Laparoscopic / Robotic-assisted laparoscopic pyeloplasty (Keyhole reconstruction of the pelvis of the kidney)

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 repair a narrowed area where your kidney joins your ureter (the pelviureteric junction)
• After keyhole surgery, most patients will go home after one to two nights in hospital
• We usually put in an internal stent to help the repair heal; this is taken out after four weeks
• A radio-isotope scan after 12 weeks will be done to see how well your kidney function has recovered; in most patients, there is an improvement together with relief of the pre-operative pain
• In a small number of patients, the scan may show improvement but there is still some ongoing pain
• A small number of patients may need another operation if the narrowing comes back
• Occasionally, we need to remove the affected kidney later because of damage caused by recurrent obstruction

What does the procedure involve?

This involves repair of the narrowing or scarring at the junction of the ureter with the kidney pelvis to improve the drainage of the kidney. It is performed through keyhole incisions and involves insertion of a temporary ureteric stent to aid healing with cystoscopy and X-ray screening.

What are the alternatives to this procedure?

Observation, telescopic incision (endopyelotomy), stretching (dilatation) of the narrowed area, temporary placement of a plastic tube (stent) through the narrowing, open surgery (pyeloplasty).

What is laparoscopic surgery?

Laparoscopy (otherwise known as “keyhole surgery”) is a form of minimal access surgery. This involves performing operations which are traditionally done by an “open” method but using “keyholes” instead. A number of urological procedures are now being performed by this method. It has been shown to be safe and effective for kidney surgery; for pyeloplasty it is now the method of choice.

With robotic surgery, the laparoscopic instruments are placed onto the arms of a surgical robot through the “keyholes”. The operating surgeon sits in the same room but away from the patient and is able to carry out more controlled and precise movements using robotic assistance. Your urologist will discuss the details of the procedure with you whilst you are an outpatient, outlining the procedure as part of your consent. You should be aware that there is a small chance (less than 1%) that your procedure may need to be converted to an open procedure. For this reason, if you are insistent that you would not agree to an open operation under any circumstances, we would not be able to proceed with the laparoscopic operation.

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. If not done on the same day as your urology clinic appointment, 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.

One important thing that you must do is to prepare yourself to mobilise immediately after the operation. You should try to walk at least 10 lengths of the ward before your operation.

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?

A full general anaesthetic will be used and you will be asleep throughout the procedure.

You will be transferred to the operating theatre on your bed and you will be taken first to the anaesthetic room. They may put a drip in to your arm to allow them to access your circulation during the operation. You will be anaesthetised and taken into the operating theatre. During the surgery you will be given antibiotics by injection; if you have any allergies, be sure to let the anaesthetist know.

After exposing the kidney through “keyhole” incisions, the surgeon will divide or remove the blockage at the junction between kidney and ureter. The kidney will then be joined to the ureter again so that drainage can occur (pictured). Occasionally, a flap of tissue from the kidney may be folded down to widen the narrowing.

A ureteric stent is normally inserted to allow healing of the suture line in the pelvis of the kidney. A bladder catheter is also inserted during the operation to monitor urine output and a drainage tube is placed through the skin near the newly formed join (anastomosis).

What happens immediately after the procedure?

It is fine, and in fact you will be encouraged, to eat and drink as soon as you feel able to after surgery. You will be encouraged to mobilise as soon as possible after surgery. This helps to prevent blood clots forming in your legs, chest infection from developing, and also decreases any disturbance to your bowel function.

The catheter is normally removed the morning after surgery and the wound drain later the same day or the following day.

The usual hospital stay is one or two days. Some patients are able to go home earlier.

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
• A further procedure to remove the stent in your ureter, usually under local anaesthetic

Occasional (between one in 10 and one in 50)

• Bleeding, infection, pain or hernia of the incision requiring further treatment
• Recurrent narrowing or scarring requiring further surgery

Rare (less than one in 50)

• Bleeding requiring conversion to open surgery or requiring blood transfusion
• 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
• Need to remove the kidney at a later stage because of damage caused by recurrent obstruction
• Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)
• Prolonged urine leak from the kidney requiring longer catheter time and/or drainage of the kidney by a small tube through the side

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

• Colonisation with MRSA (0.01%, two in 15,500)
• Clostridium difficile bowel infection (0.02%; three in 15,500)
• MRSA bloodstream infection (0.00%; 0 in 15,000)

(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.

If a ureteric stent has been inserted, it may cause pain in your kidney area, especially when you pass urine, or pain in your bladder. You may notice that you pass urine more frequently than usual.

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?

The ureteric stent will normally be removed in the day surgery unit under local anaesthetic after four to six weeks.

To assess the effectiveness of the operation, a nuclear medicine scan will normally be arranged for you 12 weeks after the surgery and a follow-up appointment will be arranged for you thereafter to discuss the results.

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)

Is there any research being carried out in this field at CUH?

All laparoscopic procedures are subject to continuous audit by the British Association of Urological Surgeons Section of Endourology. In addition, the National Institute of Health and Clinical Excellence (NICE) requires that we maintain a careful review of laparoscopic procedures.

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 216897 or bleep 154-548

Surgical care practitioner
01223 348590 or 256157 or bleep 154-351

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608 or 586748 or bleep 157-237

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
01223 349800 or bleep 152-879

Patient Advice and Liaison Centre (PALS)
Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS
Mail: PALS, Box No 53
Cambridge University Hospitals NHS Foundation Trust
Hills Road, Cambridge, CB2 0QQ

Chaplaincy and multi faith community
Telephone: 01223 217769
Email the chaplaincy
Mail: The Chaplaincy, Box No 105
Cambridge University Hospitals NHS Foundation Trust
Hills Road, Cambridge, CB2 0QQ

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…………….………………….