Heminephrectomy or partial nephrectomy is a surgical procedure to remove a part of the kidney if it is not working properly. It is also used for people with duplex kidneys, i.e., two ureters attached to one kidney. Laparoscopic heminephrectomy is a minimally invasive procedure in which the surgeon performs the surgery through keyhole incisions.
Anatomy and Physiology
- Kidneys are long, bean-shaped organs that sit behind the abdomen in the small of the back on both sides of the spine.
- They are responsible for removing toxic waste products and excess salts and water from the body in the form of urine.
- The collecting system funnels the urine from the kidneys into the ureter (tubes), which go down to your bladder.
- Normally, the kidneys have one ureter each.
- However, in the case of a duplex kidney, two ureters drain a single kidney.
- One ureter drains the upper pole, and the other drains the lower pole of the kidney.
- A duplex kidney may occur in one or both of your kidneys.
- It can be either complete or incomplete.
- Complete duplication involves two separate ureters from the kidney entering the bladder separately.
- Incomplete duplication involves two separate ureters attached to the kidney that meet at some distance and enter the bladder as one.
Who Needs Laparoscopic Heminephrectomy?
You may need a laparoscopic heminephrectomy if:
- A part of your kidney is not working properly, either due to a congenital defect or as a result of infection, accident, or disease. Removing the unhealthy part of the kidney can enable the rest to work properly.
- Recurrent UTIs (Urinary Tract Infections)
- Ureterocele (the ureter forms a balloon as it enters the bladder)
- Ectopic ureter (one of the ureters may drain into the nearby organs instead of the bladder)
- Vesicoureteral reflux (abnormal flow of urine from your bladder back up the ureter, reaching the kidneys)
- You have benign and malignant conditions of a horseshoe kidney (a condition when two kidneys fuse together and form a shape of a horseshoe).
How is Laparoscopic Heminephrectomy performed?
- During a laparoscopic heminephrectomy, the surgeon makes around 3 to 5 small keyhole incisions (less than 1 cm) in the abdomen.
- Through these incisions, the surgeon inserts portals called trocars.
- These trocars allow the surgeon to insert a laparoscope (a thin tube-like instrument at a camera at the end) and hand-held surgical instruments in the abdomen.
- The laparoscopy enables 10X magnification of the surgical field, allowing the surgeon to complete the procedure with proper visualisation.
- Next, he/she fills the abdomen with carbon dioxide gas to create a larger working space.
- He/she dissects and exposes the affected kidney.
- The blood supply to the kidney is either clipped or closed temporarily to minimise blood loss during the excision of the damaged portion of the kidney.
- The surgeon excises and removes the damaged portion, surrounding fat, and visible surrounding lymph nodes.
- He/she closes the kidney defect with sutures and restores the blood supply to the kidney.
- He/she leaves a small drain in the kidney area, exiting one of the keyhole incisions in the abdomen.
- Finally, the surgeon removes the trocars, closes the skin incisions with absorbable sutures, and applies a sterile dressing on the wound.
- If too much of a kidney is damaged, you may need a total or radical nephrectomy.
What Can You Expect Before the Surgery?
Consultation and Evaluation
- Before the surgery, the doctor will advise you for a pre-anaesthetic checkup.
- He/she will evaluate your medical history and conduct pre-operative tests, such as blood tests, ultrasound, CT scan, and MRI.
- Inform your doctor about any medical problems you have, such as allergies.
- Also, inform him/her about the medications you currently take, including prescribed, over-the-counter, herbs, and supplements.
- The doctor will briefly explain the procedure, hospital stay, estimated cost, and insurance formalities.
- You may need to stop taking blood-thinning medications, such as aspirin a few days before the procedure.
- Your healthcare team will ask you to stop eating or drinking anything 6-12 hours before the procedure.
- If you smoke, the doctor will advise you to quit smoking as it can interfere with healing.
What Can You Expect on the Day of the Surgery?
- Your doctor will ask you to sign the consent formalities, giving your permission for the procedure.
- The team will ask you to wear a hospital gown and remove all jewellery pieces.
- The nursing staff will shave the excess hair at the surgical site.
- The doctor will record your last meal and give you medicine with a sip of water.
- The anaesthesiologist will monitor your vitals, such as breathing, heart rate, and blood pressure.
- Finally, the team will shift you to the OT room.
What Can You Expect During the Surgery?
- In the OT room, you will be made to relax on the operating table in an oblique position, with an elevation of the operative side.
- The anaesthesiologist will start an IV line for fluids and medications in your arms or hands.
- You will undergo general anaesthesia to put you to sleep during the procedure.
- Someone from the team will clean the surgical site with an antiseptic solution.
- The anaesthesiologist will monitor your vitals throughout the procedure.
- The surgeon will make the incisions, insert the surgical instruments in your abdomen, and perform the surgery.
- Once the surgery is completed, he/she will close the incisions with absorbable stitches and cover the wound with a sterile dressing.
- The complete procedure takes approximately 3-4 hours.
What Can You Expect After the Surgery?
In the hospital
- The team will shift you to the recovery room after the surgery to observe your vitals and the effect of anaesthesia.
- Once your vitals stabilise, the team will shift you to a general ward.
- You will have a urinary catheter for two days after the surgery.
- The doctor will remove the drain placed in your kidney area the second day after the procedure.
- Once you feel a little better, the doctor will encourage you to move around to prevent the formation of blood clots in your legs.
- You will be taught deep breathing exercises to prevent respiratory infections like pneumonia.
- You will undergo an ultrasound examination of the urinary tract, enabling the doctor to determine postoperative care.
- You may have a poor appetite for a week following the surgery.
- Your diet will slowly advance from liquids to solids as and when you can tolerate it.
- Start by taking only small amounts of liquids orally.
- As your oral intake improves, an intravenous catheter will provide the required hydration to your body.
- The doctor will prescribe pain medications to manage pain.
- He/she may also prescribe stool softeners to help with constipation.
- You may get discharged from the hospital within a day or two.
- Before discharge, the doctor will provide you with home care and follow-up instructions.
- You can resume your normal diet once you start to pass gas and experience an improved appetite.
- You may shower immediately after discharge, allowing the incisions to get wet.
- Pat your incisions dry after the shower.
- Avoid using lotions or heavy creams on the incisions.
- Do not submerge your incisions in a bath, tub, or swimming pool for about two weeks after the surgery.
- The sutures underneath your skin will get absorbed in 4-6 weeks.
- Do not lift heavy objects or engage in strenuous activities for four weeks post-surgery.
- Walk six times a day for the first two weeks to avoid pneumonia and deep vein thrombosis.
- You can begin driving once you achieve full range of motion at the waist.
- You can climb stairs.
- Usually, you can return to your normal activities within 3 to 4 weeks after the procedure.
- The doctor may prescribe one or two days of narcotic pain medication.
- After two days, Tylenol is sufficient to manage your pain.
First Follow-Up Appointment
- Your doctor will schedule the first follow-up appointment about one month after the surgery. During this visit, he/she will evaluate your recovery and examine the wounds.
Risks and Complications of Laparoscopic Heminrphrectomy
Though rare, the possible complications specific to laparoscopic heminephrectomy include:
- Urine leak
- Adjacent organ or tissue injury
- Hernia at the incision site
- Need for complete removal of kidney
In rare cases of complications, the surgeon may sometimes require conversion to open surgery.
You should call your healthcare provider if you experience symptoms of infections, including:
- Drainage and redness around the incision site
- Urinary discomfort
When to Consult a Doctor?
As with any other surgery, the common side effects of laparoscopic heminephrectomy include:
- Scar formation
- Reaction to anaesthesia
Complications of Delaying Laparoscopic Heminephrectomy
If the laparoscopic heminephrectomy for a duplex kidney is delayed, it may lead to complications such as:
- Acute urinary retention (inability to pass urine voluntarily)
- Stone formation
- Renal atrophy (shrinkage of the kidney)
- Kidney damage