Nephrectomy. A Guide for Patients and Family. Department of Urology, NHS Forth Valley

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1 Nephrectomy A Guide for Patients and Family Department of Urology, NHS Forth Valley

2 This leaflet has been produced to give you general information about the nephrectomy procedure. The leaflet should answer most of your questions. It is not meant to replace the discussion between you and your doctor, but may act as a starting point for your discussion. If after reading it you have any concerns or require further explanation please discuss this with a member of the health care team who has been caring for you. What is a Nephrectomy? A nephrectomy or partial nephrectomy is an operation in which the kidney or part of the kidney is removed. The aim of the operation in cases of suspected cancer is to remove the cancer and to prevent progression of the disease and its spread to other organs. Occasionally this surgery is offered when the disease has already spread to other organs in order to slow the disease down. This is done open (a cut in the abdomen) for large kidneys or where part of the kidney only is being removed, or through keyhole (laparoscopic) surgery if the kidney is small enough. Surgery can also precisely stage the cancer and control bothersome symptoms associated with the tumour. Why is a nephrectomy necessary? A nephrectomy is being recommended as treatment for your suspected kidney cancer. Before recommending surgery your case will have been discussed at a multi-disciplinary team meeting (MDT). This team is made up of a group of doctors and nurses who specialise in Urological cancers. A consensus will have been reached as to the best options for you. Your specialist will then explain in detail what these treatment options are. The final decision will be arrived once you have had a chance to discuss these options and ask any questions you may have. What Are The Alternatives? The only proven cure for kidney cancer is the removal of the tumour through surgery. The most appropriate means of removing that tumour will be recommended to you by your surgeon however a lot will depend on the size of tumour we are trying to treat. Other forms of treatment are still experimental such as superheating tumors (Radio Frequency Ablation) or freezing tumors (Cryotherapy) and are largely reserved for patients who could not tolerate curative surgery or have complicated kidney disease. Radiotherapy and chemotherapy do not cure kidney cancers and have therefore not been recommended to you. In certain circumstances where the diagnosis is in doubt or if there are significant medical reasons to avoid surgery it is possible to observe tumors through repeated scans. This is generally only regarded as safe for smaller tumors where the risk of spread is thought to be less.

3 Why have I (had/ not had) a biopsy before surgery? Biopsies of kidney tumors are reserved for specific cases. In larger tumour 95% of these are cancerous. In smaller tumors the risk of cancer remains high and biopsy can misdiagnose tumors that eventually turn out to be cancerous. If biopsy has been recommended to you it may be because there are higher risks of surgery. What exactly is done at the operation? Open Nephrectomy The kidney with the fat that surrounds it as well as part of the tubing that drains the kidney (the ureter) is removed through an abdominal wound. Occasionally the adrenal gland is also removed which sits on top of the kidney. Laparoscopic Nephrectomy The same tissues are removed as in an open nephrectomy however instead of one large wound you will have several much smaller cuts in your abdomen. This is done by filling your abdomen with gas and through keyhole instruments detaching the kidney and removing the kidney through a cut in the lower part of your abdomen. Open Partial Nephrectomy This is done through a similar cut in the abdomen to the open nephrectomy. The cancerous part of the kidney is removed and the kidney repaired. This type of surgery can only be done on smaller tumours. What are the Risks? These are risks common to all types of major surgery. For this reason you will have an extensive assessment to determine if there is anything that can be done prior to the operation to improve your fitness for surgery. You should be reassured that although these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure. It is important to realize that nephrectomy has been recommended to you because of a high risk of cancer affecting your kidney. It is possible in a small number of cases that the tumour removed is a benign lump. The risks include: Bleeding that may require a blood transfusion. Pain. You will be given regular pain relief although it is important to tell staff if you are experiencing any pain that is not controlled, as this may slow your recovery.

4 Chest Infection. You may be treated by a physiotherapist who will teach you deep breathing exercises to reduce the risk of this occurring. All patients will receive a spirometer which they will be shown how to use and which will help you with your breathing exercises. Deep Vein Thrombosis - DVT (a blood clot forming in one of the veins in your leg). You will be given a pair of surgical stockings to wear to help blood circulation in the legs and an injection to thin the blood slightly to prevent clots from forming. You will be encouraged to get up and about as soon as possible and may be taught a range of leg exercises to help maintain your range of movement. Wound Infection & poor wound healing. Despite all aseptic precautions as well as the use of antibiotics at the time of your surgery you may develop an infection at the surgical wound site. This risk is significantly higher in patients who are diabetic, overweight or have been unwell before their operation. Bowel upset. Your bowel will not function normally for a number of days after your operation. Bloating of the abdomen and vomiting may occur in the initial stages and your bowel habit may be erratic in the first few weeks. Damage to other organs. In certain situations due to how the tumour has affected the space within your abdomen it is possible to damage other organs being pressed upon by the kidney. These organs include the liver, spleen, pancreas, bowel and intestine. Every effort will be made to remove the kidney safely but may require repair of any other organs affected by the removal of the kidney. In rare cases it may be felt that it is not possible to safely remove the kidney at the time of operation. Other risks include; Need for further surgery; the main risk in all kidney surgery is related to bleeding. Despite the fact that all efforts are made to ensure that all bleeding has stopped at the end of an operation it is possible for bleeding to recur and require a second operation. This risk is slightly higher in patients who have a partial nephrectomy. There is an increased risk of death (approx 1 in 100) in the month or so following the operation. Specific risk related to type of nephrectomy; Laparoscopic Nephrectomy; in some cases it is not possible to safely remove the kidney through keyhole surgery. In these circumstances a larger cut will be made and the kidney removed in the standard open manner. Laparoscopic nephrectomy runs a slightly higher risk of injuring the bowel than open surgery.

5 Partial Nephrectomy; In some cases it proves not possible to remove only the tumour either because the tumour is more extensive than anticipated or it is not safe to do so because of the risk of bleeding. In these cases the entire kidney will be removed. Because there is a kidney repair there is a higher risk of bleeding from the kidney both into the abdomen and into the urine which may require further surgery. It is also possible for urine to leak out of the kidney into the abdomen. Preparing for the Operation You will be given an appointment to attend the pre-operative assessment clinic. Here you will have a number of investigations including blood tests and an ECG (heart tracing). At this assessment you will be asked to make arrangements regarding your transport to and from hospital. It would be a good opportunity to think about and discuss any issues you may have at home, for example, who will do your shopping or heavy housework when you are discharged home? You will be advised about any changes you need to make to your medication. Please inform the nurse if you take Warfarin, Aspirin or any medication to thin your blood. Your specialist will consent you for your operation and answer any final questions you may have. If you have any additional questions before that date either the nurse specialist or consultant will be happy to speak to you. For patients undergoing this type of surgery, there are two main aims: To improve the recovery and minimise stay in hospital To achieve the optimum recovery following surgery, patients are encouraged to work together, in partnership with the Urology team. Other important elements to recovery are: 1. Pre-operative assessment and planning. 2. Good care planning and pain relief post-operatively. 3. Early mobilisation (getting patients out of bed and moving around) 4. Early return to eating and drinking.

6 Preparing for Surgery The day before surgery you will be able to eat and drink as normal, you will also be given high carbohydrate drinks. These are an essential part of your care and help boost your energy prior to surgery. You will be given instructions on how and when to take these. Once you are in hospital, you will be given a blood thinning injection, to help reduce your risk of blood clots. What Happens To Me When I Arrive At The Ward? You will be admitted on the day of surgery. We will ask that you administer an enema on the evening prior to your admission. This will help clear you bowels in preparation for the operation. On the Day of the Procedure You will be admitted on the day of surgery. A nurse will check you in, detail your normal medications and supply you with special stockings to prevent leg clots. Before going to the operating theatre, you will be asked to change into a theatre gown. Any make-up, nail varnish, jewellery (except your wedding ring), and contact lenses must be removed. You will be seen by an anaesthetist who will discuss your anaesthetic as well as make recommendations about how to manage any pain after the procedure. You will be consented by your surgeon and after a number of checks have a mark drawn on your abdomen to confirm the side of operation. You will have nothing to eat or drink for about 2hrs before your operation but will be advised in more detail when you attend for your pre-op assessment. Your operation will take about 4-5 hours and is performed under general anaesthetic (you are completely asleep during all of this time). What Happens After The Procedure? A bed will be booked for you either in ward B31 or the High Dependency Unit (HDU) or intensive care unit (ICU) where your condition can be monitored closely. This is often necessary after major surgery, as you will have spent a long time under anaesthetic. You will spend 24 to 72 hours before returning to the ward. To reduce pain after the operation you will be given regular painkillers. The anaesthetist will have discussed this with you and will have decided on either: A pain killer device that you control releases painkillers into your blood stream through a drip. This is called Patient Controlled Analgesia (PCA). An epidural - pain killers and local anaesthetic are given directly into the spinal nerve system. This involves inserting a very fine tube into your back at the time of you operation through which these drugs are given.

7 After a few days your need for these drugs will have reduced greatly and you will then be given pain killing tablets or injections. You will have a drip running into a vein in your arm or neck. This is to give you fluids until you are able to drink normally. The passage of wind via the rectum is the sign that things are returning to normal. Most people will be allowed to eat and drink immediately after surgery. You will have a dressing over the wound on your abdomen. There may be a drain placed to the side of the wound to collect any blood or fluid remaining after the operation. This will be removed about 1 to 2 days after your surgery. You will also have a catheter in your bladder which will be removed when you are able to move around more freely. After your operation you will be seen by the physiotherapists and you will be expected to commence deep breathing and leg exercises, it is important for you to follow their instructions to reduce your risk of chest infection and blood clots. You will be given a spirometer to help expand your lungs and the nursing staff will show you how to use this. Mobility: You will be encouraged to mobilize on the day of your operation. Preparation for Home. When you are eating and drinking and the various drain tubes have been removed you will be ready for home. It is important that you continue to wear the special stockings supplied to you for at least 2 weeks after your operation even if you are at home. You will be asked at Pre-op admission if you have any concerns about how you might manage when you are discharged home. We can arrange for assessment by Physio and Occupational Therapist to assess your needs. The ward nurses will arrange for the district nurse to visit you at home during your initial recovery period. Discharge Arrangements It is necessary to arrange for a responsible adult to collect you from hospital and transport you home. A letter will be sent to your GP explaining what has happened during your stay in hospital and you will be given a supply of any new medication which may have been started whilst you were in hospital. A sick note may be obtained to cover your stay in hospital. Further sick notes can be obtained from your GP. You will be telephoned at home after 24 hours by a nurse to ensure there are no problems. You will be notified of any necessary further follow-up, including an outpatient clinic appointment to discuss your histology results and any further treatment

8 required, before going home and any necessary appointments will be sent to you via a letter to your home address. Longer term we will also want to regularly review your condition over the next months and years. Day To Day Living Recovery time after abdominal surgery varies but generally you should feel improvements after about 6 to 12 weeks. During the first 6 weeks after your operation you should bear the following in mind. Patients who have undergone laparoscopic keyhole surgery should notice improvement earlier than this. You should NOT drive a car. After the 6 weeks you should consider if you would feel comfortable to do an emergency stop without difficulty or pain. You also need to contact your insurance company to check that you are covered to start driving again. You should NOT attempt to lift or move heavy objects or perform heavy household work. You should ask your surgeon when you can return to work. This may vary depending on the type of job you do. You can obtain a sick note for the time you are expected to be off work before leaving the ward. You can have a bath or shower as soon as the drains are removed. You should not use perfumed soaps or talcum powder until your wound is well healed. If there is a Problem? If you experience any problems following the procedure, please contact your GP or Ward B31 for advice. Ward B31, Forth Valley Royal Hospital (Direct Dial) Urology Specialist Nurses: (Available Monday-Friday 9-4pm) NHS 24: Other Information and Support MacMillan Money Matters: Stirling Alloa Falkirk Macmillan Cancer Support (provides specialist advice through Macmillan nurses and doctors and financial grants for people with cancer and their families) 89 Albert Embankment, London, SE1 7 UQ

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