Nephrectomy - Laparoscopic/Robotic Radical

Figure 1: Radical nephrectomy.

What are the indications for a radical nephrectomy/ nephroureterectomy?

Radical nephrectomy / nephroureterectomy or partial nephrectomy is needed for a range of problems including

• Lumps in the kidney confirmed to be / suspicious for cancer.

• Cancer of inner lining of the ureter or kidney.

• A poorly functioning kidney that is causing symptoms 

What pre-operative work up is needed?

Your urologist will organise any necessary urine and blood tests and imaging scans at your consultation prior to your procedure. You will need a CT scan of the chest, abdomen and pelvis and sometimes an MRI of the kidneys to assess the lump better.

If you take any blood thinning medication such as aspirin, plavix (clopidogrel), warfarin or other anticoagulants, you should discuss this with your urologist as these may need to be stopped temporarily before your procedure. 

Please ensure you return any admission forms given to you to be filled out back to the hospital.

What happens on the day of the procedure?

You will be given fasting instructions prior to your admission (usually for 6 hours prior to the procedure). You should bring a list of your medications, any recent scans or reports with you to the hospital. After you are admitted from the admission lounge, your urologist will see you to discuss the surgery. An anaesthetist will see you to discuss the general anaesthetic and pain relief options before you are taken to the operation theatre. You may be provided with a pair of TED stockings to wear to prevent blood clots from developing and passing into your lungs. 

What does this procedure involve?

This involves removal of the entire kidney (radical nephrectomy) or entire kidney and ureter (radical nephroureterectomy) for suspected cancer of the kidney through four - six “keyhole” incisions, using telescopic instruments inserted into your abdominal cavity. One of these incisions may need to be enlarged to extract the part of the kidney being removed.

Robotic surgery uses sophisticated mini-instruments, which are completely under the surgeon’s control. The robot mimics and assists the surgeon’s movements; it does not do the operation. This technique is now widely used because of its high degree of surgical accuracy, and because recovery is much faster than it is for open surgery. 

The procedure is performed under a general anaesthetic. After inserting a catheter in your bladder, an injection of antibiotics is given before the laparoscopic / robotic instruments are inserted through five or six keyhole cuts in your abdomen. Gas is instilled into your abdominal cavity to create space to allow the surgeon to perform the operation. The kidney, which contains the tumour, is removed, together with its surrounding fat. For a nephroureterectomy, the ureter is followed down and disconnected from the bladder (this may sometimes require a separate incision). The specimen is removed from your abdomen by enlarging one of the port incisions. A drain tube may be left at the surgical site to prevent fluid accumulation. Local anaesthetic is instilled into the wounds for pain relief. The procedure takes approximately three hours to complete.

After the procedure, you are given a fluid based diet that day. The next day, you will be given injections to thin your blood to prevent clots in the legs and lungs and encouraged to do deep breathing exercises and move around the ward. The catheter and the drain are removed as soon as you are mobile (if you had a nephroureterectomy the catheter will be left in the bladder for 3-7 days) and you are able to eat a normal diet. You will be in hospital for 2-3 days.

Are there any risks or side-effects?

• Pain or discomfort at the incision site 50-80%

• Shoulder tip pain due to irritation of your diaphragm 20-30%

• Temporary abdominal bloating (gaseous distension) 20-30%

• The abnormality in the kidney may turn out not to be cancer 5-10%

• Bleeding, infection, pain or hernia at the incision site requiring further treatment 2-5%

• Bleeding during or after surgery requiring transfusion or conversion to open surgery 1-2%

• Failure to remove all the tumour requiring close observation or re-operation at a later date 1-2%

• Recognised (or unrecognised) injury to organs/blood vessels requiring conversion to open surgery (or deferred open surgery) 1-2%

• Entry into your lung cavity requiring insertion of a temporary drainage tube 1-2%

• Involvement or injury to nearby local structures (blood vessels, spleen, liver, lung, pancreas & bowel) requiring more extensive surgery 1-5%

• Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death) 2-3%

What can I expect when I get home?

You will get some abdominal discomfort especially at the incision sites, which may last for up to a week. This can be controlled by simple painkillers such as paracetamol. You should keep up a good fluid intake, remain active and eat a normal diet after returning home. It is normal to feel tired for 1-2 weeks. You should have recovered completely after 10 to 14 days. Most people can return to light work after 2-3 weeks and strenuous work and driving after 4-6 weeks.  

In case of a nephroureterectomy, if you are sent home with a catheter, it will be removed a week later (sometimes after a dye test and Xray to check the bladder has healed completely)

The keyhole incisions are closed with dissolving stitches, which do not require removal.  

What follow-up do I need?

A follow-up appointment will be made in 2-4 weeks for you once the pathology results are available. After this if you have cancer identified in your kidney on pathology, you will need follow-up periodically for 5 years with your urologist. This is to ensure that any signs of the cancer returning are identified and treated in time.