Other Kidney Conditions

Robotic Assisted Laparoscopic (da Vinci®) Pyeloplasty

Laparoscopic Pyeloplasty provides patients with a safe and effective way to perform reconstructive surgery of a narrowing or scarring where the ureter (the tube that drains urine from the kidney to the bladder) attaches to the kidney through a minimally invasive procedure.

General Information

This operation is used to correct a blockage or narrowing of the ureter where it leaves the kidney.  This abnormality is called an ureteropelvic junction (UPJ) obstruction which could potentially cause pain, stones, infection, high blood pressure and deterioration of kidney function. When compared to the conventional open surgical technique, laparoscopic pyeloplasty 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 identical to that of the open procedure (Fig 1).

The Operation

Typically, the length of the procedure is 2-3 hours.  The surgery is performed through making 3-4 small (1cm) incisions in the abdomen (Fig. 2).  A small plastic tube (called a ureteral stent) is left inside the ureter at the end of the procedure to bridge the pyeloplasty repair.   The stent will remain in place for 4 weeks and is usually removed in the doctor’s office.

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 minimal and only rarely is a blood transfusion necessary.
  • Infection: All patients are treated with broad-spectrum intravenous antibiotics prior to starting the surgery to decrease the chance of infection from occurring. Hernia at incision site is uncommon.
  • 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.
  • Conversion to open surgery: this surgical procedure may require conversion to the standard open operation if difficulty is encountered during the laparoscopic procedure. This could result in a larger standard open incision and possibly a longer recuperation period.
  • Failure: Roughly 3 % of patients undergoing this operation will have persistent blockage due to recurrent scarring.  If this occurs, additional surgery will be necessary.

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 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: Pain medication can be controlled and delivered by the patient via an epidural or an intravenous catheter or by injection (pain shot) administered by the nursing      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.
  • Urinary Catheter: You can expect to have a urinary catheter draining your bladder (which is placed in the operating room after you are asleep) for approximately one day after the surgery. 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) 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; 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.
  • Fatigue: Fatigue is common and should start to subside in a few weeks.
  • 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 of 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).
  • Hospital Stay: The length of hospital stay for most patients is approximately 1 day.
  • 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 the stool softeners daily at home will also help to prevent constipation.

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.
  • Showering: You may shower at home. 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 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 at least 1-2 weeks after surgery. Absolutely no heavy lifting (greater than 20 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 3 weeks after surgery. You can expect to return to work in approximately 4 weeks.
  • Diet: You should be on a regular diet unless otherwise directed by your surgeon.
  • Follow-up Appointment: You should have a follow up appointment arranged for you prior to your discharge. The usual initial visit is 2-3 weeks after surgery.
  • Stent Follow up: The stent remains in place and will be removed in the doctor’s office in about 4 weeks. It is not 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 but may persist until the stent is removed.

Links for More Information

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