Laparoscopic pyeloplasty surgery. That is not something you ever thought you would need. Neither did I. But I did and had nowhere to go to find out what to expect.
I could not find much of anything online of what to expect from a robotic-assisted laparoscopic pyeloplasty. So, I am going to fill in the gaps for you as it might help calm some of your anxieties.
What is pyeloplasty?
First off, I am not going to get into the technical details other than the following. You have an obstruction that is preventing proper drainage of urine from the kidney. That is a big problem.
If this obstruction continues, your kidney will start to die. The urine builds up in your healthy kidney and kills off the healthy cells. Your kidney swells with urine that cannot be excreted. In short, you cannot drain urine from your kidney.
If you currently have any type of hydronephrosis, swelling of the kidney, this is an urgent matter. Make sure to take your health into your hands and check what your GFR (glomerular filtration rate) number is. Do not listen to any doctor that tells you it is no big deal and just to drink 2 liters of water a day.
If your kidney drainage is blocked, you could be a walking time bomb.
All you need is a simple blood test to tell you. Unfortunately, sometimes this number can be missed by your primary care physician because it is usually at the end of a typical blood panel.
Check your GFR (glomerular filtration rate), make sure it is over 60 and you are not in chronic kidney disease territory. CKD is no laughing matter. It is silent and while you think everything is fine, your kidney function is deteriorating.
And once you start losing kidney tissue, it is gone, forever. You do not want CKD, because this means eventual dialysis and/or a kidney transplant.
So, treat any hydronephrosis of your kidney as an urgent matter and take immediate action. The question is, what can you do if the hydronephrosis is due to an obstruction?
The obstruction could be from a kidney stone, or you could have been born with it. Or this UPJ obstruction, aka ureteropelvic junction UPJ, could be something your child was born with.
The bottom line is that once you have a UPJ obstruction, you are now facing an anatomical blockage. This means that you cannot correct it by eating less animal protein or a more alkaline diet.
There is no dietary intervention that will save you from the catastrophic effects of an obstruction.
Signs of Obstruction
Some signs of obstruction are:
- flank pain
- or sudden intense flank pain
You have no clue what is going on other than a sudden piercing pain in your side. As mentioned, it might be a kidney stone, but it also might be a congenital condition. Meaning you were born with this UPJ obstruction, but it never presented in the past.
Sometimes babies will have to be treated for this and other times a person well into their older years, even upwards of 80 or 90.
Make sure that you have a CT scan, Ultrasound, some type of renal pelvis scan to determine if your kidney is in a state of hydronephrosis.
The most advanced scan, a Nuclear Medicine scan can give you a split function view of how both of your kidneys are functioning.
All of the renal scans above are a piece of cake. So, do not delay in getting them done. The only caveat is to make the effort to get an Open MRI. Unless you enjoy claustrophobia. Then you can opt for a closed MRI, since a closed MRI is the gold standard.
My suggestion though is to go for the Open MRI. No matter what type of music they put on is not going to make you feel better when they roll you into the closed MRI, strapped down to the table with the machine humming all around you.
Even xanax won't help you and you cannot afford using up your general anesthesia, since you will need that for surgery.
Here comes a medical miracle
Laparoscopic pyeloplasty surgery can resolve this ureteropelvic junction obstruction with minimally invasive surgery. As hard as this might be to believe, the technology exists today where your surgeon can make an incision in your belly button the size of the tip of your thumb.
They then insert all the instruments necessary for the pyeloplasty through that tiny incision. Don't get me wrong, this incision is going to hurt. And, the pain and tenderness of this incision will leave you with limited mobility.
But, I will get to that a bit later when I discuss what you can expect the day after robotic surgery, and the week after surgery and beyond.
The surgeon will then cut the healthy ends of your ureter, reattach them , place a tube called a ureteral stent to promote healing, close you up and now is the hard part.
You have to recover. You know nothing till you wake up from the anesthesia cocktail. But when you do and the narcotic effects wear off, you will feel it.
Is laparoscopic pyeloplasty a major surgery?
This will answer the question if open pyeloplasty is a major surgery or not. Here is the answer. Yes. Pyeloplasty is not a little procedure. No matter how small the incision is, pyeloplasty is a major surgery. So be prepared.
The main benefits of robotic assisted laparoscopic pyeloplasty are:
- greater detail for the surgeon to see the via the robotic lens
- more stability using the instruments on your precious organs as they are held by the robot but guided by the surgeon
- small incision
- shorter hospital stay (that does not mean you will feel any better, just that you can leave the hospital faster for your own good so you don't end up with a medical condition that is worse than you are already dealing with.)
A random blood test
Random blood test results showed on Jan 10, 2019, that my kidneys were not functioning properly. My GFR was between 47 and 51, meaning I have chronic kidney disease, and I had no clue because I was feeling fine. I had a blood test because of the flu and had no symptoms to tell me that I was losing my left kidney day by day.
A CT scan on Jan 10th showed severe hydronephrosis of the left kidney and extensive damage to tissue.
At the time, I did not understand that this was a mechanical obstruction and that only surgery could help. I still held out hope for some type of dietary intervention.
It is in cases like these where modern medicine is a real lifesaver.
On March 1st I did a nuclear medicine scan. That was a walk in the park compared to a closed MRI. In any case, the results showed that I only had 20 percent function remaining in the left kidney. I was devastated.
My left kidney was dying and if I had not taken that blood test, I would never have known. Because I was not having any pain or discomfort.
I went to five kidney specialists, 2 surgeons and 3 nephrologists. There was a unanimous consent that for 20 percent it is worthwhile for surgical intervention.
The previous year, someone mentioned to me that her husband had a kidney removed at Hackensack Medical Center University. She said her husband recovered well, so I had that information in the back of my mind.
First, I went to a urologist at NYU Langone in New York City who said he would do a cystoscopy to try and clear the obstruction and that there was a 50 percent chance it would be successful.
For a second opinion, I went to another urologist who said that the cystoscopy will not work in my case.
The UPJ obstruction in my case was caused by crossing blood vessels, a congenital condition. This means that I was born with one blood vessel that was pressing down so hard on the ureter that urine could no longer drain.
This urologist, Dr. Michael Stifelman, the chairman of Urology at Hackensack Medical University said that a robotic-assisted laparoscopic pyeloplasty has a 98 percent success rate. And he will use the latest and greatest robot called the Da Vinci. The robot magnifies all of the elements in the body and allows the surgeon to be extremely precise.
I had to choose between doing nothing with no pain now or doing the surgery with pain now, but hopefully saving my left kidney, reversing the chronic kidney disease and avoiding dialysis and/or transplant in the worst case.
If the surgery works, the pain is worth it, and that is what I chose.
One Day Before Surgery
Surgery was scheduled for April 1st, 2019. Not the best day I could imagine, but the alternative was to wait another month. Unbeknownst to everyone who is healthy right now, there are so many people waiting for surgery to help them.
As an aside, I realized how amazing it is that one obstruction of just one tube leading to the urinary tract in my body created incredible havoc. Requiring open surgery.
If you get up in the morning and can go to the bathroom normally, walk around, get up, sit down, even sneeze, breathe, without physical pain, that is something to celebrate and feel great about.
In any case, the prior day I was instructed to drink a bottle of magnesium citrate and do an enema in the evening.
I put the magnesium citrate in apple juice. The big mistake I made was to not chase the concoction with water. Because by the end of the day, my teeth were killing me.
And only this magnesium citrate was allowed, together with water or other clear liquids. It is a vile drink, so do your best to drink enough water afterward so the solution does not cause your teeth to get too sensitive. It took me hours to finish it off.
I was instructed to eat no other solid food, approximately 24 hours before the surgery.
Day of Surgery
Staff were all kind and accommodating at Hackensack. But that does not take off the edge of fear and anxiety when you have to disrobe and know that soon they will be making an incision in your body.
It gets emotional in the waiting area, especially when the physician assistant asks if you have a living will or not. Because so many speak about overnight hospital surgery as a procedure. You do not expect to be asked about a will.
In the Operating Room
The attendants wheel you in on a table in your gown. Lift you up and move you to the operating table. I could see my reflection in one of the enormous lights and wondered how fast life passes by.
I imagine it is human nature. We never expect to be in such a situation. I saw myself with the head covering on and said a prayer. The anesthesiologist said something and next thing I knew I was singing five hours later.
I remembered nothing in between, thank G-d. But the hours after surgery were nothing less than horrific as the pain medication wore off.
A laparoscopic robotic pyeloplasty surgery
Night of the Surgery
I spent the night in a hospital room. In a ward where there were many other kidney patients. Some who had surgery for cancer and some who were going through a transplant.
If you are not in a hospital today or any day, that is another great reason to celebrate, no matter how much of a jerk your boss is. The moaning and groaning of many patients were disturbing, besides my own pain.
I was given oxycontin narcotic, but it quickly wore off.
By midnight, 12 hours after the surgery, I was in intense pain. I am not telling you this for you to not have the surgery. Rather, you should know now what options you might have to reduce your pain.
Besides the pain of the incision in your stomach, where you were effectively stabbed professionally, you wake up with a catheter. I think most men would agree that a catheter seems like the worst form of medieval torture.
The nurse said that she would be taking it out about midnight and it is not a big deal. Really. Not a big deal. I do not think so. If your doctor can put you back under, I'd do it. Whatever sedative gels they can use, go for it.
The catheter removal was the most fearsome pain I can remember in my life. Just thinking about it as I am writing these words makes me wince. Unfortunately, technology today still requires a catheter to help your kidney drain fluid.
The good news is once the catheter is out, you are now free of one of the worst moments a man can imagine.
Lack of Appetite
Don't expect to be ready to enjoy a meal. I could not eat and even though I felt like I wanted to urinate, I just felt the pressure and burning, but nothing came out.
At 5 am another doctor said he would have to reinsert the catheter if I did not pass urine. Do you see how great it is that you can go without needing a catheter?
I was so frightened by the catheter that I pushed myself harder to go. Finally, it was enough that they stopped they took that option off the table.
I could not sleep all night. In the middle of the night tried to walk to prevent blood clots. I could barely walk. And they gave me a tube to breathe into to prevent pneumonia.
Pyeloplasty is not a procedure. Getting a mole off your face is a procedure, not a laparoscopic surgery. Filling a cavity or even putting a crown on a tooth is a procedure.
Robotic pyeloplasty is major surgery, no matter how ‘minimally invasive' the radio announcer says it is.
The Week After Surgery
Day After Surgery
April 2nd, my father's birthday. I was shockingly released from the hospital at 11 am. Very sore and tender where the incision was. I decided to not take additional morphine or oxycontin because of their constipating effects.
I already could not do anything.
My wife drove me home. Every bump in the road hurt. And a sneeze or cough killed me with pain. At that point, I was still on Tylenol. And a liquid diet until the first bowel movement.
The general anesthesia puts your digestive system to sleep and it takes time to wake up. Until that point, you can only have a liquid diet, clear broth, water, some juices.
You are pretty limited.
Two Days After Surgery
April 3rd -- Urination still very difficult and painful. Still taking Tylenol. But no oxycontin. At this point, my hands and feet are swollen from the IV solutions during the operation.
My left knee where I have a torn medial meniscus starts to stiffen up so much that I can no longer walk at all.
Cannot sleep at night. Mainly because I cannot lie down due to the incision, so sleep sitting up and wake up every hour to void as they call it.
Took a total of 3000 mg of Tylenol over the course of the day.
Three Days after Surgery
April 4th -- I start to freak out because I see blood in the urine. That is one frightening sight. The doctor assured me this is normal and to only be concerned if I see a clot, have flank pain or a fever.
A small bowel movement allows me to graduate to soft food. Still no real food, just some puree, and mashed items.
You will never feel as good passing some gas as now. Because you will be passing some of the gas which they use to expand your body and make way for the instruments and surgery.
4 days later
April 5th -- Finally the blood in the urine stops. That was a great relief, but the pain and tenderness do not.
Nevertheless, I am feeling a little bit better. Ankles and hands are still a bit swollen and left knee still hurts, so I can only hobble around.
If you are mobile, celebrate!
Friday April 6th -- swelling in hands is gone. Urination still hurting. But the tenderness of incision getting a little better.
Finally, I took off my t-shirt and saw all of the bloodstains on my stomach. We are only flesh and blood, flesh and blood. Very sobering.
Another bowel movement allowed me to eat more regular but bland food.
Friday night I got dressed and felt a bit philosophical. Voice was still sore very the tubes they put down your throat for breathing during the operation.
April 7th -- Trying to keep my weight up by eating more. From the day before surgery for another four days, I lost five pounds in total, mainly had some liquids. Surgery is not the way to lose weight. If you need to lose weight, try my guide to lose 20 pounds in 3 months.
Spent the day home with my wife. Reflecting on how different circumstances led to finding out that my kidney was near failure, and given the opportunity to save it.
Sunday the 7th day
April 8th -- I still cannot lift anything heavier than 10 pounds. Still waking up multiple times in the evening. But can lie down a bit more at night. So got my first sleep of a couple of hours.
But, felt good enough to walk outside for 15 minutes. That was refreshing.
The remainder of April
For the next month, walking was very uncomfortable. I thought the stent is only an inch, but in fact, walking with a 10 to 12-inch stent inside you from your kidney to the bladder is not comfortable, so don't get too happy.
During this time, I did my best to keep my weight up and was optimistic that my left kidney had been saved. Your kidneys are so powerful that even 20 percent of a kidney can keep you alive just fine if your other one shuts down.
Stent removal after pyeloplasty and upsetting news
On May 2nd, 2019 I had the stent removed. Because of the catheter removal experience, I opted to be put under, in the twilight as they call it. That was one of the best decisions I made. So, I recommend the same for anyone else who has great discomfort from the catheter removal.
On May 30th I had additional tests and while I was in the nuclear medicine test, I noticed that I could not see my left kidney at all. That was not a good sign. The nuclear medicine test at Hackensack confirmed that I only had 4 to 7 percent function remaining of my left kidney.
My surgeon, Dr. Stifelman, showed me the scans from NYU and looking at them, I could see that they looked the same as the ones from Hackensack. So why did the radiologist in NYU say that I had 20 percent left when you could see nothing of the left kidney. The doctors call that overreading, where the radiologist over or under reads the results.
Note to you, make sure you have your surgeon see as many of the images and scans that you have, and not just rely on the written report.
To say I was despondent would be an understatement. I pretty much lost my left kidney from this UPJ. The good news though was that the surgery saved my life, because, without it, I could have had internal bleeding, infection or sepsis.
You need two things with your kidneys, drainage, and filtration.
My surgeon and urologist were both encouraging that you can still have a normal life living with one kidney. They always mention that kidney donors do that all the time.
And for anyone who is a kidney donor, all honor to you, because they have to go through some real pain to make such a sacrifice.
Six months after surgery
As of today, I am now six months after surgery. My last tests show a stable GFR of 57, which is apparently as much as you can expect with one kidney. The best news is that there is no hydronephrosis or stones visible in either kidney.
Now I can walk again, and even do pushups, deadlifts, and squats, though I am working back into resistance training. My experience is so far that you will be able to resume physical activity again.
Everything that Dr. Stifelman told me about recovery after pyeloplasty has been spot on. He said that I could deadlift again, weight train, run, whatever, just make sure I keep drinking water.
Which is what everyone should be doing, about 2 liters a day at the minimum.
Pyeloplasty is a major surgery. Get the best surgeon you can and Dr. Michael Stifelman is one of the best in the world. Don't expect much nutritional advice, because he describes himself as a plumber. But, he will get back to you very promptly.
If you ever have hydronephrosis, stay on top of it. And if you have two healthy kidneys, go out now and dance in the fields for your good fortune.
Keep drinking water throughout the day, walk 30 minutes a day, eat real food, do pushups, squats and deadlifts, and enjoy your life.
May you never need pyeloplasty, but if you do, now you know what to expect.