Kidney Surgery

What is nephrectomy?

Nephrectomy refers to removal of a kidney. Human beings have two kidneys. Of course, some people are born with just one kidney. We need only one kidney to live healthily.

What are the indications for nephrectomy?

There are several reasons for removal of the kidney. I will not list all of them here, but would like to mention the underlying rationale for removing kidneys. It is usually done for the following reasons:

BENIGN CONDITIONS

The kidney is not working at all or functioning very poorly (eg. a kidney with multiple stones, a kidney that is ‘burnt-out’ following PUJ obstruction).
The kidney is infected so badly that it has to be removed (eg. severe forms of pyelonephritis, kidney abscess due to stones).
There are multiple benign tumours in the kidney (egangiomyolipoma), some of which can bleed profusely and do not respond to conservative management.

My doctor tells me I need my kidney removed. What happens next?

You would have already had several blood tests and scans. In addition, the anaesthetist will need to see your ECG and chest x-ray; and, in some, an echocardiogram (ultrasound scan of your heart) as well. Once you have been deemed to be fit for surgery, 2-3 units of blood needs to be cross-matched in case you require a blood transfusion either during or immediately after the operation.

It is likely that your urologist has gone through the procedure in detail including the short, medium and long-term complications. You may have already signed the informed consent form for the operation. If this is not the case, it is likely to be obtained after admission to hospital.

What happens actually after I get admitted to hospital?

You will be admitted the evening before surgery. You are best advised to have only a light dinner on the evening before surgery. Your anaesthetist may have prescribed a light sedative to be taken at night so that you sleep without too much anxiety. You will be asked to fast overnight (if the surgery is scheduled for the morning) for at least 6 hours. You may have been started on an intravenous ‘drip’ to keep you well hydrated.

In some patients an enema may be prescribed either on the night before or the morning of surgery.

You will be fitted for some special stockings (thrombo-embolic deterrent – TED). These prevent you from developing clots (deep vein thrombosis – DVT) in your legs. You will need to wear these before being taken to the operating rooms. You will also receive injections of heparin following the operation to protect against DVT. I generally advise my patients to wear TED stockings for a period of 4 – 6 weeks after nephrectomy.

My doctor has recommended a laparoscopic nephrectomy. What is this?

In laparoscopic surgery, instead of making big cuts in the abdomen, small incisions are made, through which special tube like structures are inserted into the abdomen – these are called ‘ports’. A telescope (laparoscope) is introduced through one of the ports, serving as the surgeon’s ‘eye’. Special instruments are then inserted through 2 or 3 other ports to enable the surgeon dissect, cut or manipulate tissues. A camera is connected to the laparoscope so that the images are displayed on a TV monitor. The surgeon looks at this monitor and performs the surgery.

Once the kidney is separated from all its attachments, it is extracted out of the body through a small (5-6 cm) cut made in the lower part of the abdomen (see pictures).

Why should I consider laparoscopic nephrectomy rather than standard open nephrectomy?

With open nephrectomy, the cut is usually made to the side of the tummy (this is related to the kidney’s location) close to the 11th or 12th ribs. In some instances, either part orwhole of the rib may have to be cut to access the kidney. Also, the cut is made through thick muscular layers. Hence, after the operation, there will be a lot of pain requiring quite strong painkillers.

Pain inhibits movement of the diaphragm (the muscular sheet that separates the chest and abdomen), which results in poor breathing effort that may then cause severe chest infection.

Pain not only decreases movement but delays it as well. This in turn delays recovery and discharge from hospital. The usual length of stay following open nephrectomy is 5-7 days. For working people, return to work is delayed significantly as well.

With lap nephrectomy, due to the smaller size of the cuts (port sites are no more than 12 mms in size) and the extraction site (which is well away from the ribs), post-operative painkiller requirements are far less compared to open nephrectomy. Similarly, risk of chest infection is far less, recovery is faster and return to work is usually within a week or so. Also, blood loss is lower with lap nephrectomy.

Is lap nephrectomy as beneficial if I am overweight or obese?

With increasing body weight all the problems associated with open nephrectomy mentioned above increase proportionately. Therefore, the benefits of lap nephrectomy are more pronounced in obese individuals.

My doctor tells me that I need to be in an intensive care unit (ICU) after the operation. Is this standard practice?

No. Usually you will be sent back to your ward / room, where you are likely to be kept under close observation overnight. In some patients, who are at high risk, or have had a prolonged / difficult procedure, it may be necessary to keep them in ICU for 1-2 days. It may be for anaesthetic and / or surgical reasons. This is equally applicable to any form of nephrectomy, be it open, laparoscopic or robotic.

What happens after the operation? How soon after the operation will I be allowed to have food?

Usually you will be able to have sips of fluid within a few hours after the procedure. Normal diet is generally resumed in 24-36 hours. You are likely to have an intravenous drip running until then.

Your urinary catheter is likely to be removed the following morning after lap nephrectomy. If you have a ‘drain’ tube inserted, this is likely to be removed 24-48 hours after surgery. A physiotherapist is likely to help you mobilize and teach you deep breathing / coughing exercises.

What is LESS nephrectomy?

LESS stands for Laparo Endoscopic Single-site Surgery. This is an internationally agreed acronym for what is commonly referred to as Single Incision Laparoscopic Surgery (SILS) or Single Port Surgery.

With conventional laparoscopic surgery, 3-4 ports are used, whilst in LESS a Single Incision or a port is used to access the abdominal cavity to perform the procedure. The kidney (or any other organ that is being removed) is then extracted through this single small incision – usually the umbilicus. As there is only a tiny incision at the end of the procedure, the need for painkillers is minimal and recovery is rapid. Patients usually leave hospital in 24-48 hours.

At present there doesn’t seem to be any difference in cancer outcome with this type of surgery, but I offer LESS surgery only in select cases.

Is there any benefit in having a robotic nephrectomy?

Compared to standard laparoscopic nephrectomy, the robotic interface does not really add much in the way of benefits apart from the ability to be extremely precise.
When it comes to partial nephrectomy (see section below), there is no question that robotic assistance is superior to standard laparoscopic partial nephrectomy.

What is partial nephrectomy?

This refers to removal of a part of the kidney but is commonly used to indicate removal of a tumour from the kidney.

My neighbour told me that any kidney with a tumour that is thought to be cancerous needs complete removal of the kidney. Is this correct?

Not really! Not every kidney tumour presumed or confirmed to be cancerous requires removal of the whole kidney (total or radical nephrectomy). In the past decade there has been a move to preserve as much kidney tissue as possible. Therefore, techniques to remove just the tumour with a healthy margin of tissue around it have gained ground. Today, we are able to remove tumours up to 7-8 cm, in select locations in the kidney, leaving behind rest of the ‘normal’ kidney. See pictures below.

In terms of pre and post-operative events / care is there anything different with partial nephrectomy?

Although partial nephrectomy is a more complex procedure and is technically challenging for the surgeon, most things related to patient care are the same as with standard nephrectomy.

Due to the highly complex nature of the procedure it is standard practice to keep the patient in ICU for 24-48 hours. Length of stay in hospital is very similar to radical nephrectomy these days.

What is complex about partial nephrectomy?

The kidneys are highly vascular ie they get a lot of blood going through them. So if it were to be cut without controlling the blood supply it will result in serious bleeding. Therefore, the surgeon controls (stops) the blood going into the kidney during this procedure that allows safe removal of the tumour and repairing the defect caused. If the kidneys are left without blood supply for a prolonged period, they can get damaged. This crucial period when the blood supply to the kidney is stopped is referred to as ‘warm ischemia time’. The surgeon has to keep this time as short as possible to allow the residual kidney to function normally.

There is a fine balance between achieving safe and complete removal of the tumour and maintenance / resumption of normal function of the residual kidney tissue.

Is it possible to do partial nephrectomy laparoscopically?

Yes, this is increasingly common. In fact, the preferred way is to perform this with robotic assistance. With the help of the Da Vinci robot it has become easier to perform increasingly complex cases of small renal cancers with excellent outcomes.

What is radical nephro-ureterectomy (RNU)?

This refers to removal of a kidney along with the entire length of ureter on that side.

Why do I need a RNU?

You have been diagnosed with urothelial cancer (TCC) either in your kidney or ureter – see KIDNEY CANCER – pt guide.

If TCC is found in the kidney it is highly likely that cancerous change has already happened in the urothelium (the lining of the inner part of the kidney, ureter and bladder) of that ureter. If the kidney alone were to be removed leaving behind the ureter, this will require inspection by way of ureteroscopy at regular intervals for many years to check for recurrence of cancer in the ureter. This is the reason for performing regular flexible cystoscopy – to check for recurrence of cancer in the bladder after RNU

Is RNU different from nephrectomy in terms of pre-op assessment or post-op care?

No. The only additional procedure that may be done post-op is instillation of a chemotherapy drug called mitomycin into the bladder – this reduces the risk of recurrence risk of TCC in the bladder.

Is the cut larger for this operation?

Yes. With open RNU, it is likely that you will have two cuts – one for removal of the kidney and the other to access the lower end of the ureter where it joins the bladder, so that it can be disconnected completely.

Can RNU be done laparoscopically?

Yes. This is now the preferred choice as all the advantages mentioned for lap nephrectomy apply to this as well, with no compromise in cancer outcomes. Also, like in lap nephrectomy, the kidney and ureter are extracted en bloc through a small cut in the lower abdomen.

Could you please give us some do’s and don’t after kidney operations like the ones discussed above?