Open de-roofing of simple renal cyst (Røvsing’s operation)

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.

What does the procedure involve?

Surgical removal of one or more kidney cysts by open surgery; this is normally only indicated after earlier cyst aspiration has confirmed that the cyst is responsible for pain.

What are the alternatives to this procedure?

Percutaneous aspiration, aspiration and sclerotherapy, laparoscopic de-roofing, observation.

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. A pre-admission appointment will normally be sent to you 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.

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?

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 post-operatively.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The incision is usually made in your loin, just below the rib cage. The kidney is mobilised and the cyst identified. The top of the cyst is removed (like taking the top off a soft-boiled egg); the inner and outer walls are stitched together to prevent the cyst from re-forming.

Occasionally, a plug of fat from the fatty envelope within your abdomen (the omentum) is used to plug the centre of the cyst and prevent fluid from reforming.

A wound drain is usually inserted at the end of the procedure, together with a bladder catheter to monitor urine output.

What happens immediately after the procedure?

You will be given fluids to drink from an early stage after the operation and you will be encouraged to mobilise as soon as you are comfortable. After your operation, you may be given an injection under the skin of a drug (dalteparin) that, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins. The catheter is normally removed once you are mobile enough to get yourself to the toilet.

The usual hospital stay is two or three 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
• Bulging of the wound due to damage to the nerves serving the abdominal wall muscles

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
• Development of further cysts requiring additional surgery at a later date
• Failure to relieve the symptoms of loin pain

Rare (less than one in 50)

• Involvement or injury to nearby local structures – blood vessels, spleen, liver, lung, pancreas and bowel, requiring more extensive surgery
• Infection, pain or hernia of the incision requiring further treatment
• Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)

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.

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

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.

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.

Are there any other important points?

A follow-up outpatient appointment will normally be arranged for you six to 12 weeks after the operation.

At a later stage, a further ultrasound scan may be arranged to determine whether any new cysts have developed.

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 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 should 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…………….………………….