Urology

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Endoscopic kidney surgery

What does this procedure entail?

It is a kidney surgery through an artificial canal in the lumbar region.

What are the alternatives to this procedure?

Follow-up – monitoring, suitable if a spontaneous improvement of the condition can be expected, or the condition cannot be treated due to various reasons
Non-invasive treatment of urinary stones with extracorporeal shock wave
Open surgery – access to the ureter or kidney via an incision through the abdominal wall
Irradiation or chemotherapy, or combination of both methods in pelvic tumours
In certain cases, the removal of the entire kidney or even the ureter

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
pacemaker
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?

You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.

The procedure is performed exclusively under general anaesthesia.

The surgery is started with cystoscopy (examination of the bladder using a telescopic instrument inserted through the urethra). A ureteral catheter (tube) is inserted into the kidney. This catheter allows for contrast agent administration into the kidney, which helps the surgeon determine the anatomy when creating the access tract. The procedure itself is usually performed in a prone patient; a telescopic instrument (nephroscope) is inserted through an artificially created hole in the lumbar area. The kidney is accessed via a puncture in the lumbar region, which is then bluntly enlarged to allow for the insertion of the instrument and visual inspection:

The detected stones are removed completely or after crushing them using an ultrasonic wave, medical pneumatic hammer or laser.

A tumour growing from the renal pelvis wall is removed using a special cutting electrode.

The narrowing of the junction between the renal pelvis and the ureter is cut with a knife or a special electrode.

The procedure uses an X-ray emitter – fluoroscopy. After the procedure, you will have a nephrostomy drain (a plastic tube inserted into the kidney) and a catheter in your bladder in your lateral lumbar region. Sometimes it is necessary to temporarily (for 24-48 hours) ensure the outflow of urine from the kidney with 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. After crossing the renal pelvis and ureter, a special stent (a tube between the kidney and the bladder with a larger diameter in the surgical field) is usually inserted for 6-8 weeks – it is then removed with a cystoscope through the bladder.

The whole procedure in the kidney usually takes 45-60 minutes (but it may be longer especially depending on local conditions).

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.

Kidney area bleeding is usual after the procedure. 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.

If a ureteral catheter (plastic tube inserted in the ureter) has been inserted into the kidney, you must not get up from the bed or sit on the bed until it has been removed. After the procedure, you will have a nephrostomy drain (a plastic tube inserted into the kidney) for 3-4 days and a catheter in your bladder in your lateral lumbar region for 3-5 days.
The average general hospitalisation is 4-6 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?

Common (10% of procedures of this type)

Mild burning when urinating or the presence of blood in the urine shortly after the surgery (hours)
Transient body temperature rise
Insertion of a stent instead of ureteral catheter (if longer kidney drainage is expected). Further surgery will be required in this case to remove the stent
Resolution of the finding and removal of the stent (sometimes necessary or possible only during another, third, procedure)

Occasional (2-10% of procedures of this type)

Failure to remove all stones requiring further surgery
Repeated formation of stones
Failure to remove or incomplete removal of the tumour with the need for further management

Rare (2% of procedures of this type)

Significant bleeding requiring blood transfusions and intensive treatment
Kidney infection with subsequent deterioration of general health condition, rarely with the development of sepsis ("blood poisoning") and the need for intensive treatment with prolonged hospitalisation
Scarring of the ureter with the formation of strictures (narrowed areas of the ureter preventing free outflow of urine from the kidney), requiring further intervention
TUR syndrome caused by the absorption of a larger amount of lavage fluid into the bloodstream. It leads to increased blood pressure and heart rate, shortness of breath, headache with nausea or vomiting. Severe events can lead to unconsciousness or renal failure requiring dialysis.
Significant injury to the ureter, kidney or other internal organs requiring revision (open surgery) – very rarely with the need to remove the injured organ.

Hospital infections

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)
- 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?

If you experience more frequent problems, burning or difficulty urinating, or have unusual bleeding, consult your attending physician.

Any important information?

Most patients need 2-4 weeks of rest at home before they are able to handle a full workload. Before returning to work, we recommend a 3-4-week-long rest period, especially if you have a physically strenuous occupation. You should avoid lifting heavy loads at this time.