envelope is readily separable from surrounding structures in clean cleavage planes permitting it to be removed intact along with its contents en masse.
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
The fascia! envelope referred to above is formed by the anterior and posterior layers of the renal fascia (O.T. fascia of Gerota). It will be clear from careful reference to the masterly Max Brodel illustration (figs. 1 and 2) that the renal fascial envelope contains all of the structures needing removal to promise cure. Any neoplasm which has extended beyond these fascial planes is hopeless. In our opinion a tumor which has extended beyo11d the renal capsule, but is still confined within these fascial planes may be
fa~cia Yensli~
(post.leaf)
Rel·ro
Frn. 1. Kidney, perinephric fat and renal blood vessels are completely enclosed in a fascial envelope formed by the anterior and posterior leaves of the fascia renalis (0.T. fascia of Gerota). Horizontal section. There is a clean cleavage plane between anterior leaf of fascia renalis and peritoneum and a similar cleavage plane between posterior leaf of fascia renalis and muscles of renal fossa. Kidney with its surrounding fat and fascial envelope may be completely separated from surrounding structures by blunt opening of these cleavage planes. (Kelly and Burnam: Diseases of the Kidneys, Ureters andB ladder, New York: D. Appleton Company, 1922, vol. 1.)
completely extirpated according to the method here described with some promise of permanent cure. In the radical nephrectomy here described and properly performed, particularly if there is normally abundant fat surrounding the kidney, the surgeon never sees the kidney any more than he sees the "cancer" in a properly made mastectomy for carcinoma of the breast. The plan of operation is based on the fact that both the anterior and posterior leaves of the renal fascia are readily separable from the structures against which they lie, with the same ease and facility with which the tunica vaginalis is separated from the dartos in excising a hydrocele. But if the operation is to be
RADICAL NEPHRECTOMY
45
made as proposed and is to accomplish the radical en masseremoval contemplated, there must be strict adherence to its anatomic plan. METHOD OF OPERATION
Position of the patient is probably the most important technical detail of any kidney operation. Without proper position the procedure will be much impaired and beset by difficulties which may even defeat the plan of operation. The shoulder girdle and spine should be rotated forward away from the flank on the side
Fm. 2. Relationships of kidney, perinephric fat, adrenal and fascia renalis to surrounding structures are shown in sagittal section. (Kelly and Burnam: Diseases of the Kidneys, Ureters and Bladder. New York: D. Appleton Company, 1922, vol. 1.)
of operation. This enlarges the space between the twelfth rib and crest of the ilium. Maximal lateral flexion of the spine is effected by the kidney elevator of the operating table and contributes most to opening the "costal-iliac" space. A generous incision is a prime requirement. Such a procedure must not be handicapped by insufficient room and inadequate exposure. Beginning close to the spinous process of the tenth thoracic vertebra the incision is extended obliquely downward across the eleventh and twelfth ribs and is continued forward below and parallel to them obliquely across the abdomen to the edge of the
46
FOLEY, MULVANEY, RICHARDSON AND VICTOR
rectus muscle. The latissimus dorsi, external oblique and internal oblique muscles are divided in the line of incision exposing the lumbodorsal fascia. The latter is split parallel to its fibers with exposure of the underlying posterior leaf of the renal fascia (fig. 3). The peritoneum is stripped away from the undersurface of the transversalis muscle medialwards to the sheath of the rectus muscle. The split in the lumbodorsal fascia is continued forward in the transversalis muscle medialwards to the sheath of the rectus. With the peritoneum freed from the undersurface of the transversalis muscle the fibers of the transversalis may be widely retracted. In the anterior part of the incision the perietal paritoneum now forms the floor of the wound cavity.
FIG. 3. Lumbodorsal fascia has been incised parallel to its fibers exposing pararenal fascia (fascia renalis). Beginning of blunt opening of cleavage plane between this fascia and muscles on which it lies is shown. Next step will be blunt opening of cleavage plane between peritoneum and anterior layer of pararenal fascia (fascia renalis). Muscles covering costovertebral angle and costovertebral ligament will be divided giving wide exposure. (Foley: New methods for exposure of the kidney and nephropexy. Arch. Surg., 18: 1413-1426, 1929.)
The deep structures in the posterior angle of the incision are now divided: latissimus dorsi muscle, lumbodorsal fascia, costovertebral ligament, and, if need be, the edges of the quadratus lumborum and sacrospinalis muscles. Forceful upward retraction of the twelfth rib usually fractures it close to the vertebra and gives added room. If necessary, the twelfth, and additional ribs, may be removed to give the needed exposure, but is rarely required. In the posterior part of the incision the posterior leaf of the renal fascia forms the floor of the wound cavity. The procedure thus far has exposed a considerable posterolateral area of fascia! envelope containing the kidney and its immediately surrounding structures to be removed with it. At the lateral border of the kidney, the parietal peritoneum, already separated
RADICAL NEPHRECTOMY
47
from the transversalis muscle, passes from the abdominal wall to the anterior surface of the kidney from which it is separated by the anterior leaf of renal fascia and perinephric fat. At this point the cleavage plane between the peritoneum and the anterior leaf of the renal fascia must be accurately identified. If need be, a small opening is made in the peritoneum to permit pulling away this single layer from the underlying renal fascia. Once this cleavage plane is entered, the peritoneum is peeled away from the renal fascia by blunt dissection medialwards over the anterior surface of the kidney to the vertebral bodies. Blunt opening of the cleavage plane is continued upward and downward thus exposing the fascial envelope covering the fat over the anterior surface of the adrenal, kidney and ureter.' ;, foscirr lumbo- ·. dor0a1 is
para· renaE:i
M.quudrntus lumboru.rn
Frn. 4. Blunt, separation of posterior layer of pararenal fascia (fascia renalis) from muscles of posterior abdominal wall is continued medial wards to vertebral bodies. (Foley, F. E. B.: Management of ureteral stone. J. A. !VI. A., 104: 1314-1317, 1935.J
vVith the parietal peritoneum, mesocolon and peritoneum-confined loops of bowel held medialwards, the anterior surface of the renal vascular pedicle should now be readily accessible for ligation. Or ligation may be postponed until the fascial envelope and its contents have been completely mobilized by separating the posterior leaf of the renal fascia from the muscles of the posterior abdominal wall, diaphragm and vertebral bodies. Starting again at the lateral border of the kidney, the kidney and perinephric fat covered by the posterior leaf of the renal fascia are retracted forward. The areolar tissue traversing the cleavage plane between the renal fascia andquadratus lumborum muscle will be put on the stretch and divided by blunt dissection (fig. 4). Continuing the blunt dissection medialwards and downwards the renal fascia is separated from the quadratus lumborum, iliopsoas and finally from the vertebral bodies along which the vena cava is exposed. Blunt· opening of this
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FOLEY, MULVANEY, RICHARDSON AND VICTOR
cleavage plane is continued downward behind the ureter, which is separated from the muscles behind it along with the peri-ureteral fat. Continuing the blunt dissection upward the renal fascia separates from the diaphragm upward beyond the upper pole of the kidney. Above the upper pole of the kidney is a tent-like extension of the fused anterior and posterior leaves of the renal fasciae in which the adrenal is contained. The upward attachments of this tent of fascia may be more dense than to permit blunt separation and may require division with the scissors or scalpel. Finally the whole renal fascial envelope with its contained kidney and other structures has been completely mobilized and is ready for removal (fig. 5). Both
Fm. 5. Peritoneum has been separated from anterior layer of pararenal fascia (fascia renalis). Posterior layer of pararenal fascia (fascia renalis) has been separated from quadratus lumborum and iliopsoas muscles and lateral aspect of vertebral bodies medialwards almost to midline. Kidney enclosed in its fascial envelope and surrounding perinephric fat has been completely mobilized without kidney or its neoplasm having been uncovered. The plane of dissection has been peripheral to neoplasm. (Foley, F. E. B. : New methods for exposure of the kidney and nephropexy. Arch. Surg., 18: 1413-1426, 1929.)
anterior and posterior leaves of the renal fascia, where they cross the vertebral bodies, are very thin and will have been broken through leaving only the vascular pedicle and ureter as attachments. If the vascular pedicle was not ligated when first exposed by separating the peritoneum from the anterior leaf of the renal fascia, it is now doubly clamped and divided. The cut pedicle is twice ligated, with release of the proximal clamp as the first ligature is tied and release of the distal clamp as the second ligature is tied. Now the only remaining attachments are the ureter and spermatic (or ovarian) vein (fig. 6).
RADICAL NEPHRECTOMY
49
The spermatic vein is divided and ligated followed by division and ligation of the ureter. If the renal tumor is not extensive, or is not located in the upper pole of the kidney, the adrenal need not be removed. In that case, the tent of renal fascia containing the adrenal is incised or bluntly divided along the line of renal-adrenal junction and the adrenal is separated from the kidney and left in place. The attachments of a lower pole tumor to the vena cava should not be disturbed. This segment of cava is excised between ligatures, one placed immediately below the renal vein, the other above the iliac bifurcation. The portion of
Fm. 6. Vascular pedicle has been divided and ligated. Tumor containing kidney, completely encased in its surrounding fat and fascial envelope, is held up out of wound in right hand of operator. Ureter and its surrounding fat are only remaining attachments. (Photograph at operation: Right radical nephrectomy for neoplasm.)
cava attached to the lower pole neoplasm is excised with the mass. The ureter is then doubly clamped, divided and ligated completing the radical nephrectomy. The nephrectomy has been made giving the kidney and its contained neoplasm the widest possible berth. The kidney itself has not been exposed and is completely surrounded by perinephric fat, the latter and the adrenal being contained in the fascial envelope. In the particular case in which the photographs illustrating this presentation were made, it was apparent when the removed kidney was shelled out of its fat that the lower pole neoplasm had extended beyond the capsule into the fat and that ordinary nephrectomy with enucleation in the cleavage plane between the capsule and fat would not have completely extirpated the neoplasm.
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