Laparoscopic simple removal 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 laparoscopic nephrectomy is to remove your kidney using a telescopic (keyhole) technique through several small incisions in your abdomen
• One of the keyhole incisions will need to be enlarged to remove the kidney
• The procedure is sometimes called “simple” nephrectomy because it is not performed for suspected kidney cancer
• The commonest reasons for a simple nephrectomy include kidney pain, bleeding from one kidney and a kidney which has stopped working
• In some surgical units, the procedure may be performed using robotic assistance
• Complications are fewer than with open surgery, but it may be necessary to convert the procedure to an open operation if any difficulties are encountered

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 three to four small incisions. One incision will need to be enlarged to remove the kidney.

What are the alternatives to this procedure?

Observation, open surgery.

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 the removal of a kidney it is now the method of choice.

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 5%) 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 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 surgical 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 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.

The kidney is disconnected 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 rarely, a drainage tube may be placed through the skin into the bed of the kidney.

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. 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 on the morning after surgery.

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

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)

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 eg 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 to 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 around six 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 to 21 days before the pathology results on the tissue removed are available. You and your GP will be informed of the results by letter.

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 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 required.

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 may need to remove hair to allow them to see or reach your skin. If the healthcare team consider it is important to remove the hair, they will do this by using 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 for hair removal, as this can increase the risk of infection to the site of the operation. If you have any questions, please ask the healthcare team who 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?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

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…………….………………….