JULY 1992, VOL 56.

NO I AORN JOURNAL

Kidney Cancer
AN OVERVIEW
OF THE DISEASE,
TREATMENT

Sandra S. LaFollette, RN
y the time actress Lee Remick was diag-
nosed with kidney cancer, the disease
had metastasized to her lungs. She died
on July 2, 1991, at the age of 55 years.’
Universal awareness of this cancer could lead
to earlier detection. As with all cancers, the ear-
lier the disease is recognized, the better the
chance for cure.
Overview
In general, kidney cancer is more common in
urban, industrial areas, but the incidence does
not seem to be related to socioeconomic status.’
The incidence appears to be increasing, possi-
bly because diagnostic advances now allow
physicians to detect kidney cancer that may
have gone undetected in the past.
Kidney
Anatomy, Physiology

T
he kidneys are located behind the

K
idney cancer is rare and accounts for
only 2% to 3% of all cancers in
humans.? It occurs in men twice as
often as in women.? It rarely is seen in people
less than 35 years of age, and the incidence
increases with age.4 Wilms’ tumor, a renal can-
cer found primarily in children and infants, is
the exception. Management of Wilms’ tumors
is a success of modem medicine.5 Advances in
diagnosis and treatment in the past two decades
have vastly improved the survival and cure rate
of children with Wilms’ tumors.h
abdominal cavity in the retroperitoneal
area, on either side of the vertebral col-
umn, under the lowest rib, and just above the
waist. Each kidney consists of the pelvis,
calyces, medulla, and cortex. A fibrous tissue,
called Gerota’s capsule or fascia, forms a firm,
smooth covering. Microscopic kidney struc-
tures include the renal tubules lined with
epithelium, blood vessels surrounding the
tubules, lymphatics, nerves, connective tissue,
and renal corpuscles.*

Sandra S . LaFollette, RN, BSN, CNOR, is a

perioperative nurse at the University of
California, Los Angeles, Medical Center. She
earned her bachelor of science degree in nurs-
ing at the University of California,Los Angeles.

All illustrations in this article are by Helen 0.

Corallo, R N , BSN. CNOR, a perioperative
nurse at the University of California, Los
Angeles, Medical Center.
@
31
AORN JOURNAL
The kidneys have two main functions:
0 to remove waste and toxic substances
from the blood and
0 to regulate and maintain body fluid bal-
ance by adjusting water and salt elimina-
ti~n.~
Blood containing oxygen, water, and waste
products reaches the kidneys via the renal
artery. In the parenchyma (ie, working part of
the kidney where all the renal tubules are locat-
ed), the renal cells remove harmful contents
and impurities from the blood and use the oxy-
gen. The oxygen depleted blood then exits the
renal vascular system through the renal vein,
travels up the inferior vena cava, and empties
into the right side of the heart. Excess water
and other waste products accumulate in the
renal pelvis (ie, a wide, funnel-shaped sac) and
are transported to the bladder via the ureter.
The ureters consist of epithelial lining sur-
rounded by connective tissue, which is sur-
rounded by muscular fibers.“’ The ureters enter
the bladder at points in the dome about 2 inches
apart. The bladder is lined with mucosa, which
is connected to the bladder’s muscular outer
layer by a connective tissue layer.
Like all other organs, the kidney is com-
posed of individual cells that usually reproduce
and divide normally. When cell division is dis-
ordered, this abnormal growth causes masses of
tissue (ie, tumors).” Kidney tumors can be
benign or malignant. Elective surgical removal
is the best treatment for both benign and malig-
nant kidney tumors.
Etiology
T
he cause of kidney cancer is not known.
Contributing factors, however, include
smoking, non-narcotic analgesic drug
use, occupational causes, diet, and genetic
influences.
Smoking. Although the actual cause of kid-
ney cancer is not known, smoking is one of the
primary factors implicated. Cigarette smokers
are twice as likely to develop kidney cancer as
nonsmokers. l 2
Non-narcotic analgesic drug use. The use of
34
JULY 1992, VOL 56. NO I
non-narcotic analgesics, especially phenacetin
(ie, a pain-relieving drug), is another possible
cause of kidney cancer. Strong circumstantial
evidence indicates that phenacetin used in com-
bination with tobacco increases the risk signifi-
cantly.13 Phenacetin is no longer available in
the United States.
Occupation. Exposure to chemicals has been
associated with kidney cancer. Cadmium, the
chemical most often mentioned in this connec-
tion, is an element used in batteries and rust-
proof electroplating. Workers exposed to cad-
mium have a four-fold risk of kidney cancer if
they also smoke. This could be caused by a
synergistic effect similar to that seen with
phenacetin and tobacco.I4
Diet. Studies relating to diet and kidney can-
cer have been inconclusive. Research has not
shown a substantial link between coffee drink-
ing and kidney cancer. As in other forms of
cancer, however, obesity may increase the risk
of kidney cancer.Is
Genetic influences. Recent studies of
patients with renal cell carcinoma show chro-
mosomal changes that may be associated with
the genesis of kidney cancer. l6 Environmental
and genetic factors could be important for
future research.
Histology
K
idney cancers can be divided into the
three cell types: renal cell, transitional
cell, and sarcomas.
Renal cell. Renal cell carcinoma (RCC) is
the most common cell type and accounts for
80% to 90%of kidney cancers.” It arises from
renal tubules in the parenchyma, which is the
functional element of the kidney. Other names
for RCC include Grawitz’s tumor, hyper-
nephroma, renal adenocarcinoma, clear cell
carcinoma, and adenocarcinoma of the renal
parenchyma.
Transitional cell. Transitional cell carcino-
ma arises in the renal pelvis and accounts for
only 7% of all kidney cancers.lx
Sarcomas. Three percent of malignant renal
tumors are sarcomas, half of which are the cell
JULY 1992. VOL 56. NO I
type leiomyosarcomas. They frequently are
large and extend into the renal pelvis. They
usually are of renal capsular origin.'"
Disease Progression
R
enal cancer spreads from its primary
lesion in the kidney to other areas in the
body along several routes. The earlier
the disease is discovered, the better the progno-
sis and the better the chance that the disease has
remained localized. The following are ways in
which renal cancer metastasizes.
Hematogenous route. T h e d i s e a s e can
spread through the vascular system to the
lungs, bones, and liver. New tumors, whose cell
types are identical to the primary tumor, can
develop in those organs.
Lymphatic route. Renal cancer can spread to
the lymphatic system from the nodes around the
hilar area (ie, the indented part of the kidney
where the vessels and the ureter are located).
Invasion. Renal cell carcinoma starts in the
parenchyma and tends to grow toward the renal
medulla and cortex invading the normal tissue
of t h e kidney or adjacent structures.
Transitional cell cancer of the renal pelvis
grows at the ureteropelvic junction and invades
peripelvic tissue or the renal parenchyma.
Extension. Renal cell carcinoma can spread
by direct extension to the renal vein, sometimes
spreading up the vena cava, and occasionally
into the right atrium. Transitional cell tumors of
the renal pelvis tend to grow down the ureter
and out through the muscular layer of the
ureter.
Kidney cancer is not always a predictable
tumor because its growth varies, and it may not
spread. It may remain localized for many years
and, in rare occurrences, the tumor or metastasis
has spontaneously shrunk or disappeared. This
happens in only 0.3% to 0.5% of the cases.2o
Signs, Symptoms
I
n its early stage, kidney cancer usually does
not present any obvious signs or symptoms.
As the tumor grows, the most common sign
AORN JOURNAL
is visible blood in the patient's urine (ie, hema-
turia). Less common signs and symptoms are
pain and an abdominal mass. Pain may mani-
fest as a dull ache in the side, abdomen, or
back. The kidneys are anatomically well pro-
tected, and the mass probably would be palpa-
ble only in the well-advanced stage or because
of hydro-nephrosis resulting from a uretero-
pelvic junction obstruction.?l
These three signs and symptoms (ie, hema-
turia, pain, abdominal mass) are known as the
classic triad of RCC. Other signs and symptoms
occur less often and could be symptoms of RCC
o r other cancers o r diseases. These include
intermittent fever, elevated blood pressure,
weight loss, fatigue, anemia, liver dysfunction,
and hypercalcemia (ie, excess calcium in the
blood).?? Less than one-third of patients present
with the classic triad; at least one-third have no
symptoms and are diagnosed on routine exami-
nation; and about one-third do not present until
they have metastatic disease and complain of
diffuse pain, weight loss, or anemia.
Diagnostic Tests
A
patient's signs and reported symptoms
help the urologist determine the diag-
nosis. Based on the results of a physi-
cal examination, the physician may order sever-
al diagnostic tests.
Intravenous pyelogram (IVP). The IVP also
may be called an excretory urogram or an intra-
venous urogram (IVU). Diagnosis of kidney
cancer relies principally on the IVP; it usually
is the first procedure performed when a renal
malignancy is suspected. An I V P involves
injecting a contrast dye into the bloodstream
and taking x-rays at various time intervals.
The radiology technician or radiologist per-
forming the IVP must check with the patient
about allergies to the dye. People who have
food allergies, especially to the iodine in shell-
fish, may have a crossover reaction to the IVP
dye. Other patients who may have complica-
tions with an IVP include those who have Type
I juvenile diabetes, renal insufficiency, dehydra-
tion, history of allergic diseases (eg, hay fever,
35
AORN JOURNAL
asthma, food allergies), congestive heart failure,
and multiple myeloma.23A test dose of the dye
should be given, or a nonionic contrast agent
should be used instead of the contrast dye.
The IVP allows the urologist to see the renal
parenchyma, calyces, renal pelvis, ureter, and
bladder. It will show if there is a mass present
in the kidney.
Ultrasound. Ultrasound is a relatively inex-
pensive, noninvasive, easy-to-perform diagnos-
tic test that frequently is used when a patient
complains of abdominal pain. Many renal
masses now are being discovered this way.
Ultrasound usually can make a differential
diagnosis between a cyst and a tumor. If ultra-
sound proves to be inadequate, computed
tomography (CT) may be necessary.
Computed tomography. A CT scan will dif-
ferentiate between a cyst and a tumor, and it
will show if there is nodal involvement and if
the renal vein and the vena cava are involved. In
the past, IVPs were largely responsible for dis-
covering asymptomatic kidney cancer. With the
increased use of CT for a variety of abdominal
conditions, more than 50% of all asymptomatic
renal masses are discovered and diagnosed.24
After a diagnosis of kidney cancer, chest x-
rays and bone scans may be done to determine
the presence of metastasis.
Renal angiography. Perinephric extension,
lymph node involvement, and renal vein and
inferior vena cava involvement may be detect-
ed with renal angiography. As CT techniques
improve, renal angiography, which is an inva-
sive procedure, plays a decreased role.25Renal
angiography can define the tumor’s vascular
structure, which is important if the patient has
only one kidney and partial nephrectomy is
planned. Another use for angiography is preop-
erative renal venography and venal cavagraphy
in patients whose tumors invade the renal vein
and/or vena cava. It helps the surgeon identify
renal carcinomas obstructed by clots.
Renal angiography is done in the angiogra-
phy suite of the radiology department. The
radiologist or urologist places a catheter in the
patient’s femoral artery in the groin and injects
dye to see the vascular system of the kidney on
36
JULY 1992, VOL 56, NO I
x-ray. After the procedure, the patient must lie
flat with a pressure dressing applied to the
groin to prevent hematoma.
The surgeon uses the information from the
various x-ray films to modify his or her surgi-
cal approach and prepare for a more extensive
procedure if necessary.26
Staging. As with any cancer, its stage (ie,
extent of the disease) influences the patient’s
survival. Staging includes the degree of region-
al lymph node involvement, invasion through
the renal capsule, and the presence of distant
meta~tases.~’ Tumor staging for RCC is deter-
mined by clinical (based mainly on CT) and
surgical (based on the pathologist’s examina-
tion of the specimen) evidence (Fig 1).
Staging systems are used to determine appro-
priate treatment. They provide valuable prog-
nostic information by comparing results from
different groups of patients. The outlook for
patients with low-stage tumors is good, but it
becomes fair to poor as the stage increases.28
The staging system in Figure 1 is the most
popular staging system and was first described
by C J Robson, MD. Some urologists think that
there are limitations in this staging system for
those patients in Stage 111. They report that
renal vein involvement or even extension into
the vena cava when not associated with peri-
nephric fat or regional lymph node involvement
does not significantly alter the patient’s prog-
nosis as compared with tumors confined to the
kidney as seen in Stage I. When patients with
renal vein or vena cava involvement are
grouped with patients who have regional lymph
node or perinephric fat involvement, it can give
Stage 111 patients a higher survival rate than
Stage I1 patients.29 Dividing Stage I11 into two
patient groups helps differentiate the prognostic
rate, but the prognosis for Stage 111 still is not
completely clear.
The “TNM” classification system for RCC
was devised to address this confusion. The T
stands for primary tumor, N stands for nodal
involvement, and M stands for distant metas-
tases. Although TNM stages the disease more
accurately, it also is complex and more difficult
to use than Robson’s classification (Table I).
 Fig 1
Staging of Renal Cell Carcinoma and Prognosis‘

Stage I: Tumor confined to Stage 11: Invasion of perine-

kidney and capsule phric fat, but within Gerota’s
fascia

Stage IIIA: Tumor throm-

bus in the renal vein and/or Stage IIIB: Involvement of
vena cava regional lymph nodes, also
includes involvement of peri-
nephric fat outside Gerota’s
capsule

Stage IV: Extension to adjacent

organs or distant metastases

Note
1. “Modification of the staging system from The American Joint Committee on Cancer,” in Munitd on
Oncdogic T/ieiu/xwfic,ed R Wittes (Philadelphia:J B Lippincott Co, 1989).

37
AORN JOURNAL JULY 1992, VOL 56, NO I

Table 1
Staging Using TNM System‘
Primary tumor (T)
T, Primary tumor cannot be assessed
TO No evidence of primary tumor (Because of spontaneous regression or some other reason.
no primary tumor is seen on examination)
T, Tumor less than 2.5 cm and limited to kidney
T, Tumor more than 2.5 cm and limited to kidney
T3a Tumor invades adrenal gland or perinephric tissues but not beyond Gerota’s fascia
T,, Tumor extends grossly into renal vein or vena cava
T, Tumor invades beyond Gerota’s fascia

Regional lymph node involvement (N)

N, Regional lymph nodes cannot be assessed
N,) No regional lymph node metastasis
N, A single lymph node less than 2 cm
N, One or more lymph nodes, 2 to 5 cm
N; One or more lymph nodes more than 5 cm
Distant metastases (M)
M, Presence of distant metastasis cannot be assessed
M, No distant metastasis
M, Distant metastasis

Note
1. Current American Joint Committee on Cancer Recommendations for Staging, from J Montie, H
Levin, “Detection and diagnosis of renal cell carcinoma,” in Clinical Management of Renal Cell Cancer-,
ed J Montie, J E Pontes, R Bukowski (Chicago: Year Book Medical Publishers, Inc, 1990) 16.

Prognosis surgeon establishes control by ligating the

patient’s renal artery, which is located directly
behind the renal vein. The surgeon does this

T
he prognosis for patients with localized
RCC (ie, Stages I, 11, IIIA) who undergo
radical nephrectomy is approximately a
70% five-year survival rate. Patients with local
nodal involvement or distant metastases have
approximately a 30% and 10% five-year sur-
vival rate respectively.30
The principle treatment for RCC in Stages I
and I1 is radical nephrectomy. The surgery can
be performed through a thoracoabdominal or
transabdominal approach. A radical nephrecto-
my means early control of the renal vascular
pedicle (ie, the renal artery and vein) and an en
bloc removal of the kidney, tumor, intact
Gerota’s capsule, and the adrenal gland. The
before the tumor and kidney are mobilized and
manipulated; this prevents potential hematoge-
nous spread of cancer cells.3’
Most surgeons perform a lymphadenectomy
with a radical nephrectomy for RCC, but this is
still somewhat controversial. Some urologists
believe that removing the regional lymph nodes
has no curative value. Others believe lym-
phadenectomy, which is done mainly as a stag-
ing procedure, is beneficial only if further treat-
ment is possible for the patient. In the past,
there has been no adjuvant treatment, and that
leads to questions about the therapeutic value
of regional lymphadenectomy.32 Most urolo-

38
JULY 1992. VOL 56. NO I AORN JOURNAL

gists believe regional lymphadenectomy does stages has not been recommended unless
not add significant time to the surgery and is patients are symptomatic or a promising thera-
important for staging and determining the peutic protocol is being studied. It may be done
patient's prognosis; therefore they believe it as a palliative measure to control pain and
should be performed in conjunction with radi- relieve bleeding. Occasionally, radical nephrec-
cal nephrectomy.77 tomy can be curative at this stage if pulmonary
Stage 111 patients who do not have involve- metastases are solitary and both the primary
ment of lymph nodes and only renal vein and the metastatic lesions are surgically
and/or inferior vena caval thrombus (ie, Stage excised.3x
IIIA) benefit from radical nephrectomy. Renal
cell carcinoma has an unusual predilection to Renal Pelvis,
produce tumor thrombi, which may occlude the Calyces Tumor- Treatment
renal vein.'" Of the 20,000 new cases of RCC

N
annually in the United States, approximately ephroureterectomy that includes a cuff
5% have involvement of the inferior vena of bladder in the specimen is the princi-
cava.jS In 0.05% to 1 % of cases, the tumor ple treatment for cancer of the renal
thrombus extends up the vena cava to the pelvis (Fig 2). In an obese patient, two separate
diaphragm and into the right atrium.'6 incisions may be required to expose the kidney
Tumor thrombus in the renal vein does not and the ureteral orifice adequately. The surgeon
require a change in surgical technique, but excises the ureter and a cuff of the bladder
when the thrombus is in the vena cava, the sur- because of the behavior of transitional cell can-
gical team must prepare more extensively. The cers, which comprise the majority of tumors of
surgeon notifies the-OR when patient informa- the renal pelvis. Transitional cell cancers arise
tion indicates a change in the scheduled from the urothelium that lines the urinary tract,
surgery. Surgical planning
and approach for tumor
thrombus in the vena cava
requires vascular control
above and below the throm-
bus. When the RCC reaches
the right atrium, cardiopul-
monary bypass is required
and the perioperative nurse
m u s t be ready for a more
extensive procedure. At least
12 units of blood should be
ready for the patient.
Prophylactic anticoagulation
therapy eliminates the possi-
bility of deep vein thrombo-
sis and pulmonary embo-
Ii~m.~'
About one third of RCC
patients have Stage IIIB
nodal involvement and Stage
IV distant metastasis at the
time of diagnosis. Radical Fig 2. A nephroureterectomy, including excision of the kidney,
nephrectomy at these two ureter, and a cuff of the bladder.

39
AORN JOURNAL
and there is a 33% chance that the patient has
or will develop another urothelial tumor in the
ureter if the ureter is left behind. There is a
50% chance that these patients will develop
transitional cell carcinoma of the bladder so
cystourethroscopy is an important part of post-
operative follow-up care.39
Adjuvant Therapy,
Other Treatment
M
any cancers are treated with adjuvant
therapy to achieve a higher survival
rate. Because most kidney cancer
patients already have late-stage disease when
they are diagnosed, adjuvant treatments usually
accompany nephrectomy.
Renal artery infarction. Preoperatively
occluding the renal artery with an inflatable
balloon, gelatin sponge, or steel coil can
accomplish renal artery infarction. This treat-
ment decreases tumor vascularity and makes
surgery easier and less bloody. Renal artery
infarction is done in the radiology department.
Its complications are similar to those associated
with arteriographic manipulation and include
patient discomfort and postprocedure sequelae
(eg, flank pain, fever, nausea).40
Radiotherapy. Renal cell carcinoma is
thought to be radioresistant, and radiotherapy
has not been shown to improve the five-year
survival rate. It may be effective in treating
localized areas of metastases, and bone pain
can sometimes be managed temporarily by
local radiation therapy.41
Chemotherapy. Presently, there is no effec-
tive chemotherapy available for metastatic
RCC. The overall response rate to chemothera-
peutic drugs was 5% in one recent study!*
Zmmunotherapy. Immunotherapy is given to
stimulate the patient’s response to a foreign
substance (eg, tumor, infection). It activates the
patient’s immune system against the cancer.
The rationale for this therapy is that it would
work with RCC because of the occasional
spontaneous tumor regression seen in estab-
lished lesions. The incidence of spontaneous
RCC regression is less than I % , but when it
40
JULY 1992. VOL 56, NO I
does occur, i t indicates that the patient’s
immune system is fighting the tumor. Although
past response rates to immunotherapeutic drugs
has been less than 16%,research projects using
different combinations of immunotherapeutic
drugs have had some response rates of 30%.j3
Most recent immunology studies use tumor
suspensions cultured in interleukin-2. In these
studies, the researcher obtains a specimen from
the patient’s excised kidney tumor. The speci-
men is kept sterile and taken to the laboratory
where cell suspensions are prepared and lym-
phocytes are isolated from the patient’s tumor.
The accumulation of lymphocytes (mostly rest-
ing T-cells) is expanded and activated with
interleukin-2 and reinfused into the patient to
treat residual metastatic sites.@
Hormonal therapy. There has been a low
overall response to progesterone drugs, but
some urologists believe that hormonal therapy
is warranted in cases of advanced RCC when
there is nothing else to offer the patient; the
therapy is relatively innocuous. Some patients
feel better, and there are minimal side effects.
Preoperative Nursing Care
y the time a patient with kidney cancer
arrives at the hospital for surgery, he or
she has already gone through preadmis-
sion tests and procedures. He or she probably is
anxious and apprehensive, so ideally, the peri-
operative nurse will have an opportunity to visit
the patient the night before surgery in the com-
fort of the patient’s room. The perioperative
nurse can explain the routine sequence of
events that will occur and answer any ques-
tions. This is a good time to assess the patient’s
physical and psychological needs and to show
support and interest and give reassurance. The
nurse can reassure the patient’s family mem-
bers that the surgical team will communicate
with them throughout the patient’s surgery.
When the patient arrives in the preoperative
area, the nurse performs another assessment and
verifies the surgical checklist by reviewing the
chart, asking pertinent questions, and listening
carefully to the patient’s responses. The nurse
Fig 3 . Posterior (lop)and anterior (bottom)views of the lateral position used for the retroperitoneal
approach for a nephrectomy.
also asks the patient to identify, both verbally
and by gesture, the correct surgical side. The
nurse requests information on allergies, lack of
mobility in limbs, previous surgeries, NPO sta-
tus, if the patient or family members have
donated blood, and where family members are
waiting so the nurse can communicate with
them during the patient’s surgery and recovery.
In the operating room, the circulating nurse
gives the patient a warm blanket and assists
with moving the patient to a pre-warmed OR
bed. The circulating nurse introduces the patient
to all those involved in his o r her care.
Anesthesia personnel apply electrocardiogram
leads, a blood pressure cuff, and a pulse oxime-
ter and place an arterial line in the patient’s
radial artery. The arterial line can be placed
before or after the patient is anesthetized. The
circulating nurse helps anesthesia personnel and
reassures the patient by explaining procedures,
encouraging communication, and touching the
patient compassionately when appropriate.
Intraoperative Nursing Care
T
he circulating nurse assists anesthesia
personnel with induction of the patient.
After the patient is intubated, the nurse
41
AORN JOURNAL
Fig 4. The thoracoabdominal position used for the transabdominal or retroperitoneal approach for a
nephrectomy .
places a Foley catheter into the patient’s blad-
der to monitor urine output throughout the pro-
cedure. If the patient is male, generous amounts
of lubricant should be used, and the balloon on
the indwelling catheter should not be inflated
until it has been inserted into the urethra up to
the hub of the catheter; if inflated before it has
been fully inserted, the balloon may inflate in
the urethra and cause hematuria and clot reten-
tion. A stricture of the prostatic urethra is an
infrequent complication of premature inflation
of the catheter balloon.
The nurse allows some slack in the catheter
when taping the tubing securely to the patient’s
thigh to prevent pressure on any portion of the
urethra or bladder neck caused by inadvertent
traction on the catheter. Prolonged traction may
cause irritation, necrosis, and possible stricture
formation. To prevent paraphimosis, the fore-
skin of an uncircumcised patient should not be
left retracted after placing the catheter!’
While positioning the patient, the nurse
42
JULY 1992, VOL 56. NO I
ensures that the body is aligned properly, bony
prominences are padded, metal does not contact
skin, the electrosurgical dispersive pad is
placed correctly, and unnecessary exposure is
avoided.
After preparing and draping the patient, the
surgery begins. The approach may be retroperi-
toneal (Fig 3) or transabdominal (Fig 4) and is
determined by surgeon preference. After mak-
ing the skin incision, the surgeon uses an elec-
trocautery pencil to divide the subcutaneous tis-
sue, fascia, and muscle; bleeding vessels are
coagulated as the layers are incised.
The surgeon explores the retroperitoneal area
to determine the extent of the primary kidney
mass. If the peritoneum is entered, the scrub
nurse provides warm, moist laparotomy
sponges and an intestinal bag (if requested) to
prevent heat loss from exposed internal organs.
Chest or abdominal retractors are used to
ensure exposure of the surgical site.
The surgeon develops a plane of dissection
AORN JOURNAL
between Gerota’s fascia and the posterior peri-
toneum. He or she uses 2-0 silk ties and large
vessel clips to secure perforated retroperitoneal
blood vessels. The surgeon is careful not to
manipulate the tumor to avoid rupture of the
tumor capsule and spilling of tumor cells into
the wound. The surgeon uses both sharp and
blunt dissection to free the kidney from its
attachments until the superior mesenteric artery
(SMA) is found. It is important to identify and
protect the Sh4A and the celiac artery because
they are the main blood supply for the small
intestines. The renal vein is located posterior to
the SMA. The surgeon very gently palpates the
renal vein for evidence of tumor thrombus into
the lumen of the renal vein or the vena cava.
The renal vein is then mobilized to expose the
renal artery. The surgeon ligates the renal
artery first to eliminate the flow of blood into
the kidney. The kidney then will become soft.
If gentle manipulation and diagnostic x-rays
have not shown any evidence of tumor exten-
sion into the vena cava, the surgeon ligates the
renal vein where it enters the vena cava. When
the vascular supply has been secured, the sur-
geon performs a radical nephrectomy with an
en bloc regional lymph node d i s s e ~ t i o n . ~ ~
The scrub and circulating nurses always are
alert for possible complications resulting from
blood loss. Because the procedure involves lig-
ating major vessels at their origins (ie, the
aorta, the vena cava) the scrub nurse should
have vascular clamps and suture ready. The cir-
culating nurse must ensure that at least two
units of blood are readily available in the event
blood replacement becomes necessary.
Anesthesia personnel draw arterial blood gases
that are used to evaluate the patient’s acidbase
status.
After the surgeon removes the kidney,
tumor, adrenal gland (because of its close prox-
imity to the kidney), ureter (with a cuff of blad-
der if the tumor cells are transitional), and
regional lymph nodes, he or she inspects for
bleeding sites. Based on surgeon preference,
normal saline or sterile water are used to irri-
gate, and the scrub nurse monitors the amount
and type of irrigant used and relays that infor-
44
JULY 1992. VOL 56. NO I
mation to anesthesia personnel. Anesthesia per-
sonnel can assess the amount of undiluted
blood in the suction bottle before the surgeon
irrigates, which helps them estimate blood loss
and fluid replacement.
The surgeon asks the anesthesia personnel‘
to fully inflate the lung on the surgical side; the
surgeon then can check for holes in the pleura.
If a small hole is found, the surgeon can place a
purse-string suture around the hole, and he or
she can use a red robinson catheter with a
catheter tip syringe to remove the excess air,
blood, and fluid from the pleural space. The
surgeon may palpate the lung for any evidence
of metastasis and use a stapling device to
remove any section of lung that feels suspi-
cious. A chest tube then is placed in the pleural
space to drain any blood, fluid, or air and allow
for lung reexpansion.
The surgeon closes the muscle and fascia1
layers. Bupivacaine often is injected around the
intercostal nerves and in the subcutaneous tis-
sue to help control incisional pain. The surgeon
irrigates the subcutaneous tissue and uses a dis-
posable skin stapler to close the incision. A dry,
sterile dressing is then applied to the wound,
and paper tape is used to hold the gauze in
place. Extubation usually is done in the operat-
ing room when breathing, color, and circulation
are stabilized. The surgical team can then trans-
fer the patient to the postanesthesia care unit
(PACU).
Postanesthesia Nursing Care
T
he PACU nurse is primarily concerned
with preventing respiratory and circula-
tory complications.
Airway. The PACU nurse frequently checks
the patient’s airway and monitors for any
immediate airway problems (eg, hypoxemia,
hypoventilation, airway obstruction, bron-
chospasm, aspiration).
Vital signs. The anesthesiologist gives the
PACU nurse an overall evaluation of the
patient’s intraoperative vital signs during
surgery to establish a baseline against which the
nurse can assess the patient. The nurse checks
JULY 1992. VOL 56. NO I
blood pressure, pulse, and respiration immedi-
ately then every 15 to 20 minutes (or more often
depending on the patient’s condition).
Circulation. The nurse assesses the patient’s
circulation by comparing current vital signs
with preoperative and intraoperative readings.
He or she notifies the surgeon or anesthesiolo-
gist of any discrepancy or change. Hemorrhage
is possible because radical nephrectomy
involves ligation of large vessels. Patients,
therefore, should be observed closely for signs
and symptoms of shock. The nurse also exam-
ines the dressing and chest tube drainage sys-
tem for excess drainage. Hypotension requires
prompt treatment, and the nurse should notify
the surgeon and anesthesia personnel immedi-
ately.
Hemodynamic monitoring. All radical
nephrectomy patients have indwelling urinary
catheters. The PACU nurse monitors urinary
output carefully t o avoid fluid overload.
lntravenous fluids can help thin secretions and
counteract third space fluid shifts. Fluid intake
and output also are charted.
Many RCC patients are considered an
increased risk for anesthesia and will have
some type of invasive hemodynamic monitor-
ing placed in the operating room by the anes-
thesiologist. This may include a central venous
pressure line and an arterial line. Any special
equipment or requirements for monitoring the
patient should be communicated to the PACU
nurse by the circulating nurse.
Pain. The PACU nurse administers narcotic
analgesics as prescribed by the urologist or
anesthesiologist and observes the patient for
possible circulatory and respiratory depression.
During surgery, a nerve block may be inject-
ed into the surgical site before the wound is
completely closed. The information regarding
local anesthetic (eg, bupivacaine) infiltration in
the skin and muscle for incisional pain and
around the intercostal nerves of the specific rib
for an intercostal block is important for the
PACU nurse to know so he or she can accurate-
ly assess the patient for pain. The anesthetic
effect lasts about four hours.
The anesthesiologist may place an epidural
AORN JOURNAL
catheter before the surgery for postoperative
pain relief. Morphine sulfate administered
through the catheter provides pain relief by
blocking pain impulses from the spinal cord to
the brain. The narcotic can be placed either
through the catheter or injected into the epidu-
ral space. Pain relief lasts 6 to 24 hours.47
The PACU nurse ensures that the patient is
kept warm to maintain body temperature and
continues to monitor the patient until he or she
is stable enough to be transferred.
Postoperative Nursing Care
N
ursing care on the surgical ward is the
same as that for any extensive abdomi-
nal surgery and is aimed at preventing
complications and recognizing potential prob-
lems.
Pain relief. The patient can experience
intense pain after nephrectomy, including inci-
sional pain as well as aches and discomfort
from positioning during surgery. Breathing
may be very painful so the patient may take
shallow breaths and avoid coughing. Deep
breathing and coughing are necessary, howev-
er, to fully inflate the lungs and to remove
secretions. The nurse should assess the patient
for pain frequently and administer pain medica-
tion as prescribed.
Respiration. The radical nephrectomy is
done below the diaphragm; therefore, cough-
ing, deep breathing, and turning from side to
side may be painful but are necessary to help
prevent atelectasis of the lung and pneumonia.
The nurse should give the patient pain medica-
tion 30 minutes before turning, coughing, or
deep breathing exercises to help make the pro-
cedures more effective.48 He or she should
teach the patient to splint the incision with a
pillow. The use of an incentive spirometer can
be beneficial, and the nurse should encourage
progressive activity.
Renal function. All nephrectomy patients
leave surgery with a Foley catheter in place.
Postoperatively, the nurse must monitor urine
output to determine overall fluid balance status.
Paralytic ileus. If the surgeon uses the
45
AORN JOURNAL
retroperitoneal approach rather than the
abdominotransperitoneal approach, there is less
handling of the intestines, and this reduces the
chances for an ileus. In addition, most radical
nephrectomy patients routinely have a nasogas-
tric tube in place for the first 24 hours. Patients
do not eat or drink until bowel sounds return.
After that point, the diet is advanced as tolerat-
ed. The nurse can help relieve some symptoms
of paralytic ileus by turning the patient from
side to side and helping him or her with early
ambulation.
Hemorrhage. The nurse should observe the
patient for signs of hemorrhage and shock. He
or she watches for an elevated pulse rate, a
drop in blood pressure, and profuse drainage
and distention at the incision site.
Wound care. The surgeon usually does not
place a drain. Postoperatively, the nurse should
change dressings as often as needed. Skin sta-
ples are removed when the patient is discharged
(ie, 7 to 10 days after surgery).
Pneumothorax. The kidney is located close
to the diaphragm, and the pleura may be
entered unintentionally. The surgeon will
attempt to remove all air or fluid from the pleu-
ral space; if this is not successful, however, a
chest tube may be placed. The chest tube
removes air, fluid, and blood that may accumu-
late and allows the lung to reexpand if it is not
reinflated during surgery. If drainage is scant
postoperatively, the surgeon can remove the
chest tube. Small amounts of fluid may accu-
mulate in the pleural cavity, but these will be
reabsorbed by the body.
Occasionally, an undetected hole in the pleu-
ra may be made. The nurse should observe the
patient postoperatively for evidence of sponta-
neous pneumothorax. Signs of dyspnea, rest-
lessness, anxiety, increased diaphoresis, shock,
or sudden, sharp chest pain should be reported
immediately. If this occurs, the nurse should
move the patient to a Fowler's or semi-
Fowler's position while waiting for the physi-
cian's help. The nurse should have oxygen and
a thoracentesis set available. The nurse should
not leave the patient because he or she will be
apprehensive and will need support.
46
JULY 1992, VOL 56. NO I
Thrombophlebitis. Anti-thromboembolic
disease stockings and/or automatic sequential
compression stockings may be used during
surgery to help prevent thrombophlebitis.
Ambulation within 24 hours postoperatively
also will prevent this.
Third space fluid shifts. Removing the
lymph nodes and the kidney may result in third
space fluid shifts (ie, an accumulation of lym-
phatic drainage and a fluid shift from the circu-
latory system into the interstitial spaces). The
patient may become dehydrated; therefore, a
colloid may be administered to increase oncotic
pressure in the intravascular compartment and
to help replace fluid in the vascular system.4Y
Follow-up Schedule
D
ischarge planning should begin when
the patient is admitted to the hospital
and is continuously updated throughout
the hospital stay. The postoperative nurse dis-
cusses a schedule for exercise, lifting, diet,
returning to work, and postoperative visit and
answers any patient questions.
Intensive long-term follow-up for RCC
patients is required at most institutions. The
primary nurse should review the hospital's fol-
low-up care plan and teach the patient to report
any symptoms of respiratory distress, hemopty-
sis, pain, or the fracture of an extremity. These
symptoms could indicate metastasis.5"
The following schedule shows the intensity
of one follow-up care plan:
Every three months for the first year, the
patient should have a chest x-ray, urinaly-
sis, complete blood count, and an evalua-
tion of liver enzymes.
0 A cystoscopy should be performed every
3 to 6 months if the patient has transition-
al cell cancer because there is a high
chance that transitional cells will develop
in the bladder.
At one-year intervals, the patient should
have an IVP.
The patient should have a bone scan at
six-month and one-year intervals.
After one year, the physician repeats tests
 done at the sixth and 12th month evalua-
tions (ie, bone scans, IVP, cystoscopy,
chest x-ray, urinalysis, complete blood
count, liver enzyme evaluation).
0 T h e patient should have repeat tests as
warranted.
If the patient is t o receive chemotherapy,
immunotherapy, or hormonal therapy, the nurse
should be familiar with the normal dose range,
the route of administration, and the potential
acute and delayed side effects so he or she can
educate and monitor the patient.
Many RCC patients and their family mem-
bers have the misconception that losing a kid-
ney m e a n s imminent death or that death is
preferable to surgery because they believe they
will die anyway.” T h e astute and supportive
nurse should reassure the patient preoperatively
and postoperatively that he or she can live a
normal life with only one kidney. 0 20. Pontes, “Epidemiology,” 3.
Notes
I . B A Folkart, “Lee Remick dies; star of films,
stage was 55,” Los Angeles Times, 3 July 1991, A4.
2. D Johnson, D Swanson, A von Eschenback,
“Tumors of the genitourinary tract,” in Smith’s
General Urology, ed E Tanagho, J McAninch (East
Norwalk, Conn: Appleton & Lange, 1988) 334.
3. J E Rotolo, W M O’Brien, J H Lynch, “Renal
cell carcinoma,” Hospital Practice 22 (Feb 15, 1987)
59.
4. J M Lind, S L Nakao, “Urologic and male
genital malignancies,” in Cancer Nursing Principles
& Practice, ed S Groenwald et al (Boston: Jones &
Bartlett Publishers, Inc, 1987) 727.
5. National Cancer Institute, Adult Kidney
Cancer and Wilms’ Tumor (Bethesda, Md: National
Cancer Institute Publications, July 1987) 16-17.
6. S Joy, J L Grosfeld, “Wilms’ tumor:
Diagnosis, surgical management,” AORN Journal 53
(February 1991) 437.
7. Johnson, Swanson, von Eschenbach, “Tumors
of the genitourinary tract.” 334.
8. N Speese-Owens, J Rutkowski, “Nursing care
of the patient with cancer of the genitourinary sys-
tem,” in Nimirig Care of the Cancer Patient, fourth
ed, R Bouschard-Kurtz, N Speese-Owens, eds (St
Louis: The C V Mosby Co, 1981) 388.
9. Ihid.
10. Ihid. 3x9.
1 1 . National Cancer Institute, Adult Kidney
Cancw and Wilnis’ Timior. 3.
12. Ihid, 4.
13. Ihid, 5 ; A Paganini-Hill, R K Ross, B E
Henderson, “Epidemiology of renal cancer,” in
Genitourinary C a n c e r , e d D G Skinner, G
Lieskovsky (Philadelphia: W B Saunders Co, 1988)
34-35.
14. National Cancer Institute, Adult Kidney
Cancer und Wilms’ Tumor. 6.
15. Ibid, 5.
16. J E Pontes, “Epidemiology,” in Clinical
Managment of Renal Cell Cancer, ed J E Montie,
(Chicago: Year Book Medical Publishers, Inc, 1990)
2.
17. Rotolo, O’Brien, Lynch, “Renal cell carcino-
ma,”59.
18. J P Richie, “Carcinioma of the renal pelvis and
ureter,” in Genitoruinary Cancer. ed D G Skinner, G
Lieskovsky (Philadelphia: W B Saunders Co, 1988)
323-326.
19. T R Pritchett, G Lieskovsky, D G Skinner,
“Clinical manifestations and treatment of renal
parenchymal tumors,” in Genitourinary Cancer, ed
D G Skinner, G Lieskovsky (Philadelphia: W B
Saunders Co, 1988) 356.
21. Lind, Nakao, “Urologic and male genital
malignancies,” 728.
22. National Cancer Institute, Adult Kidney
Cancer and Wilms’ Tumor, 7.
23. E Lang, “Current cost-effective diagnosis of
asymptomatic renal mass lesions,” in Tumors of the
Kidney, ed J deKernion, M Pavone-Macaluso
(Baltimore: Williams & Wilkins, 1986) 11-12.
24. J Kosko, J Lipuma, M Resnick, “Radiological
evaluation of renal masses,” in Cancer of the Kidney,
ed N Javadpour (New York City: Thieme-Stratton,
Inc, 1984) 64.
25. Ibid.
26. Lind, Nakao, “Urologic and male genital
malignancies,” 73 I.
27. Johnson, Swanson, von Eschenback, “Tumors
of the genitourinary tract,” 334-353.
28. D G Skinner, J deKernion, “Manifestations
and treatment of renal parenchymal tumors,’’ in
Genifourinary Cancer, ed D G Skinner, J deKemion
(Philadelphia: W B Saunders Co, 1978) 119.
29. L W Way, ed. Current Surgical Diagnosis &
Treatment (East Norwalk, Conn: Appleton & Lange,
199 1) 926.
30. N Javadpour, “Surgical management of renal
cell cancer,” in Cancer of the Kidney, e d N
Javadpour (New York City: Thieme-Stratton, Inc,
1984) 69.
3 I . G Pizzocaro, “Lymphadenectomy in renal ade-
nocarcinoma,” in Tumors of the Kidney, ed J
deKernion, M Pavone-Macaluso (Baltimore:
Williams & Wilkins, 1986) 75.
32. M Garnick, J Richie, “Renal neoplasia,” in
47
AORN JOURNAL
The Kidney, ed B M Brenner, F C Rector, Jr
(Philadelphia:W B Saunders Co, 1991) 1817.
33. R Williams, J Donovan, Jr, “Urology,” in
Current Surgical Diagnosis and Treatment, ed L W
Way (East Norwalk, Conn: Appleton & Lange,
1991) 923.
34. Gamick, Richie, “Renal neoplasia,” 1817.
35. J E Montie, “Inferior vena cava tumor
thrombectomy,” in Clinical Management of Renal
Cell Cancer, ed J E Montie (Chicago: Year Book
Medical Publishers, Inc, 1987) 122.
36. T R Pritchett, G Lieskovsky, D G Skinner,
“Extension of renal cell carcinoma into the vena
cava: Clinical review and surgical approach.”
Journal of Urology 135 (March 1986)460.
37. Way, Current Surgical Diagnosis &
Treatment, 925.
38. Ibid, 928.
39. Lind, Nakao, “Urologic and male genital
malignancies,”732-733.
40. Skinner, deKemion, “Manifestations and treat-
ment of renal parenchymal tumors,” 129.
41. A Yagoda, “Chemotherapy of renal cell carci-
noma: 1983-1989,” Seminars in Urology 7
(November 1989) 199-206.
42. A Belldegrun et al, “Immunotherapy for
advanced renal cell cancer: The role of radical
nephrectomy,” European Urology 18 (August 1990)
42-45.
43. A Belldegrun, L M Muul. S A Rosenberg,
“Interleukin 2 expanded tumor-infiltrating lympho-
cytes in human renal cell cancer: Isolation, charac-
terization and antitumor activity,” Cancer Research
48 (January 1988) 206-214.
44. Way, Current Surgical Diagnosis &
Treatment, 926.
45. J Lerner, Z Khan, “The patient with an
indwelling urethral catheter,” in Mosby’s Manual of
Urologic Nursing (St Louis: The C V Mosby Co,
1982) 76-78.
46. Skinner, deKemion, “Manifestations and treat-
ment of renal parenchymal tumors,” 117.
47. J Lundberg, “Postanesthesiacare after thoracic
surgery,” in Handbook of Postanesthesia Nursing, ed
M E Luczun (Rockville, Md: Aspen Publishers,
1987) 103.
48. Lind, Nakao, “Urologic and male genital
malignancies,”736.
49. S La Follette, “Perioperative care of the testis
tumor patient,” AUAA Journal 8 (January-March,
1988) 15.
50. Lind, Nakao, “Urologic and male genital
malignancies,”732-733.
5 1. Speese-Owens, Rutkowski, “Nursing care of
the patient with cancer of the genitourinary system,’’
393.
48
JULY 1992. VOL 56. NO I
Film Review
Managing with People:
Conflict Resolution
and Communication, How
it Works
This videotape helps the viewer identify meth-
ods to resolve conflict by using better commu-
nication. According to this videotape, better
communication begins with a personal invento-
ry of the practitioners’ basic expectations. They
then should identify their feelings and examine
their value systems.
Communication is the key issue in conflict
resolution. First, the message being sent must
be clear. It is difficult for the receiver of the
message to understand the meaning of the
communication if there are mixed or unclear
messages. It is important to use open-ended
questions when determining what conflict
exists and what resolutions are necessary.
This videotape demonstrates several ways of
dealing with the same problem using tech-
niques of active listening, closed- and open-
ended questions, acknowledging the other per-
son’s feelings, and establishing rapport. Active
problem solving is vital. It is important to not
place blame during this phase, to be aware of
nonverbal communication, and to solve the
problem. This videotape is a good tool for
teaching staff members and managers how to
resolve conflict.
The videotape is available for $250 in 1/2-
inch VHS, Beta, and 3/4-inch U-matic. To
order, call (800) 421-2363 or mail your
request to PRI/MEES, 930 Pitner Ave,
Evanston, IL 60202. The fax number is (708)
328-6706.
DAWNCORBITT JACKSON, RN, CNOR
AUDIOVISUAL COMMIITEE