Where technically feasible, partial nephrectomy is considered the standard of care for smaller, localised tumours. It has the same cure rate as removing the entire kidney. Tumours that are not suitable for partial nephrectomy include larger cancers or those that have started to grow into major veins or the fat surrounding the kidney.
Partial nephrectomy can be performed through open, laparoscopic or robotic approaches. During the operation the major artery to the kidney is clamped, temporarily stopping the flow of blood to the kidney. This makes it possible to cut into the kidney without significant blood loss. During robotic surgery the maximum time the artery can be clamped is about thirty minutes, after which kidney damage may occur. The benefit of the open approach is that it also allows the kidney to be cooled with ice slush, which in turn allows the artery to be clamped for longer. Complex, larger tumours that lie deep within the kidney are best treated with open partial nephrectomy and ice cooling.
Before Your Surgery
Certain medications increase the risk of bleeding and need to be stopped prior to surgery. You should tell your surgeon about all prescription medicines, over the counter medicines, vitamins, and herbal supplements that you are taking. Some patients, such as those with artificial heart valves or high blood clotting risk, will need to take blood-thinning injections whilst coming off their tablet medications.
After Your Surgery
When you wake from anaesthesia you will have a catheter draining the bladder and a drain tube in your abdomen. You will have dressings over the incisions in your abdomen, and a drip in your arm. The drain tube, drip and catheter are usually removed within one to two days.
You should expect some discomfort in the area of your incisions. Whilst in hospital you will receive regular oral and intravenous painkillers. You will continue to take tablet painkillers once you go home. While you are taking painkillers you should also take stool softeners (eg. coloxyl and senna) to prevent constipation.
You will be expected to get out of bed on the day after your surgery and start walking. This will help minimize the risk of blood clots in the legs. You should aim to go for a walk every two hours.
After a laparoscopic or robotic procedure most patients should be able to go home the following day or the day after that. Patients who have an open operation usually require two to three nights in hospital.
The dressings on your wounds can stay in place until your review appointment. If the dressings fall off and the wounds are clean and dry there is no need to replace them. Steri-Strips (adhesive tape) on your incisions can be removed after 7 days. You may shower any time once you are home, but you must not take a bath until the catheter is removed.
Continue to take painkillers as required. If you need to take strong painkillers containing codeine, remember to also take stool softeners to avoid constipation.
Resuming Normal Activities
No driving for a minimum of 2 weeks after the operation. Avoid heavy lifting, bending, stretching, or straining activities like mowing the lawn for up to 4 weeks after your surgery. You may resume walking or light exercise immediately after your procedure. Ask your surgeon when to recommence blood-thinning medications. You will probably be able to return to work 2 weeks after your surgery. Depending on your occupation, light duties may be required for the first few weeks.
Specific Risks and Side Effects
- Heavy bleeding is uncommon. Less than 10% of patients require a blood transfusion.
- Infection, including that of the chest, urine, abdomen and incisions. This is usually treated with antibiotics but may occasionally require a drainage procedure.
- Urine leak from the tumour resection site. This may require further procedures to allow drainage and healing. This is more common in larger, deeper tumours that invade into the urinary collecting system in the centre of the kidney.
- Delayed bleeding may occur up to two weeks after surgery, which may require emergency procedures including angioembolisation or surgery to remove the entire kidney. This is rare.
- Conversion to open surgery from a laparoscopic or robotic approach, due to difficulties encountered during the operation.
- Conversion to radical nephrectomy, with removal of the entire kidney, due to more extensive cancer being found, or bleeding that cannot be safely controlled by other means.
- Ileus refers to the phenomenon of delayed return of bowel function after surgery and is uncommon after partial nephrectomy.
- A hernia is a defect in the abdominal wall that can occur at a surgical incision site. Some hernias require surgical repair due to the risk of bowel becoming entrapped within them.
- The kidneys are located adjacent to the lungs. There is a risk of breathing difficulties after surgery due to a chest infection or rarely a collapsed lung (pneumothorax). A pneumothorax may require treatment with insertion of a chest drain tube.
- Normally patients experience some discomfort for a few weeks after surgery. Sometimes the pain is more severe and prolonged due to entrapment or scarring surrounding nerves within the wound. This rarely requires further procedures to improve symptoms.
- Damage to other organs may occur, including:
- Spleen: Very rarely injured during left-sided surgery. If injury occurs, in 5% of cases the spleen may need to be removed. Patients who have had their spleen removed require vaccinations and possibly long-term antibiotics.
- Intestine: Damage is uncommon and is usually identified and repaired at the time of surgery with no long-term consequences
- Pancreas: Rarely injured in a left-sided operation
- Liver: Rarely injured in a right-sided operation
- Anaesthetic complications, such as heart attack or stroke.
- Infection, for example of the urinary tract, chest, or other sites.
- Clots forming in the legs (DVT), which may then pass to the lungs.
- Allergic reactions to drugs, antiseptics, or wound dressings.
- The risk of death relates to the patient’s general health and the complexity of the surgery, and may arise due to either anaesthetic or surgical complications.
When to contact your surgeon
- If you experience fevers, sweats, shakes, nausea or vomiting after you go home, or if you feel generally unwell.
- If you have pain that is not relieved by regular pain killers.
- If you notice any increase in redness or swelling around your wounds.
- If you are unable to open your bowels.
- If you are unable to pass urine.