Kidney Cancer

General Information

• The American Cancer Society’s most recent estimates for kidney cancer in the United States for 2020 are:
  • About 73,750 new cases of kidney cancer (45,520 in men and 28,230 in women) will be diagnosed.
  • About 14,830 people (9,860 men and 4,970 women) will die from this disease
  • These numbers include all types of kidney and renal pelvis cancers.
  • Most people with kidney cancer are older. The average age of people when they are diagnosed is 64 with most people being diagnosed between ages 65 and 74. Kidney cancer is very uncommon in people younger than age 45.
  • Kidney cancer is about twice as common in men than in women and it is more common in African Americans and American Indian /Alaska Natives.
• Lifetime risk of kidney cancer
  • Kidney cancer is among the 10 most common cancers in both men and women. Overall, the lifetime risk for developing kidney cancer in men is about 1 in 46 (2.02%). The lifetime risk for women is about 1 in 82 (1.02%). A number of factors can be associated with kidney cancer.

Robotic Assisted Laparoscopic (da Vinci®) Partial Nephrectomy

• Partial Nephrectomy provides patients with a safe and effective way to remove a small kidney tumor, while preserving the remainder of the kidney.
• Robotic assisted laparoscopic nephrectomy is a minimally invasive technique, which provides patients with less discomfort and equivalent results when compared to the traditional open surgery. When compared to the conventional open surgical technique, laparoscopic partial nephrectomy has resulted in significantly less post-operative pain, a shorter hospital stay, earlier return to work and daily activities, a more favorable cosmetic result and outcomes that appear to be identical to that of open surgery.
• Partial nephrectomy has become a standard procedure for selected patients with renal cell carcinoma.

The Operation

• Typically, the length of the operation is 2-4 hours.
• The surgery is performed through making 5-6 small (1cm) incisions in the abdomen. The tumor is usually removed intact via one of the small incisions after being placed in a sterile bag.
• Hospital stay is typically 1 day.

Potential Risks and Complications

Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications.  The safety and complication rates are similar when compared to the open surgery.  Potential risks include:

• Bleeding:
  • Blood loss during this procedure is possible and a transfusion is possible in <1% of patients.
  • You will have your blood type checked in case a transfusion is needed but we would only transfuse you in the event of life threatening blood loss. This is very rare.
• Infection:
  • All patients are treated with intravenous antibiotics, prior to starting surgery to decrease the chance of infection from occurring. No additional antibiotics are needed after surgery.
• Tissue/Organ Injury:
  • Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. Loss of kidney function is rare, but is a potential risk. Scar tissue may also form in the kidney requiring further surgery.  Injury could occur to nerves or muscles related to positioning.  Hernia at incision site is a possibility.
• Conversion to Open Surgery:
  • The surgical procedure may require conversion to the standard open operation if difficulty is encountered during the laparoscopic procedure. This could result in a larger than standard open incision and possibly a longer recuperation period.
• Urine Leak:
  • If the urinary collecting system of the kidney needs to be cut across in order to remove the tumor, it is usually sutured closed. If urine leaks out of this hole, you may need to have an internal drainage tube (stent) placed to help seal the leakage. The urinary catheter will also be replaced.  All tubes will stay in place until the leak has resolved.  This could take several weeks.  Eventually, all tubes will be removed in sequence, with the stent being the last, which is an office procedure (cystoscopy).   The end of the stent is grasped from inside of the bladder and removed.  The procedure is under local anesthesia and you will be able to drive afterwards.

What to Expect Before Surgery

Pre-Operative Visit

You will also be scheduled for a visit in the Pre-Operative Clinic.  You will also be given written instructions regarding arrival time the day of your surgery and when to stop eating and drinking, etc. This visit can take one to three hours depending on the various tests that are ordered for you.

Diagnostic Tests

• You will have some pre-op tests before your surgery. These may include blood work, EKG, cardiac work up, x-rays, urinalysis, or others.
• Generally most of the tests can be completed the day of your pre-op visits, however, some of them may need to be scheduled on a different day. Also, some insurance plans have contracts with outside lab and x-ray facilities. In that case, you will be given the appropriate paperwork and maps for those facilities.
• It will be important to complete your pre operative testing 2 weeks before surgery so that corrective action can take place in time to avoid surgery rescheduling.

Preparing for Surgery

• Practice deep breaths and coughing before your surgery.
• Walk a mile each day.
• No Advil/Ibuprofen 48 hours before.
• No Aspirin 7 days before. You will be given a list of blood thinners to avoid as well.
• Avoid garlic and other herbal remedies a week before.

Day before Surgery:

• Eat light diet, small sandwich, eggs, toast, soup. Limit dairy. Avoid fried foods and lot of seasoning
• Shower with Hibiclens – use ½ bottle. Rub it on mid-section area.  Then rinse off. Use a clean towel.
• No eating after midnight. Can drink up to 12 ounces of water up to 2 hours before.

Day of Surgery

• Shower with ½ bottle of Hibiclens. Take your medications.
• Bring lace-up sneakers.
• Bring Health Care Proxy Form.
• Bring cell phone and charger.
• Bring a case for personal items – eyeglasses, hearing aids,
• You will get an IV. Then meet with Anesthesiologist. Compression boots will be placed. You will get a breathing tube inserted, and a urinary catheter.

What to Expect in the Hospital after the Surgery

Immediately after the surgery you will be taken to the recovery room and transferred to your hospital room once you are fully awake and your vital signs are stable.

• Post-operative Pain:
  • Before the operation, the anesthesia team will perform a nerve block (TAP block) to help decrease pain.
  • We utilize Early Recovery after Surgery (ERAS) protocols to help minimize your pain. Our goal is to minimize narcotic use and help you recover faster.
  • You may experience some minor transient shoulder pain (1-2 days) related to the gas used to inflate your abdomen during the laparoscopic surgery.
• Nausea:
  • You may experience some nausea related to the anesthesia. Medication is available to treat persistent nausea.
• Drain:
  • You can expect to have a small drain coming out of an incision in your back over the kidney area. This will drain blood tinged fluid. If persistent drainage occurs, you may have to go home with the drain and have it removed in your doctor’s office.
  • Fluid will be tested for the presence of urine. If no leak is found, the drain will be removed prior to discharge.
  • The drain site will be left open and will drain blood tinged fluid for several days. Keep this covered with clean gauze and change as needed.   Once there is no leakage, you may leave the site uncovered or use a small bandage as needed.
• Urinary Catheter:
  • You can expect to have a urinary catheter draining your bladder (which is placed in the operating room while the patient is asleep) after the surgery. This is typically removed before discharge to home.
  • It is not uncommon to have blood-tinged urine for a few days after your surgery.
• Diet:
  • You can expect to have an intravenous catheter (IV) while in the hospital. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated; in addition, it provides a way to receive medication).  Most patients are able to tolerate ice chips and small sips of liquids the day of the surgery and regular food the next day. Once on a regular diet, pain medication will be taken by mouth instead of by IV or shot.
• Incentive Spirometry:
  • You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
• Ambulation:
  • On the day after surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can expect to have SCD’s (sequential compression devices) on your legs to prevent blood clots from forming in your legs.
• Hospital Stay: The length of hospital stay for most patients is for approximately 1 day.

What to Expect After Discharge from the Hospital

• Pain Control:
  • You can expect to have some pain that may require pain medication for a few days after discharge, and then Tylenol should be sufficient to control your pain. Pain medication will be sent to your pharmacy.
• Showering:
  • You may shower at home 24 hours after discharge. If you still have a drain, cover the entry site with plastic wrap.  Your wound sites can get wet, but must be padded dry. Tub baths can soak your incisions and therefore are not recommended in the first 2 weeks after surgery. Sutures are all internal and will dissolve in 4-6 weeks.
• Activity:
  • Taking walks is advised. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible. Driving should be avoided for 1 week after surgery. Absolutely no heavy lifting (greater than 10 pounds) 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 2-3 weeks after surgery. You can expect to return to light work in approximately 4 weeks.  Occupations that require intense activity and heavy lifting should be on hold for 6 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.
• Constipation:
  • You may experience sluggish bowels for several days or several weeks. Suppositories and stool softeners are usually given to help with this problem.  Taking mineral oil at home will also help to prevent constipation.  You may use any over the counter laxatives to help ease this problem.  Straining must be avoided to reduce the risk of hernia.
• Fatigue:
  • Fatigue is common and should start to subside in a few weeks.
• Follow-up Appointment:
  • You should have a follow up appointment arranged for you prior to your discharge. The usual visit is 1 week after surgery. Your pathology report will be discussed with you at that time.
• Stent Follow-up:
  • If a stent is placed, the length of the time the stent remains in place is variable. Your doctor will probably request it to be removed within a 2-6 week period.  This can be removed in the doctor’s office. It is common to feel a slight amount of flank fullness and urgency to void, which is caused by the stent.  These symptoms often improve over time if the stent is left in.  The severity and duration of the symptoms is highly variable and will resolve when the stent is removed.

Figure 1 Open Surgical Incision

Figure 2 Laparoscopic Incisions

Laparoscopic Nephrectomy

General Information

• Nephrectomy (total kidney removal) provides patients with a safe and effective way to remove a cancerous kidney tumor or diseased kidney.
• Laparoscopic nephrectomy is a minimally invasive technique, which provides patients with less discomfort and equivalent results when compared to the traditional open surgery. When compared to the conventional open surgical technique, laparoscopic partial nephrectomy has resulted in significantly less post-operative pain, a shorter hospital stay, earlier return to work and daily activities, a more favorable cosmetic result and outcomes that appear to be identical to that of open surgery.
• Laparoscopic nephrectomy has become a standard procedure for selected patients with renal cell carcinoma (kidney cancer).

The Operation

• Typically, the length of the operation is 1-2 hours.
• The surgery is performed through making 3-4 small (1cm) incisions and one slightly larger (7 cm) incision in the abdomen. The tumor is usually removed intact via the larger incision.
• Hospital stay is typically 1 day.

Potential Risks and Complications

• Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery.  Potential risks include:
• Bleeding:
  • Blood loss during this procedure is possible and a transfusion is possible in <1% of patients.
  • You will have your blood type checked in case a transfusion is needed but we would only transfuse you in the event of life threatening blood loss. This is very rare.
• Infection:
  • All patients are treated with intravenous antibiotics, prior to starting surgery to decrease the chance of infection from occurring. No additional antibiotics are needed after surgery.
• Tissue/Organ Injury:
  • Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. Loss of kidney function is rare, but is a potential risk. Scar tissue may also form in the kidney requiring further surgery.  Injury could occur to nerves or muscles related to positioning.  Hernia at incision site is a possibility.
• Conversion to Open Surgery:
  • The surgical procedure may require conversion to the standard open operation if difficulty is encountered during the laparoscopic procedure. This could result in a larger than standard open incision and possibly a longer recuperation period.

What to Expect Before Surgery

Pre-Operative Visit

• You will also be scheduled for a visit in the Pre-Operative Clinic. You will also be given written instructions regarding arrival time the day of your surgery and when to stop eating and drinking, etc. This visit can take one to three hours depending on the various tests that are ordered for you.

Diagnostic Tests

• You will have some pre-op tests before your surgery. These may include blood work, EKG, cardiac work up, x-rays, urinalysis, or others.
• Generally most of the tests can be completed the day of your pre-op visits, however, some of them may need to be scheduled on a different day. Also, some insurance plans have contracts with outside lab and x-ray facilities. In that case, you will be given the appropriate paperwork and maps for those facilities.
• It will be important to complete your pre operative testing 2 weeks before surgery so that corrective action can take place in time to avoid surgery rescheduling.

Preparing for Surgery

• Practice deep breaths and coughing before your surgery.
• Walk a mile each day.
• No Advil/Ibuprofen 48 hours before.
• No Aspirin 7 days before. You will be given a list of blood thinners to avoid as well.
• Avoid garlic and other herbal remedies a week before.

Day before Surgery:

• Eat light diet, small sandwich, eggs, toast, soup. Limit dairy. Avoid fried foods and lot of seasoning
• Shower with Hibiclens – use ½ bottle. Rub it on mid-section area.  Then rinse off. Use a clean towel.
• No eating after midnight. Can drink up to 12 ounces of water up to 2 hours before.

Day of Surgery:

• Shower with ½ bottle of Hibiclens. Take your medications.
• Bring lace-up sneakers.
• Bring Health Care Proxy Form.
• Bring cell phone and charger.
• Bring a case for personal items – eyeglasses, hearing aids,
• You will get an IV. Then meet with Anesthesiologist. Compression boots will be placed. You will get a breathing tube inserted, and a urinary catheter.

What to Expect in the Hospital after the Surgery

Immediately after the surgery you will be taken to the recovery room and transferred to your hospital room once you are fully awake and your vital signs are stable.

• Post-operative Pain:
  • Before the operation, the anesthia team will perform a nerve block (TAP block) to help decrease pain.
  • We utilize Early Recovery after Surgery (ERAS) protocols to help minimize your pain. Our goal is to minimize narcotic use and help you recover faster.
  • You may experience some minor transient shoulder pain (1-2 days) related to the gas used to inflate your abdomen during the laparoscopic surgery.
• Nausea:
  • You may experience some nausea related to the anesthesia. Medication is available to treat persistent nausea.
• Drain:
  • There is a small possibility of having a drain coming out of your abdomen after surgery. This should be removed prior to discharge from the hospital.
  • The drain site will be left open and will drain blood tinged fluid for several days. Keep this covered with clean gauze and change as needed.   Once there is no leakage, you may leave the site uncovered or use a small bandage as needed.
• Urinary Catheter:
  • You can expect to have a urinary catheter draining your bladder (which is placed in the operating room while the patient is asleep) after the surgery. This is typically removed before discharge to home.
  • It is not uncommon to have blood-tinged urine for a few days after your surgery.
• Diet:
  • You can expect to have an intravenous catheter (IV) while in the hospital. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated; in addition, it provides a way to receive medication).  Most patients are able to tolerate ice chips and small sips of liquids the day of the surgery and regular food the next day. Once on a regular diet, pain medication will be taken by mouth instead of by IV or shot.
• Incentive Spirometry:
  • You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
• Ambulation:
  • On the day after surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can expect to have SCD’s (sequential compression devices) on your legs to prevent blood clots from forming in your legs.
• Hospital Stay: The length of hospital stay for most patients is for approximately 1 day.

What to Expect After Discharge from the Hospital

• Pain Control:
  • You can expect to have some pain that may require pain medication for a few days after discharge, and then Tylenol should be sufficient to control your pain. Pain medication will be sent to your pharmacy.
• Showering:
  • You may shower at home 24 hours after discharge. If you have a drain, cover the entry site with plastic wrap.  Your wound sites can get wet but must be padded dry. Tub baths can soak your incisions and therefore are not recommended in the first 2 weeks after surgery. Sutures are all internal and will dissolve in 4-6 weeks.
• Activity:
  • Taking walks is advised. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible. Driving should be avoided for 1 week after surgery. Absolutely no heavy lifting (greater than 10 pounds) 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 2-3 weeks after surgery. You can expect to return to light work in approximately 4 weeks.  Occupations that require intense activity and heavy lifting should be on hold for 6 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.
• Constipation:
  • You may experience sluggish bowels for several days or several weeks. Suppositories and stool softeners are usually given to help with this problem.  Taking mineral oil at home will also help to prevent constipation.  You may use any over the counter laxatives to help ease this problem.  Straining must be avoided to reduce the risk of hernia.
• Fatigue:
  • Fatigue is common and should start to subside in a few weeks.
• Follow-up Appointment:
  • You should have a follow up appointment arranged for you prior to your discharge. The usual visit is 1 week after surgery. Your pathology report will be discussed with you at that time.

Links for More Information

For more information on kidney cancer:
https://www.kidneycancer.org/

For more information on robotic kidney surgery:
https://www.davincisurgery.com/procedures/urology-surgery/kidney-surgery

For more information on Dr. Sanjay Ramakumar and the Abrazo Urologic Institute:
AbrazoMedicalGroup.com