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Robot Assisted Radical Nephrectomy

Robot Assisted Radical Nephrectomy is a minimally invasive surgical technique to remove the entire kidney and surrounding fat. This surgery is performed to treat primary renal tumors. When compared to conventional open surgery, Robotic surgery results in significantly less post operative pain, shorter hospital stay and earlier return to work and daily activities. It gives a more favorable cosmetic result while the oncological outcomes are identical to that of open surgery.

Not all the cases are candidates for a robotic approach (depending upon the tumor size, extent of spread of tumor etc). You should discuss with your doctor to determine whether you are the right candidate for this approach.

The Surgery

Robot assisted Radical Nephrectomy is performed under general anesthesia. The typical duration of the operation is 3-4 hours.

The surgery is performed through 3 to 5 small incisions (5-12 mm) made in the abdomen. The robotic arms with its attached instruments (that includes a camera) are passed through these “keyholes”. The camera provides the surgeon a 3-dimensional, high definition, magnified view of the tissues inside the body. Various types of Endowrist instruments with capability to move in various directions allow the surgeon to precisely dissect the kidney along with the tumor and make it completely free without having to place his hands into the abdomen. The dissected kidney, its surrounding fat and sometimes the adrenal gland (if removed) are then placed in a sterile retrieval bag and removed through a small incision. The entire kidney with the tumor is then sent to the pathologist for complete examination and to evaluate for detailed histopathological diagnosis.

What are the potential risks and complications?

Although the safety and efficacy of this procedure has been well established for selected patients, as with 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 operation is typically minor (average of 100ml) and need for blood transfusion is observed in less than 5% of the patients. If you are interested in autologous blood transfusion (donating your own blood) you must make your surgeon aware.
  • Infection: In order to decrease the chance of infection after surgery, all patients are treated with intravenous antibiotics given prior to the surgery. If you develop any signs or symptoms of infection after the surgery {fever (>100.5o F) drainage from incision, urinary frequency/discomfort, pain or anything that you may be concerned about}, please inform your doctor immediately.
  • Tissue / Organ Injury: Although uncommon, possible injury to the surrounding tissue and organs including bowel, lung, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. In case of partial nephrectomy, loss of kidney function is a rare but potential risk. Scar tissue may also form in the kidney requiring further surgery.
  • Conversion to Open Surgery: The surgical procedure may require conversion to the standard open operation. The conversion to open surgery should not be considered as a failure of the procedure but it is a sound surgical decision made by the operating surgeon to complete the challenging procedure safely and effectively without compromising the results. This could result in a larger than standard open incision and possibly a longer recuperation period.
  • Pathology: After the surgery, the pathologist will review the specimen in detail. The detailed information available from the pathological examination of the specimen helps in decision regarding any further treatment and followup of the disease. Approximately 15% of patients may have a final diagnosis of a benign tumor.
  • Hernia: As with any surgery, a hernia may form at the surgical site. Injury could also occur to nerves or muscles related to positioning.

What to expect immediately 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 medications are used to control the pain associated with the incision after the surgery. Pain medication can either be controlled and delivered by the patient or administered by the nursing staff via an intravenous catheter. You may also experience some minor transient shoulder pain (1-2 days) related to the gas used to inflate your abdomen during the laparoscopic surgery. Most patients see a large improvement in their pain level on the second day after surgery.
  • Nausea: You may experience some nausea related to the anesthesia. Medication are given to treat nausea.
  • Urinary Catheter: You can expect to have a urinary catheter draining your bladder (which is placed in the operating room prior to surgery) for approximately one to two days after the surgery.
  • Diet: You can expect to have an intravenous catheter (IV) in for 1-3 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.). Following surgery, the bowels will transiently “go to sleep”. Most patients are able to tolerate ice chips and then clear liquids the day after surgery. The diet is then advanced as tolerated by the patient. Once on a regular diet, pain medication will be taken by mouth instead of by IV or shot.
  • Fatigue: Fatigue is common and afternoon fatigue is common even several weeks beyond surgery. This is part of the body’s normal healing process.
  • Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections by 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 help prevent pneumonia and other pulmonary complications.
  • Ambulation: On the day after 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) along with tight white stockings on your legs to prevent blood clots from forming in your legs.
  • Hospital Stay: The length of hospital stay for most patients is for approximately 2-3 days.
  • Constipation: You may experience sluggish bowels for several days or several weeks. This is a combination of the surgery as well as the narcotic pain medicines. Suppositories and stool softeners are usually given to help with this problem. Taking stool softeners and mineral oil daily at home will also help to prevent constipation.

What is to expect after discharge from the hospital

  • Pain Control: You can expect to have some pain that may require pain medication for 2-7 days after discharge, and then paracetamol tablet should be sufficient to control your pain. Do not restart aspirin or blood thinner medicines until you have seen your surgeon and he gives the okay.
  • Showering: You may shower at home. Your wound sites can get wet, but must be patted dry. Tub baths can soak your incisions and therefore are not recommended in the first 2 weeks after surgery. You may have adhesive strips across your incision. These are not to be removed. They will fall off in approximately 5-7 days. 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 but should be taken slowly. 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 keep yourself well hydrated. Discuss with your doctor if you need to be on a salt or protein restricted diet.
  • Pathology results: The results from final histopathological analysis by the pathologists are usually available in one week time following surgery. Your doctor will discuss the results and its implication on future treatment at the time of your followup visit.

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