Open pyeloplasty

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 Nurse Specialist.

Key Points

• The aim of this operation is to repair a narrowed area where your kidney joins your ureter (the pelvi-ureteric junction)
• We usually put in a stent to help the repair heal; this stent will be removed four to six weeks after your operation
• A radio-isotope scan after 12 weeks will be arranged to see how well your kidney function has recovered; in most patients, there is an improvement, together with relief of the pre-operative pain
• In a small number of patients, the scan may show improvement but there is still some ongoing pain
• Some patients develop discomfort and bulging in the loin after open kidney surgery; the bulging can be improved by exercises
• A small number of patients may need another operation if the narrowing comes back
• Occasionally, we need to remove the affected kidney later because of damage caused by recurrent obstruction

What does the procedure involve?

This involves repair of narrowing or scarring at the junction of the ureter with the kidney pelvis (the pelvi-ureteric junction) and insertion of a temporary stent or kidney drainage tube to aid healing.

What are the alternatives to this procedure?

• Observation – this may be an option when symptoms are minor and not felt to
• justify surgery
• Telescopic incision (endopyelotomy)– cutting open the narrowed area with an electric wire passed up from the bladder or through the skin over the kidney
• Stretching of the area of narrowing–using a balloon passed up from the bladder or through the skin over the kidney, under X-ray screening
• Temporary stenting–by placing a small plastic tube (stent) through the narrowed area
• Laparoscopic / Robotic (keyhole) surgery– reconstruction of the narrowed area using a telescope passed through your tummy wall

What should I expect before the procedure?

You will usually be admitted on the same day as 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 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 post-operatively.

The kidney is usually approached through an incision in your loin although, on occasions, the incision is made in the front of the abdomen.

After exposing the kidney through ‘keyhole’ incisions, the surgeon will divide or remove the blockage at the junction between kidney and ureter. The kidney will then be joined to the ureter again so that drainage can occur. Occasionally, a flap of tissue from the kidney may be folded down to widen the narrowing.

A bladder catheter is normally inserted post-operatively, to monitor urine output, and a drainage tube is usually placed through the skin into the bed of the kidney.

It is normal to insert a ureteric stent, to allow healing of the reconstruction. We put a drain close to the kidney to collect any fluid which forms around the surgical site.

What happens immediately after the procedure?

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 catheter is normally removed when you are mobile and the wound drain afterwards.

The expected hospital stay is three days. Some patients are able to go home earlier.

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

☐ Further procedure to remove ureteric stent, usually under a local anaesthetic

☐ 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

Rare (less than one in 50)

☐ Continuing pain, even when the post-operative scans show that your kidney drainage has improved

☐ Recurrent kidney or bladder infections

☐ Recurrent narrowing or scarring can occur needing further surgery

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

☐ Need to remove kidney at later time because of damage caused by recurrent obstruction

☐ Infection, pain or hernia of incision requiring further treatment

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 in-patient 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 your discharge from hospital.

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?

Your stent may cause pain in your kidney area when you pass urine, or pain in your bladder. If you feel unwell or feverish, you should contact your GP to check for a urine infection. If you have a stent, this will be removed four to six weeks after the procedure, usually under local anaesthetic

We normally arrange a radio-isotope kidney scan 12 weeks after surgery, to assess the drainage of your kidney.

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

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?

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?

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…………….………………….