Removal of the entire kidney and surrounding fat (radical nephrectomy) is often necessary when a patient develops a tumor on their kidney. 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 since 1995, 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 kidney cancer data following laparoscopic radical nephrectomy.
Dr. Scott Miller uses a relatively uncommon modification to perform a laparoscopic radical nephrectomy. The kidney does not exist within the abdominal cavity, but rather behind the intestines in a location called the retroperitoneal space. Most kidney removals involve going through the abdominal cavity in order to enter this space. Avoiding the abdominal cavity can minimize recovery and risk of intestinal injury. Although this technique (retroperitoneal laparoscopy) is more difficult to learn, once mastered, it is actually easier for the surgeon (and the patient).
Similar to other laparoscopic procedures, the surgeon makes a button-size incision below the side of the ribcage for the insertion of a telescope (near where one’s elbow would hang while standing). After expanding the retroperitoneal space with carbon dioxide gas, two or three 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 kidney’s blood vessels are then tied off and divided. Unlike traditional large-incision surgery, separating the blood vessels early in the procedure eliminates the major communication between the tumor and the rest of the body prior to manipulating the kidney. Once the kidney is separated from all of its surrounding structures, it is placed in a protective plastic bag that closes with a purse-string (all while inside the body).
Now the kidney and its surrounding fat must be removed in one piece. 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. Since the retroperitoneal space actually extends from the ribcage down to the pelvis, a long instrument can be placed through the additional incision in order to grasp the bag’s purse-string. 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.
Results & More
Laparoscopic radical nephrectomy facilitates quicker recovery, less pain, and a lower complication rate as compared to the typical open-incision radical kidney 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: Is the adrenal gland removed during a laparoscopic radical nephrectomy?
A: Removal of the adrenal gland is not always necessary. Location of the tumor and anatomy of the adrenal gland are the most important factors in this decision.
Q: Are lymph nodes removed during a laparoscopic radical nephrectomy?
A: Unless an abnormal lymph node is encountered, lymph node removal is typically not needed.
Q: What happens to the space once occupied by the kidney?
A: Normal abdominal structures will re-occupy the area.
Q: Is a laparoscopic radical nephrectomy performed with robotic assistance?
A: Robotic assistance provides no significant advantage to an experienced laparoscopic surgeon during kidney removal. Although this procedure can be performed robotically, Dr. Scott Miller usually prefers operating at the patient’s side rather than remotely from a control console. Instrument movements outside of the surgeon’s view can lead to a catastrophic complication.
Q: What is the difference between the retroperitoneal and standard laparoscopic methods for kidney surgery?
A: The kidney does not exist within the abdominal cavity, but rather behind the intestines in a location called the retroperitoneal space. Most kidney removals involve going through the abdominal cavity in order to enter this space. Avoiding the abdominal cavity can minimize recovery and risk of intestinal injury. Although this technique (retroperitoneal laparoscopy) is more difficult to learn, once mastered, it is actually easier for the surgeon (and the patient).
Q: What is the difference between hand-assisted and pure laparoscopic kidney surgery?
A: Hand-assisted laparoscopy is actually a hybrid between laparoscopic and open-incision surgery. A 3-4 inch incision is made in the abdomen and the surgeon inserts a hand into this cavity to assist with the surgery. After expanding the retroperitoneal space with carbon dioxide gas, two or three additional small incisions are made to place narrow tubes used for interchangeable instruments and telescope. The surgeon can then visualize the kidney, interchangeable instruments, and hand on a television monitor. Since the recovery is better than open surgery, this technique can be useful for less experienced laparoscopic surgeons. However, the outcomes do not match pure laparoscopy in an experienced set of hands.
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: 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 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 radical nephrectomy 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 influence whether I am a candidate for laparoscopic radical nephrectomy?
A: For tumors much greater than 10 centimeters, open surgery may be more appropriate.