Cancer that occurs in the ureter or in the lining of the kidney often requires removal of the kidney and the entire drainage tube (nephrouterectomy). Traditionally this procedure has been performed through large incisions across the ribcage or upper abdomen, resulting in a potentially long recovery. However, the same procedure can be performed with equal effectiveness laparoscopically, thereby lessening both the recovery and surgical risk.
Scott D. Miller, MD has one of the largest private practice experiences with laparoscopic kidney removal in the country. Having specialized in urologic laparoscopy for 12 years, he was the first urologist in the state of Georgia to perform laparoscopic removal of the kidney for cancer in 1995. As a result, he has one of the largest series of long-term cancer data following laparoscopic kidney surgery.
Removing the entire ureter in addition to the kidney (laparoscopic nephroureterectomy) requires a much higher level of expertise when compared to kidney removal alone (laparoscopic radical nephrectomy). Similar to other laparoscopic procedures, the surgeon makes a button-size incision for the insertion of a telescope. After expanding the body cavity with carbon dioxide gas, three or four additional small incisions are made to place narrow tubes used for interchangeable instruments. The surgeon can then visualize the kidney and the interchangeable instruments on a television monitor. The ureter is fully exposed and clamped below the tumor in order to help prevent cancer cells from traveling down to the bladder. The kidney’s blood vessels are then tied off and divided.
Once the kidney is separated from all of its surrounding structures, the lower ureter is separated from the bladder. A small piece of bladder is taken with the end of the ureter to ensure complete removal of the ureter. The resultant opening in the bladder is meticulously closed with dissolvable suture. Now the kidney, its surrounding fat, and entire ureter are placed in a protective plastic bag that closes with a purse-string (all while inside the body). Rather than enlarging one of the small incisions, an additional incision (usually as small as 2 to 3 inches) is made in the skin overlying the pubic bone slightly towards the side of the surgery. By temporarily pulling the muscle away, the kidney can then be removed through the lower incision without cutting any muscle, thereby decreasing post-surgical pain and minimizing the risk of hernia formation. The skin openings are closed with shower-resistant glue as a substitute for both stitches and bandages. A temporary drainage tube and urinary catheter are usually left in place.
Results & More
Laparoscopic nephrouterectomy facilitates quicker recovery, less pain, and a lower complication rate as compared to the typical open-incision kidney and ureter removal. Obviously, the primary goal is cancer cure. Our cure rates have either matched or surpassed any other published series for open-incision kidney removal. A vast experience and a world-class surgical team help ensure this high level of success.
Most patients are discharged from the hospital the day following surgery. Risk of transfusion, damage to surrounding organs, blood clots, pneumonia, and wound infection are each under 1%.
Q: How do I keep my kidney(s) healthy? A: The kidneys are very vascular organs. For that reason, whatever is healthy for the body tends to be healthy for the kidney. The obvious recommendations are exercise, a balanced diet, and management of other medical conditions such as high cholesterol, hypertension, and diabetes. Of course, smoking is detrimental to both kidney and overall health. Although protein restriction is usually unnecessary, seek the advice of a physician prior to starting a high protein diet. A physician can also advise you of any medications to minimize or avoid.
Q: How much pain can I expect after the procedure? A: Pain is typically less with laparoscopic procedures when compared to open-incision surgery. Some abdominal cramps and shoulder discomfort can occur from the carbon dioxide gas used during surgery. This type of pain is best treated with anti-inflammatories rather than narcotics. Although everyone is different, post-operative discomfort is usually easily managed and short-lived.
Q: Is bruising normal after a laparoscopic procedure? A: When a narrow tube is placed through a button-size skin incision, a small blood vessel just below the skin can break. However, since the snug fit of this tube will compress the blood vessel during surgery, bleeding will often not occur. If this blood vessel were to re-open at a later time, a small amount of blood could track over a large surrounding area (including the genitalia). This is not a true bruise but will have the same appearance. Most important, this finding is not an indication of internal problems.
Q: When can I return to work or other normal activities following my surgical procedure? A: Dr. Scott Miller recommends at least two weeks away from work. Very few jobs would require more than four weeks of leave. In many cases, a small amount of light work-related duties are acceptable during the first two weeks. All patients should move around frequently from the time of surgery and resume light exercise at one week (gradually increasing to a normal routine by four weeks). Driving a car is often reasonable in approximately one week if reaction time is good. Of course, Dr. Scott Miller will provide guidance for each individual situation.
Q: Are lymph nodes removed during a laparoscopic nephrouterectomy? A: Unless an abnormal lymph node is encountered, lymph node removal is typically not needed.
Q: How long does the surgery take Dr. Scott Miller to perform? A: Although many variables can affect the time necessary for Dr. Scott Miller to meticulously perform the surgery, he usually completes the procedure in two to three hours. However, the time away from family members also includes preparation (30-40 minutes), anesthetic reversal (15-20 minutes), and recovery room stay (2 or more hours). Dr. Scott Miller asks patients to arrive two hours prior to this process, during which time family members can remain present. Occasional updates are given to the family by the operating room nurse. Dr. Scott Miller will come to the waiting area when the patient is ready for transfer to the recovery room.
Q: How long do I stay in the hospital following surgery? A: Most patients are ready for discharge on the day following surgery.
Q: How does cancer cure with laparoscopic nephrouterectomy compare to open-incision kidney removal? A: Dr. Scott Miller’s oncologic (cancer-related) outcomes match nationally published data for open-incision surgery from the premier academic centers. Since Dr. Scott Miller performs a much higher volume of kidney removals than the average urologist, he is able to achieve these results.
Q: Should I donate blood prior to my procedure? A: Since the risk of needing a blood transfusion is less than 1%, blood donation is not necessary.
Q: When can I shower or bathe following my surgery? A: Since shower-resistant glue was used as a substitute for both stitches and bandages, showering is acceptable once discharged from the hospital. Although water will not harm the surgical areas, mechanical cleansing of the incisions should be avoided for the first week to prevent premature removal of the glue. Complete immersion such as bathing or swimming is allowed at two weeks.
Q: What long-term follow-up care will I need? A: Following examination of the tumor by the pathologist, Dr. Scott Miller will recommend a schedule for any follow-up x-rays and blood tests.
Q: What other cancer treatments will I need after my surgery? A: No other treatments (such as radiation or chemotherapy) are routinely recommended unless disease is discovered outside of the kidney.
Q: Does tumor size or location influence whether I am a candidate for laparoscopic nephroureterectomy? A: For tumors much greater than 10 centimeters, open surgery may be more appropriate.