Radical removal of the kidney and ureter

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 open nephroureterectomy is to remove a tumour-bearing kidney and its ureter through an incision in your loin (occasionally extended into your abdomen or chest)
• Sometimes, an additional incision is needed to remove the lower part of the ureter
• Recovery can take up to three months, and may take longer in some patients
• You will require regular, long-term follow-up with scans and bladder examinations to be sure the tumour has not recurred elsewhere in your urinary tract

What does the procedure involve?

This involves removal of the kidney (and surrounding fat) for suspected cancer of the kidney and/or the ureter. The whole ureter is removed either using a telescope or with a separate incision in the lower abdomen.

What are the alternatives to this procedure?

• Observation alone – leaving the tumour in your kidney and observing it carefully for any signs of enlargement
• Laparoscopic (keyhole) nephroureterectomy – removing the whole kidney and ureter through several, small abdominal incisions using telescopic (keyhole) instruments and techniques
• Endoscopic control of the tumour – usually using flexible instruments passed up from your bladder and laser treatment to the tumour
• Palliative treatment – using radiotherapy or chemotherapy to control symptoms such as bleeding, if surgery is not appropriate or is deemed too hazardous

What should I expect before the procedure?

You will usually be admitted the day of 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?

A full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post operatively.

You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

The kidney is usually removed through an incision in your loin although, on occasions, the incision is made in the front of the abdomen or extended into the chest area. You may require a second incision in the lower part of the abdomen to detach the ureter form the bladder; sometimes, this detachment can be performed using a telescope passed into the water pipe (urethra).

A bladder catheter is inserted at the time of the operation to monitor urine output, and a drainage tube is usually placed through the skin into the bed of the kidney.

Occasionally, we may need to put a tube into your stomach, through your nose, to prevent bloating with gas.

What happens immediately after the procedure?

After the operation, you may remain in the special recovery area of the operating theatres before returning to the ward; visiting times in these areas are flexible and will depend on when you return from the operating theatre. You will normally have a drip in your arm and, occasionally, a further drip into a larger vein in your neck.

We will encourage you to get up and about as soon as possible. This reduces the risk of blood clots in your legs and helps your bowel to start working again. You will sit out in a chair shortly after the procedure and be shown deep breathing/leg exercises. We will encourage you to start drinking and eating as soon as possible. The usual hospital stay is five to seven days. The wound drain will need to remain in place for 48 hours in case urine leaks from the bladder. The catheter will need to remain in place for up to 10 days after surgery to keep your bladder empty and give it a chance to heal. You will go home with the catheter in place and will be taught how to take care of it by the nurses before you go home. Arrangements will be made to remove your catheter in the urology clinic, usually after an X-ray (cystogram) to ensure the bladder is fully healed. Just before the catheter is taken out, an anti-cancer drug (Mitomycin C) is instilled into your bladder and left for 1 hour before it is drained and the catheter removed.

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)

☐ Bulging of the wound due to damage to the nerves serving the abdominal wall muscles (if a loin approach has been used); this may resolve

☐ Risk of tumour recurrence elsewhere in your urinary tract requiring repeated telescopic examinations of the bladder

Occasional (between one in 10 and one in 50)

☐ Bleeding requiring further surgery or transfusions

☐ Entry into the lung cavity requiring insertion of a temporary drainage tube

☐ Need for additional treatment for cancer after surgery

☐ Infection, pain or bulging of the incision site requiring further treatment

Rare (less than one in 50)

☐ Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)

☐ Involvement or injury to nearby local structures (blood vessels, spleen liver, lung, pancreas and bowel) requiring more extensive surgery

☐ The histological abnormality in the kidney may subsequently be shown not to be cancer

☐ Persistent urine leakage from the bladder requiring prolonged catheterisation or further surgery

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?

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.

It will be at least 14 days before healing of the wound occurs but it may take up to six weeks before you feel fully recovered from the surgery. You may return to work when you are comfortable enough and your GP is satisfied with your progress.

It is advisable that you continue to wear your elasticated stockings for 14 days after you are discharged from hospital.

Many patients have persistent twinges of discomfort in the loin wound which can go on for several months. It is usual for there to be “bulging” in the wound when a loin incision has been used; this is due to the nerves supplying the abdominal muscles being weakened and is not a hernia but it can be helped by strengthening up the muscles of the abdominal wall by exercises. You will have a catheter present when you go home.

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.

After surgery through the loin, the wall of the abdomen around the scar will bulge due to nerve damage. This is not a hernia but can be helped by strengthening up the muscles of the abdominal wall by exercises.

Are there any other important points?

It will be at least 14 to 21 days before the pathology results on your kidney 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.

An out-patient appointment will be made for you around four weeks after the operation when we will be able to inform you of the pathology results and give you a plan for follow-up. If any further treatment is needed this will be discussed with you by your consultant or specialist nurse. You will usually need to undergo regular bladder inspections to check that the growth that involved your kidney is not affecting the bladder lining.

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 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 Addenbrooke’s Hospital?

Yes. As part of your operation, various specimens of tissue will be sent to the Pathology department so that we can find out details of the disease and whether it has affected other areas. This information sheet has already described to you what tissue will be removed.

We would also like your agreement to carry out research on that tissue which will be left over when the pathologist has finished making a full diagnosis. Normally, this tissue is disposed of or simply stored. What we would like to do is to store samples of the tissue, both frozen and after it has been processed. Please note that we are not asking you to provide any tissue apart from that which would normally be removed during the operation.

We are carrying out a series of research projects which involve studying the genes and proteins produced by normal and diseased tissues. The reason for doing this is to try to discover differences between diseased and normal tissue to help develop new tests or treatments that might benefit future generations. This research is being carried out here in Cambridge but we sometimes work with other universities or with industry to move our research forwards more quickly than it would if we did everything here.

The consent form you will sign from the hospital allows you to indicate whether you are prepared to provide this tissue. If you would like any further information, please ask the ward to contact your consultant.

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…………….………………….