Singh Urology

Secretary: 01332 783423
Derby Private Health: 01332 785200
Nuffield Health, Derby Hospital: 0300 790 6192

Kidney

Q | Where are the kidneys?

A | The 2 kidneys are bean shaped organs approximately 12cm in length sitting either side of the spine at the level of the middle back. They have many functions including removal of waste products from the body, production of urine and are important in controlling the body’s water and salt balance. The kidneys are also play an important role in controlling blood pressure.

 

Q | What is renal cancer?

A | Renal Cell Carcinoma (RCC) is the most common form of kidney cancer. This arises within the parenchyma (or meat of the kidney) and accounts for up to 3% of new cancers found each year, overall. See also Transitional Cell Carcinoma (TCC).

 

Q | What are the risk factors for renal cancer?

A |

  • Sex: Renal Cell Carcinoma (RCC) is twice as common in men as it is in women.
  • Age: The peak age for RCC is in your sixties but it can affect all ages.
  • Genetics: A family history of RCC can increase your risk of renal cancer, as can specific genetic diseases, such as, Von Hippel Lindau disease.

 

Q | What are the symptoms and signs?

A | Kidney cancers are very often found incidentally these days when patients undergo scans of their abdomen for unrelated reasons.The classic symptoms and signs include an abdominal mass, loin pain overlying the kidney and haematuria. Although these are classic symptoms they may only occur in 20% of patients with RCC particularly since tumours are usually found at en earlier stage thesedays.

 

Q | How is the diagnosis made?

A | If your urologist suspects a renal cancer at the time of your consultation, an ultrasound of your kidneys will be arranged.

This test will usually demonstrate any abnormalities of the kidneys. A CT scan of the abdomen will then be arranged which will give more accurate information about the renal cancer.

This will indicate the size of the cancer, the blood vessels supplying the kidney and demonstrate if there is any spread of the cancer out of the kidney. If any further tests are necessary, these will be discussed with you after the CT scan.

 

Q | What is “staging”?

A | Staging of the cancer enables your urologist to decide how extensive the disease is. The special X-ray scans that you have will enable your urologist to decide on:

  • The size of the renal cancer
  • Whether the cancer has spread into the large blood vessels, particularly the renal vein
  • Whether the fatty tissue or capsule of the kidney has been infiltrated by the cancer
  • If the cancer has spread to other organs such as liver, lungs or bone.

 

Q | Do you biopsy the kidney to confirm cancer?

A | Using CT guidance, a small needle can be introduced into the kidney to remove a small sample of the kidney growth. This can be looked at under the microscope to confirm if a renal cancer is present.

The main problem with this particular biopsy is of sampling error. This means that the biopsy which represents a small proportion the tumour ends up showing non cancerous tissue even though the rest of the tumour is cancerous.

 

Q | What are the treatments available for renal cancer?

A | If the cancer is localised to the kidney, surgical nephrectomy is usually advised. This can be an open nephrectomy or laparoscopic nephrectomy. If a patient has a very small cancer, there are situations where continued observation of the patient may be appropriate over active treatment. If you have poorly functioning kidneys or a single kidney for some reason, you may be advised to have a partial nephrectomy.

If your kidney cancer has spread beyond the kidney to other organs you may be suitable for chemotherapy or immunotherapy, which will be discussed with the urologist and oncologist.

In certain situations, a nephrectomy may be advised in the presence of metastatic disease as occasionally it may give symptomatic relief to the patient and may also have a beneficial effect on the metastatic deposits.

Your urologist will discuss the pros and cons of all of these options with you on an individual basis at your consultation.

 

Q | What is the follow-up after treatment?

A | If you have had a nephrectomy, you will be seen in the outpatient department some weeks later to discuss the results of the microscopic findings (histopathology).

If all is well you will be followed up on a regular basis with a CT scan of your abdomen, chest X-ray and blood tests.

If everything remains clear after 5 years, you may be discharged from the care of the urologist at this time.

 

Q | What is a nephrectomy?

A | Nephrectomy is removal of a kidney.

A “simple” nephrectomy is carried out for non-cancerous conditions, which cause the kidney to become non-functioning. This includes kidney damage due to infection, obstruction, stones, and occasionally developmental abnormalities of the kidneys.

A “radical” nephrectomy is removal of the kidney with its surrounding fat and covering layer and the adrenal gland. This is carried out for cancerous diseases of the kidney such as Renal Cell Carcinoma (RCC), when it is localised to the kidney

 

Q | What is a laparoscopic nephrectomy?

A | This procedure is a form of keyhole surgery to remove the kidney.

Three or four small incisions are made in the abdomen. The surgeon uses a telescopic camera and long small calibre instruments to dissect the kidney from its surrounding organs and then remove the kidney.

 

Q | How is the kidney removed?

A | At the end of the operation, one of the small incisions (“ports”) is enlarged slightly to allow a small bag to be introduced into the body cavity and ensnare the now free kidney. This can then be removed through this larger port.

 

Q | Are all patients suitable?

A | No. From a kidney point of view, laparoscopic nephrectomy is best reserved for the smaller kidney tumours and benign conditions of the kidney. During the patient pre-operative workup, a CT scan is carried out which gives an indication as to how easy it will be to dissect the kidney from the surrounding organs. Inflammation around the kidney in such conditions as renal stones and infections can make the operation difficult and sometimes ill-advised.

From the patient’s general health perspective, there are reasons why laparoscopic surgery should be advised against. These include generalised peritonitis (inflammation and infection of the abdominal cavity), severe airways or cardiac disease, uncorrectable bleeding disorders and morbid obesity.

 

Q | What kind of pre-op preparation do I need?

A | You will be seen one week prior to your booked surgery date for pre-admission assessment. At this time you will be seen by a clinical nurse specialist who will go through your past medical history, medications etc. Routine blood tests, ECG (heart tracing) and a chest X-ray will be performed at this time. A urine test will also be taken to exclude urine infection. If you take aspirin or warfarin, these are usually stopped prior to surgery as excessive bleeding may sometimes occur. This will be discussed with you at the time of the pre-assessment clinic

 

Q | What are the advantages?

A | The advantages of this approach include:

  • Reduced patient discomfort after the operation and the need for fewer painkillers as a consequence.
  • Rapid recovery post-operatively with an earlier return to normal work and social activities.
  • Shorter stay in hospital, normally ranging from 1-3 days post-operatively.
  • A more pleasing cosmetic result due to the much smaller incisions and subsequent scars.

 

Q | Are there any complications or risks?

A | As with any major surgery, there are risks. Both laparoscopic and open nephrectomy can result in bleeding and infection. Patients may require blood transfusion if there is bleeding at the time of operation. Again, as with open surgery, injury to surrounding organs can occur on rare occasions. If problems are encountered during the operation, such as difficulty in dissecting the kidney free of the surrounding tissues etc., the safest option may be to convert to an open procedure. This means making a larger incision and continuing the operation as an open nephrectomy. This can occur in up to 20% of cases Correct patient selection is vital to minimise the above complications.

I will discuss all these issues with you before booking your operation during your out patient appointment.

 

Q | What is the discharge & follow up procedure?

A | After your operation you will be discharged from the ward and asked to attend clinic two weeks later. At this time, the histopathology (microscopic examination) will be discussed with you. Your wounds will be inspected to make sure that they are well healed and future follow-up will be arranged. In the case of kidney cancer follow-up, you will usually be asked to have a chest X-ray, CT scan of the abdomen and blood tests at regular intervals to make sure that there is no evidence of recurrence.

If you have any questions regarding the operation or follow-up, these will be addressed at the first consultation with me or one of my team.

 

Kidney (Renal) Stones

Q | What is a kidney stone?

A | A kidney (renal) stone is a mixture of salt or crystals and minerals can that come together and grow as stones in a solution (i.e. urine in this case).

If you imagine adding everyday salt or sugar to water until no more will dissolve, in certain situations, crystals will form due to super-saturation of that solution.

 

Q | What is the cause of kidney stones?

A | There are no definite answers but it appears that there is a mix of genetic factors (the risk of stones tends to run in families) and environmental factors such as a hot climate or your dietary intake.

Stones tend to occur in the 20-40’s age group and are three times as common in men as compared to women. Other factors include abnormalities of the urinary tract system, recurrent urinary tract infections and some metabolic disorders.

 

Q | What are the symptoms of renal colic?

A | Symptoms can vary greatly ranging from an intermittent dull ache in the middle back associated with general lethargy and fatigue to acute renal colic.

In the latter the patient experiences a sudden onset of pain in the back, abdomen or groin or all of the above. The pain is usually intermittent in nature and can be so severe as to make the patient double over in pain.

Classically, the patient is unable to keep still because of the pain. Feelings of nausea and vomiting may accompany the pain and the patient may notice blood in the urine.

 

Q | What is the treatment for renal stones?

A | Treatment varies according to size and position of the stone within the urinary tract. The size of the stone can range from a small pinhead to the size of a walnut, completely filling the kidney collecting system. Smaller stones may pass spontaneously, however if the stone is too big, intervention may be necessary.

The actual treatment will depend on your clinical history, examination and imaging, usually in the form of X-rays or a CT scan. Nowadays, with the advent of advanced instruments and telescopes, the stone can usually be removed without making any incisions.

Other methods of treating stones include percutaneous nephrolithotomy (PCNL), which is a form of keyhole surgery, or dissolution therapy where the stone can be dissolved by changing the acidity of the urine. In some instances, lithotripsy can be used to shatter the stone using a focused, magnified, sound wave.

Your surgeon will discuss with you the best options for stone removal at your consultation.

 

Q | Which stones may pass without needing treatment?

A | As a rule of thumb, the smaller the stone, the higher the chance of the stone passing. The small table below illustrates your chances of passing a stone of a particular size as a percentage.

Upper Urinary Tract Stones (kidney and upper ureter)

Stone size% Chance
< 5 mm29-98%
5-10 mm10-50%

Lower Urinary Tract Stones (lower ureter and below)

Stone size% Chance
< 5 mm71-98%
5-10 mm25-50%

Q | Can all kidney stones be dissolved?

A | No. Only stones made up of uric acid can be dissolved effectively by changing the acidity of the urine. These stones are formed as a result of the breakdown of products from a high protein diet becoming supersaturated in the urine, causing stones to grow.

Uric acid stones are peculiar in that they are translucent (invisible) on normal X-ray pictures. They can, however, be seen on CT scans.

 

Q | Do all stones in the urinary tract originate in the kidney?

A | Nobody knows for sure but it is thought that most stones do form in the kidney and colic (pain) occurs when these stones move from the kidney down into the ureter. Bladder stones, however, usually arise within the bladder itself and are probably the result of stagnation of the urine due to bladder outflow obstruction.

This obstruction can be caused by prostatic enlargement (in men) for instance.

 

Q | What are infection stones?

A | Infection stones consist of a mixture of magnesium, ammonium and phosphate mixed with carbonate salts. They are more common in women who suffer with urinary tract infections.

They usually occur when the urine is alkaline (pH above 7) and when there is ammonia in the urine. Certain bacteria that cause urinary infections can also produce ammonia leading to the formation of these stones.

Infection stones can be very large, even filling the whole kidney system, forming a staghorn calculus.

 

Q | When the stone has been removed or passed, will I need any further investigations?

A | Patients can be categorised with regards to their risk of getting further stones. A high-risk patient may have one or more of the following:

  • Previous problems with stones
  • A strong family history of urinary tract stones
  • Bone or specific gut diseases
  • Gout
  • Chronic urinary tract infections
  • Known nephrocalcinosis (calcium deposits within the kidney)
  • Children who present with stones

The investigations will include urine tests, blood tests and X-rays or CT scans, which will be discussed with you at your consultation.

 

Q | Urine infection and stones

A | Occasionally the patient may present with a urinary tract infection (cystitis like symptoms). If the patient presents with symptoms of renal colic and has a fever or rigor, the obstructing stone may need to be dealt with as an emergency. This usually involves having a nephrostomy or J-J stent to relieve the obstruction.

 

Q | What is a nephrostomy?

A | A nephrostomy involves putting a small needle directly into the kidney to drain urine if the kidney is obstructed.

 

Q | What is a J-J Stent?

A | A J-J stent is a small plastic tube that can be passed from the bladder up into the kidney to relieve obstruction and enable urine flow.

 

Q | Will changing my diet help?

A | Patients often ask, “Should I cut down my calcium intake (milk, cheese, etc.)?” Dietary changes are much more complex than this when considering stone disease.

A wide range of foodstuffs can affect your chances of developing kidney stones and this will depend upon what the stone is made of and the results of metabolic screening tests. This will be discussed with you at your consultation.

 

Removal Methods

Percutaneous Nephrolithotomy (PCNL)

 

Q | What is a PCNL?

A | Percutaneous nephrolithotomy (PCNL) is a preferred treatment for large stones within the kidney using keyhole surgery. PCNL is offered in the following circumstances:

  • Large stones present in the kidney
  • Abnormal anatomy of the kidney
  • Stones inaccessible using normal endoscopic (telescopic) methods
  • Stones resistant to shock wave lithotripsy treatment

 

Flexible Ureteronoscopy

Q | What is a FURS?

A | Flexible Ureterorenoscopy (FURS) is a preferred treatment for small stones within the kidney using a very thin flexible telescope that can be passed up from the female urethra or end of penis in a man, into the bladder and up the ureter (tube connecting the kidney to the bladder. FURS is offered in the following circumstances:

  • Small stones present in the kidney
  • Stones resistant to shock wave lithotripsy treatment
  • It can also be used to diagnose other abnormalities within the kidney such as unexplained pain or bleeding

The laser is a very fine fibre that can be passed up through the scope to the kidney. Energy from an external power source can break up stones or act as a “spot welding” tool for bleeding points, for example.

 

Q | Before the operation

A | The X-ray findings will be explained to you in the outpatient clinic and if suitable, you will be booked to come in for the FURS procedure. You will be asked to attend for a pre-assessment appointment where you will have blood tests, chest X-ray and ECG depending on your general health and any pre-existing medical conditions. Please bring any medications with you to this appointment and you will be told if any of them need to be stopped prior to surgery. Make sure you alert the staff if you take warfarin, aspirin, clopidogrel or any other blood-thinning medications.

You will be asked to come into Hospital on the morning of the proposed FURS procedure. You should be “Nil By Mouth” for a certain time prior to admission. Please check when you can eat and drink before the operation as your procedure may be cancelled on the day if you have had anything to eat or drink at the wrong time.

The anaesthetist will see you in your room to go through any questions before surgery. You will be asked to sign a consent form, which explains the risks and benefits of the FURS procedure (see Consent section below).

 

Q | The FURS procedure

A | FURS is carried out under a general anaesthetic. The first step is to examine the bladder with a telescope and to pass a guidewire and plastic tube up into the ureter (the pipe with connects the kidney to the bladder).

X-ray contrast (dye) fluid is injected up the tube in your ureter. This outlines the kidney system on X-ray and acts as a “roadmap for the FURS procedure (see X-ray picture). A small dilating sheath is passed over the guidewire into the ureter and the FURS telescope is then advanced up through the sheath into the kidney. The surgeon can manoeuvre the end of the FURS scope into all parts of the inner kidney using a hand control outside the body to flex the end of the scope as necessary. When the stone is seen, using a video transmitted image to a computer screen, it can be shattered using the laser fibre and power source. Once fragmented, the pieces can be removed using a tiny wire basket, which is passed up through the FURS scope.

 

Q | After the operation

A | You may have a bladder catheter, which can be removed after a few hours. You will be able to eat and drink on the ward and if you feel pain or feel sick, let the staff know, as they will be able to give you appropriate medication. You will be given regular, as well as stronger painkiller tablets as and when you need them. Don’t hesitate to ask for them, because if you are free from pain, you will be able to mobilize more quickly. Patients are usually booked for an overnight stay, however, if you feel well after the procedure, you may be discharged the same day.

 

Q | Discharge advice

A | Once discharged, some patients may require a few days off from work. Driving can recommence immediately as long as you are pain free. You should avoid heavy lifting or straining for the first few days. You may have some pink colour to the urine for a week, which is normal.

You will be given an appointment to attend the outpatient clinic about 3-4 weeks after surgery. Any questions can be answered at this time. You may be booked in to have formal Metabolic Stone Analysis (MSA), so that advice can be given as to how to try and prevent further stones forming in the future.

 

Q | Consent

A | You will be asked to sign a consent form prior to surgery. The main complications that may occur are as follows:

  • Urine infection post-procedure – rare as antibiotics are given to cover you during the operation
  • Bleeding and pain in the kidney afterwards – this usually settles within 24-48hrs
  • Damage to the ureter tube – below 1%
  • Stone fragments remaining in kidney – below 5%
  • Readmission for pain control/bleeding – below 1%

 

Rigid Ureteroscopy

Q | What is a rigid ureteroscopy?

A | Rigid ureteroscopy is a preferred treatment for small stones within the ureter tube, which connects the kidney to the bladder. A thin semi rigid telescope can be passed up from the female urethra or end of penis in a man, into the bladder and up the ureter to the stone. A fine laser fibre can be passed up through the scope to the stone in the ureter. Energy from an external power source can then break up stones and fragments removed using a small wire basket, again passed up the telescope.

  • Small stones present in the ureter tube
  • Stones resistant to shock wave lithotripsy treatment
  • It can also be used to diagnose other abnormalities within the ureter such as unexplained pain or bleeding

 

Q | Before the operation

A | The X-ray findings will be explained to you in the outpatient clinic and if suitable, you will be booked to come in for the ureteroscopy procedure. You will be asked to attend for a pre-assessment appointment where you will have blood tests, chest X-ray and ECG depending on your general health and any pre-existing medical conditions. Please bring any medications with you to this appointment and you will be told if any of them need to be stopped prior to surgery. Make sure you alert the staff if you take warfarin, aspirin, clopidogrel or any other blood-thinning medications.

You will be asked to come into Hospital on the morning of the proposed ureteroscopy procedure. You should be “Nil By Mouth” for a certain time prior to admission. Please check when you can eat and drink before the operation as your procedure may be cancelled on the day if you have had anything to eat or drink at the wrong time.

The anaesthetist will see you in your room to go through any questions before surgery. You will be asked to sign a consent form, which explains the risks and benefits of the FURS procedure (see Consent section below).

 

Q | The rigid ureteroscopy procedure

A | Rigid ureteroscopy is carried out under a general anaesthetic. The first step is to examine the bladder with a telescope and to pass a guidewire and plastic tube up into the ureter (the pipe with connects the kidney to the bladder).

X-ray contrast (dye) fluid is injected up the tube in your ureter. This outlines the upper urinary system on X-ray and acts as a “roadmap for the ureteroscopy procedure. The telescope is then advanced up alongside the guide wire up the ureter tube. The surgeon can manoeuvre the scope until the stone is seen. Using a video image transmitted to a computer screen, it can be shattered using the laser fibre and power source. Once fragmented, the pieces can be removed using a tiny wire basket, which is passed up through the FURS scope.

 

Q | After the operation

A | You may have a bladder catheter, which can be removed after a few hours. You will be able to eat and drink on the ward and if you feel pain or feel sick, let the staff know, as they will be able to give you appropriate medication. You will be given regular, as well as stronger painkiller tablets as and when you need them. Don’t hesitate to ask for them, because if you are free from pain, you will be able to mobilize more quickly. Patients are usually booked for an overnight stay, however, if you feel well after the procedure, you may be discharged the same day.

 

Q | Discharge advice

A | Once discharged, some patients may require a few days off from work. Driving can recommence immediately as long as you are pain free. You should avoid heavy lifting or straining for the first few days. You may have some pink colour to the urine for a week, which is normal.

You will be given an appointment to attend the outpatient clinic about 3-4 weeks after surgery. Any questions can be answered at this time. You may be booked in to have formal Metabolic Stone Analysis (MSA), so that advice can be given as to how to try and prevent further stones forming in the future.

 

Q | Consent

A | You will be asked to sign a consent form prior to surgery. The main complications that may occur are as follows:

  • Urine infection post-procedure – rare as antibiotics are given to cover you during the operation
  • Bleeding and pain in the kidney afterwards – this usually settles within 24-48hrs
  • Damage to the ureter tube – below 1%
  • Stone fragments remaining in kidney – below 5%
  • Readmission for pain control/bleeding – below 1%