Nephrectomies for Neoplastic Disease
of evaluating kidneys resected for neoplasms is to determine the type of tumor,
its extent, and the completeness of the resection. This can easily be achieved
if you approach the nephrectomy as if it were made up of three individual
compartments: the kidney, the renal hilum, and the perinephric fat. Describe
each component of the kidney individually and sys-tematically (Table 33-1).
First, weigh and measure the entire specimen. The renal capsule and the perinephric fat should not be stripped from the kidney until after their relationships to the tumor are established. Anat-omically orient the specimen. The ureter will provide a useful landmark: the downward course of the ureter points to the inferior pole of the kidney. By knowing whether the kidney is from the right or left side, you can easily iden-tify its anterior and posterior surfaces.
the dissection at the kidney hilum. Iden-tify the ureter, renal artery, and
renal vein. Shave the margin from each, and then open each with a small pair of
scissors to the point at which they enter the kidney. Look for the presence of
vas-cular invasion, atherosclerosis, and thrombosis. Carefully inspect the mucosa
and wall of the ureter. Is the ureter dilated or strictured? Are any masses
present? Occasionally, lymph nodes will be present in the soft tissues of the
hilum, and these should be individually measured and sam-pled. Other lymph node
groups are usually sub-mitted separately by the surgeon.
ink the soft tissue margins and direct your attention to the dissection of the
kidney itself. The objective of the initial section is to bivalve the kidney so
that the relationship of the tumor to the kidney can be easily visualized. The
plane of this initial section may vary de-pending on the location of the tumor,
but in gen-eral it will be a sagittal cut that begins at the hilum and exits
laterally through the perinephric fat. It may be helpful to insert probes into
the calyces of the upper and lower poles of the kid-ney to guide the knife
through the renal pelvis. Once the tumor is exposed, obtain fresh tissue for
special studies such as electron microscopy, immunofluorescence, and
cytogenetics, as is in-dicated. Describe the size, shape, color, and
con-sistency of the tumor. Does the tumor appearto be centered in the cortex,
medulla, or pelvis? Measure the distance of the tumor to the nearest margin,
and note its relationship to the peri-nephric fat, renal pelvis, renal vein,
ureter, and adrenal gland. Photograph the bivalved speci-men. At this point you
may choose to complete the dissection of the kidney in its fresh state, or you
may want to submerge the specimen in formalin until it is well fixed.
outer surface of the fat represents Gerota’s fascia. Ink this surface where it
overlies the tumor, and submit perpendicular sections to show the relationship
of the tumor to the soft tissue margin. Then carefully peel back the
peri-nephric fat from the kidney, examine the capsular surface, and look for
tumor extension through the renal capsule. Keep in mind that when renal tumors
invade through the capsule, they tend to bulge from the surface of the kidney.
Note any bulges, and document any disruption of the normal contour of the
kidney surface by submit-ting sections that include the tumor, the adja-cent
non-neoplastic kidney, and the overlaying capsule. Make additional sections
through the tumor and surrounding kidney. Look for any satellite tumors.
at least four sections of tumor (or more if necessary) to demonstrate the
relation-ship of the tumor to the kidney parenchyma, renal pelvis, major blood
vessels, renal capsule, and perinephric fat. Because some renal neo-plasms are
multifocal, section through the re-mainder of the kidney, looking for smaller
tumors. Do not forget to describe the cortex, medulla, and collecting system of
the non-neoplastic kidney. Also, submit one or two sec-tions of the
non-neoplastic kidney for histology. Finally, dissect the fibrofatty tissue
enveloping the kidney, and submit one or two sections of the fat to assess
infiltration by tumor.
specimens often will include the adrenal gland. Be sure to look for it in the
superior perinephric fat; if it is present, weigh it, measure it, and submit a
section. Keep in mind that the lymph nodes will be found in the soft tissues at
the kidney hilum. A misdirected search for lymph nodes in the perinephric fat
outside of the hilum will be a waste of your time.
procedure was performed, and what structures/organs are present?
· Is a
· Where is
the tumor located?
large is the tumor?
· Does the
tumor invade the renal capsule, Gerota’s fascia, major veins, or the adrenal
· What are
the histologic type and grade of the neoplasm?
· What is
the status of each of the margins (ureter, renal vein, soft tissue)?
metastases identified? Record the number of nodes involved and the number
· Does the
non-neoplastic portion of the kidney show any pathology?