The surgical removal of the kidney, renal pelvis (the center part of the kidney that collects urine), ureter (a long tube that drains urine from the kidney into the bladder), and bladder cuff (a small piece of tissue where the ureter connects to the bladder) is known as "Nephroureterectomy." It is a minimally invasive (does not involve extensive incisions or bleeding, with quick recovery) procedure used to treat upper urinary tract transitional cell carcinoma (TCC), also known as urothelial cancer. TCC is a tumor of the renal pelvis and ureter that may also involve the urothelium (the tissue that lines most of the urinary tract, including the renal pelvis, the ureter, and the bladder).
"Nephro" means related to the kidneys; "ureter" is the thin, long tube that collects urine from the renal pelvis and drains it into the bladder; and "ectomy" means to remove a part of the organ. Nephroureterectomy is a minimally-invasive radical removal of the kidney, renal pelvis, the entire ureter, and the bladder cuff.
Nephroureterectomy is always radical surgery, which means your surgeon will remove the tumor along with the organ into which cancer has spread. It is performed through
- Open nephroureterectomy- Involving one or two large incisions (cuts) for removal.
- Manual laparoscopic nephroureterectomy- Involves a laparoscope (a long hollow tube that consists of a light source and a camera) manually inserted through keyhole-sized incisions.
- Robot-assisted laparoscopic nephroureterectomy- Involves inserting a laparoscope through keyhole-sized incisions using a robotic arm handled by the surgeon.
Urothelial cancer can develop from the tissue lining of the urinary tract (urothelium), which may progress and spread to nearby structures. Symptoms include- hematuria (blood in the urine), unexplained weight loss, an abnormal mass in the kidney area, and persistent backache and fever. These tumors are best removed through a radical (complete) nephroureterectomy through a traditional open approach or other minimally invasive techniques (laparoscopic or robotic-assisted).
Urothelial carcinoma (cancer) causes 90% of all bladder cancers and 7% of all types of kidney cancer (including ureter and kidney pelvis).
Nephroureterectomy has remained the gold standard for surgical management of upper tract transitional cell carcinoma, especially if it is on the aggressive end of the cancer spectrum.
When you notice any symptoms associated with urothelial cancer, schedule an appointment with a urologist (a doctor specializing in urinary tract diseases) and discuss your symptoms.
- Your urologist will recommend a series of tests to confirm the diagnosis and plan the treatment accordingly. These include:
- Blood tests evaluate your blood urea nitrogen (BUN), and creatinine levels.
- Urinalysis to check for any urinary tract infections.
- Urine cytology examines your urine microscopically to check for abnormal cells. Kidney cancer cells are most often shed in the urine.
- Intravenous pyelogram (IVP) by injecting dye into your veins and examining the X-ray images to check for any blockage.
- Ureteroscopy uses a thin tube with a light source and camera to view the interior of the ureter and renal pelvis and takes tissue samples.
- CT (Computed Tomography), and MRI (Magnetic Resonance Imaging) scans provide a detailed picture of the inside of the ureter and renal pelvis.
- X-ray and ECG (electrocardiogram) to evaluate your overall health.
- You must inform your surgeon if you have any medical conditions like asthma, diabetes (increased blood sugar levels), thyroid, heart, or lung diseases. This will help your surgeon plan the surgery with proper precautions.
- List the medications being taken, including anti-inflammatory drugs, blood thinners, and other herbal supplements. These must be discontinued 2 weeks before the surgery to prevent the risk of excessive bleeding.
- Alcohol and smoking should be strictly avoided 2 weeks pre-procedure to prevent delay in wound healing.
- You will be advised to follow a clear liquid diet 24 hours before the procedure and fast after midnight, the night before the surgery.
Nephroureterectomy is an inpatient procedure and requires 1–2 days of hospitalization.
- On the day of the surgery, the nurse will check your vitals (blood pressure, pulse, heart rate, urine output), before you are wheeled into the operating theater.
- Your anesthesiologist (a doctor who administers anesthesia and specializes in pain management) will administer general anesthesia (GA).
- The surgical site (abdomen) where the incisions (cuts) are made will be disinfected with an antiseptic solution to remove surface contaminants.
- The procedure will be performed in one of the following ways:
- Once you are prepped, a large incision will be made on the abdomen using a surgical knife (scalpel).
- Your surgeon will separate the tissues carefully and excise (cut away) the kidney, renal pelvis, ureter, and bladder cuff, which contains the cancer cells.
- The wound will be closed with resorbable (dissolve on their own) sutures (stitches).
- The procedure will take around 1 to 2 hours.
Hand-assisted Laparoscopic Nephroureterectomy
- The procedure involves around 4 to 5 keyhole-sized incisions around the abdomen to access the kidney.
- Your surgeon will use gas to expand or inflate the surgical site for a better view.
- A laparoscope will be inserted manually by the surgeon through one of the incisions to view the interior of the ureter and the kidney and capture images.
- The images will be projected on the screen, guiding the surgeon in performing the surgery.
- Small surgical instruments will be inserted through other keyhole incisions to excise the ureter and surrounding structures.
- Small drainage tubes will be inserted to facilitate fluid and blood drainage.
- The incisions will be closed through small stitches with the tubes in place.
- The procedure will take around 2 to 3 hours.
Robotic-assisted Laparoscopic Nephroureterectomy
- This procedure is the same as a laparoscopic approach, but instead of manually inserting the laparoscope, a robotic arm will be used.
- The surgeon will sit at a platform (console) away from you to operate the robotic arm to perform the procedure.
- The surgery usually takes a little longer, around 3 to 4 hours.
You will be kept under observation in a recovery room following a nephroureterectomy. Your vitals will be monitored, and once they have stabilized, you will be shifted to your room.
At The Hospital
- You may feel mild pain and discomfort once the effect of the anesthesia wears off. Your surgeon will prescribe painkillers to manage pain.
- A urinary catheter will be placed for 1 to 2 days post-procedure to drain the urine.
- You will be given a liquid diet for the initial 24 hours following the nephroureterectomy. You will be given a solid diet from the 2nd-day post nephroureterectomy.
- The day after the surgery, you will be made to walk as walking helps to limit the risk of blood clots in your legs. Once you are ambulating and your vitals are stable, you will be discharged from the hospital.
- Rest, a healthy diet, and proper hydration are important for healing.
- You may experience some pain at the incision site, which may take a week to subside. You will be given pain medications for relief.
- You will be allowed to shower at home but make sure to pat dry the wound site. You should avoid sauna, tub baths, and swimming for 2 weeks after the surgery.
- Walk regularly and do mild exercises. This will prevent the development of clots in the legs.
- You should avoid driving for 1 to 2 weeks after the surgery as it will hamper the healing.
- You must not lift heavy weights or perform strenuous exercises for 3 to 4 weeks after surgery.
- Drink ample water to keep yourself hydrated.
- In most cases, patients are allowed to follow a normal diet plan. Your surgeon will inform you of the diet plan. In some patients, protein-restricted or salt-restricted diets will be advised. Avoid processed, oily and spicy food as they may cause bloating and constipation.
- You should follow up with your surgeon after 7 to 10 days. Your surgeon will examine you and check the progress of your recovery.
- You should be able to resume your job 4 weeks after surgery.
- Recovery may take around 3 to 4 weeks.
Nephroureterectomy is the gold standard surgical treatment for aggressive transitional cell carcinoma (urothelial cancer), with a high success rate (up to 95%). The benefits and risks of the procedure are listed below:
- Minimally invasive procedures like laparoscopic and robotic surgeries offer high precision and result accuracy.
- Shorter hospital stays with quick recovery.
- Smaller incisions with minimal scarring.
- The procedure successfully removes the tumor and improves your survival rate.
- Improved kidney function due to removal of the diseased ureter, kidney pelvis, and bladder cuff.
- The associated symptoms like hematuria, weight loss, abdominal cramps, and pain are alleviated through the procedure.
- Allergic reactions to anesthesia- May cause hives, skin rashes and itching, nausea, vomiting, confusion, dizziness, and breathing difficulties.
- Seroma- A condition characterized by fluid-up at the surgical site.
- Hematoma- Abnormal mass of clotted blood.
- Infection- With associated symptoms like fever, chills, and body aches
- Blood clots- These may eventually dislodge in the bloodstream and travel to internal organs (e.g., Pulmonary embolism in the lungs).
- Delayed healing- Leading to repeated infections and pus discharge at the surgical site.
- Excess blood loss- With the possible need for blood transfusions.
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