Partial removal of the kidney

General information

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 open partial nephrectomy is to remove the part of your kidney containing a suspected cancerous tumour through an incision in your loin.
• If successful, it allows better preservation of kidney function than complete removal of your kidney.
• If partial removal is not considered feasible, or is felt to be unsafe, we may decide to perform complete removal of your kidney.
• Bleeding, incomplete tumour clearance and urine leakage from the cut edge of the kidney are the major side effects.

About the procedure

What does the procedure involve?

This involves removal of part of the kidney with surrounding fat with or without the adrenal gland or suspected cancer of the kidney, using an incision either in the side or 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.
• Open radical nephrectomy – removing the whole kidney and its surrounding tissues through an abdominal or loin incision.
• Laparoscopic partial nephrectomy – removing only the part of the kidney containing the tumour, using a telescopic (keyhole) technique and robotic assistance.
• Laparoscopic radical nephrectomy – removing the whole kidney, using a telescopic (keyhole) technique; this can be performed using robotic assistance.
• Cryoablation – freezing the tumour with cooled metal probes using CT (computed tomography) guidance, telescopic (keyhole) techniques or direct puncture through your skin.
• Radiofrequency ablation – using an electric current to 'heat up' the tumour under x-ray control without damaging the surrounding kidney.

What should I expect before the procedure?

You will usually be admitted on 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 surgical 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?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure.

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

The kidney is usually accessed 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. A bladder catheter is normally inserted post-operatively to monitor urine output, and a drainage tube is usually placed through the skin to sit beside the cut kidney surface. Occasionally, a small tube (or stent) is placed internally from the collecting system of the kidney to the bladder to help with healing. If placed, this will need to be removed by a second procedure, usually performed telescopically via the bladder under local anaesthetic, a few weeks after surgery.

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

What happens immediately after the procedure?

You will be given fluids to drink from an early stage after the operation and you will start a light diet within one to two days. You will be encouraged to mobilise early to prevent blood clots in the veins of your legs.

The wound drain will need to stay in place for a few days in case urine leaks from the cut kidney surface. In some patients, the drain needs to stay in place longer, and you will then go home with the drain and catheter still in place to allow the kidney to heal fully.

We would expect your hospital stay to be three to four days but some patients go home sooner.

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.

☐ Urinary leak from kidney edge requiring further treatment or a stent.

☐ Total nephrectomy will be performed if partial is not possible.

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

☐ Need of further therapy for cancer control.

☐ The abnormality may turn out not to be cancer.

☐ Temporary insertion of a bladder catheter and wound drain.

☐ 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.

☐ Need for further treatment if histology suggests incomplete removal.

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 eg with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.)

Privacy & 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.

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

References

• National Institute for Health and Care Excellence (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).

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 nurse specialist 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…………….………………….