Partial Nephrectomy Laparoscopic

What does this procedure involve?

Removal of part of your kidney, with its surrounding fat (pictured), for suspected cancer of the kidney through three to five “keyhole” incisions, using a telescope and operating instruments put into your abdominal (tummy) cavity. One of these incisions may need to be enlarged to remove the resected part of kidney.

What are the alternatives?

• Observation alone – leaving the tumour in your kidney and observing it carefully for any signs of enlargement
• Open radical nephrectomy – removing the whole kidney and its surrounding tissues through an abdominal or loin incision
• Open partial nephrectomy – removing only the part of the kidney containing the tumour, through an abdominal or loin incision
• Robotic-assisted laparoscopic partial nephrectomy – removing only part of the kidney using a telescopic (keyhole) technique assisted by robotic control
• Laparoscopic radical nephrectomy – removing the whole kidney, using a telescopic (keyhole) technique; this can be performed using robotic assistance
• Cryoablation – freezing the tumour with cooled metal probes using CT guidance, telescopic (keyhole) techniques or direct puncture through your skin
• Radiofrequency ablation – using an electric current to “heat up” the tumour under X-ray control, without damaging the surrounding kidney

What happens on the day of the procedure?

Your urologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent.

An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you.

We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home.

Details of the procedure

• We normally carry out the procedure under a general anaesthetic
• We usually give you an injection of antibiotics before the procedure, after you have been checked for any allergies
• We distend (inflate) your abdominal (tummy) cavity by injecting carbon dioxide gas using a special needle
• We create several keyhole incisions (ports) and insert operating instruments through them (pictured)
• We free your kidney and its surrounding fat using these instruments, and resect the part of your kidney which contains the tumour, together with its surrounding fat
• We extract the resected part of your kidney from your abdomen by enlarging one of the port incisions
• We close the wounds with absorbable stitches which normally disappear within two to three weeks and inject local anaesthetic into the wounds for pain relief
• We put a catheter in your bladder to monitor your urine output; this is removed as soon as you are mobile
• We usually put a drain down to the area where the tumour was removed, to prevent fluid accumulation; this is removed when it stops draining
• The procedure takes from one to three hours to complete, depending on complexity
• You can expect to be in hospital for two to three days

Following major abdominal surgery, some urology units have introduced Enhanced Recovery Pathways. These actually start before you are admitted to hospital. After your surgery, they are designed to speed your recovery, shorten your time in hospital and reduce your risk of re-admission.

We will encourage you to get up and about as soon as possible. This reduces the risk of blood clots in your legs and helps your bowel to start working again. You will sit out in a chair shortly after the procedure and be shown deep breathing/leg exercises. We will encourage you to start drinking and eating as soon as possible.

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual:

After-effect	Risk
Pain or discomfort at the incision site	Almost all patients
Shoulder tip pain due to irritation of your diaphragm by the carbon dioxide gas	Almost all patients
Temporary abdominal bloating (gaseous distension)	Almost all patients
The abnormality in the kidney may turn out not to be cancer	Between 1 in 2 & 1 in 10 patients
Bleeding, infection, pain or hernia at the incision site requiring further treatment	Between 1 in 10 & 1 in 50 patients
Removal of the whole kidney may be needed if partial removal is not thought to be possible	Between 1 in 10 & 1 in 50 patients
Bleeding during or after surgery requiring transfusion, embolisation or conversion to open surgery (and sometimes loss of the entire kidney)	Between 1 in 10 & 1 in 50 patients
Failure to remove all the tumour requiring close observation or re-operation at a later date	Between 1 in 10 & 1 in 50 patients
Recognised (or unrecognised) injury to organs/blood vessels requiring conversion to open surgery (or deferred open surgery)	Between 1 in 50 & 1 in 250 patients
Entry into your lung cavity requiring insertion of a temporary drainage tube	Between 1 in 50 & 1 in 250 patients
Urinary leakage from the cut edge of the kidney requiring further treatment (e.g. putting in a ureteric stent)	Between 1 in 50 & 1 in 250 patients
Involvement or injury to nearby local structures (blood vessels, spleen, liver, lung, pancreas & bowel) requiring more extensive surgery	Between 1 in 50 & 1 in 250 patients
Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)	Between 1 in 50 & 1 in 250 patients (your anaesthetist can estimate your individual risk)

What is my risk of a hospital-acquired infection?

Your risk of getting an infection in hospital is approximately 8 in 100 (8%); this includes getting MRSA or a Clostridium difficile bowel infection. This figure is higher if you are in a “high-risk” group of patients such as patients who have had:

• Long-term drainage tubes (e.g. catheters);
• Bladder removal;
• Long hospital stays; or
• Multiple hospital admissions.

What can I expect when I get home?

• You will get some twinges of discomfort in your incisions which may go on for several weeks; this can be controlled by simple painkillers such as paracetamol
• You should have recovered completely after 10 to 14 days
• Most people can return to work after two to four weeks
• You will be given advice about your recovery at home
• You will be given a copy of your discharge summary and a copy will also be sent to your GP
• Any antibiotics or other tablets you may need will be arranged & dispensed from the hospital pharmacy
• The pathology results on your kidney will be discussed in a multi-disciplinary team (MDT) meeting
• You and your GP will be informed of the results at the earliest possible opportunity
• We normally arrange a follow-up appointment for you once the pathology results are available

General information about surgical procedures

Before your procedure

Please tell a member of the medical team if you have:

• An implanted foreign body (stent, joint replacement, pacemaker, heart valve, blood vessel graft);
• A regular prescription for a blood thinning agent (warfarin, aspirin, clopidogrel, rivaroxaban or dabigatran);
• A present or previous MRSA infection; or
• A high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment).

Questions you may wish to ask

If you wish to learn more about what will happen, you can find a list of suggested questions called “Having An Operation” on the website of the Royal College of Surgeons of England. You may also wish to ask your surgeon for his/her personal results and experience with this procedure.

For several years, BAUS has collected data from urologists undertaking this surgery. You can view these data, by unit and by Consultant, in the Surgical Outcomes Audit section of the BAUS website.

Before you go home

We will tell you how the procedure went and you should:

• Make sure you understand what has been done;
• Ask the surgeon if everything went as planned;
• Let the staff know if you have any discomfort;
• Ask what you can (and cannot) do at home;
• Make sure you know what happens next; and
• Ask when you can return to normal activities.

We will give you advice about what to look out for when you get home. Your surgeon or nurse will also give you details of who to contact, and how to contact them, in the event of problems.

Smoking and surgery

Ideally, we would prefer you to stop smoking before any procedure. Smoking can worsen some urological conditions and makes complications more likely after surgery. For advice on stopping, you can:

• Contact your GP;
• Access your local NHS Smoking Help Online; or
• Ring the free NHS Smoking Helpline on 0300 123 1044.

Driving after surgery

It is your responsibility to make sure you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If it is, you should check with your insurance company before driving again.