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November 22, 2004

A Description of a Laparoscopic Radical Nephrectomy
Done on October 28, 2004
Walt A. Albro

This is a brief description of the discovery of a tumor in my right kidney, followed by the laprascopic procedure to remove the kidney. I am a 56-year-old male in reasonably good health

Discovery of kidney tumor
In early October 2004 I noticed a large volume of blood in my urine during a trip to the bathroom. The urine was colored brown. This happened only once. Since I was scheduled to see my internist two days later for an unrelated reason, I took no action until seeing the doctor. He referred me to my urologist. When I saw the urologist a week later, he sent me for abdominal x–rays and CAT scans. A day after the tests, I returned to the urologist. After examining the pictures, he reported that there was a solid-mass tumor growing in the bottom half of my right kidney. He said that more than 90 percent of this type of solid-mass tumor turned out to be cancerous. Based on his experience, he identified it as renal cell carcinoma (RCC). For this reason, he recommended that the entire right kidney be removed immediately — before the tumor had an opportunity to spread outside of the kidney.

Surgery was scheduled for October 28, 2004. The procedure would be a laprascopic radical nephrectomy (hand assisted). The procedure would be done by Dr. Padrosa. with assistance from my urologist, Dr. Friedlander. Doctor Padrosa told me that he had performed 36 radical nephrectomies within the previous 12 months. Of these procedures, only two had to be done by the open surgery when it became clear (usually because of excessive bleeding) that the operation could not be completed laprascopically. I was told that they would plan to perform the operation laprascopically but, if they were unable to complete it that way, they would switch to the open procedure.

The surgery was scheduled at Shady Grove Adventist Hospital in Rockville, Md., which is a suburb of the city of Washington, D.C.

I was not allowed to eat solid food on the day prior to the procedure. In the morning of that day, I had to drink 16 eight-ounce glasses of a liquid designed to clear out my bowels. I was instructed to drink one glass every 10 minutes during a 3.5-hour period. After that, I ate broth and Jello for lunch and dinner.

Day of surgery
I arrived at the hospital at 10:30am and changed into a hospital gown. Surgery was scheduled for 12:30pm I had an IV inserted in my arm. The two urologists came in and discussed the procedure. I was told that they would attempt to do a laprascopic procedure but they might have to finish with open or traditional surgery (consisting of a large incision from the front to the back of the abdomen).

I was told initially that I would be given an epidural to ease the pain of the procedure. I was told that the epidural was designed primarily to ease the pain from open surgery and that it really was not needed for a laprascopic procedure. As the time of surgery grew nearer, the urologists expressed greater confidence that they would be able to perform the procedure laprascopically, so I was not given the epidural.

I met the anesthesiologist. I was wheeled into the operating room at about 12:30. I was given a sedative intravenously. This made me feel calm. Shortly afterward, I was told that they were going to give me the regular anesthesia. I blacked out completely and have no further recollections until after the operation was over. I was told later that the procedure started at 1pm and was completed at 4:45pm, a total of three hours and 45 minutes. When finished, I had a three-inch vertical incision immediately above the belly button. I had two puncture incisions (for scopes and instruments) immediately above the vertical incisions. There were two more puncture incisions, one on the lower right side of the abdomen and the other on the right side.

The hours immediately following surgery
I began hearing people calling my name as I came out of a deep sleep. Dr. Friedlander was talking to me. He gave me a thumbs-up signal and said that everything had gone well and that there were no complications. I was wheeled into the recovery room. I was surprisingly alert and was soon transferred to a hospital room. I had no pain in my back, where my right kidney had been located. I had some abdominal pain, but only when I attempted to move my body. When I remained still, there was no discomfort. After about an hour the pain medication began to diminish, and I had abdominal pain even when not moving. The pain felt as if someone had struck me hard in the stomach with his fist. The pain felt similar to the soreness one might experience after such a blow.

Whenever I reported that I was feeling pain, the nurse responded by giving me more morphine intravenously. The pain was never unmanageable. It was noticeable mostly when I moved. For this reason, I tried to move as little as possible. I lay on my bed as motionless as possible. During the night, I slept poorly, mainly because the hospital was noisy and the door to my room was kept open (for some unknown reason). Also, I was awakened every three hours or so by nurses or technicians checking on me or taking my vital signs.

The day after surgery
The nurses encouraged me to discontinue using morphine and to switch to a less potent pain-killer in pill form, which I took every four hours. The nurses got me out of bed in the mid-morning and had me sit up in a chair in the room. Although this was uncomfortable at first, I found that modest exercise actually reduced the pain. I walked out in the hospital corridor for about five minutes.

During the operation a catheter had been inserted in my bladder to remove urine. The catheter had been left in to monitor the volume of urine flow. The doctors wanted to ensure that my remaining left kidney was functioning normally.

At about 3pm on this day, the word came down that the catheter could be removed. After it was removed, I noticed that I did not seem to be going to the bathroom, which I thought was odd. (In general, I have a middle-aged man's problem with frequency of urination.)

Within several hours, I noticed that whenever I had an urge to urinate, I would pass only a few drops. But, within a few minutes, a strong urge to urinate would return. This continued for some time and was very annoying. I called for the nurse. She explained that some patients experienced urinary problems after the catheter was removed. She talked to the physician's assistant and returned to the room with a little sonogram machine for taking pictures of the bladder. The test showed that the bladder was full of urine. Yet, for some reason, the bladder was releasing only a few drops of urine at a time. To give me relief, she inserted another catheter into the bladder and drained about a liter of fluid out of me. She then removed the catheter for a second time.

If I stood while urinating, I was able to pass an ounce or so of fluid at a time. My urinary habits returned to normal as the hours passed.

My urologist later explained to me that the bladder muscles sometimes function improperly as a result of the effects of anesthesia and the use of the bladder catheter. The muscles particularly have difficulty operating when the body is in a lying position, as was the case with me.

On this day, I was given a plastic device designed to exercise my lungs and allow them to fill up completely with air, thus reducing the dangers of developing pneumonia. I was instructed how to inhale through the device and to raise the floating plastic part to a predetermined level with the force of the air I inhaled. I was instructed to inhale through the device at least 10 times every hour while awake.

Two days after surgery
There was some discussion about the possibility of releasing me from the hospital on this day. However, this was postponed when one of my temperature readings jumped to 101 degrees °F. The doctor ordered blood work and a chest x-ray, apparently to assess whether I was developing a case of post-operative pneumonia.

The x-ray came back with some suspect areas on the picture. When my urologist examined the x-ray, he concluded that the suspect areas stemmed from compression injuries related to the surgery itself, and were not a sign that I was developing pneumonia. He said that if my temperature remained normal, it would be likely that I would be released from the hospital the following day.

On this date, I walked up and down the hospital corridor for about five to 10 minutes. Pain was slightly less than from the previous day. I was using about two pain pills approximately every four hours. I continued to sleep poorly, mainly because of the hospital noise and constant interruptions during the night.

Three days after surgery
I received another follow-up x-ray. After looking at this picture, my urologist concluded that there were no complications, and it was safe to release me from the hospital. I was released at 3pm One of my sisters picked me up in her automobile and drove me to my condominium. Although I was able to walk and engage in light physical activity, I could move only at a very slow pace. At times, I moved so slowly that it looked like I was a 90-year-old man.

My sister stayed with me for four days (I normally live alone). My sister cooked for me and washed the dishes and did light cleaning around the house. This was a big help. Although it would have been possible for me to do some cooking from the first day home, it was difficult for me to stand for any length of time. It was much more convenient to use a housekeeper.

Later recovery
Starting on day four, I began a daily walk to improve my stamina. I started with a 10-minute walk and increased my time by about five minutes daily. I rested at home for seven days. At this point, I may have felt a little bit overconfident about my rapid recovery. On the eighth day after the operation, I had one of my sisters drive me to the house of one of my other sisters and brother-in-law. I stayed there for three nights, going to the movies with the family one day and watching a portion of my nephew's Little League baseball game. When I returned home on Monday, I felt exhausted and did little for two days besides sleep or lie on the sofa watching television.

Two weeks after the operation, I began doing office work on my home computer for several hours each day. My plan is to return to the office (for at least part of each work day), two weeks and four days after the operation.

In general, the discomfort from the operation was less than I had imagined and the recovery was surprisingly rapid. Both the discomfort and rate of recovery were no worse than from a groin hernia repair that I had had about a decade ago.

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