Nephroureterectomy

Nephroureterectomy surgery

Nephroureterectomy is a surgery to remove a kidney and its ureter often together with a cuff of the bladder around the point where the ureter connects. It is most commonly performed for urothelial (transitional cell) cancer of the upper urinary tract. 

Indications

The typical indication for nephroureterectomy is: 

• Carcinoma of upper tract urethra.
• Extensive injury or destruction of each kidney and ureter. 
• Non-functioning kidney due to chronic infection or obstruction. 
• In the rare cases, it is congenital or represents gross kidney and ureter disease.

Classifications of Nephroureterectomy

Open Nephroureterectomy

• Conventional method by a big flank or abdominal cut.
• It is frequently selected in large tumors or complicated cases.

Laparoscopic Nephroureterectomy 

• Minimal incision
• The choice is transperitoneal or retroperitoneal.

Robotic Nephroureterectomy 

• Like laparoscopic, except that robotic instruments are utilized to provide precision.
• Useful in complicated perinectomy around the bladder cuff.

Nephroureterectomy procedure

Indications: Nephroureterectomy is indicated for the management of upper tract urothelial carcinoma and non-functional kidney. 

Preoperative Preparation

• Imaging: CT or MRI to identify the tumor and to evaluate its function.
• Laboratory studies: CBC, renal function, electrolytes, coagulation panel.
• Anaesthesia clearance: General anaesthesia is a must. 
• Prophylactic antibiotics to prevent infection.
• Bowel prep if transperitoneal approach is going to be performed.
• Consent: Consent for bleeding, infection, injury to adjacent organs, or open conversion.

Anaesthesia and Positioning

• General anaesthesia, tracheal intubation.

Position of the patient: 

• Flank (lateral decubitus) to access the kidneys and proximal ureter.
• Bladder cuff excision may be done with Supine or Trendelenburg.
• Positioning and padding helps to eliminate nerve damage.

Surgical Approach

Open nephroureterectomy

• Kidney exposure using flank or thoracoabdominal incision.
• Move kidney through tearing of fat and tissues around it.
• Recognize and sew artery and vein of renal.
• Disssect the ureter down to the bladder and remove ureter with kidney en bloc. 

Laparoscopic 

• A number of port abdominal incisions (5-12 mm).
• CO2 insufflation in order to provide working space.
• Kidney and ureter dissecting laparoscopic instruments.
• Vessels clipped and divided.
• Sample has been stored in retrieval bag and excised using small incision.

Robotic nephroureterectomy

• Ports inserted in a similar manner to laparoscopy.
• Dissection can be performed through robot instruments.
• Especially applicable in removing distal ureter cuffs and bladder cuffs.

Bladder Cuff Excision

• Vital to excise the distal ureter including bladder cuff to avoid recurrence.

Techniques:

• Open: incision through small bladder ureteric orifice.
• Laparoscopy/robotic: intracorporeal bladder cuff excision and closure.
• It may also be performed by means of endoscopic (transurethral) stapling or resection. 

Specimen Removal

• Cuff of kidney, ureter and bladder excised in bloc.
• Examined to ensure that all tumor is removed.
• Occasionally put in retrieval bag to prevent tumor spillage.

Closure

• Examine bleeding or trauma of other organs.
• Install a drain beside kidney bed as required.
• The layers of the abdominal wall (muscle, fascia, skin) lie adjacent to each other.
• Leave the bladder catheter for 1-3 days to heal. 

Postoperative Care

• Measure vital signs, urine output.
• Pain management (IV or oral drugs).
• Early upsurge to avoid blood clots.
• Take out drain/catheter according to protocol.
• Gradual return to normal activities (4 to 6 weeks). 

Laparoscopic nephroureterectomy

It is resection of the kidney, full length ureter and a cuff of bladder using laparoscopic instruments with the same principles as open resection. It is mostly done in case of upper tract urothelial carcinoma or intact kidneys that do not work.

Indications

• UTUC.
• Blocked, non-functioning kidney, chronic infection or stones.
• Trauma or non-reconstructable renal/ureteral disease.

Benefits over Open Surgery

• Minor cuts + less pain after surgeries.
• Reduced blood loss
• Quick recovery and reduced hospitalization.
• Faster resumption of normal functions.
• Better cosmetic results

Robotic nephroureterectomy

It is a minimally invasive surgery, involving the excision of the kidney, the whole of the ureter and a cuff of bladder by application of a robotic surgical system. It is primarily performed on upper tract urothelial carcinoma and provides precision in strenuous dissections.

Indications

• Upper tract urothelial carcinoma
• Chronic obstruction or infection of their kidneys makes them non-functional.
• Surgical instances involving laparoscopic access that can be hard or precision are critical.

Benefits 

• More accuracy using robots.
• Improved 3-D magnified images.
• Increased dissection-suturing dexterity.
• Less challenging bladder cuff removal.
• Less bleeding and post-surgical pain.
• Short recovery compared to open operation.

Nephroureterectomy recovery

Recovery times differ according to whether the surgery was open, laparoscopic or robotic, but the underlying principles are the same. 

Recovery Period after Surgery (0–48 h) 

Hospital stay:

• Open surgery: 5–7 days
• Laparoscopic/robotic days 2–4 

Monitoring:

• Vital signs such as BP, Pulse and Oxygen
• Pass urine to empty kidney and bladder.
• Output drain in case there was a drain.

Pain management:

• First IV analgesics, followed by oral painkiller.

Catheter care:

• Foley catheter typically retained 1-3 days (depending on excision of bladder cuff)

Nutrition:

• Begin with clear liquids and gradually switch to normal diet.

Early Recovery (1–2 weeks)

Activity:

• Rest to begin with followed by light exercise to avoid blood clots.
• Do not lift heavy objects or be physically active.

Wound care:

• Wipe incision areas dry.
• Observe redness, swelling and discharge.

Drain and catheter:

• Drain removed when the output is small.
• Catheter taken out due to the instruction of the surgeon.

Follow-up labs:

• Kidney functioning blood tests.
• Electrolytes and hemoglobin levels.

Intermediate Recovery (2 to 6 weeks)

Physical activity:

• Cautiously resume normal life.
• Do not perform heavy lifting in 4-6 weeks.

Diet:

• Proper protein diet and healing.
• Hydration is important

Medication:

• Take pain medication as required.
• Antibiotics if prescribed

Long-term Recovery

Return to work:

• Laparoscopic/robotic: 2–4 weeks
• Open surgery: 4-6 weeks off work

Follow-up visits: 

• Check incision healing
• Recurrence imaging (ultrasound, CT or MRI).
• Urine cytology when surgery was due to cancer.

Lifestyle:

• Maintain healthy weight
• Control alcohol and avoid smoking.

Surveillance:

• It is imperative that regular monitoring is done in case of operation that was caused by cancer.
• The prognosis is enhanced by early recurrence diagnosis.

Nephroureterectomy complications

They may be characterized by complications which may depend on the surgery type (open, laparoscopic, robot), on the patient factors (age, kidney function, comorbidities).

General Surgical Complications

• Bleeding / Hematoma
• Infection
• Complications associated with Anaesthesia
• Deep Vein Thrombosis 

Urinary Complications

• Urine Leak
• Bladder Dysfunction
• Hydronephrosis of Remaining Kidney

Vascular Complications

• Renal artery or vein injury
• Bleeding from surrounding vessels

Gastrointestinal Complications

• Bowel injury
• Ileus
• Nausea and vomiting

Incision / Port Site Complications

• Hernia at incision site
• Poor wound healing
• Scarring

Long-Term Complications

• Chronic kidney disease
• Hypertension
• Persistent pain or discomfort

Best hospital nephroureterectomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Nephroureterectomy is the removal of the entire kidney, ureter and a small part of the bladder and is predominantly performed in upper tract urothelial carcinoma or very comorbid/non-functioning kidney patients. Modern surgical techniques such as laparoscopic and robotic surgeries have made it safer more minimally invasive with lesser side effects when compared with the open surgery, but at the same time ensuring complete removal of the involved urinary tract. 

Nephroureterectomy India GetWellGo

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FAQ

1. Do I have to use a catheter?

• Yes, a Foley catheter is typically left in place for 1–3 days after surgery to let the bladder heal (if a bladder cuff was removed).

2. How will my kidney function?

• If the remaining kidney is healthy most people do very well with the surgery. Preoperative renal function is routinely evaluated to ensure safety.

3. Does this surgery cure cancer?

• Nephroureterectomy is curative in early-stage upper tract urothelial carcinoma.
• Close monitoring with periodic imaging and urine tests are required for recurrences.

4. Can nephroureterectomy be done minimally invasively?

• Yes, laparoscopic and robotic approaches are commonly utilized. They have small incisions, quicker healing, and less pain when compared to open surgery.

5. Will I have scars?

• Open surgery: a larger flank or abdominal incision
• Laparoscopic/robotic: 3–4 small cuts (most 0.5 – 1.5 cm long each)
• Usually the best cosmetic result: Robotic surgery.