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Laparoscopic renal pelvis reconstruction
What does this procedure entail?
The laparoscopic technique accesses the operating field using telescopic instruments, which are introduced through small skin incisions. The method puts less strain on the patient during the surgery, and the subsequent shorter recovery will allow an early return to normal activities.
In this case, it is a surgical adjustment of ureteropelvic junction (UPJ) stenosis = narrowing in the area of the transition of the renal pelvis to the ureter. The narrowing is either congenital or it arises during the healing of damaged tissue with scar creation (kidney stones, inflammation). Urine congestion occurs in the calyx-pelvic system of the kidney (the excretory urinary system of the kidney) due to this narrowing, which gradually leads to decreased function and irreversible damage to kidney tissue in the long term.
What are the alternatives to this procedure?
- Open (laparotomy) surgery
- Endoscopic discision (access via the kidney or the bladder)
- Stent insertion (a temporarily inserted plastic tube bridging the narrowed site)
- Stenosis dilatation
What should I expect before this procedure?
If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.
At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.
You will be asked not to eat or drink for at least 6 hours before the surgery!
In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.
Remember to inform your physician about the following possible facts before the surgery:
- artificial heart valve
- coronary artery stent
- artificial joint
- artificial vascular graft
- neurosurgical bypass
- other implanted foreign body
- use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
- drug and other allergies
- any abnormalities or eventualities
It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.
What will happen during the surgery?
The whole procedure is performed under general anaesthesia. You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.
The surgery is started with cystoscopy (examination of the bladder using a telescopic instrument inserted into the urethra), where the ureteral catheter or stent is inserted into the renal pelvis (a plastic tube between the kidney and the bladder). The stent is necessary for a better overview during the surgery and for the drainage of the kidney after the surgery until the new connection of the renal pelvis and ureter is healed. A drainage tube is inserted through the skin into the area of the new anastomosis before the end of the surgery, and a catheter is inserted into the bladder.
What will happen immediately after the procedure?
You will wake up at the intensive care unit equipped for the continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.
The area of the kidney as well as the entire abdomen may be sensitive after the surgery. Blood in the urine usually disappears within 48-72 hours. If blood loss is more significant, you will be given a blood transfusion. Revision (surgical control) may be considered in case of massive or persistent bleeding. You will probably not be able to eat or drink until the next day.
After the procedure, it is sometimes necessary to temporarily ensure urine excretion from the kidney through a ureteral catheter (a plastic tube inserted in the ureter). In such case, it is forbidden to get out of bed or sit on the bed until it has been removed. Instead of a ureteral catheter, a stent is more often used (see above), whose structure allows for mobilisation and positioning. After the procedure, you will have a drain in your hip (a plastic tube that drains tissue fluid, blood and initially sometimes urine leaking from the surgery site) for 2-4 days and a catheter in the bladder for 4-5 days.
The average hospitalisation is 5-7 days.
Once you are fully conscious, you should:
- ask if the planned outcome was achieved
- inform the medical staff about any problems
- ask what you can and cannot do
- ask all the questions you have for the healthcare professionals and members of the medical team.
- remember (and understand) why the surgery was performed, how it turned out, and what will follow
What are the postoperative risks or complications?
Need for further surgery to remove the ureteral stent (usually in an outpatient manner)
Common (10% of procedures of this type)
- Need for conversion to open (laparotomy) surgery – in case of sudden or serious complications
- Temporary pain in the hips or shoulder (due to nerve irritation during the surgery caused by filling the abdomen with gas)
- Transient problems with the intestinal passage, with spontaneous improvement
- Need for blood transfusions (approximately 14% of cases)
- The inserted stent may be associated with more frequent urination urge, a feeling of discomfort or mild pain in the bladder area (especially when urinating). Sometimes, blood may appear in the urine.
Occasional (2-10% of procedures of this type)
- Bleeding requiring further surgery or transfusion
- Lung injury requiring temporary removal of gas from the chest cavity
- Infections, pain or recurrences of the finding requiring further treatment
Rare (may occur in 2% of procedures of this type)
- Cardiovascular or anaesthesia-related complications that may require a longer stay at the intensive care unit (lung infections, pulmonary embolism, heart attack, deep vein thrombosis, etc.)
- Method failure with the development of congestion in the kidney with eventual need for removal of the entire kidney
- Injuries to nearby surrounding structures (blood vessels, spleen, liver, lungs, pancreas and intestines) requiring more extensive surgery or planned revision
- Injury of the kidney or ureter itself, which will require surgical revision and possibly removal of the kidney
- MRSA colonisation (0.9% – 1 of 110)
- Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
- MRSA blood infection (0.02% – 1 of 5,000)
Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.
What should I expect when I return home?
When you are discharged from the hospital, you should:
- Get recommendations on recovery at home
- Ask when you can return to normal activities such as work, exercise, driving, housework
- Get a contact number for further questions after returning home or in case of trouble
- Ask about the date of the following check-ups and the place where you should come (hospital or your attending physician), eventually about the date of stent removal
- Make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs
At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.
What else should I watch out for?
It is recommended that you wear elastic stockings for 2-3 weeks after discharge from the hospital. If you experience more frequent problems, burning or difficulty urinating, or have unusual bleeding, consult your attending physician.
Gradual recovery after this procedure takes 10-14 days and most people will return to their normal activities after 3-4 weeks.
In case of fever, redness, pulsation or secretion at the site of the surgical wound, contact your attending physician. Inform your attending physician of any other problems related to the procedure, do not underestimate any breathing difficulties. There is no bulging in the area of the abdominal wall due to the minimal extent of the incisions.
The date and place of your check-up will be determined upon discharge based on the course of the surgery and postoperative care (usually 6-8 weeks after the surgery).