A 61-year-old man presents with back pain and hematuria. The patient says his back pain gradually onset 6 months ago and has progressively worsened. He describes the pain as moderate, dull and aching, and localized to the lower back and right flank. Also, he says that, for the past 2 weeks, he has been having intermittent episodes of hematuria. The patient denies any recent history of fever, chills, syncope, night sweats, dysuria or pain on urination. His past medical history is significant for a myocardial infarction (MI) 3 years ago status post percutaneous transluminal coronary angioplasty and peripheral vascular disease of the lower extremities, worst in the popliteal arteries, with an ankle:brachial index of 1.4. Also, he has had 2 episodes of obstructive nephrolithiasis in the past year caused by calcium oxalate stones, for which he takes potassium citrate. His family history is significant for his father who died of renovascular hypertension at age 55. The patient reports a 20-pack-year smoking history and moderates to heavy daily alcohol use. A review of systems is significant for an unintentional 6.8 kg (15 lb) weight loss over the last 2 months. The vital signs include: blood pressure 145/95 mm Hg, pulse 71/min, temperature 37.2℃ (98.9℉), and respiratory rate 18/min. On physical examination, the patient has moderate right costovertebral angle tenderness (CVAT). A contrast computed tomography (CT) scan of the abdomen and pelvis reveals an enhancing mass in the upper pole of the right kidney. A percutaneous renal biopsy of the mass confirms renal cell carcinoma. Which of the following was the most significant risk factor for the development of renal cell carcinoma (RCC) in this patient?

History of obstructive nephrolithiasis

Moderate to heavy daily alcohol use

Family history of renovascular hypertension

A 61-year-old man comes to the physician because of several episodes of dark urine over the past 2 weeks. He does not have dysuria or flank pain. He works in a factory that produces dyes. Since an accident at work 5 years ago, he has had moderate hearing loss bilaterally. He takes no medications. He has smoked a pack of cigarettes daily for 29 years and drinks one alcoholic beverage daily. Vital signs are within normal limits. Physical examination shows no abnormalities. His urine is pink; urinalysis shows 80 RBC/hpf but no WBCs. Cystoscopy shows a 3-cm mass in the bladder mucosa. The mass is resected. Pathologic examination shows an urothelial carcinoma with penetration into the muscular layer. An x-ray of the chest and a CT scan of the abdomen and pelvis with contrast show a normal upper urinary tract and normal lymph nodes. Which of the following is the most appropriate next step in management?

Transurethral resection of tumor with intravesical BCG instillation

Transurethral resection of tumor with intravesical chemotherapy

A 63-year-old man undergoes uncomplicated laparoscopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. Which of the following is the most appropriate next step in management?

Evaluate urinary catheter for obstruction

Obtain bilateral renal ultrasonography

Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?

Administer intravenous furosemide

A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

Nephrectomy indications for USMLE Step 3: High-Yield Surgery Lessons

🔪 Why Remove a Kidney?

Primary reasons for surgical removal of a kidney (nephrectomy).

Malignancy:
- Renal Cell Carcinoma (RCC): Most common indication.
- Wilms Tumor: Key pediatric renal malignancy.
- Upper Tract Urothelial Carcinoma.
Benign (Non-Salvageable/Symptomatic):
- Severe Trauma: Grade V injury (shattered kidney).
- Non-functioning Kidney: Due to chronic infection (e.g., xanthogranulomatous pyelonephritis), severe hydronephrosis, or refractory renovascular HTN.
- Large Symptomatic Tumors: e.g., Angiomyolipoma >4 cm at risk of hemorrhage.
Donation:
- Living or deceased donor for transplantation.

⭐ Pearl: The classic RCC triad (hematuria, flank pain, palpable mass) is rare (<10% of patients). Most RCCs are found incidentally on imaging.

🔪 Nephrectomy Indications

Nephrectomy is the surgical removal of a kidney. The approach (partial vs. radical) depends on the underlying pathology, tumor characteristics, and patient factors.

📌 Mnemonic "KIDNEY":

Kancer (Malignancy)
Infection (Severe/Chronic)
Donor (Living Transplant)
Non-functioning/Obstructed
Extreme Trauma
hYpertension (Refractory Renovascular)

Indication Categories

Malignant Indications

Renal Cell Carcinoma (RCC): Most common reason.
- Partial Nephrectomy (Nephron-Sparing):
  - Standard of Care for T1a tumors (<4 cm).
  - Preferred for T1b tumors (4-7 cm) if feasible.
  - Imperative for solitary kidney, bilateral tumors, or pre-existing CKD.
- Radical Nephrectomy:
  - Large tumors (>7 cm), centrally located, or with extensive invasion.
  - Involves removal of kidney, adrenal gland (if involved), and Gerota's fascia.
Wilms Tumor (Nephroblastoma): Primary pediatric renal malignancy.
Upper Tract Urothelial Carcinoma: Requires nephroureterectomy (kidney + entire ureter).

⭐ For localized Renal Cell Carcinoma (RCC), partial nephrectomy is now the standard of care for T1a tumors (<4 cm) and preferred for T1b tumors (4-7 cm) when technically feasible, as it preserves renal function with equivalent oncologic outcomes to radical nephrectomy.

Benign Indications & Donor

Non-functioning Kidney: Due to chronic obstruction or reflux, with <10-15% differential function and causing symptoms (pain, infection).
Severe Infection: Xanthogranulomatous pyelonephritis (XGP) or emphysematous pyelonephritis unresponsive to conservative management.
Trauma: Uncontrollable hemorrhage from high-grade (Grade V) renal injury.
Living Donor Nephrectomy: For transplantation.
- 💡 Left kidney is typically preferred due to its longer renal vein, facilitating easier anastomosis.

⚠️ Complications - Post-Op Perils

Hemorrhage: Renal artery/vein stump failure → retroperitoneal hematoma. Suspect with ↓ H/H, hypotension, tachycardia.
Adjacent Organ Injury:
- Left-sided: Spleen (most common!), pancreas tail, colon.
- Right-sided: Liver, duodenum, colon.
Renal: Transient ↑ Creatinine is common. Risk of AKI, especially with pre-existing CKD.
Thromboembolic: DVT/PE risk is significant; prophylaxis is crucial.
Other: Pneumothorax (supracostal approach), surgical site infection, incisional hernia (late).

⭐ Splenic injury is the most common visceral injury during a left nephrectomy, often requiring splenectomy.

⚡ Biggest Takeaways

Renal Cell Carcinoma (RCC) is the most common indication for radical nephrectomy in adults.

Partial nephrectomy is standard for small renal masses (<4-7 cm) to preserve renal function.

In children, Wilms tumor is the primary indication, often after neoadjuvant chemotherapy.

Severe renal trauma (Grade V) with hemodynamic instability or uncontrollable hemorrhage requires removal.

Living donor nephrectomy is a major indication for transplantation.

A chronically infected, non-functioning kidney (e.g., xanthogranulomatous pyelonephritis) may be removed.

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Nephrectomy indications