What questions will my attending ask during a radical nephrectomy for a Wilms tumor?

Common Questions During a Radical Nephrectomy for Wilms Tumor

During a radical nephrectomy for Wilms tumor, your attending will likely ask questions focused on surgical anatomy, oncological principles, and perioperative management to assess your knowledge and clinical judgment.

Surgical Anatomy Questions

• What are the key anatomical structures you need to identify before clamping the renal hilum?

  • Renal artery, renal vein, and ureter
  • Variations in renal vasculature (accessory vessels)
  • Relationship to adjacent structures (adrenal gland, spleen, liver)

• What is the proper sequence for hilar control during a radical nephrectomy?

  • Artery first, then vein (to minimize blood loss and potential tumor embolization)

• What are the anatomical boundaries of Gerota's fascia and why is complete removal important?

  • Contains kidney, perirenal fat, and adrenal gland
  • Complete removal is essential for oncological principles in Wilms tumor

Oncological Principles

• Why is the ipsilateral adrenal gland typically removed during radical nephrectomy for Wilms tumor?

  • To ensure complete tumor removal, especially for upper pole tumors
  • To prevent local recurrence 1

• What are the indications for lymph node sampling during radical nephrectomy?

  • Provides prognostic information
  • Virtually all patients with nodal involvement subsequently relapse with distant metastases 1

• What is the risk of tumor rupture during surgery and how do you prevent it?

  • Gentle handling of the tumor
  • Early vascular control
  • Wide exposure
  • Tumor rupture significantly upstages the disease

Perioperative Management

• What preoperative imaging studies are essential for surgical planning?

  • CT abdomen/pelvis with and without contrast
  • Chest imaging (radiograph or CT)
  • Assessment for inferior vena cava involvement 1

• What are the potential complications specific to radical nephrectomy for Wilms tumor?

  • Tumor rupture
  • Massive hemorrhage
  • Adjacent organ injury
  • Respiratory compromise from large tumor 2

• How would you manage intraoperative tumor rupture?

  • Immediate containment
  • Irrigation of the surgical field
  • Documentation for upstaging
  • Implications for postoperative management

Surgical Technique Questions

• When is partial nephrectomy considered instead of radical nephrectomy for Wilms tumor?

  • Bilateral Wilms tumor
  • Solitary kidney
  • Underlying renal dysfunction 3, 4

• What are the key steps in performing a safe radical nephrectomy for Wilms tumor?

  • Wide exposure
  • Early vascular control
  • En bloc removal of kidney with Gerota's fascia
  • Lymph node sampling
  • Minimal tumor manipulation

• What are the advantages and disadvantages of open versus minimally invasive approaches?

  • Open: Better exposure, easier management of large tumors
  • Minimally invasive: Faster recovery, less pain, but requires advanced skills and careful patient selection 5, 6

Postoperative Management

• What is the standard follow-up regimen after radical nephrectomy?

  • History and physical examination every 3-6 months for 3 years, then annually up to 5 years
  • Baseline abdominal imaging within 3-6 months
  • Continued imaging every 3-6 months for at least 3 years 1, 7

• What are the long-term renal function considerations after radical nephrectomy?

  • Risk of chronic kidney disease
  • Need for monitoring renal function
  • Potential cardiovascular morbidity 1

Preparation Tips

• Review the patient's imaging thoroughly before the case
• Understand the staging of Wilms tumor and its implications for surgical management
• Be familiar with the potential complications and their management
• Know the relevant anatomy and surgical approaches
• Understand the principles of oncological surgery, particularly for pediatric renal tumors

Remember that your attending will be evaluating not just your knowledge but also your clinical judgment, communication skills, and ability to think critically under pressure during this complex oncological procedure.