Laparoscopic de-roofing of simple renal cyst

What is the evidence base for this information?

This leaflet 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 practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

Key points

• The aim of this operation is to remove one or more simple cysts from your kidney using open or keyhole surgery
• This procedure is only used for cysts that are benign (non-cancerous)
• Normally, we only do this after the cyst has been emptied (by puncturing it with a needle) to confirm that it is responsible for your symptoms
• Keyhole surgery uses three or four small incisions to access the cysts(s)
• Open surgery involves an incision under the bottom of your rib cage and is normally reserved for patients in whom keyhole surgery is not felt to be appropriate
• Keyhole surgery has the benefit of a quicker return to full activity after the procedure
• Further cysts can develop later and you may be offered ultrasound monitoring to check this

What does the procedure involve?

Surgical removal of one or more kidney cysts by keyhole surgery; this is only indicated after earlier cyst aspiration has confirmed that the cyst is responsible for pain.

What are the alternatives to this procedure?

Percutaneous aspiration, aspiration and sclerotherapy, open de-roofing, observation.

You will usually be admitted on the same day as your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, 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 which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

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 urologist 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 prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. Using a keyhole approach and several entry ports, the surgeon will expose the cyst(s) and remove the roof of the cyst (pictured below); the walls of the cyst are sometimes stitched together to prevent recurrence.

A bladder catheter is normally inserted during the operation to monitor urine output.

What happens immediately after the procedure?

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. After your operation, you may be given an injection under the skin of a drug (dalteparin) that, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins. The catheter is normally removed after 24 hours.

The usual hospital stay is one or two 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.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

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

Occasional (between one in 10 and one in 50)

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

Rare (less than one in 50)

• Bleeding requiring conversion to open surgery or requiring blood transfusion
• Entry into lung cavity requiring insertion of a temporary drain
• 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)
• Further development of cysts which cause similar symptoms

Hospital-acquired infection (overall risk for Addenbrooke’s)

• Colonisation with MRSA (0.02%, 1 in 5,000)
• Clostridium difficile bowel infection (0.04%; 1 in 2,500)
• MRSA bloodstream infection (0.01%; 1 in 10,000)

(These rates 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?

Before you leave hospital, the team will ensure you are safe to be discharged home. When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, 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 to 14 days to recover fully from the procedure and most people can return to normal activities after two to four weeks.

What else should I look out for?

If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, increasing abdominal pain or dizziness, please contact your GP or the urology ward (Ward M5, 01223 254850). Any other post-operative problems should also be reported to your GP, especially if they involve chest symptoms.

Are there any other important points?

A follow-up outpatient appointment will normally be arranged for you 6 to 12 weeks after the operation. At this time, we will be able to inform you of the results of any biopsies taken from the kidney.

If biopsies are taken from the cysts, it will be at least 14 to 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 multidisciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion.

This operation on a simple cyst of the kidney only deals with the individual cyst which has been troubling you. It is possible that, at a later date, further cysts will develop although it is unlikely that they will cause symptoms. A further ultrasound scan may be arranged from the outpatient department to determine whether any new cysts have developed.

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 three 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.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is require.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. 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 leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….