Radical or total nephrectomy is the surgical removal of the kidney, the fat surrounding the kidney and the adrenal gland, which sits atop the kidney. A nephroureterectomy is a more involved procedure, which includes a radical nephrectomy plus removal of the entire ureter together with a cuff of bladder. This latter procedure is performed for a specific type of kidney cancer, a transitional cell carcinoma. In this type of cancer, the abnormal cells may also be present in the ureter, necessitating its removal.
Radical nephrectomy and nephroureterectomy may be performed through an incision in the abdomen, or flank (side if the abdomen). Alternatively, it may be performed through laparoscopic or “keyhole” surgery. The possible advantage of this latter approach is less immediate postoperative pain and earlier return to work. The decision regarding which surgical approach is best for you depends on many factors, including the size of the tumour, its position in the kidney and whether there is evidence of extension of the cancer into nearby vital structures (e.g. large veins). Great care and consideration is taken in deciding the best and safest approach for you. This will be discussed in detail before your operation.
A total nephrectomy is only recommended if a tumour is so large or in such a position that the entire kidney must be removed in order to deal with the tumour. In many cases, smaller tumours can be removed without sacrificing the entire kidney. These issues will be discussed with you before your surgery.
Please refer to the detailed information provided by the rooms. This information is also available from this website. Because of the involved nature of these procedures, we may arrange a full cardiac review before you undergo the operation. In addition, any blood thinners such as Aspirin, Warfarin or Plavix must be stopped 5-7 days before the operation.
Often today, removal of the kidney and/or adrenal gland is done with laparoscopic surgery. Laparoscopic surgery is a technique of putting a camera and surgical instruments into the body through small holes and performing the operation on a television screen. Hand-assisted laparoscopy is similar except that one hand is placed in the body through a tight fitting hole. We will have discussed the advantage and disadvantages of laparoscopic surgery versus open surgery with you.
For open surgery, your position on the table will depend on the approach decided upon before the operation. The incision may be in the flank (or side, just above the lowermost rib) or in the front of the abdomen, just below the rib cage. For a nephroureterectomy a second incision is performed above the pubic bones. This is required in order to remove the lowest portion of the ureter and a small cuff of bladder tissue.
After the procedure, regardless of whether it has been performed with keyhole surgery or open surgery, your urine will be coming out through a catheter and emptying into a bag. The urine may be crystal clear or appear slightly bloody for a few days. Both are normal findings. You may have drainage tubes attached to bags to empty the excess fluid accumulation in the body from the operation.
A typical hospital stay for these operations is usually about a week depending on your particular health status and your post-operative hospital course. With keyhole surgery, the hospital stay may be less than this. It is important to get out of bed either the first or second morning and spend time in the chair. With assistance from a nurse or family member, you may walk on the first day. Drains or catheters will be gradually removed. You will be discharged with instructions for follow-up in our office.
When you are seen in the office, the results of the pathology evaluation of the kidney will be discussed. We will then have a better idea of the prognosis and any further treatment that may be required.
Expectations of Outcome
It is normal to feel a bit tired or weak for several weeks. We recommend that you plan for a period of 3-6 weeks off work. For those with jobs that involve strenuous activity, more time may be needed.
Possible Complications of the Procedure
Most patients recover very well after a nephrectomy, with no significant problems regardless of how the operation is performed. Aside from anaesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Blood Loss / Transfusion
There is always some blood loss expected. In some instances, blood loss necessitates a transfusion. This is more common with very large tumours, tumours that are close to the large vessels in your abdomen, or with operations done for inflammatory or infectious kidneys where adhesions (scarring) are present.
- Wound Infection
As with any incision, an infection can occur. This would present with unusual redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics and local wound care.
- Wound Bulge
If a radical nephrectomy is performed through an incision in the side, muscles must be divided in order to gain access to the kidney. Whilst these muscles are sutured closed, they may never be quite as strong as before, resulting in a bulge effect. This may vary from a very subtle prominence to a significant bulge. This problem tends to be more common in elderly and overweight patients.
- Ileus or Bowel Obstruction
Because we operate near the intestines, they can go into prolonged spasm (ileus), or they may become blocked (obstruction). Treatment ranges from observation to less commonly, surgery.
- Deep Vein Thrombosis (DVT) / Pulmonary Embolus (PE)
In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should return to the hospital. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
- Injury to nearby structures
The kidneys lie in close proximity to many important structures including the bowels, the liver (in the case of the right kidney) or the spleen (in the case of the left kidney). In very rare cases, especially when a kidney tumour is large, these structures may be injured during a nephrectomy. In some cases, we can predict if there is likely to be a problem with a nearby structure before the procedure, so that plans can be made for this eventuality
- Chronic Pain
While unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
The incidence of death during or shortly after the operation is less than 1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung) event.
Please contact the office within 3 days of discharge. You should make an appointment to see Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital. Do not hesitate to call at any time if you have any concerns.