Following surgery, patients will require post-operative care as for any abdominal /pleural operation. The majority of patients will recover without incidence or complications.
Recovery after laparoscopic surgery is likely to be more rapid, since the technique does not involve resection of muscle tissue and minimises handling of organs.
Having an awareness of the potential intra-operative and post-operative complications (Unit 2) will ensure that they are identified and treated promptly.
- Haemorrhage could be catastrophic, due to the proximity of the kidney to the great vessels, and any sign of hypotension must be promptly reported to the medical team.
- Transfusion is rarely required – average blood loss is approximately 200mls.
- Paralytic ileus may occur if the trans-abdominal approach has been used. Oral fluids should not be commenced until the medical team have evidence that normal peristalsis has returned. Return to a normal diet will maximise recovery.
- A chest drain may be required after a thoraco-abdominal approach has been used, as pneumothorax may occur.
- Pyrexia of <38⁰C is common during the first 24 hours post-surgery. Antibiotic prophylaxis will probably be prescribed for 3 post-operative doses (as per hospital protocol). Careful observation of the wound/drain site and reporting of evidence of infection is paramount.
- Pain is more evident in patients who have undergone open surgery. Deep breathing and coughing may be difficult, particularly if a thoraco-abdominal incision has been made because of the proximity of the wound to the diaphragm. Patient controlled analgesia (PCA) or an epidural infusion of a narcotic analgesic will be in place to minimise pain experience.
- ‘Wind’ type pain is common after laparoscopic surgery, as the abdomen will have been insufflated with carbon dioxide. Narcotic analgesia is not required in such patients and oral analgesia is usually sufficient.
- Urine output must be carefully monitored. A urethral catheter may be in situ post-operatively, but can be removed as soon as the patient is mobile.
- Early mobilisation is essential to maximise recovery and minimise thrombo-embolic complications. The use of subcutaneous low-molecular weight heparin and anti-embolic stockings will also minimise such complications.
- Delayed urine leak – this is specific to partial (nephron-sparing) nephrectomy. Suturing of the collecting systems intra-operatively is a complex procedure. If not identified before wound closure, defects may not become evident for several days. It is manifest by urine leakage from wounds. Sampling and biochemical analysis of any wound discharge will provide evidence of content. Leaks will usually resolve spontaneously after prolonged drainage or may require insertion of a ureteric stent.
Patients who have had a laparoscopic approach will have markedly reduced post-operative morbidity and may be discharged within 48 hours, while those undergoing open surgery are usually discharged 5-7 days post-surgery. Patients will be able to return to normal activity within 3-4 weeks after laparoscopic surgery and 6-8 weeks after open surgery.
Follow-up
There is no general recommendation on the method and timing of investigations required during follow-up after surgery. The urologist can therefore be selective in the use of imaging and the need for intensive surveillance. Surveillance should be based on a patient’s risk factors and the type of treatment delivered. The aim is to detect either local recurrence or metastatic disease while the patient is still surgically curable.
Table 8.1: Proposed follow-up schedule following treatment for localised RCC, taking into account patient risk of recurrence profile and treatment efficacy (based on expert opinion [1]
| Risk profile (*) | Oncological follow-up after date of surgery | ||||||||
| 3 mo | 6 mo | 12 mo | 18 mo | 24 mo | 30 mo | 36 mo | > 3 yr (**) (***) | > 5 yr (**) (***) | |
| Low risk of recurrence
For ccRCC: Leibovich Score 0-2 For non-ccRCC: pT1a-T1b pNx-0 M0 and histological grade 1 or 2. |
– | CT | – | CT | – | CT | – | CT once every two yrs | – |
| Intermediate risk of recurrence
For ccRCC: Leibovich Score 3-5 For non-ccRCC: pT1b pNx-0 and/or histological grade 3 or 4. |
– | CT | CT | – | CT | – | CT | CT once yr | CT once every two yrs |
| High risk of recurrence
For ccRCC: Leibovich Score ≥ 6 For non-ccRCC: pT2-pT4 with any histological grade or pT any, pN1 cM0 with any histological grade |
CT | CT | CT | CT | CT | – | CT | CT once yr | CT once every two yrs |
Some Trusts perform Chest x ray and Renal Ultrasound instead of CT scans for low Risk stratified patients but this is down to consultant/Trust preference.
The Leibovich score is a scoring algorithm designed by American urological surgeon, Bradley Leibovich and is designed to focus on patients with clear cell renal cell carcinoma. It is used to predict a patient’s risk of developing metastases after having a radical nephrectomy. The algorithm separates patients into three risk groups and these are:
– Low risk (score 0 – 2)
– Intermediate risk (score 3 – 5)
– High risk (score above 6) [2]
Ljungberg, B., et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update. Eur Urol, 2019. 75: 799. Table 8.1: Proposed follow-up schedule following treatment for localised RCC, taking into account patient risk of recurrence profile and treatment efficacy https://uroweb.org/guideline/renal-cell-carcinoma/#8
2.
A scoring algorithm to predict survival for patients with metastatic clear cell renal cell carcinoma: a stratification tool for prospective clinical trials. Leibovich et al, 2005 https://pubmed.ncbi.nlm.nih.gov/16217278/