Laparotomy to remove a large retroperitoneal mass

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 Addenbrookes. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

Key points

• The aim of the procedure is complete removal of a mass situated at the back of your abdominal cavity
• These masses are usually malignant sarcomas and can become very large, presenting a technical challenge for the surgeon
• The procedure involves complex, major, abdominal surgery and may require removal of any structure attached to the mass (e.g. bowel or kidney)
• When the pathology tests on the mass have been reviewed, some patients are found not to have cancer whilst others require further treatment for their cancer

What does the procedure involve?

This operation involves an abdominal incision to remove a large retroperitoneal mass situated at the very back of your abdomen. In order to remove the mass completely, we may also need to remove other organs such as a kidney, portions of the large or small bowel and blood vessels. The surgeon will discuss this aspect with you.

What are the alternatives to this procedure?

Many of these large masses eventually turn out to be sarcomas. Most sarcomas are not very sensitive to radiotherapy of chemotherapy and are, therefore, best removed surgically. Surgery, therefore, is usually the only effective treatment for these tumours.

Often, these masses become very large before a patient presents to his/her doctor and, as a result, the operation can require a very long incision and a significant amount of surgery inside the abdomen.

This leaflet has been developed at Addenbrooke’s; it is based on joint working with the specialist medical and surgical oncologists who treat people with retroperitoneal tumours, including sarcomas.

What should I expect before the procedure?

If you are taking a prescription for Warfarin, Aspirin, Rivaroxaban, Dabigatran, Apixaban, Edoxaban or Clopidogrel , Ticagrelor or blood thinning medication you should ensure that the Urology staff are aware of this well in advance of your admission.

You will normally undergo a 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 for six hours but may drink clear fluids up to two hours before surgery. 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, Rivaroxaban, Dabigatran, Apixaban or Clopidogrel (Plavix®)
• 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?

Normally 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 after the operation. You will usually be given injectable antibiotics before the procedure to prevent infection, after checking for any allergies.

The mass will be removed through an incision in the abdomen. This is normally a long incision in the midline although, on occasions, a sideways extension is required towards the side of the mass. A bladder catheter is normally inserted to monitor urine output and a drainage tube placed through the skin into the area from which the mass has been removed.

Occasionally, it may be necessary to insert a stomach tube through your nose to prevent distension (bloating) of your stomach and bowel with air.

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 large vein in your neck.

You will be able to drink clear fluids immediately after your operation and start a light diet within three to four days. We will encourage you to mobilise as early as possible and to take fluids as soon as you are able.

The average length of stay is seven days.

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 insertion of a bladder catheter and wound drain

Occasional (between one in 10 and one in 50)

• Bleeding requiring further surgery or blood transfusion
• Infection, pain or bulging of the incision site requiring further treatment
• Accumulation of lymph fluid requiring needle drainage or further surgery
• Temporary problems with delayed bowel function requiring prolonged nasogastric (stomach) tube insertion
• Need for further treatment of the cancer
• Pathology of the mass may show that it is not cancer

The need to remove other organs (kidney, small bowel, large bowel or blood vessels) as part of the procedure – the likelihood of this will have been discussed with you by the surgeon in advance of the operation

Problems with weak or absent ejaculation after surgery (depending upon the site of the mass)

Rare (less than one in 50)

• Anaesthetic or cardiovascular problems possible 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)

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 six weeks before full healing of the wound occurs and it may take up to two months 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 can take several months for the strength of the wound to return to normal and you should avoid heavy lifting for up to six months.

Many patients have persistent twinges of discomfort in the wound which can go on for several weeks.

What else should I look out for?

You should watch out for signs of inflammation of the wound or swelling of the abdomen which might indicate fluid collection.

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 point?

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

Once the results have been discussed, it may be necessary for further treatment but this will be discussed with you by your consultant or specialist nurse.

If removal of the kidney is required, there is no need for any dietary or fluid restrictions since your remaining kidney can handle fluids and waste products without any difficulty.

If a sideways extension of the wound has been required, the wall of the abdomen around the scar may bulge due to some nerve damage. This is not a hernia but can be helped by strengthening the muscles of the abdominal wall using special exercises.

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 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 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?

Sarcoma nurse practitioner
01223 257167

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…………….………………….