Kidney/Ureters

The kidney and ureter+-

Humans typically have two kidneys that filter out waste products from the blood to produce urine. This urine is then carried down to the bladder by tubes called the ureters. Anatomical variations are common. Some individuals have more than the normal single artery or vein, others have changes to the ureter and the way it drains into the bladder. These can be of no consequence but may increase the risk of stone disease, impair urinary drainage or cause other symptoms. The kidney may not develop properly (renal agenesis) or shrivel away (renal atrophy) which patients commonly have no awareness of and only comes to light during a scan for other reasons. This is partly because we only need approximately an eighth of our total kidney function to live a normal life, without the need for dialysis.

The adrenal gland+-

The adrenal gland is a small organ that is found just above the kidney on each side. It produces several hormones that are integral to the bodies control sytems. There are several reasons that a urological opinion at SCU may be needed. A growth or lump may be discovered at a scan. Most of these are small and benign or none worrying. Primary cancerous growths are rare but occasionally secondaries deposit in the adrenal. Our expert uro-radiologists are often able to distinguish these with one or occasion two different scans. If the growth is large or suspicious for malignancy then surgical removal or occasionally percutaneous ablation may be required.

Occasionally the adrenals produce too much of one or several of the hormones which then cause problems with blood pressure control or salt balance within the body. These are often controlled by an endocrinologist (hormone expert) using medications but may require surgery to remove.

If surgery is required then one of our surgeons at SCU would discuss the options, but most of these lesions are removed by keyhole (laparoscopic) surgery.

Hydronephrosis (blocked kidney)+-

Hydronephrosis simply means excess fluid or water in the kidney and appears as a ballooning or dilating kidney on a scan. This can occur with or without obstruction and it can be useful to compare current to any previous imaging to see if this is a new phenomenon. The likely cause of the problem may be clear from a detailed history and imaging, but further tests may be required. If there are signs of obstruction then this usually needs to be dealt fairly quickly to protect long term kidney function.

Kidney pain+-

Pain originating from the kidney typically is felt in the loin, which is the space below the rib cage in the middle level of the back. It can also radiate down the groin towards the genitals and can vary in intensity from a dull intermittent ache to a severe pain that patients find very difficult to get comfortable with. Ladies who have experienced both say that it can be more painful than childbirth! Your surgeon or GP will discuss suitable painkilling options with you as some are more effective than others, can affect your kidney function or cause stomach problems.

Kidney infection+-

A kidney infection commonly makes a patient feel quite unwell with loin pain, a high temperature and often nausea and vomiting. It may be preceded by symptoms of bladder infection e.g. burning and stinging during urination, but this is not always the case. Treatment is usually increased fluid intake, antibiotics for 7 to 10 days and analgesia. If symptoms worsen then admission to hospital may be required for intravenous antibiotics and fluids.

Once the infection has been adequately treated, we recommend further investigations to establish whether there were any reasons for the infection, such as stones, anatomical abnormalities or poor bladder drainage. Imaging options include an ultrasound scan, plain X-ray, renogram or CT scan.

Kidney cancer+-


Kidney cancer is the 8th most common cancer in the UK with over 9500 cases diagnosed each year. It is more common in men than women. Most are renal cell cancers which occur in the cortex or ‘meat’ of the kidney. Transitional cell cancers are less common and occur in the cells which line the area where urine is collected within the kidney or the ureter (tube from kidney to the bladder).

Symptoms

Most people have no symptoms and these tumours are discovered incidentally during scans for other conditions. Symptoms that can occur include haematuria (blood in the urine), pain in the back, abdomen or flank

Treatment

The majority require an operation to remove or ablate (kill) them. Occasionally small tumours can be safely watched for a time rather than immediately treated. At SCU we have extensive experience in diagnosis and all possible treatments, including laparoscopic (keyhole) or open radical and partial nephrectomy. We also provide cryoablation for smaller renal tumours utilizing our world reknown interventional radiology service. Our subspecialised practice allows us to provide an expert opinion on the best suitable options for each patient. This starts with expert interrogation of imaging by our uro-radiologists (doctors who specialise in scanning of the urinary tract) and then an expert opinion based on the size and position of a tumour, taking account of previous medical history and the individual patient’s preferences.

Our surgeons subspecialise which means the majority of the kidney tumours seen at SCU are dealt with by minimally invasive methods. Our expertise allows us to remove bigger tumours compared with average in the UK, without resorting to open surgery.

Pelviureteric junction obstruction (PUJO)+-

This is a condition that individuals may be born with or acquire through their lifetime. It describes an abnormality of the join between the renal pelvis (where urine collects in the kidney) and the upper ureter, typically resulting in more fluid upstream (hydronephrosis). For some patients this is an incidental finding on a scan, but for others it can be quite painful. The classic symptoms are pain brought on by increased fluid intake and can mimick renal colic.

Most patients require a detailed CT scan in addition to a nuclear medicine scan (MAG3 renogram) to confirm the diagnosis. Following the tests one of the SCU surgeons would discuss your options. Occasionally the tests are equivocal and a temporary stent may be suggested as a minor procedure to try and establish whether your symptoms are genuinely from the kidney, before embarking on more complex surgery.

Some patients require no treatment and are simply monitored. Others may have an internal stent placed to relieve the blockage, however these stents are temporary and do have to be changed, approximately, every 6 months. Many with definite obstruction and symptoms will require surgery to refashion the drainage using a pyeloplasty operation. If the kidney is poorly functioning then removal may be recommended. The majority of these procedures are performed laparoscopically at SCU.

Tests for kidney/adrenal disease+-

Treatment for kidney and adrenal disease+-

Pyeloplasty+-

This operation is normally performed laparoscopically (keyhole surgery) and aims to alter the way the urine drains from the kidney by refashioning the join between the renal pelvis and the ureter. This may involve moving the ureter to the other side of a crossing kidney blood vessel. The join is protected post-operatively using a temporary ureteric stent that encourages urine to drain alongside and prevent a leak. A drain is also left in after the procedure for a day or so and is removed after the catheter is taken out. Occasionally the operation is performed through an open incision or using a robot. After the procedure, the stent will be removed at roughly six weeks and then a MAG3 renogram repeated at three months to see if the drainage is improved.

Laparoscopic surgery+-

It is now uncommon for a kidney operation to be performed using an open/standard incision as the use of keyhole surgery is now widespread. This is because the insult to a patient is less, allowing them to recover quicker, use fewer painkillers, have smaller and less painful incisions. The subspecialised nature of surgery at SCU means that our surgeons perform a high number of their specialist operations, which we believe, leads to better outcomes. The procedure takes around three hours and patients may need one to three nights in hospital. There is about a 5% risk of needing to convert to an open procedure, which is often due to previous operations causing scar tissue internally.

Nephrectomy+-

This term means removing the whole kidney, including the surrounding fat. It can be achieved using a keyhole (laparoscopic) approach or an open/standard cut. The majority at SCU are performed laparoscopically. Laparoscopic surgery results in shorter recovery and inpatient stay. You should avoid heavy lifting for up to six weeks but can return to work when you feel ready.

Partial nephrectomy+-

It is always best to preserve as much functioning kidney tissue as possible. For smaller renal tumours, nephron sparing surgery or partial nephrectomy may be considered. It can be technically challenging and has a higher complication rate from bleeding or urine leakage internally. These procedures can be carried out laparoscopically (keyhole) or by open surgery. Like all cancers treated by SCU, these patients are discussed through the central MDT (multidisciplinary team meeting including the cancer surgeons from SCU) at University Hospital Southampton. This expert panel take into account the size and precise location of these tumours before coming to a consensus on the best treatment plan. A surgeon from SCU would then discuss the pros and cons of any treatment with you before deciding on the next step.

Renal cryotherapy+-

An alternative to partial nephrectomy for small tumours is percutaneous cryotherapy. SCU work closely with Dr David Breen who is an interventional radiologist. He has the biggest series in Europe of patients treated this way. As with partial nephrectomy, above, we discuss these tumours through the central cancer MDT. If you have had a scan in another hospital we can arrange for Dr Breen to review the images to confirm it is an option before you travel to meet one of the SCU team. Many, but not all, patients suitable for partial nephrectomy are also suitable for cryotherapy.

The procedure is carried out under a general anaesthetic using the CT scanner to guide a series of needle probes into the tumour. A special gas mixture is used to generate an ice ball, which envelops the tumour. When tissue is frozen it dies and therefore the tumour is destroyed internally. Like surgery there is a small chance of major complications but generally this procedure involves one night in hospital and very quick return to normal activities. A biopsy or sample of tissue is also taken to determine the nature of the mass. Further CT scans are then required to ensure all cells have been treated and no recurrent disease is evident. The size and position of the mass determines whether this technique is feasible or not.

Renal cryoablation+-

Robotic renal surgery+-