Laparoscopic Radical Removal of the Kidney

This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse.

What does the procedure involve?

This involves removal of the kidney through several keyhole incisions. It requires the placement of a telescope and operating instruments into your abdominal cavity using 4-5 small incisions. The adrenal gland may also be removed and one incision will need to be enlarged to remove the kidney

What are the alternatives to this procedure?

Observation, embolisation, chemotherapy, immunotherapy, open surgery

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. You will normally receive an appointment for pre-assessment to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team.

You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation.

You will need to wear anti-thrombosis stockings during your hospital stay; these help prevent blood clots forming in the veins of your legs during and after surgery.

Please be sure to inform your surgeon in advance of your surgery if you have any of the following:

• An artificial heart valve
• A coronary artery stent
• A heart pacemaker or defibrillator
• An artificial joint
• An artificial blood vessel graft
• A neurosurgical shunt
• Any other implanted foreign body
• A regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix®)
• A previous or current MRSA infection
• A high risk of variant-CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human-derived growth hormone)

At some stage during the admission process, you will be asked to sign the second part of the consent form giving permission for your operation to take place, showing you understand what is to be done and confirming that you wish to proceed. Make sure that you are given the opportunity to discuss any concerns and to ask any questions you may still have before signing the form.

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively.

The kidney is dissected free through several keyhole incisions and put into a bag which is then removed by extending one of the keyhole incisions.

A bladder catheter is normally inserted during the operation to monitor urine output and a drainage tube may rarely be placed through the skin into the bed of the kidney.

What happens immediately after the procedure?

In general terms, you should expect to be told how the procedure went and you should:

• Ask if what was planned to be done was achieved
• Let the medical staff know if you are in any discomfort
• Ask what you can and cannot do
• Feel free to ask any questions or discuss any concerns with the ward staff and members of the surgical team
• Ensure that you are clear about what has been done and what is the next move
  You will be given fluids to drink from an early stage after the operation and you will be encouraged to mobilise as soon as you are comfortable to prevent blood clots forming in your legs. The wound drain and catheter are normally removed after 24- 48 hours.

The average hospital stay is 2-3 days.

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than 1 in 10)

• Temporary shoulder tip pain
• Temporary abdominal bloating
• Temporary insertion of a bladder catheter and wound drain

Occasional (between 1 in 10 and 1 in 50)

Bleeding, infection, pain or hernia of the incision requiring further treatment

Rare (less than 1 in 50)

• Bleeding requiring conversion to open surgery or requiring blood transfusion
• Entry into lung cavity requiring insertion of a temporary drain
• The histological abnormality may eventually turn out not to be cancer
• Recognised (or unrecognised) injury to organs/blood vessels requiring conversion to open surgery (or deferred open surgery)
• Involvement or injury to nearby local structures (blood vessels, spleen,
  liver, kidney ,lung, pancreas, bowel) requiring more extensive surgery
• Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)
• Dialysis may be required to stabilise your kidney function if your other kidney functions poorly

Hospital-acquired infection

• Colonisation with MRSA (0.9% – 1 in 110)
• Clostridium difficile bowel infection (0.01% – 1 in 10,000)
• MRSA bloodstream infection (0.02% – 1 in 5000)

The rates for hospital-acquired infection may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.

What should I expect when I get home?

By the time of your discharge from hospital, you should:

• Be given advice about your recovery at home
• Ask when to resume normal activities such as work, exercise, driving, housework and sexual intimacy
• Ask for a contact number if you have any concerns once you return home
• Ask when your follow-up will be and who will do this (the hospital or your GP)
• Ensure that you know when you will be told the results of any tests done on tissues or organs which have been removed

When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

There may be some discomfort from the small incisions in your abdomen but this can normally be controlled with simple painkillers.

All the wounds are closed with absorbable stitches which do not require removal.

It will take 10-14 days to recover fully from the procedure and most people can return to normal activities after 2-4 weeks.

What else should I look out for?

If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, you should contact the hospital and your consultant immediately.

Are there any other important points?

A follow-up outpatient appointment will normally be arranged for you 3-4 weeks after the operation. At this time, we will be able to inform you of the results of pathology tests on the removed kidney.

It will be at least 14-21 days before the pathology results on the tissue removed are available. It is normal practice for the results of all biopsies to be discussed in detail at a multi-disciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion.

After removal of one kidney, there is no need for any dietary or fluid restrictions since your remaining kidney can handle fluids and waste products with no difficulty.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than 3 months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

What to expect after the operation?

Scar: You can expect between 3 and 5 small scars at different points on your abdomen. One of these will be longer than the others as it is through this wound that the kidney is removed. Most of these will have one dissolvable stitch.

Stitches: Most stitches will not require any removal as they will be dissolvable

Dressings: You do not need to keep the scars covered, though some people find it more comfortable to do so. You do not need to worry about getting the scar wet. Many patients have concerns that standing up straight will pull at the stitches. Don’t worry about this. Getting out of bed and standing straight will actually help you to recover more quickly.

Discomfort: You will experience some pain and discomfort around the scars, especially in the first week after the surgery. You may also experience some pain in your shoulders for a few days after the operation. Simple painkillers should be able to relieve this effectively for you.

Tiredness and feeling emotional: Your body is using a lot of energy to heal itself, so you will feel more tired than normal – sometimes it can come upon you suddenly.

Feeling emotional: If you feel upset or emotional in the days and weeks after your operation, don’t worry – this is a perfectly normal reaction which many people experience.

Painkillers: Painkillers may well cause constipation, so it’s important to get plenty of fibre in your diet while you are recovering. Fresh fruit and vegetables will help to keep your bowels moving regularly.

Things that will help you recover more quickly

Eat healthily: Eating a healthy diet will help to ensure that your body has all the nutrients it needs to heal.

Stop smoking: By not smoking – even if it’s just for the time that you’re recovering – you immediately start to improve your circulation and your breathing – not to mention a whole list of other benefits to the heart and lungs.

Family and friends: Family and friends can give you two important things: Practical help with the tasks you might be temporarily unable to do while you recover – such as driving, the weekly shop, or lifting heavier items.

Keeping your spirits up: the novelty soon wears off being home alone all day, and it’s easy to feel isolated by this. Having company can help you to worry less. It’s important not to let anxiety set in, as it can become a problem in itself which stands in the way of you getting back to your normal routine.

Keep a routine: Get up at your normal time in the morning, get dressed, move about the house. If you get tired, you can rest later.

Build up gradually:

Have a go at doing some of the things you’d normally do, but build up gradually. Obviously, everyone recovers at a different speed. When you’re building up your activities, you may feel more tired than normal. If so, stop, and rest until your strength returns. If you feel pain, stop immediately and consult your GP or Consultant.

Don’t sleep in – you can always rest later. Staying in bed can cause depression. If you live alone, and you do not have family or friends close by, organise support in advance – have family or friends come to stay with you for the first few days after surgery if possible.

Returning to work

Fact: Work can be part of your recovery

Everyone needs time off to recover after an operation – but too much of it can stand in the way of you getting back to normal. In fact, by staying off for too long, people can become isolated and depressed. Getting back to your normal work routine sooner rather than later can actually help you to recover more quickly.

Getting back to work

• How quickly you return to work depends on a number of things:
• How you heal
• How you respond to surgery
• The type of job you do
• People whose work involves a lot of heavy lifting, or standing up or walking for long periods of time, will not be able to return to work as quickly as those who have office jobs which are less demanding physically.

How soon can I go back?

Every person recovers differently and has different needs. Some people find that they are well enough to return to work 2 weeks after surgery, though most people take 4 weeks to get back to work. However, if your job involves heavy lifting (more than 5kg at a time) or standing for prolonged periods of more than 20 minutes, then you will need between 4 and 6 weeks before you can return to normal work activities.

Your GP or surgeon will help you decide on the best time for you to return to work, based on your individual needs.

If your employer has an occupational health nurse or doctor they will advise you on this. Alternatively your GP can give you advice. Ultimately, it’s your decision when you want to go back, and there’s no insurance risk to your employer if you choose to do so.

Planning for your return

• Talk to your Occupational Health service or GP to work out when and how is best for you to return to work.
• Depending on the nature of your job, you might want to ask your employer about returning to work on lighter duties at first. This means:
  • Spending more time sitting rather than standing or walking
  • Doing work that is mostly paperwork, using a computer or telephone
  • Not carrying more than around 5kg any significant distance
  • Avoiding tasks such as prolonged loading or unloading, packing or unpacking.
• If you have an HR Department at work, they will be able to advise you on how your absence might affect any benefits you may be receiving during your time off.

Confidence:

It will take you a little while to regain your full confidence when you go back to work. You may be slower than normal at first, so don’t take on too much responsibility too soon. Don’t be too hard on yourself about this – it’s perfectly normal and you’ll start to get back up to speed after a few days.

3 Golden rules for a speedy recovery:

• Stay active
• Keep a normal daily routine
• Keep social contact with people

Driving

Your insurance company should be informed about your operation. Some companies will not insure drivers for a number of weeks after surgery, so it’s important to check what your policy says.

Driving – An exercise

Before resuming driving, you should be free from the sedative effects of any painkillers you may be taking. You should be comfortable in the driving position and able to safely control your car, including freely performing an emergency stop.

In the weeks after surgery, as you build up your strength and return to your normal range of activities, one of your final tasks will be returning to driving. Before you go out on the road again, practice the basic movements you need to drive safely, including an emergency stop. Do this in a safe place without putting the key the ignition. If you feel pain or soreness afterwards, leave it for few days and try again.

It is advisable not to restart driving with a long journey.

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When can I have sex?

For many people, being able to have sex again is an important milestone in their recovery. There are no set rules or times about when it’s safe to do so other than whether it feels OK to you – treat it like any other physical activity and build up gradually.

What should I do with this information?

Thank you for taking the trouble to read this publication. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this publication to be filed in your hospital records for future reference, please let your Urologist or Specialist Nurse know. However, if you do agree to proceed with the scheduled procedure, you will be asked to sign a separate consent form that will be filed in your hospital. You will, if you wish, be provided with a copy of the consent form.

Disclaimer

While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned by any person acting or refraining from action as a result of the material in this publication can be accepted