www.flinturology.com
Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
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John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions
Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.
This procedure is performed to eradicate upper tract cancers of the renal pelvis and ureter. The most common cell type is a transitional cell cancer. The operation includes removing the kidney, entire ureter and a 1 cm diameter bladder cuff around the ureteral orifice. This procedure actually is two operations completed at the same time. A standard 12th rib flank incision is used to remove the kidney and as much of the ureter as possible. Once the nephrectomy portion is complete, a second incision in the lower abdomen is made to compete the ureterectomy and bladder cuff. To do this the bladder must be opened and then closed. For this reason, a bladder catheter is required for 2 weeks after the surgery.
Your pre-operative appointments
Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.
Change In Health Status
Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.
Pre-Operative Medication Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:
Your operation occurs near the bowels so your preparation involves an intermediate-level bowel prep, as follows.
Pre-Operative Diet Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:
Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.
Pre-Operative Cleaning Instructions (bathing and showering instructions)
Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:
On The Day Of Surgery
The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.
After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.
Time To Arrive For Your Surgery
During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.
ARRIVAL TIME:
WHERE TO ARRIVE:
The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.
Indications:
Patient was found to have a mass of the renal pelvis or the middle/proximal ureter (benign or malignant) with CT characteristics suggesting malignancy. Metastatic work-up (blood work, CT Abdomen, bone scan and CXR) is supportive of this procedure. This procedure is being performed for cure, and may cause chronic renal insufficiency in the future requiring dialysis or transplantation.
Alternatives:
Alternatives include laparoscopic procedure in experienced surgeons hands, ureterorenoscopy with laser ablation of tumor, prolonged ureteral instillation of immunotherapy drugs (BCG, Interferon), percutaneous surgery.
Risks/Complications:
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.
The specific risks of this procedure include, but are not limited to: chronic hypertension, recurrence of the tumor in the future, possible new bladder tumor formation, failure of the procedure requiring adjuvant radiation and/or chemotherapy, damage to surround organs and their sequellae (lung, liver, spleen, colon, small bowel, great vessels, pancreas, gondal artery injury leading to loss of ovary or testicle), pleural effusion, pneumothorax requiring chest tube placement post-operatively, may have to do extensive vascular surgical procedures if there is a renal vein, vena caval, hepatic vein thrombosis, if the thrombus extends into the right heart then a by-pass procedure and additional chest incision will be required to attempt removal of all the tumor, partial loss of a rib. Patient is aware that he will require two incisions, one flank incision to remove the kidney pelvis and proximal ureter and one in the lower abdomen to remove the distal ureter and bladder cuff.
You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.
To view the actual printable form for this surgery, click here: Counseling Note for Nephroureterectomy. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.
Indications: Patient with upper tract GU mass.Sample Procedure Dictation:
TRadical Nephrectomy
The patient was given general anesthesia with an epidural, placed in the flank position making sure there were no pressure points on the legs and the elevated arm. The patient was prepped and draped in the usual standard sterile manner. A skin incision was made between 11th and 12th rib from the posterior axillary line to the mid-clavicular line anteriorly. The subcutaneous tissues were sequentially divided with bovie dissection. All three muscle layers were incised in a similar fashion until we encountered the 11th / 12th rib. The periosteum was elevated with the bovie the entire length of the incision. Care was taken not to injure the neurovascular bundle under the rib. The rib was elevated and then removed with the bone cutters. The cut end of the rib was blunted with the raspers and plugged with bone wax.
--------------Care was also taken during this maneuver not to enter the pleural cavity.
----or-------The pleural cavity was entered during the rib dissection without consequence. It was identified and then closed with 3-0 chromic sutures. At the end of the case once skin closure was accomplished, the air was removed using a red Robin catheter held under water. Hyperventilation, deep breathing and suction were used to remove the pneumothorax. A post-operative chest x-ray was obtained and noted not to have a significant pneumothorax.
--------------The kidney could be palpated without difficulty. Gerota's fascia was identified and with a combination of blunt hand dissection and sharp scissor dissection for area's more adherent, the kidney was isolated. All bleeders were identified and either coagulated, clipped or tied with 3-0 vicryl free ties.
--------------The adrenal gland was also removed with this procedure.
------or------The adrenal gland was noted to be left behind with no evidence of bleeding.
---------------Attention was directed to the identification of the ureter inferiorly. The ureter was dissected free and isolated with a yellow vascular loop. The ureter was then bluntly dissected superiorly to encounter the renal pelvis. The gonadal artery and vein were ligated and cut. Attention was focused on exposing the renal pedicle anteriorly first, then the pedicle was exposed posteriorly. The vessels were palpated gently to rule out any evidence of tumor thrombus. During the dissection, anteriorly and medially the peritoneum was encountered and care was taken not to enter the abdominal cavity. Once the vessels were identified, they were tagged with a red and blue vascular loop. All tributaries to the artery and the veins were then individually isolated tied or clipped and then cut. The entire kidney was then inspected and noted to be free from attachments. The pedicle was noted to be fully isolated. The ureter was then clipped with a large clip and divided. The renal artery was then tied with 2-0 silk sutures twice and a suture ligature was placed on the remaing stump. The artery was divided without blood loss. The renal vein was also sutured and divided in a similar manner. The kidney, peri-renal fat, Gerota's fascia and the renal pelvis with its lymph nodes were removed in block. The kidney and the mass were bivalved on the back table and noted to be of malignant character. The renal fossa was inspected, irrigated with warm water and all bleeders were identified and coagulated. The pedicle stumps were stable without any bleeding. A small piece of thrombin gel foam was placed for added security. The patient was taken out of the flexed position to allow the flank incision to close. The incision was closed in a three- layer fashion using partially running interrupted #2 PDS sutures. Each layer was irrigated with saline. The subcutaneous tissues were approximated and the skin was closed with staples. The wound was cleaned, Xerofoam gauze was placed and 4x8 bandaged were secured with tape. The Foley catheter was secured.
Distal Ureterectomy and Bladder Cuff
The patient was taken out of the flank position and repositioned in the supine position. The patient was prepped and draped in the usual standard sterile manner. A Fannestile incision was performed below the panty/underwear line. The skin and subcutaneous tissue was incised down to the rectus fascia. The rectus fascia was divided the length of the incision and the space of Retsius was developed bluntly to expose the bladder and obturator fossa. The obturator lymph nodes were palpated. All nodes were normal in character. The bladder was then entered in a vertical manner from the dome to the bladder neck with bovie coagulation and using 0-chromic stay sutures for traction. A 2-0 vicryl suture was placed at the apex of the bladder neck incision to prevent tearing the lateral wall of the bladder. The ureteral orifices were noted to be intact with good efflux. The ureteral orifice of the side involved was secured with a 3-0 vicryl suture through the ureteral orifice and the 5-French feeing tube. The ureter was then identified at the level of the iliac vessels and bluntly dissected free to the bladder. A 1 cm cuff of bladder mucosa and wall were excised and removed with the ureter as a specimen. This was sent for pathological review. The bladder defect was closed with a two-layer closure using 2-0 vicryl sutures. A 24 Fr three-way hematuria catheter was placed per urethra and the balloon was filled with 10 cc of normal saline. The vertical bladder incision was closed in a two-layer fashion with running 2-0 vicryl sutures. The bladder was then filled with normal saline by gravity and checked for leakage. The areas of leakage were closed with figure eight 2-0 vicryl sutures until no leakage occurred at a 350 cc volume. A 15mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain was secured with 3-0 nylon sutures to the abdominal wall. These and the Foley were securely tapped. The Foley was set-up with CBI at a rate of 150cc/hr. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR). The patient arrived to the RR in stable condition and without complications.
To the family and friends of patients undergoing surgery.
SCHEDULED STARTING TIME OF SURGERY:ESTIMATED LENGTH OF SURGERY:
You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.
The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.
We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.
Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.
Activity
Diet
Medication
Catheter and Wound Care
Bowel Movements
When to Contact your Doctor
Contacting Your Physician
Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.
Frequently Asked Questions after surgery
This section is under construction.