Kidney Partial Nephrectomy

Dear patient, if you are reading this, then you were likely diagnosed with a kidney abnormality such as a solid tumor or suspicious cyst that may be removed while saving the rest of the normal kidney. This type of surgery is called a “partial nephrectomy.”

There are various methods of doing this procedure. In the past, the only approach was to make a long cut on the side of the belly to get to the kidney. Then in the 1990’s, we began doing these procedures through small cuts in the belly (laparoscopically) with “chopstick” type of instruments. In the early 2000’s a new instrument came into play called the DaVinci robot that allows for wrist-like movements of the thin instruments that are placed through small cuts in the belly and are controlled by the surgeon with joysticks.

The robotic surgery allows for high definition 3-D view of the inside of the belly improving precision of the operation. Currently, the Robotic Partial Nephrectomy is the “gold standard” treatment for the removal of small kidney tumors. Dr. Gorbatiy spent an extra 2 years, after his residency, in an “exclusive” fellowship in Robotic Urologic Surgery.  He has operated on several hundred patients with this type of surgery over the past decade at Broward Urology Center.

This guide is intended to explain how the procedure is done, how to prepare for it and what to expect after the procedure.

What are the Kidneys?

The kidneys are a pair of organs located towards the back of the belly (flank area). Each is about the size of a fist. The kidneys are essential organs, which filter the toxins from the blood and balance the water and salts in the body. As the kidneys filter blood, they create urine, which collects in a funnel-shaped structure called the pelvis of the kidney” and leaves the kidneys down tubes called ureters" to finally reach the bladder. The kidneys are essential to life.

What is a Kidney Tumor?

A kidney tumor, also referred to as a mass” or lesion” is simply a solid growth in the kidney. There are growths in the kidney that may be full of liquid (resembling a pimple) that are referred to as kidney cysts. The majority of kidney cysts are benign and in most cases do not require any intervention. However, solid tumors typically need to be addressed.  Some cysts may have solid elements and thus be suspicious for cancer so these may need to be addressed as well.

Most kidney tumors are malignant, which means they are a kidney cancer. On average, 80% of tumors about 1.5 inches in size are malignant while 20% of those are benign tumors.

How is the Partial Nephrectomy Surgery Done?

Partial Nephrectomy is considered to be the standard treatment for most smaller kidney tumors and in some larger masses that are in a “good” location.  A partial nephrectomy means that a surgeon cuts the tumor out of the kidney and saves the rest of the normal kidney.

This surgery may be done these days through small holes in the belly (laparoscopically) as well as with the assistance of a robot” machine that allows for the surgeon to control small laparoscopic instruments with joysticks. The surgeon must control the arms of the robot and the laparoscopic instruments attached to them.  The robot does NOT function independently on its own.  The robot has become an essential tool for this operation as it dramatically improved the safety and duration of the surgery compared to the traditional laparoscopic methods. In rare cases, the surgery may need to be done with the traditional large open incision.

The steps of the operation:

  1. Patients are put under general anesthesia in the operating room and are given IV antibiotics
  2. A catheter (tube) is placed to drain the bladder and then patients are placed on their side so that the kidney that is being operated on is up toward the ceiling
  3. Patients are then secured to the bed and cushions are placed on any pressure points
  4. After cleaning the skin, we make small holes in the belly to insert a camera and instruments inside.
  5. The inside of the belly is examined and the intestines are moved away to expose the kidney.
  6. The blood vessels of the kidney (artery and vein) are then identified
  7. An ultrasound of the kidney is used to identify the tumor and mark the edges of the resection
  8. Clamps are used to temporarily close the blood supply to the kidney and the tumor is cut out. We then use stitches to sew up the crater where the tumor was removed and fix the kidney. Several layers of stitches are used to stop any bleeding and close the defect. This needs to be done in under 30 minutes as the kidney will suffocate without blood and the oxygen it carries.
  9. The clamps are then removed and the kidney once again gets its blood supply back. The tumor is placed in a plastic bag. A small drain (plastic tube) is placed inside through one of the belly holes to monitor for any bleeding after surgery.
  10. One of the small incisions is made large enough to remove the bag with the tumor and all the belly cuts are closed. All of the skin cuts are closed with superglue.

How Long Does the Operation Take?

The operation takes 3-4 hours to complete. In cases where patients are obese, the tumor is large, the anatomy is difficult or there are multiple tumors, the procedure may take longer.

What is the Recovery After the Operation?

Most patients stay in the hospital for 2 days. The goal is to get you out of the hospital as fast as possible, when you are safe to go, so that you may avoid catching any hospital related infections. The most important step to a speedy recovery is to move as much as you can. The more you move, the faster the bowels wake up, and the less likely you will get blood clots in the legs. The following is the typical hospital course:

Immediately after surgery

  1. You will wake up in the recovery area called the “PACU” (Post Anesthesia Care Unit) with a tube draining the bladder and a small tube from the belly. You will also have squeezing/pumping devices on your legs to prevent blood clots. Blood work will be done.
  2. Once you are fully awake, you will be moved to your hospital room. You will be allowed to have some clear liquid fluids at first and if you are hungry, you may have a very light meal.
  3. You will be encouraged to get up in bed and at least sit up.
  4. You will be encouraged to take deep breaths and clear up your lungs with coughing.
  5. Ask for pain medications so you may be able to move around. Don’t take pain medications for sleep.

Day #1 after surgery

  1. Early in the morning, the catheter draining the bladder will be removed so that you may be able to urinate on your own
  2. Bloodwork will be done in the morning
  3. You will be served a light meal for breakfast and a normal diet for lunch
  4. Continue to use the incentive spirometer to take deep breaths and continue to get out of bed and walk around as much as possible.

Most patients are ready to go home when they have passed gas, pain is well controlled with pills, there are no signs of an infection and blood levels are good. When the doctor deems you to be safe to go home, we will remove the tube from the belly (this doesn’t hurt, just uncomfortable).

Most patients report that they feel like they are back to “normal” at about 2-3 weeks after the operation. Typically, patients feel that their belly is a bit swollen for a few weeks. The incisions  may have some bruising. Male patients may feel some testicular discomfort on the same side of the kidney that was operated on. Some patients may feel like their bowels are not moving normally for a little while after surgery and many report feeling more tired for a few weeks.

What are the Risks of the Partial Nephrectomy Surgery?

  1. Bleeding - from the area of the kidney that was cut. During the surgery most patients have some bleeding from the area that is cut but typically not enough to require a transfusion. Delayed bleeding (bleeding that occurs a few hours to a few days after surgery) occurs very rarely. You may feel severe back or abdominal pain, bruising on the side, or blood in the urine if there is significant bleeding.
    1. Treatment for bleeding may include bedrest, blood transfusions and in rare cases a procedure called embolization (where x-ray doctors are able to find the blood vessels are bleeding and block them). Only in extreme cases do patients need to go back to the operating room.
    2. Infection
    3. Injury to the surrounding organs (intestine, spleen, liver, gallbladder, major blood vessels)
    4. Urine Leak - when urine leaks from the area where the kidney was cut and into the belly. Most of the time this leak seals itself with time. At times, a small plastic tube, called a stent, is required to be placed into the kidney to drain the urine into the bladder and help the kidney heal faster.
    5. Conversion from Robotic to an Open Surgery
    6. Conversion from a partial to a total/complete kidney removal
    7. Anesthesia-related heart and/or lung problems
    8. Decline in kidney function
    9. Positive Margins - when a small amount of tumor is left behind in the kidney

What are the Alternative Treatment Options?

 The treatment options for solid kidney tumors besides a partial nephrectomy (starting with the least aggressive to the most aggressive option) include:

Active Surveillance - close monitoring with repeat imaging of the kidneys over time; Surveillance may be done with or without a diagnostic biopsy.  This is usually reserved for very small kidney masses or for patients who are too ill for surgery.

Kidney Tumor Embolization - certain benign tumors (like Angiomyolipomas) are treated with this procedure where the Interventional Radiologist is able to cut off the blood supply to the tumor.

Kidney Tumor Ablation - either through the back (percutaneously) or laparoscopically (small belly opening), a special needle is used to penetrate the tumor and either burn it or freeze it to death.

Radical Nephrectomy - surgery to remove the entire kidney is reserved for larger kidney tumors and the smaller tumors which appear to involve the main blood supply to the whole kidney. This surgery is commonly done laparoscopically and at times with the assistance of the robot. For patients with very large tumors, the surgery may need to be done in a traditional open fashion with larger incisions in the belly and with the assistance of other surgical specialists.

Pre-Operative Instructions: Robotic Partial Nephrectomy

If you are currently awaiting a robotic partial nephrectomy, it is essential for your own safety and for the success of your operation that you carefully read and observe these instructions.

Overall Preparation

Medications

Ten (10) days before surgery please STOP taking any Aspirin, NSAID’s (non-steroidal anti-inflammatory drugs) such as Ibuprofen, Motrin, Aleve, etc., Vitamin E, Fish Oil and any other blood thinners, including Herbal medications and multi-Vitamins.

If you are on Plavix (clopidogrel), Coumadin (warfarin) or any other prescribed blood thinner, make sure you mention this to Dr. Gorbatiy so we could have a clear permission from your primary doctor or cardiologist to stop those medications safely prior to surgery.

Take your usual doses of heart, thyroid, and asthma medications on the morning of surgery with a tiny sip of water.  If you are diabetic and take medication, do not take them on the morning of surgery. If you take insulin, only use half the normal dose the morning of surgery.

Get Your Body Prepared for Surgery

  • In the days leading up to surgery, eat a healthy diet to help the body heal faster.

  • Please be more active prior to surgery, even 5 or 10 thousand extra steps in a day will increase your stamina and help you bounce back much faster after any operation.

  • Losing weight (even 5 pounds) helps patients recover faster as it makes the anesthesia easier to administer.

  • Quit, or at least cut down on smoking, alcohol or recreational supplements.

  • Stay positive. An optimistic outlook gives you energy toward a rapid recovery.

The Day of Your Procedure

  • Please don’t drink or eat anything for 8 hours prior to the procedure
  • Take ALL your blood pressure and heart medications as usual with just a sip of water
  • For other medicines, please check with your primary care doctor prior to surgery

-    What to Bring to the Hospital

  • If you have the disks of CT scans/MRI scans of your abdomen, please bring them with you for the operation.
  • A pair of loose-fitting pants, like sweat pants.
  • Brief-style underwear that is 1 to 2 sizes larger than you normally wear.
  • Sneakers that lace up. You may have some swelling in your feet so lace up sneakers can accommodate this swelling.
  • If you have a history of sleep apnea and use a CPAP, then bring it to the hospital.
  • Your cell phone with a charger cord/plug.
  • Your Health Care Proxy Form, if you have completed one.
  • A case for your personal items, such as eyeglasses, hearing aid(s), dentures, toothbrush, shaving kit, and religious articles.
  • This handout as a reference.
  • Your Driver’s License for ID and insurance cards.
  • List of all your current medications.
  • All jewelry usually needs to be removed from your body before the operation so it is best left at home.
  • Do not wear makeup on the day of surgery.
  • Do not wear nail polish.
  • Do not wear your contact lenses.
  • Shower the night before or the morning of surgery as you will not be allowed to shower for 2-4 days after this surgery.

Recovery at Home

  • Please make an appointment to see your primary care doctor as soon as you get out of the hospital as you may need to have some medications (typically blood pressure medications) adjusted after surgery.
  • Continue to stay active at home after surgery with regular daily walking.
  • Continue to use the incentive spirometer (breathing device) to take deep breaths and help prevent pneumonia prevention for up to a week after surgery.
  • All the cuts on the belly are covered with superglue that will eventually peel off after 1-2 weeks.
  • You may shower once you get home after surgery.
  • You may NOT use the bathtub or go in a pool until the skin is completely healed which may take a few weeks.  Ask Dr. Gorbatiy about this at your follow-up office.
  • Heavy lifting >10-20 pounds is discouraged for the first 6 weeks after surgery to prevent from getting a hernia.
  • It is common for the stitches underneath the skin to make the cuts feel firm for even as long as a year from surgery, but eventually they soften up.
  • Bruising is often seen around the incisions and will go away on its own.
  • Rarely, the cuts may open up and drain some fluid. Keep the incision clean by showering daily with soap and water. If there is some drainage, keep a clean gauze or a band aid over the incision.
  • If you see redness that is spreading around the incision, please let the doctor know as this may be a sign of a wound infection.
  • You may maintain your usual diet at home, unless told otherwise by the doctors prior to your discharge from the hospital.
  • Please contact the doctor if you’re experiencing fevers (>101 F), shortness of breath, chest pain, inability to pass any gas, vomiting, swelling in one leg, dizziness, blood in the urine or sudden and severe abdominal or flank/back pain.
  • Most patients are seen at our office 1-2 weeks after surgery at our office. Please call the office at 954-463-6408 to schedule the appointment.

 We hope these instructions are useful to you. If there are any questions not covered by the instructions, please contact us at the above phone number. It has been a pleasure working with you to resolve your problem.

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