Robotic Assisted Partial Nephrectomy
Indications:
- Small renal cancers
- Exophytic
- Not involving the collecting system
- Single kidney
- Fit for surgery
- Nephron-sparing
Robotic Assisted Radical Nephrectomy
Indications:
- Renal Cancer meeting the criteria for surgery
Unfortunately, this procedure is no longer done in my practice, and you will be referred to a Urologist who does.
Drainage Renal Abscess
To drain a large abscess causing low grade to high temperatures. Percutaneous or open procedure for the drainage of abscess.
Why is it done?
- Patients presenting with low grade persistent fevers, even high fevers requiring admission to High Dependency Unit for septicemia.
- Usually immune compromised patients: Diabetics, Corticosteroid users, Viral immune-deficiency states etc.
- This condition requires urgent drainage.
- The patients’ need to be resuscitated first by an emergency team with appropriate fluids and antibiotics and placed in an area where all systems can be supported (HDU).
- As soon as the patient is stable, this abscess needs to be drained, either with open surgery or percutaneous drain placement.
- If it is a large pyonephrosis with a non-functioning kidney, a nephrectomy should be considered.
How is it done?
Patients will receive a general anesthesia.- Appropriate resuscitation would have been started.
- Prophylactic anti-biotics is given.
- An indwelling catheter is placed.
- The correct kidney is identified and marked while you are awake.
- If it is a small abscess, an ultrasound guided needle is placed through your back or side into the fluid collection. A guidewire will be placed through the cannula and a drain fed in over the guidewire. All the pus will be drained.
- If it is a large loculated abscess, an incision will be made over the area closest to the skin. The cavity will be opened, drained and rinsed, after which a drain will be placed.
- If you have a non-functioning kidney associated with this, your kidney may be removed at the same time.
- A drain is left post-operatively.
What next?
- You will spend up to 7 or more nights in hospital.
- You may be on life support depending on the degree of sepsis.
- You will have intravenous fluids, antibiotics and circulatory supporting drugs being administered. Either a central venous line for monitoring, an arterial line and a peripheral infusion line.
- You will have a catheter for that time.
- A drain for 2-3 days.
- Your drain will be removed with minimal drainage present.
- You will a trial without the catheter as soon as you are back in the ward.
- You will be discharged as soon as your renal function has stabilized, and you have opened your bowels.
- Allow for 6 weeks for stabilization of symptoms.
- A follow-up appointment will be scheduled for 6 weeks.
- DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!
Risks
- This a potentially dangerous condition, which could result in death. It requires urgent management!
- May lose your kidney in serious cases.
- May risk dialysis when in septic shock.
- Wound Infection.
- Prolonged stay in HDU.
- Post-operative hernia formations especially associated in the elderly with atrophic abdominal muscles.
- NB! Each person is unique and for this reason symptoms vary
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Nephropexy – Robotic Assisted
Why is it done?
- Nephroptosis causing abdominal pain
- Confirmed on standing Urogram with hydronephrosis caused by kinking of the ureter as the kidney falls down due to loss of supporting structures
- Done with robotic assistance
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How is it done?
- GA
- Prophylactic anti-biotics is given.
- An indwelling catheter is placed.
- The correct kidney is identified and marked while you are awake
- Depending on the affected side of 5 incisions will be made.
- Porst placed and attached to the Da Vinci robotic system
- The colon is reflected to reveal the retro-peritoneal space
- The ureter is identified and cleared up to the hilum
- The upper pole of the kidney is mobilized with its surrounding fat.
- A proximal spot on the psoas muscle is cleared
- 2 non-dissolvable sutures are used to fix the upper pole of the kidney to the Psoas Muscle
- A drain is placed
Complications
Side–effects
- Minimal Blood loss
- Wound Infection.
- Post-operative hernia formations especially associated with the elderly with atrophic abdominal muscles
- NB! Each person is unique and for this reason, symptoms vary
Repeat CT in 6 weeks
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Copyright 2019 Dr Jo Schoeman
Pelvi-Ureteric Junction Repair (PUJ) – Robotic Assisted
A congenital or acquired narrowing in the ureteric pelvis junction. This narrowing is excised with a reconnection. There are several techniques described in repairing this: I prefer the Dismembered Pyeloplasty
Why is it done?
- High grade obstruction.
- Causing deterioration of renal function.
- Thinning of renal cortex.
- Chronic pain.
- Chronic infection.
- Recurrent renal calculi.
Causes
- Congenital lack of muscle, or neuro transmission in this area, causing a non-functioning part leading to obstruction.
- Vesico-ureteric reflux, longstanding can also cause this.
- Usually diagnosed in kids.
- Crossing vessel.
How is it done?
Robotic assisted pyeloplasty.
- Types
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- Dismembered.
- Foley’s Y-V Pyeloplasty.
- Culp-Dewierd.
- Pelvi-calyceal pyeloplasty.
- Endopyelotomy with laser.
- Patients will receive a general anaesthesia.
- Prophylactic antibiotics is given.
- The correct ureteric system is identified and marked while you are awake.
- This will be mostly a robotic / laparoscopic procedure.
- The endoscopic procedure is reserved as a second line in my practice.
- Laparoscopic ports are placed
- The affected ureter is exposed, the defect cut out with a re-anastomosis of a spatulated ureter to a trimmed renal pelvis over a ureteric stent.
- An indwelling catheter is placed. A drain is placed.
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What next?
- You may be in hospital for 3 days
- Your drain will be removed when there is no urine draining.
- Your catheter will be removed the following day.
- As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged
- A ward prescription may be issued on your discharge, for your own collection at any pharmacy.
- A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anaesthesia with a Flexible Cystoscope.
- A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
- Any pain or signs of fever require an urgent review.
- DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!
Possible Complications
- Re-stenosis with recurrent obstruction.
- Second procedure.
- With further deterioration of renal function, you may require a nephrectomy where affected kidney contributes < 15-20% of total renal function.
- Urine leak, Urinoma, requiring drainage.
- Infection possible sepsis requiring long-term antibiotics.
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Rigid Cystoscopy, Retrograde Pyelogram, Stent Management
A therapeutic procedure under general anaesthetic, where a rigid cystoscopy is done in the bladder via the urethra, ureteric catheters are placed to enable imaging of the upper tracts with/without insertion or removal of ureteric stents
Why is it done?
To investigate:
- Hematuria (blood in the urine)
- Recurrent upper urinary tract infections
- Space occupying lesions in the kidneys and ureters
- Abnormal cells suggestive of urothelial carcinoma, on urine cytology
Risk factors:
- Strong family history of bladder cancer
- Smokers or passive smokers
- Factory workers: dyes, paints, etc
- Exposure to Schistosoma (Bilharzia)
- Renal stone disease, bladder stones
How is it done?
- This is done under General anaesthesia.
- A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant gel and saline irrigation.
- The bladder is then distended with saline.
- The inside of the bladder is viewed for pathology.
- A retrograde pyelogram is done at the same time, (placement of small silicone catheters up the kidney pipes). Through this iodine contrast is injected up into the kidney collecting systems. This facilitates the viewing of kidney pipes and kidney collecting systems on X-ray to exclude any upper tract pathology.
- If any abnormalities are found in the kidney/ ureters, a ureteroscopy (which is the placement of a long thin camera up the ureter) will be performed.
- If any suspicious lesions are seen, a biopsy will be taken.
- A ureteric stent may be placed
- Urine would have been sent for cytology, to rule out the existence of cancer.
Antibiotics may be given to prevent infection
Complications
What to expect after the procedure?
- Pain on initial passing of urine
- Bladder infection ranging from a burning sensation to, fever, to puss (rare)
- Bloodstained urine
- Lower abdominal discomfort which will persist for a few days
- Pain radiating from bladder to renal angle associated with urinating.
- An infection could present with a stent being present.
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Wes Cystoscopy RGP and Ureteric stents
Copyright 2019 Dr Jo Schoeman
Uretero-Renoscopic Stone Extraction with Laser (URSE)
A ureteric or renal calculus is removed with technique and may require a laser. A rigid/ flexible ureteroscope can be used.
Stones in the kidney, urinary bladder and ureter. medical illustration with a cross section of the kidney and bladder. anatomy of the urinary system. Human kidney.
Why is it done?
- Removal of renal or ureteric stones.
- Ureteric stones can vary from 5mm to over 1 cm in size.
- You may present with excruciating pain on the affected side. (This pain may be worse than childbirth).
- Renal stones usually larger than 1cm obstructing the renal pelvis.
- Or renal stones not causing any symptoms.
- Any fevers or a single kidney is deemed an emergency!
Two Treatment Options
- Ureteric Calculi.
- Managed with rigid ureteroscopy.
- Prior stenting with a ureteric stent,
- 7-10 days after stenting the stent is removed, and the stone is addressed with laser
- Renal Calculi.
- Prior stenting for 7-10 days.
- After stent removal the kidney is accessed with a flexible uretero-renoscope and the stone is fragmented with laser
How is it done? /Picture35.png)
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- Patients will receive a general anesthesia.
- Prophylactic antibiotics is given.
- The correct kidney is identified and marked while you are awake.
- You would have had a cystoscopy with retrograde pyelogram 10 days prior with placement of ureteric stent to prepare your ureter.
- A cystoscopy will be done first to remove the stent, and 2 guidewires will be placed to enable access up the ureter.
- Depending on the position of the stone, either a rigid or flexible uretero-renoscope will be used.
- If a stone is in the kidney a flexible uretero-renoscope will be used with access obtained with an access sheath to protect the ureter from damage.
- Laser will be used to fragment the stone.
- All fragments will be attempted to be cleared. Small 1-2 mm fragments may be left as “Clinically Insignificant Fragments (CISF)” and will pass spontaneously.
- A Ureteric catheter with an indwelling catheter is left post-operatively overnight.
- Catheters will be removed the next morning depending on the presence of blood in the urine.
What next?
- You will spend at least one night in hospital.
- You will have a catheter for that time.
- On removal of your catheter, you may experience sharp colicky pain, exactly the same as your presenting renal colic. This is due to your ureter contracting back to its usual size. (The stent has dilated this to 5X its usual size).
- You will be discharged as soon as your pain has stabilized and you can function independently.
- Allow for a few days for stabilization of symptoms.
- A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
- A follow-up appointment will be scheduled for 6 weeks. Stone analysis results will then be discussed in order to formulate a plan to proven recurrences
- DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!
Types of Stones:
- Calcium Oxalate.
- Uric Acid.
- Calcium Phosphate.
- Struvite (Infection stones).
- Cystine.
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