Friday, May 30, 2014

Partial nephrectomy - the story

I have experienced digestive and lower intestinal discomfort for a long time. Periodically, I get concerned that something major is amiss rather than just having a temperamental gut. Thus my GP and I thought it prudent to have a CAT scan just to be sure everything was what it should be inside.

The CAT scan took place April 1st (2014), a Tuesday. On Thursday I received a call from my GP telling me that the scan showed a 3 cm cyst in my left kidney and that he wanted to have an ultrasound done to determine whether it was fluid filled (benign) or solid (tumour). The ultrasound took place on Monday April 7. On Tuesday, at a pre-scheduled appointment with him, he had the results and the ultrasound evidence was that I was dealing with a tumour in my left kidney. He immediately arranged for an appointment with a urologist the following day.

The meeting with the urologist was direct and it was clear I really had two choices: full kidney removal or remove the tumour and save as much of the kidney as possible. He recommended, an I concurred, that some kidney function is better than none, even though the right kidney was there in either case. That settled, the first day available for the surgery was Tuesday May 20, just over a week ago.

I had a pre-admission appointment at the hospital on April 14th. While discussing the process with the anesthesiologist, I was offered and chose to have epidural pain management. This involves the insertion of a tube into the spinal column and the administration of pain medication specifically targeting my mid-section. The two key benefits of this technology are more effective pain management and avoiding the mental impact of narcotic pain management, such as morphine.

In the interim, we went to Akumal, Mexico as previously planned and were able to enjoy the warmth and water and the underwater pictures from that trip are available here. We returned to Nova Scotia on May 3rd.

Donna drove me to the hospital at 6:00 AM Tuesday May 20 where I was admitted and "fitted out" in preparation for surgery. After what seemed like extensive waiting, I was finally ushered into the operating room. The epidural tube was then inserted. While not a "comfortable" procedure, the pain of inserting the tube was quite minimal. I was sitting up and covered in warmed blankets. It felt very nice.

Once the epidural was in place, I lay down on the OR bed, on my back. The last thing I remember is an "oxygen" mask being placed over my mouth and nose. I did not count backward from 100 or 10 (or 1). I regained consciousness in the recovery room about 3 1/2 hours later.

After about an hour in the recovery room, I was transferred to the Intermediate Care ward. All surgery patients with epidural inserts spend some time in Intermediate Care. I was connected to an electronic vital signs monitor, as is everyone else in Intermediate Care. At this point I had 5-6 wires connected to me (I never did actually count), an IV drip providing both hydration and some other stuff, a catheter (which was very thankfully inserted while I was unconscious), a surgical site fluid drain consisting of a tube into the area around the kidney and a plastic bulb that collected excess fluid from inside, an oxygen tube in my nostrils and draped around my ears, and the epidural.

One of the key advantages to Intermediate Care is there are two nurses assigned specifically to this unit of 4 patients. This is a very busy room. It seemed like someone was always receiving attention for something, either the patient needing assistance or the nurses needing to check on a patient. I stayed in Intermediate Care until Friday, roughly mid-day, at which point I was transferred to a semi-private room on the surgical ward.

On Wednesday, I had my first "walk" which was no more than about 15 m (32 ft.) round trip and it was very slow. Not only was my body refusing to move in more than very small increments, I was towing or pushing a pole containing my IV and epidural medication. The next day I made a loop of the nurse's station, about double the distance.

The surgeon/urologist visited at least once a day. He indicated the surgery was a success. He had removed the tumour and was able to keep 50-75% of the kidney.

On Thursday afternoon, the epidural was removed and pain management was through morphine injection. While I was happy to have one less tube connected to me, morphine is not quite as an effective pain management system. With the epidural, pain, even immediately following the operation, was always at 3 or below and averaged between 1 & 2 on a scale of 0-10. The morphine was able to control pain at about 1 step higher - not bad, but not as good as the epidural.

I think it was on Thursday that I noticed a great deal of pain in my right hip. (Although this may have been on Wednesday - while the epidural left me more mentally aware, I was still doing little more than sleeping. I couldn't manage to read more than three pages at a time before deciding it was time for another nap. As a result, some of the timing and sequence of events remain somewhat fuzzy.) Both nurses and doctors explained that this was caused during surgery. While unconscious, I was twisted onto my right side so that the surgeon could have the best access to the left kidney. The patient couldn't complain about the uncomfortable position, being unconscious, so the strain put on the right hip by twisting it around is simply part of the operational procedures.

The pain in my right hip was debilitating. I couldn't shift the position of my right leg without intense pain. This meant the walking I was supposed to do was difficult. I was told that this would go away once I got home and was able to walk about more.

On Friday the remaining tubes were removed, I was disconnected from the vital signs monitor and moved to a semi-private room in the early afternoon. I was also shifted from the morphine injection to morphine pills, primarily because pills are much more manageable at home than injections.

Later, another patient arrived who was waiting for appendectomy surgery, hoping it would be that evening. Since this was an emergency admission, he was waiting for an opening in the surgical schedule. At some time in the evening, he was taken off to have his surgery and returned to the room in the very late hours of Friday or the early hours of Saturday morning.

On Saturday, the urologist informed me that he had received the biopsy report on the tumour. He was a bit surprise that it had come back so soon, but was generally pleased with the report. The tumour was definitely cancerous, but the report also indicated he had successfully removed it completely and there were no signs of the cancer in any of the lymph nodes, indicating that it had not spread. The cancer was also identified as the most common form of kidney cancer. I think that means primarily that we know how the cancer develops and what the future likely entails, which in this case I think means things will be OK.

Later that afternoon, my roommate was sent home. Very late on Saturday night, another patient arrived. He was dealing with a blood clot of some sort and unlike my first roommate, was not communicative.

I left the hospital at about 10:30 AM Sunday morning, along with discharge instructions and a prescription for morphine, and arrived home at 11:00 AM. Getting in and out of the car was challenging and every little bump seemed to reverberate through my incision, my right leg and my back. The five steps from the driveway to the door were slow and challenging. Fortunately, Donna and Ian were there to assist. They had assembled a bed on the main floor thus eliminating any need to go upstairs. Donna got the prescription filled and got a walker.

It's now 8 days after the surgery and my right hip is almost completely pain-free. I can get up and down out of chairs and from the toilet without further difficulty. I have been taking less and less morphine and haven't had any since Monday night at around 11:00 PM. Tomorrow I see my GP to have the staples removed from the incision.

I'm quite pleased with the progress of the whole thing and feel things are getting better every day. I'm still looking at a lengthy recovery period of about another five weeks before returning to life as normal and I still feel the need for naps. There is still some pain, but it's manageable.

This report wouldn't be complete without comments concerning the health care system. I was exceptionally pleased with the speed with which the problem was addressed. Once the potential tumour was spotted, it was just over a week until the ambiguity of the observation was eliminated and I had the surgery scheduled, which was just under six weeks from my first appointment with the urologist. The surgery itself was the surgery that provided the best long term benefit to me, not the least costly to the system or the easiest for the surgeon. (That would have been a full nephrectomy done through laparoscopic surgery, but would have left me with no left kidney.) The epidural pain management is also clearly a superior technology. Finally the nursing care I received was excellent. While in the semi-private room on the surgical floor, it was evident the nurses were going flat-out. Despite that, I was always given the attention I needed, even when what I needed was just more water. The Canadian health care system is not perfect and we have to figure out how to more effectively fund it. (However, we should be spending more on nurses.) Despite those concerns, it is a superb system that meets the needs of those of us who require its services, regardless of ability to pay.

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