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Robotic Partial Nephrectomy

Introduction

Robotic Partial Nephrectomy (RPN) is a minimally invasive surgery which provides patients with less discomfort and equivalent results when compared to the traditional open surgery.

RPN causes less post-operative pain, requires a shorter hospital stay, earlier return to work and better cosmesis. Partial nephrectomy is an accepted standard for patients with T1a (< 4cm) renal tumors. Patients with larger tumors depending upon their individual condition & status of opposite renal unit maybe offered RPN too, but the treatment stands individualized.

 

Preoperative Workup

Your first preoperative consultation

Your initial consultation with us would require a review of your medical history & any other investigations if available. A brief physical examination may also be performed. Any other investigations like a CT scan, MRI or Doppler etc as per each patients requirement would be done. If you are a candidate for surgery, you will then meet with our Patient Coordinator to arrange for the date of your surgery.

NOTE: It is very important that you gather and bring all of your CT scan/ X-ray films and reports to your initial consultation with your surgeon.

 

What to expect prior to the surgery

Patients are required to undergo

  • Investigations
    • Urology Preoperative Panel (CBC, Blood Urea, Creatnine, Sodium, Potassium, Calcium, Phosphorus, Albumin, Alkaline, Phosphatase, Uric Acid (Serum), Bicarbonate, Urine Analysis, Urine Culture, PT / INR, APTT, HbsAg, HCV Antibody, HIV I & II)
    • Chest X-ray & ECG
    • Imaging investigations as asked, after consultation.
    • PAC clearance [4th Floor, Room No-18]
  • Financial Clearance
    • TPA (Mediclaim)
    • Cash
  • Stoppage of Blood thinners, if any after clearance by the prescribing physician.
  • Filling up of Admission Form
  • Confirmation of date of admission and date of surgery
  • Final clarification of doubts, if any

 

Preparation for surgery

Medications to Avoid Prior to Surgery

  • Any blood thinners like aspirin, clopidogrel, coumarin, acetrom, warfarin , ibuprofen, vitamin E and some other arthritis medications can cause bleeding and should be avoided 1 week prior to the date of surgery (Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery.)
  • Do not stop any medication without contacting the prescribing doctor’s approval.

 

Dietary advice

Do not eat or drink anything after midnight the night before the surgery. Patients need to be 6 hours fasting ( not even water is allowed) prior to the surgery for anesthesia safety requirements.

We don’t do routine bowel preparation for our LPN patients unless specifically indicated. Patients may be routinely given Tablet Dulcolax on the night prior for which they are instructed in the ward.

 

The Surgery

RPN is performed under a G.A. The typical length of the surgery is 2-4 hours. It’s a keyhole surgery performed via 4-5 small 5-12 mm incisions. Prior to beginning the robotic surgery, a ureteric catheter may be kept in the ureter to help repair the kidney at a later stage. Patient is placed in the kidney position. Standard ports are established & the robot docked. The kidney is mobilized & tumor dissected all around. Renal vessels are clamped to prevent bleeding during tumor resections. The defect left behind after excision is then repaired with sutures and tissue sealant glue. It is here at the reconstruction stage that the dexterity & 3 D vision of the robot are helpful to the surgeon & help achieve better results. The tumor is placed in a plastic bag & retrieved by extending one of the port sites or making a separate small infraumblicalmidline/pfannensteil incision.

 

Tubes to be expected inside the body at the end of the procedure

A drain & a Foley’s catheter is kept after the procedure is completed. A Double J stent is kept depending on case-to-case basis. In case a Double J stent is kept , it’s taken out after 3-4 weeks by flexible cystoscopy under local anesthesia.

 

Potential Risks and Complications in Laparoscopy

As in any surgery there are potential risks & complications & one needs to be informed about them. Potential risks are –

Bleeding: Blood loss during this procedure may range from 200-500 ml. 1 unit of blood are arranged preoperatively. Transfusion may be needed occasionally. The family needs to donate one unit blood as blood is provided by the hospitals on a replacement basis.

Infection: Intravenous antibiotics are given at the beginning of surgery. This reduces the chances of infection. However in case of any fever, discharges from your incisions, frank hematuria (thick blood in urine) or unbearable pain please contact us immediately.

Tissue / Organ Injury: Rarely injuries to bowel, vascular structures, spleen, liver, pancreas and gallbladder requiring further surgery have been reported. Positional injuries to nerves & muscle stretches are possible. However these are self-healing over 4-6 weeks.

Hernia: Hernias at incision sites rarely occur. The 12 mm ports are closed under vision.

Conversion to Open Surgery: One needs to understand that any consent for a laparoscopic procedure would also imply consent for open surgery in case intraoperative condition so merits. This could result in a conventional open incision and possibly a longer recovery.

Conversion to radical nephrectomy (robotic/laparoscopic/ open) or open partial nephrectomy. One needs to understand every patient brings along different scenarios & surgical challenges. Despite latest imaging investigations available, the condition of the disease during surgery may be different & more advanced. This may merit a conversion to robotic, open or laparoscopic radical or open partial nephrectomy. This consent is taken on the day prior in the hospital after admission & one needs to stand informed of such a possibility occurring during such procedures.

Urine Leak: The pelvicalyceal system of the kidney may at times be cut across to achieve margin clarity. It is usually sutured closed. Rarely urine continues to leak out of this area & patients may need to keep a drain in situ for longer durations than usual. Sometimes the stents get blocked & patients may need a change of stent to stop such leaks.

Robotic Factors

Mechanical failure during robotic procedure though rare is not unknown. In such a scenario a conversion to open surgery is mandated , which is done after informing the family. Dr Manav Suryavanshi, carries an advantage of having performed all these procedures laparoscopically as he has mastered his advanced learning curves for laparoscopy. In the event of any such scenario we can complete these procedures laparoscopically. However there are multiple other factors which may still need the procedure to be completed by open technique. Any consent signed by you automatically implies consent for conversion to other techniques keeping patient interest supreme. Any further queries should be discussed in person with Dr Manav Suryavanshi.

 

Post operative period after Robotic Partial Nephrectomy

During your hospitalization

Immediately after the surgery you will be kept under observation in the recovery room & then shifted to Ward or ICU depending upon comorbid factors present in the patient.

Postoperative Pain: Pain medication is delivered in a controlled manner by the patient himself via an i.v patient-controlled analgesia (PCA) pump or by injection (pain shot) given by the nursing staff.

Shoulder pain: Occasionally you may get a shoulder pain (1-2 days) related to the carbon dioxide gas used during laparoscopy.

Drain: The drain as explained is kept to drain blood tinged fluid and urine. If persistent drainage occurs, you may have to go home with the drain and have it removed onOPD basis. Usually drains are out by 2-4 days.

Nausea: is expected, usually related to anesthesia medications or slow recovery of your bowel. However this is usually controlled by medications or withholding food for a day or two.

Urinary Catheter: is kept for 2-3 days. They may also drain blood-tinged urine for a few days . This usually subsides & should not be a cause of worry, unless it changes to thick clots, which can occur rarely.

Diet: You can expect to have an intravenous catheter (IV) in for 1-2 days. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated & it also provides a way to receive medication.) Most patients are able to tolerate sips of liquids the day of surgery and regular food the next day. Once on a regular diet, pain medication will be taken by mouth.

Fatigue: Fatigue is common due to surgical stress and subsides in a few weeks following surgery.

Incentive Spirometry: Breathing exercises help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you by the nursing staff during your hospital stay). Coughing and deep breathing exercises help prevent pneumonia and other pulmonary complications.

Ambulation: Patients are expected to begin mobilizing in bed on the evening of surgery & get out of bed and begin walking with the supervision of your nurse or family member by next morning. This helps prevent blood clots from forming in your legs.

Hospital Stay: The length of hospital stay for most patients is approximately 4-5 days.

Constipation/Gas Cramps: You may experience sluggish bowels for several days. Suppositories and stool softeners are given to help with this problem. Narcotic pain medications can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.

 

Discharge Instructions

Pain Control: You can expect to have some pain that may require pain medication for a few days after discharge.

Showering: You may shower after returning home from the hospital. Your wound sites can get wet, but must be padded dry immediately after showering. Tub baths are not recommended in the first 2 weeks after surgery as this will soak your incisions and increase the risk of infection.. You may have adhesive strips across your incision. These are not to be removed. They are waterproof & will fall off in approximately 5-7 days. Sutures will dissolve in 3-4 weeks. In case the dressings do not fall by themselves get them removed on first follow up visit with us. In case the dressings come off by themselves earl;ier there is no need to panic as they can be reapplied anew or may not need to be applied if 72 hours have elapsed after surgery & the wound sites are dry & healthy.

Activity: Taking daily walks are strongly advised. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible, but should be taken slowly. Driving should be avoided for at least 4 weeks after surgery. Absolutely no heavy lifting or exercising (jogging, swimming, treadmill, biking) for six weeks or until instructed by your doctor. Most patients return to full activity on an average of 2 weeks after surgery. You can expect to return to work in approximately 4 weeks.

Diet: You should drink plenty of fluids and discuss with your doctor if you need to be on a salt or protein restricted diet.

 

Follow-up

Pathology Results: The pathology results from your surgery are usually available in 7-8 days following surgery. You may discuss these results with your surgeon in yourfollowup appointment in the office.

Kidney Function Tests and Imaging: Patients are encouraged to have an annual blood test, called serum creatinine to follow their overall kidney function. We shall also review these results in the office during follow up visits. In patients with kidney tumors, followup Xray tests (e.g. CT, MRI, sonograms) may be periodically required to follow the appearance of your remaining kidney.

Double J Stent Removal: If a double J stent is placed during your surgery, the length of the time the stent remains in place is variable. We shall decide for it to be removed within a 4-6 weeks period. This can be removed in your doctor’s office as a local daycare procedure. It is common to feel a slight amount of flank fullness and urgency to void while the stent is in place, however, these symptoms often improve over time. The severity and duration of the symptoms is highly variable and will resolve when the stent is removed. It is critical that patients return to have their stent removed as instructed as a prolonged indwelling double J stent can result in encrustation by stone debris, infection, and obstruction of the kidney

Follow-up

The patient is supposed to follow up with us after 7 days of discharge by which time the histopathology report is available. You will be given an outpatient appointment at Urofort (+91-9910103545) or at our hospital with Dr Manav Suryavanshi by Urology Coordinator (+91-9560398967) as per your convenience 5-7 days after surgery. Based on the report the follow up & the need & frequency of follow up & any adjuvant treatment; if required is decided.

Contact your doctor if

  • Any of your wounds become red, hot, swollen, painful or continue to discharge
  • If your urine becomes cloudy, offensive smelling or you have any other signs of a urine infection
  • If you have any concerns at all
  • If you have fever >100°F or rigors and chills.

For More Information

Meet us at

Medanta Kidney & Urology Institute

Medanta – The Medicity

Sector 38, Gurgaon, Haryana – 122001, India

For appointment Call+91-9910103545

Email – info@urofort.com

Web address – www.manavsuryavanshi.com